Lisa Spanovich

Clinical Practicum III

CSI Project

Introduction
Medulloblastoma is a common malignant brain tumor in children, and it is also a rare
brain tumor in adults. The disease affects the cerebellum, which controls balance and other motor
and cognitive functions. Medulloblastoma is known to spread quickly, but it usually responds
well to treatment. Typically, the patient will have surgery to remove or de-bulk the tumor, and is
then followed by chemo and radiation. When radiation therapy is suggested for this diagnosis,
they undergo crainospinal irradiation (CSI). This is a type of radiation treatment where the brain
and the entire spinal canal are treated.1

After some conducting some research myself, one of my medical dosimetrists directed
me towards an article of a treatment technique that he had used when he worked at another
facility. This article is titled A three-isocenter jagged-junction IMRT approach for craniospinal
irradiation without beam edge matching for field junctions. This technique uses 3 isocenters,
with a total of 13 fields, using static IMRT. Jason Fields, CMD, explained to me that techniques
such as this article are the more common ways to treat patients who need CSI. This article was
published in 2012, which proves to be fairly new technique. I did find newer styles of treatment
but decided this would be the best fit for me.

Patient Positioning

For this assignment, we had the option to plan on a supine or a prone patient. I opted to
plan the supine patient because it would be more comfortable for the patient. Whether the patient
receives 3D technique or IMRT, they will still be laying on the table for a significant amount of
time, so I took that into consideration. Even though the patient may be more comfortable supine,
I do believe the best positioning for treatment would be for the patient to be prone. When a
patient lies prone, gravity helps the medical dosimetrist, and organs/structures fall away from
where we want to treat. Think about the esophagus; its typically very proximal to the vertebrae,
but when a patient is laying on their stomach, it get gets pulled away from that area. Even if its
only a 5 mm advantage, every bit helps when it comes to lessening side effects for the patient. I
would assume this patient would be in a head and neck mask to stabilize the upper portion of
their body, and a vacbag to immobilize the lower portion of their body.

Treatment Planning

I planned this patient on Eclipse treatment planning system (TPS). Eclipse only wants
one isocenter per plan, so in order to plan this patient, I had to ungroup each treatment field,
and assign isocenter coordinates to each field, so they can all be optimized at one time. If this
plan was used for an actual treatment, I would have to separate out each of the 3 parts, and assign
them to their own treatment plan.

Due to the length of the patient, I knew that 3 isocenters would be needed. The article
that I am modeling my project after also uses 3 isocenters. First of all, I wanted to make sure that
all 3 of my isocenters were on the same axis. This is important for the therapists because it
requires minimal shifting. For my plan, the therapists will align to the brain markings (first
isocenter), then shift inferior to the other 2 isocenters. The less shifts that are made in a treatment
such as this, the better. From my patients brain markings, the therapist will shift 22 cm inferior
to the 2nd isocenter (upper spine). The therapist will shift 47 cm inferior from the brain markings
to get to the 3rd isocenter.

Per the Cao et al2, the brain portion of treatment is to have 7 fields, and both of the spinal
fields (upper spine and lower spine) will have 3 fields each, giving a total of 13 fields. Each of
these fields are to overlap by 1.1 cm, giving a total of 9.9 cm overlap between the brain and
upper spinal fields, and a 5.5 cm overlap between the 2 spinal fields (Figures 1, 2).
Figure 1. Jagged edge techique2

Figure 2. Field placement using Jagged-Edge Technique.

 After my conversation with Jason Fields, he explained how this article does not show
what the collimator angles should be. At his previous place of employment, they would turn
collimator to insure that there were no definitive edges of the fields, it makes the edges
blurred, which further solidifies the need for no field matching. For each of the posterior
oblique fields, I rotated the collimator in 7 degrees each way, while leaving the PA fields
collimator at 0 (Figure 3). I was told to rotate the collimator in the direction that made central
axis more parallel with the spine (Figure 4).

Figure 3. Gantry/Collimator angles for supine CSI treatment.2

Gantry/ Upper Gantry/ Lower Gantry/

Brain Coll Coll Coll

Spine Spine
Angle Angle Angle
Field 1 0/0 Field 8 145/7 Field 11 145/353
Field 2 65/0 Field 9 180/0 Field 12 180/0
Field 3 100/353 Field 10 215/353 Field 13 215/7
Field 4 123/353
Field 5 230/7
Field 6 257/7
Field 7 290/0
Figure 4. Collimator angles on Isocenter 2 (upper spine).

PA Field RPO Field LPO Field

After I optimized for the first time, I noticed a couple of things that needed adjusted. The
dose to the thyroid was extremely high, so after viewing the upper spinal fields, I decided to
close my X jaw down to block the thyroid. My esophagus dose was also 3x higher than
ProKnows minimum requirement. The esophagus was within every field of my spinal treatment.
To fix this, I decided to rotate the oblique fields of the spine so that there was some separation
between the spine and esophagus, so the optimizer could then successfully limit dose to the
esophagus. I also had issues with my lens dose. I found 2 fields of the brain treatment where I
was able to close the jaw down and effectively block the lens.

Results

The final result for my ProKnow score was 119.21/127, with over 98% coverage on the
total brain/spine planned target volume (PTV) (Figure 5). I had a 16% hotspot. The major issue I
had was limiting dose to the optic nerves and the lens. Upon further inspection, I did meet the
minimum requirement of the optic nerves. The ProKnow minimum requirement was 36 Gy to
each optic nerve. My right optic nerve received 3565 (Proknow shows 3650), and the left optic
nerve received 3530 (Proknow shows 3798). The results also showed my lens dose to be a little
bit higher than what Eclipse showed. The right lens received 7.82 (Proknow shows 9.98), and my
left lens received 8.03 (ProKnow shows 9.9). Overall, I am happy with the way this plan turned
out, except for my hot spot. I could not get my hotspot below 16%, though it was a small
amount, in the upper spine. I believe the reason my plan was so hot was because I angled my
oblique spinal fields more posterior, so with the PA spine field, the fields were too close and
caused a higher hotspot.

This was the most challenging plan I have done, to date. Because of the length of the
volume we are treating, there are so many critical structures to pay attention to. I noticed that
when I focused on limiting dose to one structure, it would cause the dose to rise in another. It
takes some time to analyze all of the structures after optimization, because you have to look at
them separately so that it doesnt get too confusing. I did not include a dose volume histogram
(DVH) in this assignment because most of the statistics we are viewing are mean and maximum
doses, and considering the amount of structures we are to analyze, I didnt see the importance.
See figure 6 for the maximum and mean dose results.

Some possible clinical issues with this setup is that since the patient is supine, we are
forced to treat through the treatment table. Some styles of treatment tables have metal portions
where the therapists should not treat through because of attenuation of the beam. If this is not an
issue, I think treatment in the supine position would make the patient more comfortable, which
also means less movement will occur during treatment.
Figure 5. Final isodose distribution (red is 100% line).
Figure 6. Maximum and mean dose results.
Figure 7. ProKnow score sheet.
 References

1. Medulloblastoma. MD Anderson Website. https://www.mdanderson.org/cancer-

types/medulloblastoma.html. Accessed 10-3-17.
2. Cao F, Ramaseshan R, Corns R, et al. A three-isocenter jagged-junction IMRT
approach for craniospinal irradiation without beam edge matching for field junctions.
Int J Rad Onc. 2012;84(3):648-654. https://doi.org/10.1016/j.ijrobp.2012.01.010.