Brittany Bird

CSI Project
October 4, 2017
Craniospinal Irradiation Treatment
Medulloblastoma is the most common malignancy seen in pediatrics and constitutes
approximately 25% of all childhood malignancies.1 The tumor arises in the cerebellum and has a
high probability to disseminate throughout the cerebrospinal fluid (CSF). Surgery alone is not
curative and must be used in adjuvant with radiation therapy. Craniospinal irradiation (CSI) is
used to treat medulloblastoma and other brain tumors. Treatment methods often include three-
dimensional conformal radiotherapy (3DCRT), intensity-modulated radiation therapy (IMRT),
volumetric-modulated radiation therapy (VMAT), and helical tomotherapy. Typically, opposed
lateral brain fields with one to two posterior spinal fields are used to treat a patient with CSI.
The popularity of VMAT has grown immensely, because it allows for increased precision,
conformity, and achieves a steep dose gradient to spare nearby critical structures. CSI is a highly
complex treatment and planning process due to trying to irradiate a large target volume and keep
the dose uniform. Several organs at risk (OR) are also in the treatment fields and must be taken
into consideration to stay within the acceptable constraints.
The CT dataset was provided by ProKnow and included a patient who was diagnosed
with medulloblastoma and simulated in the head first prone position. ProKnow is one of the first
analytic companies to develop a software program for measuring contouring accuracy and
radiation dose delivery. Along with the dataset, a structure set was provided. The following
were some of the OR that were contoured and of primary focus: the esophagus, heart, kidneys,
lens, liver, lungs, optic nerves, and thyroid. A treatment plan was generated using an Eclipse
treatment planning system (TPS) and a TrueBeam linear accelerator was selected as the beam
delivery device. The prescription dose was set to 180 cGy per fraction for 20 fractions for a
cumulative dose of 3600 cGy.
The treatment field and borders were determined by using the arc geometry tool within
external beam planning. All three adjacent fields were intentionally overlapped. Over-dosing
and under-dosing at the junctions is irrelevant, because the inverse planning incorporates the
junctions into the optimization. A planning target volume (PTV) structure was created to
combine the brain and spinal volumes together (Figure 1). This PTV structure was chosen as the
target volume and the setup encompassed three isocenters: the PTV brain, upper portion of the
PTV spine, and lower portion of the PTV spine. This technique avoids daily feathering or gap
junctions and allows for the radiation therapists to shift in the longitudinal direction only. This
can also be said for using a source-to-axis (SAD) technique, where the dose is normalized to the
isocenter. This is very advantageous in reducing the possibility of treatment errors or near
misses and greatly reduces the time that the patient is on the table. Blocking of OR is
accomplished through the multi-leaf collimation and adjusted according to the objectives used in
the optimizer. The MLCs shape the beam and therefore minimize dose to the surrounding
structures. The lens of the eye, optic nerves, and kidneys were blocked heavily in this treatment
plan.

Figure 1. The PTV brain and PTV spinal fields combined to set as optimization target.

In a study by Li et al2, VMAT was utilized to compare the dose distribution to other
treatment techniques. I followed similar guidelines to get started on the treatment planning
process. A total of six half-arcs, 6 MV, VMAT beams were chosen for this treatment plan given
the depth of the target volume. Half-arcs were used to avoid treating through the patients
shoulders and treatment table. Displayed in Figure 2 are the field energy, gantry rotation,
collimator rotation, couch rotation, and field size.
Figure 2. Treatment parameters for CSI plan using a VMAT technique.

Once the fields were delineated and the gantry geometry was determined, the
optimization process began. Figure 3 shows the priorities and objectives of OR and target
volumes that were applied. The optic nerves and the lens of the eye were difficult to achieve the
desired goal provided by ProKnow. I placed both a mean objective and high priority on these
critical structures in order to meet constraints. This decreased the PTV brain coverage
drastically. A PTV opt structure was created by making a 100% isodose line structure and
subtracting it from the PTV brain. In optimization, this new structure was given the same upper
and lower objectives, but with a slightly higher lower objective priority.
Figure 3. Optimization objectives and priorities used for the CSI treatment plan.

The plan was normalized so that 95% of the PTV was receiving 100% of the prescription
dose. The plan was not normalized to a calculation point, however, this point was inserted at the
end to track dose. The plan was also calculated using the Acuros algorithm as it takes into
account various heterogeneities. The isodose distribution can be viewed in Figure 4. The one
disadvantage of using VMAT is the low dose radiation to the body that can be seen as the green
20% isodose line. The cyan 50% isodose line remains fairly conformal, and avoids several of the
critical structures. Figure 5 demonstrates another view of the dose color wash distribution in the
coronal plane.
Figure 4. A coronal view of the isodose distribution to the PTV. The red isodose line is the
100% line and the yellow isodose line is the 95% line.

Figure 5. Dose color wash distribution in the coronal plane.

The hot spot was located in the skull region at 117.4% or 4226.4 (Figure 6). This is a
greater percentage compared to the ideal 110%, however, the Acuros algorithm was utilized and
the OR in that area were the hardest to meet constraints. I would expect the hot spot to be in the
skull rather than the brain, due to the varying heterogeneities. This is acceptable, however, I
would try reducing my coverage to 95% of the PTV receiving 99% of the prescription dose since
the PTV coverage surpassed the minimum requirements. The cold spot in Figure 7 is located
where the PTV brain is receiving the minimum dose, due to trying to avoid the lens and optic
nerves.

Figure 6. The hot spot located in the skull at 117.4%.

Figure 7. The cold spot in the coronal view.

Overall, I am satisfied with utilizing this specific treatment technique and found it to
meet the majority of the dose constraints. Using the score sheet provided by ProKnow, I
compared the DVH (Figure 8 and 9) to see if it met or exceeded each structure criteria.
Figure 8. Dose-volume histogram (DVH) of the significant structures in the plan.

Figure 9. DVH of the clinical target volume (CTV) and PTV target structures.
ProKnow Score Sheet
ProKnow partnered with the University of Wisconsin La Crosse medical dosimetry
program and created a CSI plan study. A total of 17 metrics were provided and the finalized
treatment plan was scored against the minimum requirements as seen in Figure 10. Each OR had
a different metric and was weighted accordingly. The PTV coverage of the spine and brain was
scored the highest with 22 points and the remaining OR were 3 points each. Both the lens of the
eye and the optic nerves were difficult to meet the required objectives, because part of the PTV
brain touches or is in close proximity to these structures. If either the lens or optic nerves were
given tighter constraints, the PTV coverage of the brain decreased. The metric for the kidneys
was not able to be fully achieved due to the low dose radiation. The final CSI treatment plan
score achieved was a 122.13 out of 127.00.

Figure 10. ProKnow plan study results for a CSI treatment plan.

Self-Reflection
This clinical planning assignment was essential for me to perform, given the fact that my
clinical facility rarely treats CSI cases. I was able to have a first-hand experience of how to
correctly set fields, assign objectives, and evaluate the final outcome. The popularity of the
VMAT technique has gained popularity, however, not all institutions agree with this treatment
method. I would like to experiment with other methods of treatment delivery in order to produce
a deliverable plan.
 References
1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St.
Louis, MO: Mosby Elsevier; 2010.
2. Li Q, Gu W, Mu J, et al. Collimator rotation in volumetric modulated arc therapy for
craniospinal irradiation and the dose distribution in the beam junction region. Rad Onc
(London, England). 2015;10:235. http://dx.doi.org/10.1186/s13014-015-0544-z