Nick Nguyen

Clinical Practicum III

10.16.19
Craniospinal Irradiation

Craniospinal irradiation (CSI) is a type of radiation treatment for cancer that has invaded

the cerebrospinal fluid (CSF). Typical primary tumors that are treated with CSI techniques are

medulloblastoma, germ cells, and tumors arising from the meninges. With the advancement and

progression of the radiation oncology field, there are multiple ways to plan and treat these

tumors, such ways are: three-dimensional conformal radiotherapy (3D-CRT), intensity

modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT).1 For this

write-up, I will be discussing the technique of IMRT for planning a CSI treatment. The

prescription for the plan is 36 Gy at 1.8 Gy/day. There are two targets: PTVbrain and PTVspine. The

goal is for both PTVs to receive 100% of the prescription to cover 95% of their volume.

Patient Position

For this project, the patient is in the head-first-supine (HFS) position on the treatment

table. The patients’ arms are at their sides and the head is resting on a headrest device. CSI

treatment can either be in the prone or supine position. There are both positives and negatives for

each type of setup. In the prone positions, visualization of the junctions of the fields is easily

visible. The spine can also be easily palpable which help the radiation therapist in aligning the

patient. However, prone position is uncomfortable, difficult to reproduce, and difficult to

maneuver anesthetic. The supine position is comfortable for patients, can easily be reproducible,

and safer for anesthesia. Looking closely at the patient in the UWLax Supine CSI data set, the

patient appears to have a line catheter entering the upper right chest. This patient would
definitely benefit from the supine position. On the negative aspect, it is not possible to visualize

the spine and the field junction.2

Beam setup

Before starting this project, I discuss with the physicists at my clinical site to get an

insight on how past patients were planned. Unfortunately, we don’t typically get patient for CSI

treatment and they can only recall one patient that they planned years ago. I then discuss with the

radiation oncologist about different methods and techniques for CSI treatment. We discuss 3D,

IMRT, and VMAT as the possible options. 3D has a lot of variables that needs to be managed

accurately, such as collimator angles, half beam block, couch kick, and gap calculations. The

more variable there are, the higher the chance of making a mistake. Between IMRT and VMAT,

one of the aspects that my radiation oncologist feels really strongly about is the volume of low

doses to the lungs. Although VMAT would produce a more conformed dose distribution, the

volume of the lungs receiving the low doses is much higher. For those reasons, I chose to plan

using an IMRT technique. An IMRT technique that I found was from an article by Wang et al.1

In this article, Wang et al describes the use of 7 beam angles for the cranial and 3 beam angles

for the upper and lower spine (Figure 1, 2). This specific configuration is called the three-

isocenter overlap-junction (TIOJ). The first isocenter is located center to the brain and on the

midsagittal plane of the patient. The 2nd and 3rd isocenters were located 25 cm inferior from the

previous iocenter location on the same sagittal plan (Figure 1). The coordinates for the position

of the isocenter only changed in the superior/inferior (y-coordinate) direction and not the lateral

(x-coordinate) or anterior/posterior (z-coordinate) direction (Figure 3). This is beneficial to the

treating therapist because the setup is much simpler as they only need to move from one

isocenter to the next in the y-coordinate. Wang et al describes in their article that for the entire
length of treatment (PTVbrain and PTVspine) is under 80 cm, then the isocenter are placed 25 cm

apart and if it is over 80 cm, then the isocenters are located 30 cm apart.1 I measured the

combined PTV for this patient along the midsagittal plane to be 71 cm long, respectively, and

therefore, the isocenters (A, B, C) were set 25 cm apart (Figure 1). The overlapping junctions

between fields are from 10-15 cm, respectively. The distance of each isocenter to the source is

100 cm making it a source to axis distance (SAD) technique. Couch and collimator angles were

set to 0. The 7 beam angles for the cranial are 0º, 65º, 100º, 123º, 230º, 257º, and 290º and the 3

beam angles each for the upper and lower spine are 145º, 180º, 215º (Figure 1, 2). The energy for

this plan utilizes 6 MV photon and is calculated with the Monte Carlo algorithm.

Figure 1. TIOJ method with 7 beams for the cranial and 3 beams for the upper and lower spine
field on sagittal plane. Three Isocenter (A, B, C) are positioned 25 cm apart from each other.
Figure 2. TIOJ method in axial plane displaying the 7 beams for the cranial setup.

Figure 3. Chart displaying the X,Y, Z-coordinate of the 3 isocenter.

Planning process

With the organs at risk (OAR) already contoured in the Supine CSI data set from

Proknow, I set the position of the bb skin marker, imported a treatment couch, and followed the

technique written in the article by Wang et al for isocenter location, couch and collimator angles,

beam design, and beam energy. To start the optimization process, I added the two targets

(PTVbrain and PTVspine) and place Cost Functions (constraints) starting with the Target Penalty

which acts as a lower constraint and combining it with a Quadratic Overdose (i.e. upper
constraints). Following the targets, the OAR structures and Body structures were added. The

Body structure has a Maximum Dose, Conformality, and 4 rings (Quadratic Overdose)

constraints that act on the PTV. The first ring was set at the prescription dose (36 Gy). Second

ring was place at an isodose level that was 90% of the first ring; 36 Gy x 0.90 = 32.4 Gy. Third

ring was at an isodose level that was 90% of the 2nd ring; 32.4 Gy x 0.90 = 29.16 Gy. And the 4th

ring is 90% of the 3rd ring; 29.16 Gy x 0.90 = 26.24 Gy. The hard Maximum Dose constraint is

set at 105% of the prescription dose, respectively (Figure 4). The conformality cost function was

set at 0.75.

Figure 4. Chart displaying constraints.

Initially, I placed constraints on the OAR structure with what I was comfortable with and

ran the first stage of optimization to see what coverage I was getting. From there, I refined the

constraints to get better dose coverage and to meet the constraints following the Proknow

parameter scoresheet. The OAR constraints that I had the hardest time to meet were the

maximum dose to the lens and optic nerves. The techniques that I used to try and meet the

Proknow constraint parameters are: constraining the OAR with harder/tigher margins, created

avoidance structures for the optic nerve and lens, and also by placing a hard maximum dose

constraint for the OAR per Proknow. Each of those technique individually and combined were

able to achieve the minimum coverage stated in Proknow’s parameter scoresheet. However, it
came at a cost to the constraint for the volume of the PTVspine covered by 39.6 Gy. It also

affected the esophagus coverage of 18 Gy. The plan became too hot. To gain 8 points while

losing over 20 points was not a trade that I was willing to compromise with. After multiple

attempts, I decided to try and lower the dose to the OAR as much as I can by analyzing the DVH

and constraining the mean dose (Figure 5). The TIOJ method with 7 beam angles for the cranial

target irradiation can be beneficial. However, there are many beams that are directed at entering

and exiting relatively closed to the optic nerves, eyes, and lens. Also, since the TPS was using

the Monte Carlo algorithm, it tried to account for all the possibility of scatter radiation which can

also drive the plan to be hotter. For future plans, I think if I alter the beam angles, I can meet the

constraints for the optic nerves and lens.

Figure 5. DVH displaying CTVs, PTVs, and OAR structures.

Normalization

The objective for this project was to normalize the two targets to receive 100% of the

prescription covering 95% of the volume. Since this was an IMRT plan, once the optimization

was complete, I normalized the plan to a volume. With 2 targets, I normalized the plan to the

PTV with lesser coverage. This way, it will ensure that both PTV will meet the coverage of 95%

volume getting 100% of the prescription dose. A screenshot of the isodose distribution after

normalization is provided below (Figure 6). There is however, a discrepancy between the

parameters in the treatment planning system (TPS) and the Proknow. Even though my plan

shows coverage of at least 95% in the TPS for both PTV (Figure 7), the Proknow system

recalculated the imported parameters and resulted with the PTVbrain volume covering 36 Gy at

only 92.471%. This meant that 1 point was taken away when it should have been full credit

(Figure 11).

Figure 6. Isodose distribution after plan normalization.

Figure 7. Statistic chart for CSI plan.

The maximum dose for this plan is 39.96 Gy and is located in the posterior aspect of the

brain within PTVbrain (Figure 8). I would consider this maximum dose location to be ideal

because it is not within an OAR. The largest hot spot for my plan is located in the spinous

process of one of the thoracic spine. The location of this hot spot is due to the spinous process

being more prominent and thicker in density. Also it is well within the overlapping junction

between the upper and lower spine field. It would be hard to move this hot spot because the plan

calls for 3 beams to enter from the posterior aspect of the patient. There is a large cold spot that

is located in the posterior aspect of the ethmoid sinus and at random location within the bony

structure of the skull (Figure 9). This could be due to the constraints that I placed on the lens and

optic nerve to try and meet the Proknow constraints.

Figure 8. Location of global max dose. Figure 9. Location of cold spots.

Reflection

I valued the discussion with the radiation oncologist to understand his perspective on

what is a priority in his mind when he is treating the patients. Newer technology such as VMAT

may be more advanced but it can also increase dose to OAR that he is trying to protect. This

knowledge is beneficial because it is another technique to lowering dose while achieving target

coverage. There are multiple ways of planning for CSI treatment, i.e. 3D-CRT, IMRT, VMAT,

and within each of these modality, there are multiple arrangement of beam angles, collimator

angles, and couch angles that can be used. The TIOJ method is definitely a good method to plan

for CSI treatment, however, I would alter the beam angles in a way that it does not enter and exit

through critical organs such as lens, eyes, and optic nerves. A large overlapping junction (10-15

cm) of the spine can drive up dose creating hot spots within the bony structures. With a 3-beam

arrangement for the spine (Figure 10), the TIOJ method did achieve a more conformed dose

distribution for the spine versus 1 PA beam. Overall, this project was very beneficial to me and

my clinical site because it provided more knowledge and offered different techniques to creating

CSI plan that our team have not yet tried.

Figure 10. Beam arrangement for spine field and dose conformality around PTVspine.

Figure 11. Proknow parametric scoresheet.

Reference:

1. Wang Z, Jiang W, Feng Y, et al. A simple approach of three-isocenter IMRT planning for
craniospinal irradiation. Radiat Oncol. 2013;8:217. https://doi.org/10.1186/1748-717X-8-217.
2. Nanda AK. Techniques of CSI. Paper presented at: AHRCC Cuttack; June 6, 2018.
https://www.slideshare.net/DrAbaniKantaNanda/craniospinal-irradiation-104549528.
Accessed October 12, 2019.