Amanda Lisher

DOS 531: Clinical Oncology

June 28, 2015
Craniospinal Irradiation
For this assignment, I will be describing the set-up, planning, and delivery of craniospinal
irradiation (CSI) for a 29-year-old male diagnosed with ependymoma. This patient was treated at
our clinic a number of years ago. The prescription was for 36 Gy to be delivered in 20 fractions
(1.8 Gy/day). Treatment fields included right and lateral whole brain, at 100 SAD (92 SSD), PA
upper and PA lower spine, both at 100 SSD (105 SAD). The physician requested junction
changes every 12.6 Gy, or every 7 fractions. The patient was positioned prone, on a CSI board.
His head was in a modified prone headrest, angled slightly to lift the chin away from the chest.
An Aquaplast mask was made for immobilization. His arms were relaxed at his side, and an
angled sponge was placed under his ankles for comfort.
1) For prone CSI treatments, the patient is positioned on a CSI board. This board helps to build
up the lower torso, which reduces lordosis of the lower thoracic spine. This makes for a more
even treatment depth along the length of the spine, and reduces the slope of the skin surface
posteriorly. Reducing the slope helps minimize the difference in SSD along the spine field,
which makes for a more even dose distribution.
2) The isocenter for the brain fields should be placed in the center of the head, in line laterally
with the upper and lower spine isocenter. At its maximum length, the inferior portion of the brain
fields should extend as low as possible in the neck without overlapping the shoulders. In order to
match the inferior field edge of the brain ports to the divergence of the PA upper spine field, it is
necessary to angle the collimator for each of the brain fields. The equation and calculation for
this patient are demonstrated in the diagram below.

Next, in order to match the divergence of the lateral brain ports to the superior border of the
upper spine field, the couch must be rotated towards the gantry. Again, the equation and
calculation for this patient are demonstrated in the diagram below.

3) The lens of the eye has a very low threshold for radiation. A dose of 10 Gy is enough to induce
cataracts. In order to minimize unnecessary dose to the lenses, the beam can be angled to limit
exit dose through the contralateral eye. To remove divergence through the eyes from the lateral
brain fields, the gantry should be angled slightly anterior so that the diverging rays from both
fields meet directly behind the lens of both eyes. The equation and calculation for this patient are
shown below.

The final field parameters are given in the table below:

Field
Rt Lat Brain
Lt Lat Brain
PA Upper
Spine
PA Lower
Spine

Collimator
Field Size
21 x 20cm
21 x 20cm
40 x 7.5cm

Collimator
Angle
11
89
0

Gantry
Angle
87
273
0

Couch
Angle
354
6
0

SSD/SAD

15.5 x 12cm

100/105

92.2/100
92.2/100
100/105

4) At the simulation appointment, the patient should be positioned prone on the table, with the
CSI board under the lower thorax. A prone headrest should be used, tilted slightly to angle the
patients chin away from the chest, but not so much as to create a skin bulge in the posterior
neck. An Aquaplast mask will be made to immobilize the head. To aid in localization during
planning, a BB should be placed on the mask at the level of the left and right outer canthus. The
patients arms should be relaxed by his side. An angled sponge can be placed under his ankles for
comfort.
During treatment planning, the isocenter for the brain should be centered in the field, and in line
laterally with the upper and lower spine isocenters. The brain field will be planned to 100 SAD,
the spine fields will be planned to 100 SSD. Prior to CT-based simulation, the treatment depth
for the spine would be determined from a lateral radiograph. With modern treatment planning,
depth is determined based on the CT data set. The isocenters will remain in the same position
throughout treatment. (In the time before asymmetric jaws, the isocenter might have been moved
superior/inferior to accommodate the field size changes when moving the junction.) The cranial
fields will encompass the entire brain through the upper cervical spine, initially at the level of
C3-C4. There should be approximately 1-1.5 cm of falloff (or flash) superiorly and posteriorly.
Anteriorly, the field should include the orbital roof, cribriform plate, temporal fossa and lateral
canthus. The upper spine field should be set at the maximum available length initially, usually 40
cm. The width of the spine fields should encompass the entire vertebral body plus 1.5-2 cm
margin laterally. The superior border will abut the inferior border of the brain fields at the level
of C3-C4. Ideally, the upper spine field will encompass the lower cervical spine and the entire

thoracic spine. In order to match the spine fields at the treatment depth with no overlap or
resulting hot spot, there will need to be a gap between the upper and lower spine fields on the
skin surface. The equation and calculation for this patient are shown in the figure below.

When setting up the patient for daily treatments, shifts between isocenters will be made based on
the treatment plan. The therapists will ensure there is no overlap of fields by marking the field
edges on the patients skin daily. The inferior border of the brain field can be marked on the
lateral neck. The superior border of the upper spine field should not overlap this line. The
inferior border of the upper spine field should be marked on the patients back. The superior
border of the lower spine field should also be marked on the patients back, and the gap between
the two spine fields should be measured and verified daily. The lower spine field length should
include the entire lumbar spine and sacrum through S2. The width should include the entire
vertebral column and sacrum with 1.5-2 cm margin laterally.
Alternately, if the upper spine field is long enough to include the majority of the spine, and very
little is left over to cover with a lower spine field, the entire spine can be treated with one PA
field at an extended SSD. This would eliminate the need for a gap calculation.
In order to reduce hot and/or cold spots in the areas where the brain meets the upper spine field
and where the upper spine meets the lower spine field, there is a junction change at regular
intervals throughout the treatment. In this case, the junction was changed after every 12.6 Gy, or
every 7th fraction. There are several ways to feather the gaps for CSI. Some centers utilize
planned control points to essentially feather the dose daily. Some move the inferior border of the
brain and upper spine superiorly, and the superior border of the upper and lower spine superiorly.
At our clinic, we start with the maximum field length for the upper spine field. We abut the
inferior border of the brain field with the superior border of the upper spine field at C2-3 initially.
By starting the inferior brain border slightly higher, we ensure that the shoulders are never
included in the lateral brain fields, even after field size changes. For the first junction change, the
inferior brain border is shifted inferior 1 cm; the superior border of the upper spine field is also
shifted inferior 1 cm. At the junction of the two spine fields, the inferior border of the upper
spine field is moved superior 1 cm, and the superior border of the lower spine field is moved
superior 1 cm. The inferior border of the lower spine field does not change. For the second
junction change, the same process is repeated, moving the brain/upper spine junction inferior 1
cm and the upper/lower spine junction superior 1 cm. The isocenters do not move; the junction

change is accomplished with asymmetric jaw adjustments. Also, the skin gap is maintained,
because the field sizes are changing by the same distance each time.

Initial Field Size

Whole brain
(Rt and Lt)

21 x 20 cm

Upper spine

40 x 7.5 cm

Lower spine

15.5 x 12 cm

Junction Change
#1
21 x 21 cm
(inferior border
extended 1 cm)
38 x 7.5 cm
(superior and
inferior border each
shortened by 1 cm)
16.5 x 12 cm
(superior border
extended 1 cm)

Junction Change
#2
21 x 22 cm
(inferior border
extended 1 cm)
36 x 7.5 cm
(superior and
inferior border each
shortened by 1 cm)
17.5 x 12 cm
(superior border
extended 1 cm)