1

Stephanie Sanford
Clinical Practicum III
Craniospinal Irradiation Project
October 4, 2017
Craniospinal Irradiation Project
At my current clinical internship site Craniospinal Irradiation (CSI) is performed in a
conventional 3D fashion. Patients are treated in a prone position with their arms at their sides.
The head is immobilized in a mask and the torso and upper legs are immobilized in a large
vaclock device. Lateral fields are utilized to treat the brain and uppermost sections of the spinal
cord and one to two Posterior fields are used to treat the rest of the spinal cord. Collimator
rotation is utilized to match the beam divergence of the upper spine field and couch kicks to
adjust for the cranial field divergence. Feathered junctions are planned at each junction
throughout the course of treatment. When I began my treatment plan for this prone CSI case I
setup my fields as done at our institution. Upon evaluation of the constraints outlined I could see
that I would need to take a different approach to treatment delivery. The esophagus dose was of
particular concern as 100% of the esophagus was receiving at least 1800cGy with this method. I
decided to do some research into Volumetric-Modulated Arc Therapy (VMAT) techniques for
CSI treatments. This approach would not only provide a more homogeneous dose distribution
but also allow a much better sparing of surrounding critical structures. The first article I found in
reference to this query compared three different treatment planning techniques including 3-D,
Intensity Modulated Radiotherapy (IMRT) and VMAT.1 I utilized the beam setup parameters
and planning techniques to guide my methods for this plan.
Craniospinal treatment planning and delivery can be very complex processes and leave
opportunity for errors to occur. This is especially true when staff is less familiar with procedures
due to the limited frequency of these cases in many centers. It is the medical dosimetrists job to
deliver an optimal plan as prescribed by the physician but it is also their responsibility to
consider the treatment delivery and limit the opportunities for errors to occur whenever possible.
Given that very small miscalculations of shifts can cause significant over dose or under dose to
the spinal cord the severity of these errors is amplified. By keeping shifts limited to one
direction the opportunity for errors is decreased.
 2

I setup my first isocenter points by choosing the coordinates of left and right as well as
anterior to posterior that would be best in line with the majority of the spine. I then moved the
point directly superior to be in the plane of the top of the Sella Turcica. This will be the point for
which all points are shifted from. I then created a second and third point that had matching
lateral and anterior/posterior settings but adjusted the superior inferior coordinate to midway
through the upper part of the spinal cord and midway between the lower part of the spinal cord.
The Upper Spine Isocenter was placed directly 26cm inferior to the Brain Isocenter. The Lower
Spine Isocenter was placed directly 52.5cm inferior to the Brain Isocenter. (Figure 2) The field
sizes for each field were adjusted to allow for at least 2 cm of overlap. As will be discussed
further in this paper I failed to utilize locking of the jaws and the optimizer subsequently adjusted
field sizes. The 2cm or more overlap allows the optimizer to create a homogeneous intersection
of the two fields that would have previously been created by feathering the junction points in a
conventional method. For the beam setup of the cranial fields I utilized two 350 arcs with 45
and 315 collimator rotations respectively. One arc traveled in a clockwise direction the other in
a counter-clock wise direction. (Table 1, Figure 1) Because these fields will be treated together
the arcs were flipped in direction to provide a more efficient workflow for the therapists. Cone
beam CT (CBCT) scans are routinely scheduled to arc counter-clockwise at my clinical facility
and therefore the beam delivery was planned to start in a clockwise direction for efficient
workflow as well. I then utilized 200 arcs for each of the spine fields from 260 to 100 and a
5 collimator rotation in either direction to minimize the interleaf leakage. The arc angles were
chosen to minimize the dose to the arms.1 Because each isocenter would likely be imaged with
CBCT prior to treatment I planned arc angles for the spine fields to both rotate in a clockwise
fashion for workflow as described above. Treatment delivery was planned for a Elekta VersaHD
treatment unit with 160 leaf Agility Multileaf Collimators and all fields were planned with 6MV
photon energy.
 3

Table 1. Field Parameters for VMAT CSI treatment plan

Field Label Gantry Gantry Collimator Field Size Source to Surface
Start End Distance
Arc_1 Brain 185 175 45 X1=16.4, X2=5. PA = 89.1
Y1=19, Y2=11.5 RLAT = 90.9
Arc_2 Brain 175 185 315 X1=5, X2=16.5, PA = 89.1
Y1=19, Y2 = 8.5 RLAT = 90.9
Arc_3 Upper 260 100 5 X1=3.2, X2=2, PA = 96
Spine Y1=15, Y2=6.5 RLAT = 84.4
Arc_4 Lower 260 100 355 X1=4.3, X2=2.4, PA = 97.5
Spine Y1=10, Y2=12.3 RLAT = 91.7
*Posterior Anterior Projection (PA), Right Lateral Projection (RLAT)

Figure 1. Fields displayed in Sagittal view, Cranial fields in red and green, Upper Spine field in
Blue and Lower Spine field in Yellow
 4

Figure 2. Isocenter Placement

 5

Because each of the Planning Treatment Volumes (PTVs) were prescribed to the same
dose of 36Gy I created a Total PTV structure by expanding both structures into one new
structure. I then set my prescription to calculate dose to the Mean of the Total PTV structure in
2Gy fractions to a total dose of 36Gy. I started this plan with a normalization of 100% but found
I ultimately needed to normalize down to 96% to get the coverage needed on my target
structures. This will be discussed further later in this paper.
I set my dose grid to cover the entire anatomy as well as the treatment table that was
added to the plan. This structure was added with the density of our treatment table tops.
Because not all CT simulation couch tops are of equal density to the treatment tables structures
are added to accurately compensate for the attenuation of these tables on the treatment machine.
The dose grid was calculated at 3mm by 3mm resolution.
I then created optimization structures for each PTV. These structures included a 1mm
expansion of the PTV structure and excluded any expansion into critical structures such as the
Optic Nerves. (Figure 3) I additionally created a ring structure which was 1cm away from the
Total PTV structure in all directions and expanded by 1 cm in width. I set the following goals in
my optimizer. (Figure 4)

Figure 3. Brain PTV Brown, False Structure PTV Opti Purple, Optic Nerves Orange and
Red, False Structure PTV Ring - Yellow
 6

Figure 4. Optimizer Goals

This first round of optimization I ran 100 iterations and then re-evaluated the plan and
found that I still needed to improve the coverage of the PTVs. I then normalized the plan to 98%
and added in some more goals to the optimizer to push dose out of the critical structures of
concern such as the kidneys, liver, lenses, optic nerves, esophagus, and bowel. Additionally, I
added more weight to the goals of each target structure.
After running another 50 iterations I re-evaluated the plan again. The dose coverage had
improved but was still not covering the entire Total PTV structure. To improve coverage, I
normalized my plan to 96% and I then created a structure out of the 36Gy isodose line. I created
a new planning structure to target the areas missing dose by utilizing the PTV structure and
subtracting out the area covered by the 36Gy isodose line. I added this new structure in the
optimizer with a goal of minimum dose of 36Gy. I cautiously added weight to this goal to
improve coverage for the Total PTV. I also created a structure out of the 39.6Gy isodose line
and utilized this structure in the optimizer with a goal of a maximum dose of 38.5Gy again
adding weight to this structure cautiously. I then ran the optimizer again to improve the plan.
In the end, I met all goals with at least the secondary objective as seen below in the
scorecard generated in Pinnacle. (Figure 5) After completion of this plan I reviewed the case
with our senior medical dosimetrist, Irma Diaz, and medical physicist Tomasz Bista. (October
2017) The following items were identified as opportunities for improvement to the technique
utilized.
 7

1. By utilizing the option for locking the jaw positions I would be better able to control
the length of each field. It was my intention to limit the lower field border of the
cranial fields to just above the shoulders. Because I did not lock the jaw sizes the
optimizer adjusted the field sizes as needed and the cranial arcs ended up going lower
than intended increasing dose to the shoulders. (Figure 1)
2. The scan was only acquired to the very tip of the head. In order to get proper
coverage of the top of the head additional slices should have been added to the
superior aspect of the scan. In the future, an additional 10 slices could be added to
the superior portion of the scan prior to optimization. This would likely also help
with the hot spots that occurred in this area as the optimizer was struggling to get
coverage here. (Figure 11)
3. There is adequate overlap of the cranial fields and the upper spine fields to create a
homogeneous dose distribution however the fields of the upper spine and the lower
spine could have been overlapping further. It was my intention to utilize at least 2 cm
of overlap but in this overlap only 1.3 cm was measured. This could have been
improved by pushing on the hot spot in this area further as well to force the optimizer
to open the fields up as well. This would also likely have helped lower the dose to
the kidneys that were in this region. Again, locking the field sizes may have helped
with this area. (Figure 12)
4. While PTV structures were provided for this patient it was also discussed that if the
patient were of a young age and still growing some physicians may create target
structures that cover the entire spinal body so as to minimize growth abnormalities in
the body of the spine from anterior to posterior.
 8

Figure 5. CSI treatment plan scorecard

Figure 6. ProKnow PlanIQ Scoring Report

 9

Figure 7. Dose Volume Histogram for each target structure as well as the Right and Left Globes,
Right and Left Lens, Heart, and Liver
 10

Figure 8. DVH for other critical structures including Right and Left Kidneys, Right and Left
Lungs, Thyroid, Brainstem, Mandible, Esophagus, Right and Left Optic Nerves, and Bowel
 11

Figure 9. Axial, Coronal and Sagittal Views of the CSI VMAT treatment plan.
 12

Figure 10. All Isodose lines shown on all treatment plan views

Figure 11. Hotspots and lack of coverage of Brain PTV target in cranial fields due to scan
length. Max point dose 44.534Gy seen here in green area.
 13

Figure 12. Limited Overlap between Upper Spine and Lower Spine fields yielded hot spots.
Overlap region measures 1.3 cm in length.

Finally, I discussed Quality Assurance procedures for this large VMAT field with our
medical physicist, Tomasz Bista. (October 2017) Methods of acquiring readings off axis were
discussed as options for focusing on junction areas to better analyze areas of potential hot or cold
spots. As mentioned in the Studenski article the 7mm spacing of the detectors within the
SunNuclear MapCheck QA device does cause concern about the resolution of these critical areas
so the PTW Octavius 1000 SRS detector used for SRS cases could also be considered or even
film dosimetry of these areas. Finally, we discussed the use of DynaLog files as utilized by the
SunNuclear Fraction 0 and Fraction n software to evaluate both the pretreatment treatment
delivery and also the treatment delivery itself. As with all VMAT cases close attention is paid to
accurate delivery of the planned treatment. I will be assisting in the Quality Assurance testing of
this plan in the coming week to better familiarize myself with the methods discussed.
In conclusion, this was a very valuable learning experience for me. I was able to research
a treatment planning technique that was not currently being utilized in our facility to better meet
the objective outlined in the planning directive. In addition, I learned about ways to limit jaw
motion with VMAT cases to direct the system and improve the treatment plan. Finally, I had a
very valuable discussion about quality assurance testing of these types of large fields and critical
 14

junction areas with our medical physicist. I am looking forward to participating in the testing of
these treatment fields in the near future as a learning exercise.
 15

References
1. Studenski MT, Shen X, Yu Y et al. Intensity-modulated radiation therapy and volumetric-
modulated arc therapy for adult Craniospinal irradiation-A comparison with traditional
techniques. Med Dos. 2013;38(1):48-53. http://dx.doi.org/10.1016/j.meddos.2012.05.006.