Charity Rogstad

Craniospinal Irradiation

10/2/17

Cranial Spinal Irradiation (CSI) is something I have not treated since graduating therapy
school and at that time the standard was lateral brain fields with matching spine fields that
needed to be feathered every 12 Gy. I have never seen the planning process and was a bit scared
of this project. I decided to do a little research and found a lot of very useful information. An
article by Cao et al, described a jagged junction IMRT technique that didnt require field
matching and also included information on patient position both supine and prone.1 Another
report by Hanson et al, compared the difference in isodose lines for the brain fields using four
different beam arrangements.2

Pt Position and Setup:

The patient position I decided to use was prone because that is what I am most familiar
with and thought that the setup would be the most reproducible for daily treatment. The data set
that was used was from Proknow, if this had been a real patient I would want to use a long head
and neck mask for reproducibility along with an indexed vaclok under the abdomen and pelvis to
ensure setup ease and accuracy that the patient was straight every day for treatment.

When setting up my patient in Pinnacle Treatment Planning System (TPS) I used the
advice from the articles that I had researched.1,2 They all said to set three isocenters at the same
depth and lateral coordinates so that for treatment the only shift that would be needed was
superior to inferior. So I set my brain isocenter first and then placed my two spine isocenters in
the same planes with a shift of 19 cm between the brain and upper spine and 29 cm between my
upper and lower spine isocenters.
Figure 1. Sagittal and Coronal views of isocenter placement and PTV coverage.

Figure 2. Transverse views of isocenter placement and PTV coverage

 I setup my beams with two partial arcs for the brain and single arcs for each spine field
covering 200 degrees and taking into consideration the position of the patients arms. I was able
to control my hotspot by setting maximum jaw position in the superior to inferior direction. For
my brain arcs I limited the jaw to 9.3 x 8.5 cm for arc one and 9 x 9 cm for arc two for a total
distance of 18 cm. This brought my field edge above the shoulders but the upper cspine did get
dose from my brain arcs. For my upper spine arc I limited the jaw to 17 x 20 cm for a total
distance of 37cm, my field overlapped into the brain and also the Inferior thoracic spine. For my
lower spine are I limited my jaw to 12.5 x 13.5 cm for a total of 26 cm, my field did overlap in
the lower thoracic spine and covered the inferior lumbar spine.

Figure 3. Beam field size and sagittal view of beam overlap.

Figure 4. Monitor units for each beam and gantry and collimator arrangement for each beam.
Plan Normalization

I created one Planning Treatment Volume (PTV) which included both my Brain PTV and
Spine PTV. The optimization constraints that I initially entered into Pinnacle include my
Proknow goals for this assignment. After the first optimization I didnt have the greatest
coverage and my plan was very hot in the areas of overlap. This is when I limited my beam jaw
position and optimized again giving me a much better plan with a few cold spots where I needed
to work on coverage. My brain was covered very well so I focused on getting my original Spine
PTV covered. I created a contour that gave the original spine PTV an additional 0.5 cm ring and
gave it a minimum dose constraint of 36.5Gy with a higher weighting. For this optimization I
also included a contour of my 39.6Gy isodose line to try and decrease my hotspots. I was able to
get good coverage with minimal hotspots so in my next optimization I worked on my optic
nerve, lens, and kidney dose. I got these within tolerance but lost a little PTV coverage so I drew
those covers in with hopes of getting coverage with minimal spillage of dose back into the
critical organs. I did get my coverage back but my plan was a little hot so in my next
optimization I worked on the hotspots and liver dose.

Planning Process

After placing my three isocenters I created two arcs for my brain field and a single arc for
each of my spine fields. For the brain fields my arc was a total of 165 degrees with collimator
angles of 45 and 315. The opposed collimator angle is to help decrease dose streaking throughout
the treatment. For the spine fields my arc covered a total of 200 degrees with collimator angles of
5 degrees for the upper spine and 355 degrees for the lower spine. I limited the motion of my
jaws in the superior to inferior direction for the brain fields and for the upper spine field due to
increase in hotpots during my initial optimization. After making this change I got better PTV
coverage with a decrease in hotspots.
Figure 5. DRR of each arc at its starting mlc position and field size.
 I created a scorecard to help me evaluate my plan, this scorecard included goals from my
Proknow assignment. I found this to be a very beneficial tool to use for this plan because of the
low dose constraints on some of the critical organs. Normally I do not have my low dose isodose
lines on and I found that it was much easier to decrease dose to these organs then I thought it
would be. I did have to decide if I wanted to have full PTV coverage or meet a secondary goal
for both my kidneys and liver. After multiple optimizations I decided that PTV coverage is more
important in this case. I made the decision to have a small hotspot of 40.10Gy

Figure 6. Scorecard that I created to help evaluate my plan which includes Proknow criteria for
this assignment.
Figure 7. Brain region DVH for CSI plan.
Figure 8. Chest region DVH for CSI plan.
Figure 9. Abdominal region DVH for CSI plan.
Proknow Tolerances

I used the Proknow tolerances in a couple of different ways. Firstly I used them in my
initial optimization goals. This gave me a very good plan in respect to the organs at risk (OAR) I
met all of my goals but I was lacking coverage and my plan was very hot so these were areas that
I needed to work on in my next optimizations. The second way I used the Proknow tolerances
was in my scorecard to evaluate my plan. I entered the tolerances and was able to see where I
needed to improve.

Figure 10. Proknow scoring sheet for my CSI plan.

Figure 11. Heart contour in all three planes with colorwash dose of 26 Gy (pink) and 30 Gy
(blue) which are Proknow mean dose goals.

Figure 12. Right and Left Kidney contour in all three planes with colorwash dose of 2 Gy (pink)
and 4 Gy (blue) which are Proknow mean dose goals.
Figure 13. Liver contour in all three planes with colorwash dose of 6 Gy (pink) and 8 Gy (blue)
which are Proknow mean dose goals.

Figure 14. Right and left lung contours in all three planes with colorwash dose of 20 Gy (blue)
which is a Proknow goal, less than 30-35% of the lung is to receiving this dose.
Figure 15. Right and left lens contour in all three planes with colorwash dose of 7 Gy (yellow)
and 10 Gy (blue) which are Proknow maximum dose goals.

Figure 16. Right and left optic nerve contour in all three planes with colorwash dose of 34 Gy
(yellow) and 36 Gy (blue) which are Proknow maximum dose goals.
Figure 17. Esophagus contour in all three planes with colorwash dose of 18 Gy (yellow) which
is a Proknow goal, less than 34-35% of the esophagus is to receiving this dose.

Figure 18. Small Bowel contour in all three planes with colorwash dose of 25 Gy (yellow)
which is a Proknow goal, less than 179-180cc of the small bowel is to receiving this dose.
Figure 19. Thyroid contour in all three planes with colorwash dose of 25 Gy (yellow) and 30
Gy (pink) which are Proknow maximum dose goals.
Reflection

I am very proud of the CSI plan I created. It took some real critical thinking, a little
research, and taught me a few things as well. I had never created a plan with multiple isocenters
and one prescription. I didnt know how it would turn out and initially I had created three
prescriptions with the appropriate fields attached to each. This first attempt was extremely hot at
the junction points and Pinnacle doesnt like to plan using more than one script at a time.

I also learned that by limiting the motion of the jaws at overlapping parts of the PTV it
does help decrease your hotspot and increases the dose to the PTV. Before doing this I think that
the optimizer was trying too hard to cover the PTV. This will be beneficial for me in the future
when treating patients that have to large of a PTV for one field, and extended SSD isnt an
option.

The greatest thing I learned is to face my fear of something that is unfamiliar. I realize
now that I have many tools and resources to help me when I am faced with a difficult and
unfamiliar situation.
 References

1. Cao F, Ramaseshan R, Corns R, et al. A three-isocenter jagged-junction IMRT approach

for craniospinal irradiation without beam edge matching for field junction. Int J Radiat
Oncol Biol Phys. 2012;84(3):649-654. http://dx.doi.org/10.1016/j.ijrobp.2012.01.010
2. Hanson A, Lukacova S, Lassen-Ramshad Y, et al. Comparison of a new noncoplanar
intensity-modulated radiation therapy technique for craniospinal irradiation with 3
coplanar techniques. Med Dos. 2015;40:296-303.
http://dx.doi.org/10.1016/j.meddos.2015.03.007