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Single Pontine Relapse Shortly After Hippocampal Avoidance Whole Brain Radiotherapy: A Case Report
Zeinab Dandash1, Bassem Youssef1, Ali Al Zein1
1Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon.
Cancer Reports (Hoboken, N.J.)
|August 25, 2025
Summary
Hippocampal-sparing whole brain radiotherapy (HA-WBRT) may increase the risk of brain metastasis in the upper brainstem due to underdosing. Optimizing radiation plans for brainstem coverage is crucial to mitigate this risk.
Area of Science:
- Radiation Oncology
- Neuro-oncology
- Medical Physics
Background:
- Brain metastases are the most common adult brain tumors, with incidence increasing due to improved cancer detection and treatment.
- Whole brain radiotherapy (WBRT) is standard for unresectable or non-stereotactic irradiation cases, but causes cognitive decline.
- Hippocampal-sparing WBRT (HA-WBRT) reduces brain toxicity, yet carries a risk of metastasis in the spared hippocampal region.
Observation:
- A 73-year-old male with multiple brain metastases treated with HA-WBRT developed a new pontine lesion.
- The lesion was located in a peri-hippocampal area that received an under-dose of radiation.
- Dosimetric comparison of the patient's plan with optimized IMRT and VMAT plans showed improved brainstem dose distribution.
Findings:
- HA-WBRT plans inherently under-dose the upper brainstem, increasing the risk of peri-hippocampal metastasis.
- Optimized planning techniques incorporating brainstem coverage can improve dose distribution.
- This case highlights an uncommon but significant risk associated with HA-WBRT.
Implications:
- Radiation oncology planning for HA-WBRT should prioritize brainstem coverage to minimize metastasis risk.
- Further research into optimizing HA-WBRT techniques is needed to balance efficacy and toxicity.
- This finding may influence treatment guidelines for patients with brain metastases.
