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Whole Brain Irradiation with

Hippocampus Sparing
Ryan Kisamore
General Patient Facts

• Female
• Aged: 64
• Metastatic Disease from second battle with Breast CA, current lesions in
multiple sites.
• Treated at V7 with Whole Brain Irradiation
• VMAT with fields that spare the Hippocampus
Past Medical History


• Medical History
Social
• Single
• Breast Cancer – 1997 + 2009 • No Children
• Hypothyroidism • No Spouse
• Thyroid Cancer • Menarche at age 14

• Chronic Migraines • Menopause at age 49



• Surgical History
Family
• Mother: Breast CA + Colon CA
• Thyroidectomy-2015 • Father: Prostate CA
• Breast Lumpectomy- 1997 +2010 • Sister: Breast CA
• Sister: Breast CA
• Maternal Grandmother: Breast CA
• Paternal Grandmother: Breast CA
History of Present Illness

• Initiate Diagnosis of Left Breast Invasive Lobular Carcinoma in 1997.


Underwent lumpectomy and Radiation Therapy.
• In 2009 she was diagnosed with Invasive Ductal Carcinoma of the Right
Breast. Treatment with lumpectomy , Chemo, and Radiation.
• In 2017 she was tested and found positive for malignant disease from a
biopsy in the sternum.
• Referred to Radiation Oncology for treatment of brain, skull, and c-spine.
Signs and Symptoms

• Typical presenting signs can vary depending on location and size of lesion
within the brain.
• Patient is pleasant women with minimal symptoms.
• Primary Symptom is recurrent “episodes” of left sided numbness.
• Also reports mild pain in areas of metastasis. She associated this with her
growing age.
• Migraines
Medications

• Dexamethasone
• Letrozole
• Levothyroxine
• Multi-Vitamin
• Was prescribed decadron in July, but claimed the only
• Omega-3 Capsule effect it has had is that it “makes her crazy.”
• Probiotic • After these problems her Primary Physician prescribed
the Sumatriptan which has helped limit symptoms.
• Sumatriptan
• Vitamin D3
• Omeprazole
• Fulvestrant
Breast
Review
• Lies over the Pectoralis
Muscle.
• Attached to the Chest Wall
via Cooper’s Ligament
• Consist mainly of Glandular
and Fatty Tissue
• Filled with several lobes
which contain even smaller
lobules.
• Ducts from the lobes
converge into the nipple.
Breast Lymphatics
• Axilla – 3 Levels • Sentinel Lymph Node Biopsy
• Removing and Testing the first lymph node
• Level-1: Proximal/Low Axilla
that drains from a Tumor
• Level-2: Mid Axilla • Dye or Radioactive Tracers are injected into
• Level-3: Apical Axilla tumor.
• Following the movement of substance, we
• Internal Mammary Chain (IMC) remove the first node of drainage.
• Supraclavicular Nodes
• Intra Mammary Nodes
• Rotter’s Nodes
Breast CA: Incidence and Epidemiology

• Most Common Cancer in women of the


US.
• Second Leading Cause of Death
• Very High Cure Rate
• ~60% of cases will be considered cured.
• Incidence Rates increase with Age,
median age being 62.
• Normally Presents with single, painless
lump or mass within the breast.
Breast CA Risk Factors

• Female
• It is possible for men to develop Breast Cancer
• Age
• Family History
• BRCA Mutations
• Past Breast CA History
• Alcohol Consumption
• Minimal Exercise
• Hormone Replacement
• Early Menarche
• Late Menopause
• Late Age of First Child
Types of Breast CA

• Ductal Carcinoma in situ or DCIS • Mucinous


• 5 subtypes: Can anyone name them? • Aka Colloid
• Lobular Carcinoma in situ or LCIS • Adenocystic
• Invasive Ductal Carcinoma • Papillary
• Tubular Carcinoma • Paget’s Disease
• Medullary Carcinoma • Inflammatory
• Lobular Invasive • Phyllodes
Breast CA Staging

• Standard TNM Staging system is


used.
• T: Size of Primary Tumor
• N: Nodal Involvement
• M: Presence of Metastasis
Metastatic Brain Tumors

• Most common lesion of the brain.


• Lung and Breast are most common primary
sites to have brain metastasis.
• Median Survival is around 6 months.
• Can be treated with WBRT for multiple lesions.
• Can appear at any stage in the disease process.
• SRS, Gamma Knife, or Conformal Tx are
The size of primary tumor does not matter.
options for single solitary lesions.
• Can be multiple sites or single lesion.
Metastatic Brain
Treatment Options
• Whole Brain Radiation Therapy
• Critical to have portion of
informal border intersecting the
superior orbital ridge in order to
avoid eye.
• SRS
• Uses immense conformity of
MLCs along with high dose and
dose rate to remove small
lesions.
Imaging Studies

• Patient has had a lengthy number of studies done.


• MRI of Brain
• CTs of nearly entire body
• Many Bone Scans
• Lesions we recently found in both sides of Pelvic Bones
• Extensive Lytic Osseous Metastatic Disease
How did we get here today?
• Surgery
• Lumpectomy in 1997 on left breast
• Lumpectomy in 2010 on right breast
• Thyroidectomy in 2015
• RT
• Previous Radiation on both breasts
• Current Whole Brain Irradiation with Hippocampus Sparing
• Possible future RT to other metastatic sights.
• Chemotherapy on initial IDC Treatment
Patient
Prescription
• 3000 cGy in 10 Fractions
• VMAT
• 6MV Photons
• CBCT Daily with 6DOF
• Orthogs for alignment of upper c-
spine
• Discontinued during Tx
Patient Set-Up
Treatment Plan
• Three Complete Arcs
• 300 cGy per fraction for 10 fractions
• 6 MV Beam Energy
• No Wedges, No Bolus
Dose Histogram and Critical Structures
Critical Structures Limiting Set Up
• Lens of Eyes: 1000 cGy
• Spinal Cord: 5000 cGy
• Optic Nerve: 5000 cGy
• Parotid Gland: 3200 cGy
• Inner Ear: 3000 cGy
• At 3000 cGy prescription dose the Lenses of
the Eyes pose the greatest limitation.
• This is why we MUST make sure we
avoid the orbit and lens when we
image.
Hippocampus Sparing
• Purpose is to spare or delay onset of
neurocognitive decline within the patient as well
as decrease the frequency and severity.
• Hippocampus contains a larger concentration of
stem cells that are susceptible to the effect of
radiation.
• We can effectively block it while maintaining
dose, target volume coverage, and homogeneity.
• It does create challenges with contouring and
treatment planning.
Possible Side Effects

• Headaches
• Hair loss • This patient has had issues with change in
emotions due to treatments and drugs.
• Nausea
• She expressed a lot of fatigue and soreness
• Vomiting
• Her hair has not thinned more than already thin
• Fatigue before treatment.
• Hearing loss • Less Episodes of Numbness
• Skin and scalp changes • This treatment was used to ensure an increased
Quality of Life without too many major side
• Trouble with memory and speech effects.
• Seizures
Prognosis and Survival Over Five Years

Breast CNS Tumors


• Stage 0: 93% • Typical survival time for
• Stage I: 88% patients with metastatic
• Stage IIA: 81 % disease to the brain is 4-6
• Stage IIB: 74 % months.
• Stage IIIA: 67%
• Stage IIIB: 41%
• Stage IIIC: 49 %
• Stage IV: 15%
References

• Griffin, Haley. Breast Introduction. Present at: RADSCI 3574 - Applied Radiation Oncology 2; March 2018; Columbus, Ohio
• Griffin, Haley. Breast CA. Present at: RADSCI 3574 - Applied Radiation Oncology 2; March 2018; Columbus, Ohio
• Griffin, Haley. Breast Treatment. Present at: RADSCI 3574 - Applied Radiation Oncology 2; March 2018; Columbus, Ohio
• Hackworth, Ruth. CNS Adult Tumors. Present at: RADSCI 3573 - Applied Radiation Oncology 1; Fall 2017; Columbus, Ohio
• Gondi V, Tolakanahalli R, Mehta MP, et al. Hippocampal-Sparing Whole Brain Radiotherapy: A “How-To” Technique,
Utilizing Helical Tomotherapy and LINAC-based Intensity Modulated Radiotherapy. International journal of radiation
oncology, biology, physics. 2010;78(4):1244-1252. doi:10.1016/j.ijrobp.2010.01.039.
• Washington, CM & Leaver, D. Principles and Practice of Radiation Therapy. 4th Edition. St. Louis, MO: Elsevier, Inc;
2016:822-836.
Questions?

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