DOS 773 Clinical Practicum III

Craniospinal Irradiation (CSI) Assignment

Joanne Li
October 3, 2016
Craniospinal Irradiation (CSI) Assignment
Diagnosis: Medulloblastoma
Prescription dose: 36 Gy=1.8 Gy/fraction x 20 fractions
Energy: 6 MV
TPS: Varian EclipsesTM
Target: whole brain to S2 spine.
Setup: SAD technique
Table 1: Organs at risk (OAR) in the treatment area with tolerance dose and achieved objectives
Organs at risk
Dmax (GY)
Achieved
Achieved objectives
objective(s) in plan
in plan after dose
feathering (nonISO shift) (Gy)
<60 Gy
Max 30.6 Gy
39
Brain
Brainstem
54 Gy
Max 38.2 Gy
37
Liver

<30

Max 35Gy

36

Right/left Lung

Mean: 10 Gy

21

Heart

17.5, or Mean 20Gy

Or 20cc20Gy
Max < 40 Gy

Max 31.6Gy

32

Spinal Cord

<45 Gy

Max 43Gy

Max: 38

Lt/Rt Eye

50 Gy

Lens

25 Gy

Mean Rt: 25.3 Gy

Lt: 20.5 Gy
Max: Rt:16 Gy
Lt:21Gy

Rt: 38
Lt: 38
Rt: 28
Lt: 25

Immobilization and CT simulation Patient was immobilized in prone position with

thermoplastic mask and head rest. Thick foam block was used in the abdomen region to

straighten the spine. Three reference CT markers (one sagittal and two laterals) were placed on
thermoplastic cast.
Target volume and organs at risk The CT scan images were imported to Eclipse treatment
planning system (TPS). The OARs including right and left eyes, heart, right and left kidneys,
right and left lens, liver, right and left lungs, spinal cord and bowels were contoured. The clinical
target volume (CTV) was drawn with the combination of brain and spinal canal down to S2. The
planning target volume (PTV) was created by adding 0.5 cm margin from CTV.
Planning The treatment plan was planned with 6 MV photon beam in Eclipse TPS with AAA
13.6 version algorithm for dose calculation. The prescription dose was 36 Gy with 1.8
Gy/fraction in 20 fractions. The planning method was used with half beam technique for bilateral
cranial fields and full beam for spine fields. The plan was created majorly through beams eye
view (BEV) and sagittal and frontal views.
I selected the given CT data with prone position for my project. Prone position is a
typical position for CSI treatment with easy visualization of gap/junction on skin surface.
However, the position may not be practical or comfortable for patients depending on their
conditions. I assumed this patient could tolerate this position. Because the maximum treatment
field size for Linac linear accelerator is 40cmx40cm, the target irrigation from brain to spine
(down to S2) needs to be split to brain and spinal fields. For the adult patient, the spine field is
split to upper and lower spine typically at L2 to L3 which is the end of spinal cord. So my plan
was to create a brain field with blocked right and left lateral half beams, an upper spinal field
posteriorly abutted to brain field and a lower spinal field abutted to the upper field using field
alignment. I noticed the patients cheek was extended which was good to avoid the exit energy at
mouth and the shoulders were also pulled down for easier planning.
I started the cranial field by creating right lateral field with 90 degree gantry angles, and
zero degree of collimator and couch rotations. I turned the PTV structure on and added MLC to
shield the cranial portion of PTV with 1.2 cm margin. I manually adjust the jaws to shape the
field and blocked MLC to protect right lens. I wanted the isocenter at cervical area with Y2 =20
cm and Y1 =0cm. so I moved the jaw to that point. Luckily, the exit of the beam was below the
mouth. Based on this field, I created the left lateral field with 270 degree gantry angles and zero
degree of collimator and couch by adding a new opposite field function. Again, I manually
blocked MLC to spare the lens.

I then added another new symmetric field to upper spine. Without knowing the isocenter
and the field size, I manually adjusted jaw based on spine anatomy to encompass the whole
vertebra including the lateral transverse process and spinous process. The inferior boarder fell at
around L2, and the superior boarder must be well abutted to the inferior border of cranial field.
To do so, I manually moved the spine field to make the superior boarder of the field to abut to
the inferior boarder of the brain field under frontal and sagittal views to make sure all alignment
matched well. The field size was decided at 33.8 cm. I then calculated the brain collimator angles
for right lateral cranial field by using the formulas below: 1
Brain coll angle = arc tan [ length of spine x (1/SAD)]
.

=arc tan

=9.6

Because the brain field was used half beam technique with minimal divergence, the couch was
not necessary to rotate for field matching. The collimator degree for left lateral cranial field was
calculated by 360-9.6=350.4. I wanted the isocenter being the same level of cranial field with the
same X and Y values, but different Z value. This setting aims to make easier setting for therapist
during treatment. After the field was set up, I added MLC and manually cut the MLC along with
the boarder of jaw resulting at a tall rectangle along with spine posteriorly abutted to brain field.
With the similar method, I created the lower spine field mainly based on BEV and
sagittal views. The isocenter of lower spine field was at the same level to the upper spine field.
To be perfectly matching the upper and lower spine field for minimal unnecessary divergence, I
used Field Alignments function in Eclipse TPS. This technique was introduced in a journal by
Athiyama, et al.2 The rule of field alignment is any two plans of the adjacent fields can be
matched in parallel or opposite manner with automatic rotations of the couch, gantry and
collimators of one field to the defined master field. In my plan, the master field was upper spine
field. Following the setting of the alignment rule as shown in figure 1 below, the gantry of lower
spine field was rotated to 15.3 degree, collimator to 90 degree, and couch to 90 degree too.
Therefore, the diverging planes (Y2 and Y1) were perfectly matched and verified in sagittal and
frontal plans and BEV of the fields shown in figure 3 and figure 4.

Figure 1: Field alignment tab in the field setup work space.

Figure 2: The unmatched diverging edges of spine fields.

Figure 3: The matched lower and upper spine fields with field alignment.

Figure 4: Transversal, frontal, and sagittal view of field match and BEW of right lateral half
beam cranial field.
After three fields were set up, I copied and pasted the plan to create new plans with only
each field for dose calculation. For cranial field, I deleted the two spine fields without any
changes to the field setting. I created the primary reference point for brain and a calculation point

at the isocenter of brain for normalization. Dose was prescribed to 100% of isodose line. After
calculation, I moved the calculation point superiorly to cool down the plan with at least 95%
volume covered by 98% prescription dose. To achieve the goal, I used field in field technique for
each field and adjusted the weighting while watching the dose coverage and the maximum dose
level which was 109.4% of prescription dose. To better view the dose distribution and coverage,
I increased the line width of 100% of isodose line (IDL) indicated as yellow color and 95% of
IDL indicated as green color. The field in field cranial field plan with four views was shown in
figure 5 below.

Figure 5: Transversal, frontal, and sagittal view of dose distribution of cranial field at isocenter
level and BEW of right lateral cranial field.
The same method to create upper spine field plan with reference points exclusively for
upper spine field. Again, after calculation, I moved the calculation point to a location with the
best dose distribution and minimal maximum dose. I used one field in field to cool down the hot
spot to 122% of prescription dose. Because of the treatment depth is at 6.1 cm for SAD setup, the
PDD at this depth is probably about 80%. So the resulting dose would be around 120%. The
SAD setup is easy and convenient for planning and treatment, but the calculated dose might be
high because the treatment depth is deep in spine fields. However, it is not worth to use higher
energy better penetration because it would increase the dose to OARs on the opposite site. Below

figure 6 is the transversal, frontal, and sagittal view of dose distribution and BEW of upper spine
field.

Figure 6: Transversal, frontal, and sagittal view of dose distribution of cranial field at isocenter
level and BEW of upper spine field.
With the same method, lower spine field was created with corresponding reference points.
Two field in field were used to decrease the high dose region. Because the isocenter cannot be
blocked by subfield, so I used two subfields to cool down the hot spot to 124% of prescription
dose. Enhanced Dynamic Wedges (EDW) can be used for this field if the concave nature of
sacrum is deep. However, it is not applied to this patient. Figure 7 shows the transversal, frontal,
and sagittal view of dose distribution and BEW of lower spine field.

Figure 7: Transversal, frontal, and sagittal view of dose distribution of cranial field at isocenter
level and BEW of lower spine field.
After calculating all three plans for each field, I inserted a plan sum with right and left
lateral cranial fields, upper spine field and lower spine field. Figure 8 below shows the final dose
distribution on transversal, frontal, and sagittal views at maximum dose point which was
4988cGy (139%) located at posterior spine area as seen in figure 8 and 13. I am satisfied with
this location in PTV and away from OARs. Figure 9 shows the color wash view of the 95% of
prescription dose distribution which showed a good coverage of PTV. The DVH evaluation of
dose distribution to OARs and dose coverage of PTV are shown in figure 10-13. According to
the institutional dose volume histogram limits, the OARs constrain and achieved doses are listed
in table 1 in the beginning of the writing. From the table, I can see most of the dose constrains
were achieved by the liver. As the liver was close to the PTV in the path of the beam and the
treatment depth was deep, so it is hard to reduce the dose to liver. However, the doses to lens
were not ideal and should be spared more.
Even though the good field matching was perfectly set up, there are still hot and cold
spots over the junction areas between fields due to the beam divergence. Therefore, feathering
would be a great way to smooth the cold and hot spots in the junction areas to improve the
conformity of dose distribution in the body. The junction technique is shown in figure 14.

Figure 8: Transversal, frontal, and sagittal view of final dose distribution of craniospinal fields at
maximum dose level.

Figure 9: 95% of prescription dose at color wash view of the dose distribution of craniospinal
irrigation.

Figure 10: DVH with PTV, and all surrounding critical structures.

Figure 11: Selected critical structures and PTV shown on DVH.

Figure 12: The DVH evaluation of target structures and PTV with 1 cm margins from target
structures.

Figure 13: the sagittal view of isodose lines with the maximum dose point at posterior of spine.

Figure 14: Junctions technique for feathering shifts.3

Feathering: I tried two methods for dose feathering: isocenter shifting and non-isocenter
shifting (shifting field boarder Y-jaw without changing isocenter). For 20 fractions, I planned to
shift 1.5 cm for every 10 fractions. So the dose for each shift will be 18 Gy half of the
prescription.
Non-isocenter shifting: I started from the lower spine field by moving up the superior
boarder (Y1+1.5 cm) of lower spine field without changing inferior boarder Y2. MLC were also
opened correspondingly. The subfields with MLC before merging were also adjusted. The plan
was calculated for evaluation. With the same way, the field was shifted up another 1.5 cm
without changing inferior boarder.
The same way was used to shift the upper spine field for twice with 1.5 cm at each.
Because the whole upper spine field was shifted up, the superior boarder of upper field was
finally increased 1.5cm x2=3cm while the inferior boarder was decreased 1.5 cmx2=3 cm.
The brain field shifting was more complicated with adjusting collimator degree. As the superior
boarder of brain field stayed the same while moving the inferior boarder up to 1.5 cm for the first
shift, the field matching between brain field and upper brain field was not perfectly matched
because the upper spine field was not symmetric at all. So the collimator degree for right lateral
field was recalculated regarding to the length of Y2 abutted to brain field based on the formula.
Brain coll angle = arc tan [ length of spine x (1/SAD)]
=arc tan

=8.8

The collimator degree for left lateral field will be calculated as 360-8.8=351.2.

For the second shift, the brain collimator angle for right lateral field was calculated based on the
new length of Y2 in upper spine field as below.1
Brain coll angle = arc tan [ length of spine x (1/SAD)]
=arc tan

=7.9

The collimator degree for left lateral field will be calculated as 360-7.9=352.1.
Therefore, the first feather was completed. I inserted a plan sum with all three new plans to
evaluate the field matching and dose distribution as shown in figure 15 and 16. Dose must be
calculated in each plan before plan sum.

Figure 15: Sagittal view of first feathering with 1.5 cm shift for cranial, upper spine, and lower
spine fields.

Figure 16: Frontal view of first feathering with 1.5 cm shift for cranial, upper spine, and lower
spine fields.
With the same method, a plan with the second feathering with another 1.5 cm shift was
created seen in figure 17 and 18.

Figure 17: Frontal view of second feathering with 1.5 cm shift for cranial, upper spine, and lower
spine fields.

Figure 18: Sagittal view of dose distribution after second feathering with 1.5 cm shift for cranial,
upper spine, and lower spine fields.

Figure 19: Sagittal view of dose distribution on dose color wash at 95% IDL lever after second
feathering with 1.5 cm shift for cranial, upper spine, and lower spine fields.

Figure 20: Sagittal view of dose distribution on dose color wash at 95% IDL lever at maximum
dose point without feathering for cranial, upper spine and lower spine fields.
From the above color wash view and isodose lines distribution, the plan after feathering was
cooler without conformal dose between cranial and spine fields. The hot spot was in lower spine
field existed before field matching to upper spine field. DVH evaluation was shown in figure 23.
The overall dose constrains to OARs and PTV after dose feathering were higher.
The feathering with isocenter shift was to move each isocenter 1 cm x2 superiorly
without changing field sizes and matching. Because the brain field was used half beam with
Y2=20cm. The shift could only be moved superiorly first. The shift of isocenter was achieved by
moving only Z direction while the X and Y plans remained the same. I thought this method
might be easier with better feathering the dose. However, I did not see the significant results as I
had to refine each plan by reshape MLC and subfields which revised the original plan more. The
final featherings after two shifts were shown below in figure 21 and 22. Comparison of DVH for
both techniques was shown in figure 23.

Figure 21: Sagittal view of dose distribution at global maximum dose after second feathering
with 1.0 cm shift for cranial, upper spine, and lower spine fields.

Figure 22: Frontal view of dose distribution at isocenter after second feathering with 1.0 cm shift
for cranial, upper spine, and lower spine fields.

Figure 23: Comparison of DVH for feathering with and without isocenter shifts.

Final plan after twice feathering

Figure24: Comparison of DVH for final plan with and without feathering.
References:
1. South M. Using composite planning and delivery with feathered junctions in craniospinal,
Brain-Spine and spine-spine abutted fields. [PowerPoint]. La Crosse, WI: UW-L Medical
Dosimetry Program; 2016.

2. Athiyama H. Mayilvaganan A. Singh D. A simple planning technique of craniospinal

irradiation in the eclipse treatment planning system. J. Med Phys.
http://dx.doi.org/10.4103/0971-6203.144495
3. Donatello R. Gap calculations & Divergence corrections. [PowerPoint]. Rochester, NY:
Strong Memorial Hospital Resident Radiation Oncology Department Education Program.
2016.