title: Treatment Planning and Delivery of Whole Brain Irradiation with Hippocampal Avoidance in Rats.
abstract: BACKGROUND
  Despite the clinical benefit of whole brain radiotherapy (WBRT), patients and physicians are concerned by the long-term impact on cognitive functioning. Many studies investigating the molecular and cellular impact of WBRT have used rodent models. However, there has not been a rodent protocol comparable to the recently reported Radiation Therapy Oncology Group (RTOG) protocol for WBRT with hippocampal avoidance (HA) which is intended to spare cognitive function. The aim of this study was to develop a hippocampal-sparing WBRT protocol in Wistar rats.
  
  
  METHODS
  The technical and clinical challenges encountered in hippocampal sparing during rat WBRT are substantial. Three key challenges were identified: hippocampal localization, treatment planning, and treatment localization. Hippocampal localization was achieved with sophisticated imaging techniques requiring deformable registration of a rat MRI atlas with a high resolution MRI followed by fusion via rigid registration to a CBCT. Treatment planning employed a Monte Carlo dose calculation in SmART-Plan and creation of 0.5 cm thick lead blocks custom-shaped to match DRR projections. Treatment localization necessitated the on-board image-guidance capability of the XRAD C225Cx micro-CT/micro-irradiator (Precision X-Ray). Treatment was accomplished with opposed lateral fields with 225 KVp X-rays at a current of 13 mA filtered through 0.3 mm of copper using a 40x40 mm square collimator and the lead blocks. A single fraction of 4 Gy was delivered (2 Gy per lateral field) with a 41 second beam on time per field at a dose rate of 304.5 cGy/min. Dosimetric verification of hippocampal sparing was performed using radiochromic film. In vivo verification of HA was performed after delivery of a single 4 Gy fraction either with or without HA using γ-H2Ax staining of tissue sections from the brain to quantify the amount of DNA damage in rats treated with HA, WBRT, or sham-irradiated (negative controls).
  
  
  RESULTS
  The mean dose delivered to radiochromic film beneath the hippocampal block was 0.52 Gy compared to 3.93 Gy without the block, indicating an 87% reduction in the dose delivered to the hippocampus. This difference was consistent with doses predicted by Monte Carlo dose calculation. The Dose Volume Histogram (DVH) generated via Monte Carlo simulation showed an underdose of the target volume (brain minus hippocampus) with 50% of the target volume receiving 100% of the prescription isodose as a result of the lateral blocking techniques sparing some midline thalamic and subcortical tissue. Staining of brain sections with anti-phospho-Histone H2A.X (reflecting double-strand DNA breaks) demonstrated that this treatment protocol limited radiation dose to the hippocampus in vivo. The mean signal intensity from γ-H2Ax staining in the cortex was not significantly different from the signal intensity in the cortex of rats treated with WBRT (5.40 v. 5.75, P = 0.32). In contrast, the signal intensity in the hippocampus of rats treated with HA was significantly lower than rats treated with WBRT (4.55 v. 6.93, P = 0.012).
  
  
  CONCLUSIONS
  Despite the challenges of planning conformal treatments for small volumes in rodents, our dosimetric and in vivo data show that WBRT with HA is feasible in rats. This study provides a useful platform for further application and refinement of the technique.
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: C K
authors.initials: CK
authors.lastname: Cramer
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: S W
authors.initials: SW
authors.lastname: Yoon
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: M
authors.initials: M
authors.lastname: Reinsvold
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.|Department of Anatomy and Cell Biology, Sungkyunkwan University School of Medicine, Seoul, South Korea.
authors.forename: K M
authors.initials: KM
authors.lastname: Joo
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: H
authors.initials: H
authors.lastname: Norris
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: R C
authors.initials: RC
authors.lastname: Hood
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: J D
authors.initials: JD
authors.lastname: Adamson
authors.affiliation: Department of Psychiatry, Durham VA, Durham, NC, United States of America.|Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: R C
authors.initials: RC
authors.lastname: Klein
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.|Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: D G
authors.initials: DG
authors.lastname: Kirsch
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America.
authors.forename: M
authors.initials: M
authors.lastname: Oldham
mesh_terms: D000818:Animals; D016371:Cranial Irradiation / Q000379:methods*; D004247:DNA / Q000528:radiation effects; D019583:Dose Fractionation, Radiation; D006624:Hippocampus / Q000503:physiopathology / Q000528:radiation effects*; D050397:Radiotherapy, Intensity-Modulated; D051381:Rats; D017208:Rats, Wistar; D016896:Treatment Outcome
chemical_list: D004247:DNA