1

Ali Fitzpatrick
Final Clinical Project
December 2, 2014
Craniospinal Irradiation

History of Illness: Patient JJ has a history of acute myeloid leukemia, and was being treated for
recurrent disease with a prescription of 24 Gy in 12 fractions to the whole brain and spine. For
the purpose of this final clinical project, I have chosen to increase the dose and fractionation to
36Gy in 20 fractions in order to demonstrate 3 gap changes throughout treatment.
The Plan: The recommendation of the radiation oncologist was to use two lateral beams for the
whole brain, with 2 posterior spine fields to treat the patient in the prone position with an energy
of 6 MV. Subfields will be used for the whole brain treatment to eliminate dose greater than
108%, while supplemental fields will be used throughout the C-spine, T-spine and L-spine to
deliver 100% of the prescribed dose to the spinal cord.
Patient Setup/Immobilization: Patient JJ had a CT simulation in the prone position. First, a
thermoplastic mask was made of the patients face and head while he was in the supine position
on the table. After this mold was complete, the patient then turned to lay on his stomach in the
prone position with the mask supporting his face (Figure 1). An alpha cradle of the patients
torso was formed in the prone position, and an additional thermoplastic mask was made for the
posterior part of the head to attach to the front part of the mask that was previously formed. JJ
had arm straps that pulled his shoulders in the downward position while the alpha cradle was
being created (Figure 2). The patients head was a neutral position with the neck bent slightly to
lift the chin. This assures that the chin is up and out of the way of any exit dose from the
thoracic spine fields. Avoiding any skin folds in the back of the neck is also a priority when
making immobilization devices for this type of treatment. Several scouts of the patient were
taken before the CT scan was performed to assure that the spine was as straight as possible.
Anatomical Contouring: After completion of the CT simulation scan, the CT data set was
transferred into the Varian Eclipse radiation treatment planning system (TPS). The medical
dosimetry student contoured the left and right eyes and lenses in order to determine the gantry
angle of the whole brain fields. The left and right kidney, left and right lung, brain, and spinal
canal were also contoured. The carina was contoured as well for set-up purposes on the

machine. The radiation oncologist reviewed the contours and placed a prescription note in
MOSIAQ, the record and verify system that Loyola University utilizes. Organ tolerances were
reviewed using QUANTEC data for the lungs, kidneys and lens, which states that the 30% of the
lung should receive no more than 20 Gy, 20% of the kidneys should receive no more than 28 Gy,
and the lens should receive no more than 10 Gy.1 Due to the prescription for the course of
treatment, there were no expected complications.
Beam Isocenter/Arrangement: This course of treatment had 3 different isocenters. The first
isocenter was for the upper spine field. The Y jaws of the spinal field have a limitation of
20cm x 20cm, and in order to leave room for the future feathering technique that will be
implemented, the medical dosimetry student determined the Y jaws were to be 19cm x 19cm
for this patient. Both spine fields will be treated with an SSD of 100cm. The isocenter
placement, therefore, will be on the surface of the patient, and along the Y axis that allows for
the maximum 19 x 19 field size with the superior border abutting the top of the patients
shoulders (Figure 3). The exact isocenter was adjusted slightly once the whole brain fields were
designed. A 1.5cm margin was given laterally to the vertebral bodies on each side. In order to
achieve this margin, MLCs were designed to allow 1.5 cm of coverage while blocking out other
tissues and organs at risk due to the curvature of the patients spine in the left and right directions
(Figure 4).
The second isocenter placed was for the whole brain lateral fields. This isocenter was
placed where the marks from CT simulation were made on the patients mask, making the plan
isocentric. The field size was similar to that of a typical whole brain treatment, except the
inferior border was extended to cover as much C-spine as possible without treating the patients
shoulders. The gantry was rotated to avoid divergence into the lenses of the eyes, and because
the patients head was slightly turned, the resulting gantry angles were 99 and 269. Careful
consideration must be made to assure that the inferior border of the cranial fields match the
divergent superior border of the upper spine field. In order to achieve this, there was a collimator
rotation and couch kick included in the cranial fields. The physician requested that there be a
0.4cm gap in the middle of the spinal cord for treatment, so the collimator rotation and couch
kick were 349 and 10 for the RAO field, and 10 and 350 for the LAO field.2 A 0.4cm gap
can be seen in Figure 3.
The third isocenter was placed for the lower spine field. The superior border of the lower

spine field was adjusted to abut the upper spine field with a 0.4cm gap in the spinal canal. It is
preferable to have this gap in the cauda equina instead of the spinal cord. The lower spine field
will have a 1.5cm margin laterally, but will then extend to abut the SI joints. (Figure 5). There
will be some overlap between the upper and lower spine fields because of divergence in the
anterior portion of the patients body (Figure 3). Divergence of the lower spine fields was
decreased by placing the isocenter close to the superior border of the field so that it almost
created a half-beam block. The gap in the spinal cord was 0.4cm, which means that the gap on
the patients skin was greater, approximately 1.9cm (Figure 6).
Once the field blocks, sizes and gaps had been approved by the radiation oncologist, a
dose was calculated and can be viewed in Figure 7. It was the goal of the physician to have 100%
of the prescribed dose cover the spinal canal, with the spinal canal achieving a dose no greater
than 110%. As seen in Figure 7, dose needs to be blocked from the whole brain and added to
some parts of the spine to achieve this goal. First, sub fields were added to the whole brain plan
to achieve a dose no greater than 108%. Then, several supplemental fields were created to
achieve the prescribed dose to the spinal canal. Overall, there were 4 field in fields for the whole
brain, and a total of 6 supplemental fields in the upper spine field. Isocenters for the
supplemental fields were not changed from the original upper spine field. Rather, jaws and
MLCs were used to create a smaller field size to add dose to regions of the spine that needed
extra. On average, these supplemental fields added from between 4-14 cGy to the plan per field.
A 45 wedge was placed on the lower spine field to compensate for the curvature of the spine
instead of supplemental fields.
The dose distribution looked more homogenous throughout the spine once sub fields and
supplemental fields were added. Once the isodose lines achieved the goal of the physician, the
gaps must be feathered every 5 fractions throughout treatment. For this technique, the upper
spine field will increase by 1.0 cm in size, (0.5cm in the superior and 0.5cm in the inferior
direction) whereas the cranial and lower spine fields will each decrease by 0.5cm. It is important
to remember to adjust the sub fields and supplemental fields by the 0.5 increments as well. For
the next feather, the upper spine field will increase by another 1.0 cm, whereas the cranial and
lower spine fields will again decrease by 0.5cm. Once the patient reaches fraction 15, the
therapists will go back to the original field sizes, and on fraction 20, repeat the first feather
measurements. For the patient that is prescribed 22 fractions, there will be a total of 4 gap

changes, but only 3 comprehensive plans will be designed. A plan summation with 6X energy
and feathers can be seen in figure 8.
Once the radiation oncologist reviewed the plan summation, he adjusted his request and
wanted the 90% isodose line to cover more of the vertebral body and requested that an energy of
23 MV be used for planning. The request required that the upper, lower, and all supplemental
fields be changed to an energy of 23MV, while the whole brain was still treated with 6MV.
After evaluating the adjusted coverage, calculation points for some of the supplemental fields
were adjusted as was the added dose per fraction for each supplemental field. A plan that
includes all fields and feathers with an energy of 23 MV can be seen in figure 9.
Treatment Planning: The treatment technique and overall dose prescription allowed the
medical dosimetry student to achieve all dose constraints for the kidneys, lungs and lenses. The
major concern with a craniospinal irradiation plan is giving the cord and vertebral bodies
adequate dose without over-dosing the spinal canal. Ultimately, it is the radiation oncologist that
will decide what coverage is desired for the patient and disease, and whether or not a boost
volume will be necessary.3 When comparing the isodose lines between the 6MV plan and the
23MV plan, it is obvious that the cyan (75%) line extends much more deep within the patient,
causing more organs at risk to receive dose. This is reflected in the DVH in figure 10. It should
be noted however, that the global maximum hot spot decreased from 5025 cGy (139%) to 4332
cGy (119%) when changing from 6MV to 23MV. The regions of high dose in both plans were
located posterior to the spine in fatty tissue.
Reflection: While creating this plan, many questions arose about patient set-up and how to
achieve a more homogeneous dose distribution. I was able to compare a prone with a supine setup from past patient CT data sets. The advantages and disadvantages seem to completely depend
on patient anatomy and spine curvature.4 Although the prone set-up is more uncomfortable for
the patient, the alpha cradle and headrest do a good job of getting the spine fairly straight anterior
to posterior. However, sometimes the patient cannot physically hold this position for long and a
supine treatment has to be planned. The head rests that are available can sometimes encourage a
larger bend in the neck which is not optimal. In these situations, an anterior supplemental beam
may need to be placed to achieve an adequate dose to the C-spine.
The most challenging aspect of this plan was making sure that dose was as homogenous
as possible throughout the spine, and assuring that the gap stayed at 0.4 cm even after the second

and third gap changes. The more supplemental fields that a plan has, the more careful the
medical dosimetrist has to be when feathering. It is critical that the patient does not receive too
much dose to the spinal cord throughout treatment.
Creating this plan and keeping it organized within the Eclipse treatment planning system
was also difficult. Each supplemental field was its own plan because it needed a separate
calculation point. For the first summation plan, there were 14 fields with 9 plans. To create a
feather, that increases to 24 fields with 14 plans, and finally 34 fields with 19 plans after the
second feather. Creating large summation plans including all fields with the correct gaps and
sizes for the Y jaws along with the correct fractionation pattern proved to be challenging if
everything wasnt properly labeled and organized.
Overall, I am very satisfied with what I learned while creating this plan. Not only did I
experience the difficulties of planning a craniospinal treatment, but what I learned can be applied
to a variety of other treatment techniques. There are many times when a patient needs matching
field plans whether it was current or a previous treatment. Matching with divergent fields can be
difficult, and it was a great experience to use gantry, couch and collimator rotation to create a
gap on the skin and in the cord. It was also a good experience planning a gap in the cord with a
larger gap on the skin that could be measured during treatment.

References
1. Marks L, Yourke E, Jackson A. Use of normal tissue complication probability models in
the clinic. Int. J. Radiation Oncology Biol. Phys. 2010;76(3):S10-19. doi:
10.1016/j/ijrobp.2009.07.1754
2. Cheng C, Das I, Chen D. Technical note: dosimetry in the moving gap region in
craniospinal irradiation. Br J Radiol. 1994;67(802):1017-22.
http://www.ncbi.nlm.nih.gov/pubmed/8000826
3. Moxon I, Bouffet E, Taylor M, et al. Impact of craniospinal dose, boost volume, and
neurologic complications on intellectual outcome in patients with medulloblastoma. J
Clin Oncol. 2014;32(17):1760-8. doi: 10.1200/JCO.2013.52.3290
4. Hideghety K, Cserhati A, Nagy Z, et al. A prospective study of supine versus prone
positioning and whole-body thermoplastic mask fixation for craniospinal radiotherapy in
adult patients. Radiother Oncol. 2012;102(2):214-8 doi: 10.1016/j.radonc.2011.07.003

Figures

Figure 1: Patient prone set-up with thermoplastic mask for CT simulation.

Figure 2: Patient prone set up with Alpha Cradle for CT simulation.

Figure 3: Placement of isocenters with field shapes demonstrating collimator and couch rotation.

Figure 4: MLC shape to allow a 1.5cm margin laterally from the spine.

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Figure 5: Field shape of lower spine demonstrating 0.4cm gap from upper spine.

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Figure 6: Field placement of upper and lower spine match with 0.4cm gap in cauda equina, and
1.9cm gap measured on the skin surface.

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Figure 7: Dose Distribution without field in fields in whole brain or supplemental fields in Cspine, T-spine or L-spine. Red = 110%, Pink = 105%, Yellow = 100%, Green = 95%, Blue =
90%.

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Figure 8: 6MV Dose Distribution with sub fields, supplemental fields and feathering. Red =
110%, Pink = 105%, Yellow = 100%, Green = 95%, Blue = 90%, Cyan = 75%.

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Figure 9: 23MV Dose Distribution with sub fields, supplemental fields and feathering. Red =
110%, Pink = 105%, Yellow = 100%, Green = 95%, Blue = 90%, Cyan = 75%.

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Esophagus

Spinal Cord

Eyes
Lenses

L Lung

R Lung

L Kidney
R Kidney

Figure 10: DVH comparing 6MV with 23MV CSI plan. Square = 6MV, Triangle = 23MV.