Hair-sparing whole brain radiotherapy with volumetric arc therapy in patients treated for brain metastases: dosimetric and clinical results of a phase II trial

Annemieke De Puysseleyr, Joris Van De Velde, Bruno Speleers, Tom Vercauteren, Anneleen Goedgebeur, Tom Van Hoof, Tom Boterberg, Wilfried De Neve, Carlos De Wagter, Piet Ost, Annemieke De Puysseleyr, Joris Van De Velde, Bruno Speleers, Tom Vercauteren, Anneleen Goedgebeur, Tom Van Hoof, Tom Boterberg, Wilfried De Neve, Carlos De Wagter, Piet Ost

Abstract

Purpose: To report the dosimetric results and impact of volumetric arc therapy (VMAT) on temporary alopecia and hair-loss related quality of life (QOL) in whole brain radiotherapy (WBRT).

Methods: The potential of VMAT-WBRT to reduce the dose to the hair follicles was assessed. A human cadaver was treated with both VMAT-WBRT and conventional opposed field (OF) WBRT, while the subcutaneously absorbed dose was measured by radiochromic films and calculated by the planning system. The impact of these dose reductions on temporary alopecia was examined in a prospective phase II trial, with the mean score of hair loss at 1 month after VMAT-WBRT (EORTC-QOL BN20) as a primary endpoint and delivering a dose of 20 Gy in 5 fractions. An interim analysis was planned after including 10 patients to rule out futility, defined as a mean score of hair loss exceeding 56.7. A secondary endpoint was the global alopecia areata severity score measured with the "Severity of Alopecia Tool" (SALT) with a scale of 0 (no hair loss) to 100 (complete alopecia).

Results: For VMAT-WBRT, the cadaver measurements demonstrated a dose reduction to the hair follicle volume of 20.5% on average and of 41.8% on the frontal-vertex-occipital medial axis as compared to OF-WBRT. In the phase II trial, a total of 10 patients were included before the trial was halted due to futility. The EORTC BN20 hair loss score following WBRT was 95 (SD 12.6). The average median dose to the hair follicle volume was 12.6 Gy (SD 0.9), corresponding to a 37% dose reduction compared to the prescribed dose. This resulted in a mean SALT-score of 75.

Conclusions: Compared to OF-WBRT, VMAT-WBRT substantially reduces hair follicle dose. These dose reductions could not be related to an improved QOL or SALT score.

Figures

Figure 1
Figure 1
The hair follicle volume was defined as the tissue underlying the skin up to the outer table of the skull. An automated script was written in Pinnacle, version 9.0 (Philips Medical Systems, Andover, MA, US), to automatically contour this volume with the creation of 4 subvolumes representing the different areas of the scalp: top (vertex, pink), back (posterior aspect of the scalp, orange), left (left profile of the scalp, blue) and right (right profile of the scalp, red). Panel A: frontal view, panel B, lateral view, panel C: cranial view.
Figure 2
Figure 2
Distribution of the film measurement locations across the scalp.
Figure 3
Figure 3
DVH’s for the VMAT- and OF- WBRT cadaver plans calculated with a 1 mm dose grid for 1 fraction (prescription dose 4 Gy).
Figure 4
Figure 4
Lateral view of a patient’s scalp with a 55% hair loss according to the SALT-score, but scoring 100 on the EORTC hair loss scale.

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