Answer

During my clinicals, I have had the chance to help plan multiple treatments for whole brain
irradiation. At my clinical site, the standard practice for treating brain metastases is 300 cGy for 10
fractions with a total prescribed dose of 3000 cGy. Traditionally, standard whole brain treatments
consist of using parallel opposed lateral fields of a rectangular shape. The inferior border is collimated
connecting the superior orbital rim with the mastoid tip. Adequate flashing of at least 1 cm anteriorly,
posteriorly, and superiorly is required to cover the entire skull.1,2 With the use of these treatment
borders to cover the entire skull, hot spots greater or equal to 107% may appear within the treatment
plan. The hot spots are usually located near the thinner portions of the head such as on the scalp or
vertex as well as in the frontal and occipital portions of the head. Due to these increased areas of dose,
the chances for permanent hair loss may occur. Hair loss typically starts three weeks after beginning
radiation treatments to the whole brain. With a large amount of radiation to the brain, the possibility of
developing a “reverse mohawk” or bald patch over the vertex of the scalp increases.3

Recently, my clinical site began using a field-within-a-field technique when planning whole brain
treatments. This technique is used to help limit the areas of high dose (hotspots) while sparing the scalp
to prevent a reverse mohawk. To achieve this, four fields are created; 2 open fields encompassing the
entire brain with flash anteriorly, posteriorly, and superiorly, and 2 segmented fields that use multi-leaf
collimators to shape the field and shield parts of the scalp. Most of the dose is delivered through the
open fields, which have a higher beam weighting then the segmented fields. The segmented fields use
optimization to set constraints for organs at risk such as the eyes, lens, and spinal cord. The segmented
fields also block areas of the superior portion of scalp, limiting dose to this area. In speaking with one of
our physicians, she explained that a field-within-a-field technique allows for a more concentrated and
uniform dose distribution, while decreasing the amount and location of hotspots. This type of treatment
helps to remove 105-110% hotspots that generally fall along the scalp, therefore preventing reverse
mohawks or bald spots on the vertex. Budiyono et al,3 also explains that the use of optimization
planning with a field-within-a-field MLC technique provides a more homogenous dose on the CTV
volume, lowers radiation doses to healthy tissues/organs, and reduces hot spots in the CTV volume.
Although there is not much data published supporting this technique, our department feels that the use
of the field-within-a-field can reduce the chances of permanent hair loss and improve a patient’s quality
of life. I found this technique to be interesting and beneficial for patients who are already having a hard
time accepting the possible side effects of treatment. This is one way to help preserve a patient's
cosmetic appearance and well-being during this difficult time in their life.

I have included some slices from a patient's plan showing the differences in the dose
distribution between a standard whole brain treatment with parallel opposed lateral beams and a field-
within-a-field technique for the same patient's treatment. The images on the left are from the standard
whole brain treatment and the images on the right are from the field-within-a-field technique. The
images from the standard whole brain treatment show an increased number of hot spots and higher
dose compared to the field-within-a-field technique. The red isodose line represents 110% or greater of
the prescribed dose, the yellow line represents the 105% isodose line, and the green is the 100% isodose
line. I have also included an example of the MLC blocking used for this plan. This demonstrates how the
MLCs are used to spare the scalp region. These images help to show the potential benefits of using a
field-within-a-field technique because it provides a more uniform dose distribution, reduces dose to
thinner portions of the head, and prevents the patient from having permanent hair loss.
MLC Blocking of a field-within-a-field technique used for whole brain irradiation.
References

1. Nedzi LA, Choe KS, Pompos A, Ramirez E. Cancers of the central nervous system. In: Khan FM,
Gerbi BJ.,eds. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA: Lippincott,
Williams, and Wilkins;2012:628-647.
2. Trad ML. Central nervous system tumors. In: Washington CM, Leaver D, eds. Principles and
Practices of Radiation Therapy. 4th ed. St. Louis, MO: Mosby-Elsevier;2016:686-704.
3. Budiyono T, Budi WS, Hidayanto E. Treatment planning systems for external whole brain
radiation therapy: With and without MLC (multileaf collimator) optimization. Journal of Physics
Conference Series.2016;694(1):1-5. doi:101088/1742-6596/694/1/012004.