Treatment Planning Of Volumetric Modulated Arc Therapy And Positioning Optimization For Hippocampal-Avoidance Prophylactic Cranial Irradiation

Background Hippocampal-avoidance prophylactic cranial irradiation (HA-PCI) offers potential neurocognitive benefits but raises technical challenges to treatment planning. This study aims to improve the conventional planning method using volumetric modulated arc therapy (VMAT) technique and investigate a better patient's head positioning to achieve a high quality of HA-PCI treatment plans.Methods The improved planning method set a wide expansion of hippocampus as a special region for dose decline. The whole brain target was divided into two parts according to whether the slice included hippocampus and their optimization objectives were set separately. Four coplanar full arcs with partial field sizes were employed to deliver radiation dose to different parts of the target. The collimator angle for all arcs was 90 degrees. Tilting patient's head was achieved by rotating CT images. The improved planning method and tilted head positioning were verified using datasets from 16 patients previously treated with HA-PCI using helical tomotherapy (HT).Results For the improved VMAT plans, the max and mean doses to hippocampus were 7.88 Gy and 6.32 Gy, respectively, significantly lower than those for the conventional VMAT plans (P < 0.001). Meanwhile, the improved planning method significantly improved the plan quality. Compared to the HT plans, the improved VMAT plans result in similar mean dose to hippocampus (P > 0.1) but lower max dose (P < 0.02). Besides, the target coverage was the highest for the improved VMAT plans. The tilted head positioning further reduced the max and mean doses to hippocampus (P < 0.05), significantly decreased the max dose to lens (P < 0.001) and resulted in higher plan quality as compared to nontilted head positioning.Conclusions The improved planning method enables the VMAT plans to meet the clinical requirements of HA-PCI treatment with high plan quality and convenience. The tilted head positioning provides superior dosimetric advantages over the nontilted head positioning, which is recommended for clinical application.