Advances in craniospinal irradiation

William Parker Carolyn

y Freeman
CSF pathways
Conventional technique

a y , 1977
VanDyk, 9 IJROBP
J O
 Conventional technique
From KHAN, 1998
Evolution of CSI technique
Supine position

CT simulation

Simplification of beam geometry

Improvement in volume definition (CT & MR)

Better junction planning

Forward step and shoot IMRT for dose compensation

Use of inverse IMRT for posterior fossa treatment

IMRT/Tomotherapy for CSI

Supine position

Patient comfort
Access to airway
Standard accessories
Reproducible setup
Virtual Simulation and 3D CRT
use “modern” linac features to simplify technique
asymmetric
t i jaws
j ffor junction
j ti ffeathering
th i andd easy h
half
half-
lf-
blocking
isocentric setup to eliminate unnecessary setup
motions
Posterior field & CS junction

INF limit set with

asymmetric jaw up to
11o 20 cm
20 cm
20 cm

“isocentric setup” - couch motions in one direction only

Whole brain field
Insufficient coverage of the whole brain and meninges in the treatment of medulloblastoma
may correlate with increased risk of local failure. IJROBP 37(3) 523-9, 1997

Liu, Carrie, Parker, Freeman, Med Pediatr Oncol 38(1), 2002

 Whole brain field

collimator rotation
11o to match
diverging post
spine
i fifield
ld
20 cm

isocenter

half blocked with

asymmetric jaw
Whole brain field

CTV = brain

PTV = brain+ 3mm

field edges
g are 7mm
from PTV

blocking with MLC

treat the brain forget

the lenses
Posterior spine field
Simplified beam geometry

11o
20 cm 30 cm
Anterior setup for posterior treatment

CS junction
j nction

isocenters

gap
Better junction planning
11o
20 cm 30 cm

20 cm 40 cm 10 + x cm
Better junction planning
11o
20 cm 30 cm

21 cm 38 cm 11 + x cm
Better junction planning
11o
20 cm 30 cm

22 cm 36 cm 12 + x cm
Dose compensation with “IMRT”
No compensation

S&S IMRT
Dose compensation

90% 5% 5%
Posterior field dose compensation
Posterior fossa boost

IJROBP 41(3) 625-629, 1998

MRI CT
Boost target definition
Inverse IMRT for CSI Multiple post fields

Smaller target

S
Spreadd outt low
l d
dose
conform high dose
IMRT for CSI
Junction QA
Summary

supine position is more comfortable, reproducible, and

allows airway access
CT, MR for improved volume definition
virtual simulation with simplified geometry is safer
IMRT for dose compensation
inverse conformal IMRT with tomotherapy is viable and
safe treatment for CSI
References
Parker W Brodeur M, Roberge D, Freeman CR. Treatment of standard and non-standard craniospinal
irradiation with helical tomotherapy Int J Radiat Oncol Biol Phys, in press 2009.

Parker W, Filion E, Roberge D, Freeman CR. Intensity-modulated radiotherapy for craniospinal irradiation:
target volume considerations, dose constraints, and competing risks. Int J Radiat Oncol Biol Phys 2007;69:251-
257

Parker WA
WA, Freeman CR
CR. A simple technique for craniospinal radiotherapy in the supine position.
position Radiother
Oncol 2006;78:217-222.

Liu M, Carrie C, Parker W, Freeman CR. Comparison of manual and computer-generated customized blocks for
whole brain fields used in the treatment of medulloblastoma. Medical and Pediatric Oncology 2002; 38:55-57