Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology · 2026
Strategic modulation to avoid radiation toxicities for brain integrity (SMART-BRAIN).
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Kowalchuk Roman O, Fossati Piero, Miller Janelle, Sorenson Kasie L, Spears Grant M, Frechette Kelsey M, Kraling Alan J, Wilson Zach, Daniels David J, Schwartz Jonathan, Laack Nadia N, Mahajan Anita
Аннотация
BACKGROUND: Patients with medulloblastoma require craniospinal irradiation (CSI) to optimize disease control; however, cranial irradiation is associated with significant morbidity. We sought to develop a novel target volume (CTV_2340 cGy) and explore dosimetric benefits to minimize cognitive toxicity.
METHODS: We conducted a literature review to confirm patterns of failure for average risk medulloblastoma to develop the CTV_2340 definition approach. Five patients (ages 4-16 years) were identified and proton and photon plans were generated for the new CTV_2340. Planning target goals included V100% ≥ 95% (the entire volume receiving at least 95% prescription dose) and V98% ≥ 97%. Proton planning included 3D robust optimization +/- 2 mm and +/- 2% range uncertainties. Photon plans included a 1 mm planning target volume.
RESULTS: Medulloblastoma principally recurs in the ventricular system, periventricular region, cortical surface, or posterior fossa, supporting potential omission of remaining non-target-brain (NTB, e.g. white matter tracts, thalami). The novel CTV_2340 included these regions with a 1 mm brain expansion. All proton-based plans achieved appropriate target coverage. Median whole brain volumes were 1317.1 cc (range: 1116.0-1442.1), reflecting brain size over the age spectrum. Median NTB was 15% of the brain volume (9-31%), whereas the hippocampi were < 1%. Median NTB_V12Gy and V18Gy were: 91.7% (79.3-92.3) and 70.2% (59.8-78.2). Median NTB_minimum and NTB_mean were: 2.1 Gy (0.8-2.9) and 19.4 Gy (18.0-20.2). CTV_2340 overlapped with the hippocampi, limiting hippocampal sparing (median V18 Gy 99.1%). Photon-based planning showed inferior target coverage with minimal sparing.
CONCLUSIONS: This study introduces a strategic approach to reduce radiotherapy-related neurotoxicity in medulloblastoma through proton-based sparing of critical brain regions. Multi-institutional studies are warranted to further advance this approach.
METHODS: We conducted a literature review to confirm patterns of failure for average risk medulloblastoma to develop the CTV_2340 definition approach. Five patients (ages 4-16 years) were identified and proton and photon plans were generated for the new CTV_2340. Planning target goals included V100% ≥ 95% (the entire volume receiving at least 95% prescription dose) and V98% ≥ 97%. Proton planning included 3D robust optimization +/- 2 mm and +/- 2% range uncertainties. Photon plans included a 1 mm planning target volume.
RESULTS: Medulloblastoma principally recurs in the ventricular system, periventricular region, cortical surface, or posterior fossa, supporting potential omission of remaining non-target-brain (NTB, e.g. white matter tracts, thalami). The novel CTV_2340 included these regions with a 1 mm brain expansion. All proton-based plans achieved appropriate target coverage. Median whole brain volumes were 1317.1 cc (range: 1116.0-1442.1), reflecting brain size over the age spectrum. Median NTB was 15% of the brain volume (9-31%), whereas the hippocampi were < 1%. Median NTB_V12Gy and V18Gy were: 91.7% (79.3-92.3) and 70.2% (59.8-78.2). Median NTB_minimum and NTB_mean were: 2.1 Gy (0.8-2.9) and 19.4 Gy (18.0-20.2). CTV_2340 overlapped with the hippocampi, limiting hippocampal sparing (median V18 Gy 99.1%). Photon-based planning showed inferior target coverage with minimal sparing.
CONCLUSIONS: This study introduces a strategic approach to reduce radiotherapy-related neurotoxicity in medulloblastoma through proton-based sparing of critical brain regions. Multi-institutional studies are warranted to further advance this approach.