Simulated Adaptive Radiotherapy for Shrinking Glioblastoma Resection Cavities on a Hybrid MRI–Linear Accelerator

SIMPLE SUMMARY: Cognitive function after brain radiation therapy (RT) is correlated with radiation doses to the normal brain and hippocampi. During the RT of glioblastoma, daily magnetic resonance imaging (MRI) by combination MRI–linear accelerator (MRI–Linac) systems has demonstrated significant anatomic changes due to evolving post-surgical cavity shrinkage. Therefore, this study aimed to investigate if adaptive planning to the shrinking target could reduce the normal brain RT dose with the goal of improving post-RT function. We evaluated a cohort of 10 glioblastoma patients previously treated on a 0.35T MRI–Linac with a prescription of 60 Gy delivered in 30 fractions over six weeks without adaptation (“static plan”) with concurrent temozolomide. Six weekly plans were created per patient. Reductions in radiation dose to the hippocampi (maximum and mean) and brain (mean) were observed for weekly adaptive plans. Weekly adaptive re-planning has the potential to spare the brain and hippocampi from high-dose radiation, likely reducing the neurocognitive side effects of RT. ABSTRACT: During radiation therapy (RT) of glioblastoma, daily MRI with combination MRI–linear accelerator (MRI–Linac) systems has demonstrated significant anatomic changes, including evolving post-surgical cavity shrinkage. Cognitive function RT for brain tumors is correlated with radiation doses to healthy brain structures, especially the hippocampi. Therefore, this study investigates whether adaptive planning to the shrinking target could reduce normal brain RT dose with the goal of improving post-RT function. We evaluated 10 glioblastoma patients previously treated on a 0.35T MRI–Linac with a prescription of 60 Gy delivered in 30 fractions over six weeks without adaptation (“static plan”) with concurrent temozolomide chemotherapy. Six weekly plans were created per patient. Reductions in the radiation dose to uninvolved hippocampi (maximum and mean) and brain (mean) were observed for weekly adaptive plans. The dose (Gy) to the hippocampi for static vs. weekly adaptive plans were, respectively: max 21 ± 13.7 vs. 15.2 ± 8.2 (p = 0.003) and mean 12.5 ± 6.7 vs. 8.4 ± 4.0 (p = 0.036). The mean brain dose was 20.6 ± 6.0 for static planning vs. 18.7 ± 6.8 for weekly adaptive planning (p = 0.005). Weekly adaptive re-planning has the potential to spare the brain and hippocampi from high-dose radiation, possibly reducing the neurocognitive side effects of RT for eligible patients.