HOLISTIC APPROACH IN WHOLE BRAIN RADIATION IN BRAIN SECONDARIES

1. Holistic approach
Whole brain radiotherapy in brain metastases.
Dr Kanhu Charan Patro
Dr Partha Sarathi Bhattacharya, Dr Chitta Ranjan Kundu, Dr V Krishna Reddy, Dr P
Madhuri, Dr Rashmi Shukla, Mr A C Prabu, Mr A Srinu, Dr Anil Kumar, Mrs Subhra Das
Department of Radiotherapy, Mahatma Gandhi Cancer Hospital & Research Institute.
Visakhapatnam.

2. Whole-Brain Radiotherapy
• Whole-brain radiotherapy (WBRT) is the treatment
of choice for many patients because of the high
incidence of multiple metastatic sites
• The goal of WBRT is to limit tumor progression
and, in the middle term, to limit the use of
corticosteroids.
• The optimal dose of irradiation is unknown, but in
clinical practice, the range is 20 Gy in 5 fractions
over 1 week , 30Gy in 10# to 40 Gy in 20 fractions
over 4 weeks

3. 12/1/2019 3

4. UNDERRATED
Complications of whole brain radiotherapy
• Include alopecia, transient worsening of neurologic
symptoms, and otitis.
• Continuing use of corticosteroids during WBRT may
limit the incidence of most side effects.
• Long-term side effects such as memory
loss, dementia, and decreased concentration.
• Xerostomia

6. Xerostomia was common, sometimes severe, and appeared to be parotid dose-
dependent after WBRT.

7. WHY WE SHOULD BE WORRY
WHEN SURVIVAL IS LESS?
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8. SURVIVAL IN BRAIN METSTASIS
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9. Aim and objective
• Can we spare the spareable structures?
• Can we spare at least parotid, cochlea, internal,
external ear, hippocampus and scalp?
• Just to improve the quality of life

10. Material and methods
• Supine position
• Mask
• Contrast CT vertex to lower neck
• MRI 3D FSPGR sequence
• CT MRI fusion
• Contoured scalp, hippocampus, cochlea and parotid
according to guidelines
• 2D MLC plan
• VMAT plan
• Dosimetry analysis of all these structures and PTV
coverage

11. MLC FIELD WBRT

12. Hippocampal contouring

13. Hippocampal sparing

14. Cochlea, auditory contouring and sparing

15. Parotid contouring and sparing

16. Scalp contouring and sparing

17. RESULT
DOSE DISTRIBUTION COMPARISON 2DRT VS VMAT
SL NO ORGAN 2D RT VMAT % REDUCTION
1 PTV coverage 1. D2 – 31.2 Gy
2. D98 – 29 Gy
1. D2 – 31.7 Gy
2. D98 – 28.4 Gy
1. Same
2. same
2 Hippocampus 1. Mean-31 Gy
2. Max - 30.5 Gy
3. D100 -30 Gy
1. Mean-17 Gy
2. Max -10 Gy
3. D100 -8.7 Gy
1. 45%
2. 33%
3. 61%
3 Parotid 1. Mean-26.5 Gy
2. Max -30.9 Gy
1. Mean-5 Gy
2. Max -19 Gy
1. 82%
2. 29%
4 Scalp 1. Mean-22.5 Gy
2. Max -33.1 Gy
1. Mean-17.8 Gy
2. Max -25.8 Gy
1. 21%
2. 13%
5 Cochlea 1. Mean-29.9 Gy
2. Max -30.4 Gy
1. Mean-24 Gy
2. Max -27.5 Gy
1. 20%
2. 10%
6 Middle ear 1. Mean- 29.6 Gy
2. Max -30.6 Gy
1. Mean-22 Gy
2. Max -27 Gy
1. 25%
2. 12%
7 External ear 1. Mean- 21.2 Gy
2. Max – 30.7 Gy
1. Mean-15 Gy
2. Max -25 Gy
1. 30%
2. 19%

18. INCIDENCE OF HIPPOCAMPUS MET
12/1/2019 18S. Sood et al. / Medical Dosimetry /2017
DOSE REDUCTION TO OARS IN CONFORMAL WBRT

19. DISCUSSION AND REVIEW LITERATURE

20. DOSE CONSTARINTS FOR HIPPOCAMPUS
RTOG 0933
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HA-WBRT IMRT
Planning
PTV D2% ≤ 37.5 Gy
D98% ≥ 25 Gy
Hippocampus D100% ≤ 9 Gy
Maximum dose ≤ 16 Gy
Optic Nerves
and Chiasm
Maximum dose ≤ 37.5 Gy

22. INCIDENCE OF HIPPOCAMPUS MET
12/1/2019 22Oskan F/ Strahlenther Onkol/2014
INCIDENCE OF HIPPOCAMPUS METASTASIS

23. 2D BLOCKING OF PAROTID

24. Issues
•Expertise
•Awareness
•The pessimistic thought
•Time
•Cost

25. Cost of dementia
• FINACIAL
• HEALTH
• FAMILY

26. Cost is an issue?
Incurring cost
vs
Recurring cost

27. Summary
• Survival is not less in targeted era.
• Sparing of these structures gives better QOL
• Sparing is possible
• It is feasible
• More awareness
• Do not look for the incurring cost, look for recurring
cost.

28. Do in a holistic way