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Alecia Eliason
September 23, 2017
DOS 773 Craniospinal Project
Craniospinal Irradiation
The planning and delivery of craniospinal irradiation (CSI) techniques are complex for all
individuals involved in the process. This regimen is prescribed when the entire craniospinal axis
requires radiation, including treatments for medulloblastomas, primitive neuroectodermal
tumors, high-grade ependymomas, disseminated central nervous system lymphomas, some germ
cell tumors, pineoblastomas, and leptomeningeal carcinomatosis or gliomatosis.1 Often these
cases involve pediatric patients, adding an additional layer of complexity to the treatment
process. Historically, patients requiring CSI were simulated and treated in the prone position2;
however, patient discomfort and subsequent inability to remain in this position for the required
length of time sometimes became a hindrance. As a result, supine CSI treatments were developed
with the chin and neck hyper-extended in order to avoid exit dose through the oral cavity.1
Radiation oncologists at Froedtert Hospital in Milwaukee, WI prefer to use a supine CSI
treatment method, so this is the technique I chose to focus on for this project.
Most patients who are to receive CSI at Froedtert Hospital are simulated in the supine
position on top of a 5 cm styrofoam board with chin and neck extension (Figure 1). The board is
under only the patients body, not the head, and its purpose is twofold: it brings the thoracic and
lumbar spine closer to the same plane as the cervical spine for ease of treatment planning, and it
provides an extra few centimeters of space between the patient and table top, allowing for longer
spinal treatment fields due to the added distance and subsequent beam divergence. An aquaplast
mask is made to hold the patients head as still as possible in an extended position. The patients
arms lie next to the body, and a strap is fastened around each wrist, looping under the patients
feet. This strap not only serves as immobilization, but also gently tugs the shoulders inferiorly to
prevent entrance of cranial field beams through the shoulders. Markings are placed on the mask,
as well as on the patients chest/abdominal area, for leveling, straightening, and reference. A CT
simulation is performed, with slice thickness of 2.5 mm for the cranial portion of the scan (C2
and superior) and 5 mm slices for the spinal portion of the scan. The differences in slice
thickness account for smaller volume structures of interest in the brain (i.e. lenses, optic
nerves/chiasm, etc.).
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Figure 1. Typical supine craniospinal positioning with immobilization devices for patients
treated at Froedtert Hospital in Milwaukee, WI.

For this project, I began with the 3-dimensional (3D) technique Froedtert
physicians/medical dosimetrists routinely employ. This method is a revised version of
commonly-used 3D CSI techniques. Conventional methods include feathering between cranial
and spinal fields to reduce hot or cold spots, and utilizing collimator and couch angles for the
cranial fields to avoid beam overlap.1 Additionally, if more than one spinal field is required due
to the length of the spine, the upper (superior) spinal field length is typically as large as possible.
All isocenters remain fixed throughout the entire course of treatment as well, with only the field
lengths changing. At Froedtert, the feathering technique is used with a junction change every 5
fractions, but couch angles are not utilized for cranial fields. Another difference between
conventional methods and those employed at Froedtert is that if the spine is too long for a single
field, the upper spine field is always 20 cm in length, so this fields isocenter moves with every
junction change, while the cranial and lower spine isocenters remain fixed with field lengths
changing with each junction. With a prescription of 36 Gy at 1.8 Gy per fraction for a total of 20
fractions, Froedtert customarily utilizes 4 junction changes (A-D) throughout the course of
treatment.
My first step during the planning process for a Froedtert-version CSI was to choose my
isocenters (Figure 2). I chose all 3 isocenters to be at the same depth for radiation therapists ease
of setup. The cranial isocenter was placed mid-brain. Before placing the additional isocenters, I
had to figure out (roughly) what the most inferior border (junction D) of my cranial fields would
be. I used the sagittal view to determine the most superior place where my upper spine beams
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could exit without exiting through the oral cavity; since field sizes typically change by 1 cm with
each junction change, and this plan requires 4 junction changes, 3 cm inferior from this point was
therefore where the border of my most inferior cranial field would lie. With the upper spine field
being a constant length of 20 cm, I placed this isocenter (for junction D) 10 cm inferior to the
inferior border of the cranial field for junction D. The isocenter for the lower spine was then
placed mid-field, again at the same depth as the other isocenters.

Figure 2. Sagittal view of 3D plan isocenter placement and treatment fields for brain, upper
spine, and lower spine.

The opposed lateral cranial fields were typical of a whole-brain plan, with the exception
of the inferior border being more inferior. Additionally, a collimator angle of 6 degrees for the
right lateral and 354 degrees for the left lateral was placed on the cranial fields in order to avoid
as much overlap as possible with the upper spine fields. Single fields entering posteriorly, the
spinal fields were simple rectangles, with a 2 cm margin around the vertebral bodies laterally. At
this point, I created the fields for the remaining junctions, copying each field and changing either
the abutting border by 1 cm (cranial, lower spine) or moving the isocenter by 1 cm (upper spine)
as shown in Figure 2.
After creating a primitive supine CSI plan using Froedterts technique, I knew
immediately that I would not be able to meet almost any of the constraints and/or target coverage
objectives for this project. I had numerous cold spots, so my target coverage was exceptionally
poor. Additionally, my global hot spot was 120% of the prescription dose. Almost none of the
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constraints for the organs at risk (OAR) detailed for this project were met, with little to no hope
of meeting these with Froedterts method. Therefore, I decided to abandon a 3D technique of any
kind and try my hand at a helical intensity modulated radiation therapy (IMRT) plan to be
delivered on an Accuray Radixact (formerly Tomotherapy) treatment machine.
Upon reviewing literature on CSI comparing 3D and helical radiation therapy, many
benefits of utilizing a helical technique were identified. Firstly, employing a 3D technique will
always call for one or more gaps between fields, necessitating junction changes throughout the
course of treatment.3 This not only leads to dosimetric hot and cold spots within these areas, but
the complexity of treatment delivery is increased, offering more chances for setup errors. A
helical radiation therapy plan for CSI, conversely, allows the entire neuroaxis to be treated in a
single field. Additionally, the target volume(s) has much better conformity of dose when treating
helically. Conformality of high dose regions around target volume(s) subsequently leads to lower
doses to surrounding organs at risk, thus having a greater tissue sparing effect than with a 3D
technique. Although beneficial for all patients, this specific benefit of helical CSI is especially
significant for pediatric patients, whose maturing normal structures should receive as little dose
as possible and who have an increased risk for secondary malignancies.
Of course, no treatment technique is without drawbacks, helical CSI included. Possibly
the most significant of these is the increased volume of normal tissue receiving low doses of
radiation as compared to 3D treatments. Sharma et al4 has reported a greater risk of secondary
malignancies occurring as a result of these low doses to large volumes. Again, this is noteworthy
for pediatric patients in particular. Reduced serum blood elements, such as neutrophils and
platelets, were reported by Kanos et al,5 also due to low doses to large volumes during helical
CSI. An interesting radiobiological concept must also be considered when opting for helical CSI:
craniospinal fluid is constantly in motion, therefore potentially moving malignant cells into and
out of the treatment field during helical CSI treatments, altering dose deposition.6 Another
potential disadvantage of helical CSI is the increased treatment time. Schiopu et al3 reported an
average of 12 minutes for helical CSI, but on the high end as long as 30 minutes, offering more
opportunities for patient discomfort and subsequent movement or inability to finish treatment.
Equipped with this knowledge, I set out to create a helical IMRT plan utilizing an
Accuray Precision treatment planning system (TPS), with the treatment to be delivered on an
Accuray Radixact treatment machine. I started with identifying the target structures and inputting
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the prescription of 36 Gy to 95% of these volumes. I like to put no constraints on any organs at
risk when I run my first plan, really to see which structures (if any) need to pushed harder than
others while successfully delivering the prescription dose to the target volumes. Other areas
requiring input in the treatment planning system include the field width, pitch, and modulation
factor. In the beginning, I chose factors which would produce a plan with the shortest treatment
time: a large field width (5 cm) and a low modulation factor (2). The pitch doesnt seem to make
much difference in treatment time, so I typically leave that as the default. Only one option for
dose calculation is available at my clinical site, and this algorithm for Precision is convolution-
superposition. Dynamic jaws were chosen, a Radixact-specific feature (as compared to
Accurays Tomotherapy machines) allowing the jaws to move during treatment rather than
remain fixed, so more flexibility within the TPS of dose delivery options exist.
Analysis of my first plan pointed to many areas of necessary improvement. Both target
structures, Brain PTV and Spine PTV, were receiving greater than 95% coverage of the
prescription dose, but most OAR constraints were not being met. Many of the critical structures
near the Brain PTV, such as the lenses, optic nerves, and salivary glands, were receiving far too
high of doses. The kidneys, with a goal of a mean dose less than 2 Gy each, also needed
attention. Other structures with dose constraint requirements for this assignment demanded only
slight adjustments within the TPS, including the liver, lungs, esophagus, and thyroid.
It was at this point in the treatment planning process that I decided to create a planning
structure used to limit the dose to the optic nerves. Since parts of the nerves were within the
Brain PTV target to receive 36 Gy, I knew I would struggle to achieve a maximum dose of 34
Gy to the optic nerves. Therefore, I created a Brain PTV structure with a 0.5 cm margin around
the optic nerves, rather than having the optic nerves within the target volume, and set this as a
critical structure for planning (Figure 3). I hoped this would spare the optic nerves while still
allowing the system to deliver the prescription dose to the Brain PTV. The maximum dose point
was falling near the optic nerves, so I also used this structure to bring that high dose away from
the optic nerves.
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Figure 3. Brain PTV planning structure (Brain PTV with 0.5 cm margin around optic nerves).

The constraints I then added for organs at risk correlated with their goal numbers. If an
OAR had a maximum dose limit per the planning objectives, I set the maximum dose limit in the
TPS as the goal dose. For example, the maximum dose limit per the planning objectives for each
lens was listed as 7 Gy (ideal dose), so I input 7 Gy as the maximum dose limit for each lens
within the TPS. Similarly, if an OAR had a mean dose limit per the planning objectives, I set
50% of the OAR to receive the mean goal dose. The heart is an OAR with which I used this
planning technique; the ideal mean dose in the planning objectives was listed as 26 Gy, so I set
50% of this OAR to receive 26 Gy. This, of course, was just a starting point for this plan, but it
would again allow me to see which OARs needed more attention than others.
Throughout the treatment planning process, my largest struggles were keeping the hot
spot less than 110% of the prescription dose when achieving 95% target coverage and sparing
the optic nerves. I was able to meet the ideal values for the remainder of the OARs with a few
adjustments of constraints; my final plan OAR constraints can be viewed in Figure 4 and final
plan OAR doses in Figure 5. Also, Radixact has a feature allowing the planner to choose whether
an OAR can receive entrance and exit dose, exit dose only, or neither entrance nor exit dose.
When reviewing the planning objectives and after my first few attempts at this plan, I determined
that it would be best to disallow the TPS to create a plan with entrance and exit dose to both
lenses and kidneys. These structures had such low objective mean doses, so completely blocking
them permitted dose accumulation from internal scatter only.
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Figure 4. Organs at risk constraints chosen during treatment planning.

Figure 5. Final plan OAR doses.

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In the end, I was able to meet all ideal goals from the treatment planning objectives
except for the maximum dose to the optic nerves. After battling with the optic nerves over a
period of a few days, I realized that with my current planning abilities, I would not be able to
achieve 95% coverage of the target volumes while keeping the optic nerve doses below 34 Gy. I
sought the advice of both dosimetrists and physicians regarding this issue, and all stated that if
this were a real patient, they would rather see better target coverage than lower the dose to the
optic nerves. After all, QUANTEC7 reported no radiation-induced optic neuropathy at doses less
than 55 Gy (for standard fractionations), so I was comfortable letting up on the optic nerve
constraints in order to achieve 95% target volume coverage. Screenshots of my final plan,
including the dose volume histogram (DVH) and scores from the ProKnow submission, can be
viewed in Figures 6-10. It should be noted that the maximum doses to the lenses as was recorded
in ProKnow are incorrect; the maximum dose to the right lens was actually 5.62 Gy and the
maximum dose to the left lens was 4.85 Gy, as is shown in Figure 5.

Figure 6. Axial screenshots of the final plan with 36 Gy prescription line noted in red.
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Figure 7. Axial screenshots of the final plan with 36 Gy prescription line noted in red.

Figure 8. Axial, sagittal, and coronal screenshots of the final plan with 36 Gy prescription line
noted in red.
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Figure 9. Final plan DVH, with volume (%) of OAR on the vertical axis and dose (Gy) on the
horizontal axis.

Figure 10. Final plan metrics as scored by ProKnow.

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Besides not meeting the optic nerve maximum dose goal, the only portion of my final
plan that I was unsatisfied with was the treatment delivery time. To reach 95% coverage of the
prescribed dose to the target volumes, I increased the input plan dose from 36 Gy to 37 Gy.
Normalizing my plan volumetrically to the 95% isodose line, 95% of the Brain PTV was then
covered by 36.19 Gy, and 95% of the Spine PTV was covered by 36.95 Gy. Consequently, the
final plans hot spot was 39.75 Gy, just barely higher than the wished for goal of 39.6 Gy, and
was located just outside of the Brain PTV in the superior portion of the skull (Figure 11). I would
have preferred this hot spot to be within the Brain PTV, but as it lies in the skull and not near an
OAR, Im relatively comfortable with its location. In order bring the hot spot dose down, I
changed the field width from 5 cm to 2.5 cm. This change allowed for finer articulation, bringing
my hot spot down from 41.5 Gy to 39.75 Gy, but in doing so the treatment time doubled. The
final plans treatment time is almost 40 minutes. Although this is certainly on the high side, its
not unheard of to have such a long treatment time for such a complex type of treatment. If this
was a child, however, especially if anesthesia was needed, I would reassess and seek more
assistance from the treatment planning team so to decrease the treatment time.

Figure 11. Axial and sagittal views of final plan hot spot location.

Very minimal cool spots were evident in my final plan, and only in 2 locations. The
optimization of the plan using the created Brain PTV structure with a 0.5 cm margin around the
optic nerves opened up very small areas in and around the optic nerves that were within the
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Brain PTV (Figure 6), so that area did not receive the prescription dose of 36 Gy. Additionally,
since the beams werent allowed to enter or exit through the kidneys, there was again a very
small area of the target volume (Spine PTV) receiving less than 36 Gy, as can be visualized in
Figure 7. Although these cool spots didnt receive 36 Gy, they were encompassed within the
95% isodose line of 34.2 Gy, so significant dose was still delivered to these areas.
This assignment benefited my dosimetric learning in so many ways. First, I was forced to
think outside the box in order to achieve the treatment planning objectives, utilizing different
types of technology and treatment planning systems to achieve an acceptable plan. When
creating the 3D plan, I realized how tricky it can be to minimize hot and cold spots, along with
gaining appreciation for the complexity of treatments involving gaps and junctions.
Understanding when and why to let up on a treatment planning objective for an OAR was
another significant learning experience for me. I relied upon the experience and knowledge of
my clinical preceptors, dosimetrists, physicists, and physicians when I was unsure during the
planning process. This interdependence within the radiation oncology planning team has been
vital for my learning and growth, but more importantly is something I witness on a daily basis.
Ive come to realize that even though one dosimetrist is assigned to a plan, the team often is
consulted and pools their experience and knowledge to come up with the best plan possible, and
this observation of camaraderie for the good of patients I hope to experience myself in the near
future as a medical dosimetrist.
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References

1. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2012:639.
2. Tai P, Koul R, Vu K, et al. A simplified supine technique expedites the delivery of effective
craniospinal radiation to medulloblastoma Comparison with other techniques in the
literature. Cureus. 2015;7(12):e404. dx.doi.org/10.7759/cureus.404
3. Schiopu SRI, Habl G, Haffner M, et al. Craniospinal irradiation using helical tomotherapy
for central nervous system tumors. J Radiat Res. 2017;58(2):238-246. dx.doi.org/
0.1093/jrr/rrw095
4. Sharma D-S, Gupta T, Jalali R, et al. High-precision radiotherapy for craniospinal irradiation:
Evaluation of three-dimensional conformal radiotherapy, intensity-modulated radiation
therapy and helical TomoTherapy. Br J Radiol. 2009;82(984):10001009. dx.doi.org/
10.1259/bjr/13776022
5. Kunos CA, Dobbins DC, Kulasekere R, Latimer B, Kinsella TJ. Comparison of helical
tomotherapy versus conventional radiation to deliver craniospinal radiation. Technol Cancer
Res Treatment. 2008;7(3):227-233. dx.doi.org/10.1177/153303460800700308
6. Bauman, G., Yartsev, S., Coad, T., et al. Helical tomotherapy for craniospinal radiation. Br J
Radiol. 2005;87(930):548-552. dx.doi.org/ 10.1259/bjr/53491625
7. Mayo C, Martel MK, Marks LB, Flickinger J, Nam J, Kirkpatrick J. Radiation Dose-Volume
Effects of Optic Nerves and Chiasm. Int J Rad Onc Biol Phys. 2010;76(3):S28-S35.
dx.doi.org/10.1016/j.ijrobp.2009.07.1753