Hippocampal Dosimetry and the Necessity of Hippocampal-Sparing in Gamma Knife Stereotactic Radiosurgery for Extensive Brain Metastases

Abstract

Purpose: To characterize hippocampal dosimetry in Gamma Knife stereotactic radiosurgery (GK-SRS) for extensive brain metastases and evaluate the need for hippocampal-sparing in GK-SRS treatment planning. Methods and Materials: We reviewed 75 GK-SRS plans for the treatment of 4 to 30 brain metastases generated without consideration of the hippocampi. The mean dose, maximum dose to 100% of the volume (D100), maximum dose to 40% of the volume (D40), and maximum point dose (Dmax, 0.03 cm3) were obtained for the unilateral and bilateral hippocampi and compared between plans with 4 to 9 and ≥10 lesions. The rate at which plans met hippocampal dose constraints (D100 ≤ 4.21 Gy, D40 ≤ 4.50 Gy, and Dmax ≤ 6.65 Gy) was compared between groups, and each was examined for risk factors associated with excessive hippocampal dosing. For plans that exceeded constraints, we attempted replanning to spare the hippocampi. Results: Compared with those for the treatment of 4 to 9 brain metastases, GK-SRS plans with ≥10 lesions were associated with significantly greater median bilateral mean dose (1.0 vs 2.0, P = .001), D100 (0.4 vs 0.8, P = .003), D40 (0.9 vs 1.9, P = .001), and Dmax (2.0 vs 4.9, P = .0005). These plans also less frequently met hippocampal constraints, with this difference trending toward significance (80% vs 93%; P = .1382; odds ratio 0.29; 95% CI, 0.06-1.4). Risk factors for exceeding constraints included greater total disease volume and closer approach of the nearest metastasis to the hippocampi, both of which depended upon the number of metastases present. Seven plans failed to meet constraints and were successfully replanned to spare the hippocampi with minimal increases in treatment time and without compromise to target coverage or conformity. Conclusions: Patients with extensive brain metastases treated with GK-SRS are at increased risk for excessive hippocampal dosing when ≥10 lesions are present or when lesions are in close proximity to the hippocampi and may benefit from hippocampal-avoidant treatment planning.