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Ontida Apinorasethkul
DOS 793 Fieldwork III
November 22, 2015
Proton Craniospinal Irradiation (CSI)
Patient Information
This patient is a 12-year old young man diagnosed with medulloblastoma, no staging in
the report. The patient was receiving concurrent chemotherapy while getting radiation for his
CSI treatment. Given he was a pediatric patient, proton treatment was recommended to avoid
radiation to normal tissue anteriorly to the spine. The proton CSI treatment was planned to 2340
cGy in 13 fractions.
Patient set up
Patient could not lie on the A head cup due to his incision at the back of his head.
Custom cushion with B head cup (figure 1) was used since it was more flat and the head was not
as hyperextended. It was more tolerable for the patient to be on it throughout the treatment time.
Patients head was immobilized with a head and neck mask with custom mold similar to photon
treatment set up. Both arms were rested on a yellow-wedged cushion to have the arms out of the
lateral set up field (figure 2). This enabled the radiation therapists to use orthogonal fields with
clearer lateral set up view without arms overlapping vertebral bodies on the kV image.

Figure 1. Patient was immobilized using a custom mold with head and neck mask.

Figure 2. Both arms were rested on the wedged cushion to lift the arms out of the lateral set up
field.
Target delineation
Clinical target volume (CTV) included brain, thecal sac with nerve roots (figures 3-5),
area behind the orbits (figure 6), cribriform and inferior border of the sacrum. The CTV was
reviewed and approved by the physician. Planning target volume (PTV) was created with a 3
mm expansion from CTV for set up uncertainty (figure 7). Organs at risk (ORs) close by the
treatment volume were drawn for all CSI cases, which included brain, brainstem, cauda,
cochleas, cribriform, eyes, kidneys, lens, lungs, optic nerves, temporal lobes, thecal sac, vertebral
bodies, and spinal cord.

Figure 3. Thecal sac with nerve roots in C spine (CTV light green contour). Pink contour
represented PTV.

Figure 4. Thecal sac with nerve roots in L spine (CTV light green contour). Pink contour
represented PTV.

Figure 5. Thecal sac with nerve roots in sacrum (CTV light green contour). Pink contour
represented PTV.

Figure 6. Area behind the orbits was to be included in the CTV (light green contour). Pink
contour represented PTV.

Figure 7. Entire CTV in light green contour with its PTV expansion (pink).
Treatment planning
Three sets of optimizing PTV structures were created to generate 3 gradient matching
Pencil Beam Scanning (PBS) plans; brain, upper spine, and lower spine plans. Each set of the

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optimizing structures included the gradient slices of 80%, 60%, 40% and 20% dose (figures 810). Brain plan utilized 2 lateral beams gradient matched with one posterior field upper spine
plan. The upper spine plan was gradient-matched with the brain plan and a posterior field lower
spine plan. The PBS plan had a maximum y field setting at 34 cm. In the event that 34 cm can
fit the whole spine, only one spine plan is needed instead of upper and lower spine plans. All
fields were planned with SAD treatment, no collimator rotation, and no couch rotation to
simplify the treatment set up. The isocenter and triangulation points were set up in the middle of
brain field. There were only inferior shifts for each of the spine plans. There are a total of 3
isocenters for this combined CSI plan.
Each of the 3 plans was optimized separately with the goal to have 95% of the PTV
volume covered by 100% of prescription dose. There was no blocking since the plan optimized
on treatment volumes similar to Intensity Modulated Radiation Therapy (IMRT) plans in photon.

60
%
20
%

80
%
40
%

Figure 8. Optimization contours in the brain plan with the gradient structures.

20
%
60
%

40
%
80
%

60
%
20
%

80
%
40
%

Figure 9. Optimization contours in the upper spine plan with the gradient structures.

40
%
80
%

20
%
60
%

Figure 10. Optimization contours in the lower spine plan with the gradient structures.

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Results/Discussion
Treatment volume met the constraint of 95% of volume to receive 100% of dose (figure
11). Figures 12-17 show dose distribution for each of the treatment fields and the dose
summation in figure 17. Because proton cannot spare dose proximally, left and right lateral
fields of the brain plan were optimized in separate plans in order to spare the cochlea from each
plan using the distal edge of proton beam. Left lateral field enabled the right cochlea to be
spared, while the right lateral field enabled the left cochlea to be spared. Each of the upper and
lower spine plans used one posterior beam with no exit dose to the anterior normal tissue. All
ORs met the constraints as shown in Table 1 since the patient was given a low total dose, except
right lens. The plan had a dose max of 112.5% in the cervical vertebral body region between the
match of brain and upper spine plans. The location of dose max was ideal to not be within the
spinal cord. The gradient match plan in CSI is much preferred in our institution since there is no
direct match of either no dose or double the dose in the event of set up certainty. There is no
junction shift needed since the dose gradient smears out during the course of treatment.

Figure 11. Dose volume histogram of CTV (light green) and PTV (pink). Both met constraints.

Figure 12. Dose distribution of 95% dose color wash from left lateral field.

Figure 13. Dose distribution of 95% dose color wash from right lateral field.

Figure 14. Dose distribution from one of the lateral brain fields.

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Figure 15. Dose distribution from upper spine plan with no exit dose.

Figure 16. Dose distribution of lower spine plan with no exit dose.

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Figure 17. Dose summation of all the fields.

Table 1. OR constraints in the sum plan.

OR's
Brainstem
Cochlea_L
Cochlea_R
Eye_L
Eye_R
Kidney_L
Kidney_R
Lens_L
Lens_R
Optic chiasm
Optic nerve_L
Optic nerve_R
Spinal cord

Dose
max
mean
mean
max
max

max
max
max
max
max
max

Tolerance
Objectives
(cGy)
5400
3000
3000
4500
4500
V18=50%
V18=50%
700
700
5400
5400
5400
4500

Tolerance
Achieved (cGy)

Met/Not Met

2547
2140
2211
2449
2526
V18 < 1%
V18 < 1%
695
907
2528
2542
2459
2579

Met
Met
Met
Met
Met
Met
Met
Met
Not Met
Met
Met
Met
Met

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Temporal lobe_L
Temporal lobe_R
Vertebral bodies

mean
mean
min

2500
2500
2000

2478
2476
2013

Met
Met
Met