1

Destiny Jacobs
Dos 793 Fieldwork III
October 5, 2015
3-D Conformal Craniospinal Irradiation (CSI)
This particular lab took quite a bit of research and information diving on my part due to
the fact that we do not treat craniospinal volumes at my center. As a radiation therapist I have
had experience treating this particular field arrangement on pediatric patients. I really enjoyed
doing different techniques for this project.
Patient setup and Volume
I chose the supine orientation for my patient setup. I chose this orientation because I personally
think that a supine setup is more reliable and reproducible. The data set was contoured with
typical brain and spinal cord volumes (figure1). I went back and contoured the spinal canal so
that I would have a good treatment margin. The spinal canal and the brain were then booleaned
into one structure called the SC_Brain. From the SC_Brain volume I added a 7mm margin and
called it CSI_PTV (figure2, 3, and 4). This was the volume that my blocking was created
around. After I smoothed and verified my treatment volumes and I drew the following OR: liver,
heart, right kidney, left kidney, right eye, right lens, left eye, and left lens. With a prescription
total dose of 3600cGy in 20 fractions, I probably will not have any tolerance dose issues except
for the eyes and/or lens. The kidneys will be slightly in the field, but I will block out most so
only a very small volume will receive any dose.
Planning
As I began the planning process the two main factors at the front of my mind were setup error
and time. I wanted to come up with a plan that not only offered good coverage to the tumor
volume and could also be treated efficiently and correctly. The best way I thought this could be
accomplished was to use half beam blocking.
I set the isocenter of the brain and upper spine field at C3 and extended both field borders to the
maximum 20cm asymmetrically (figure 5). Since this was half beamed there was no need for
table kicks or collimator angles for these beams. The depth of the isocenter was placed just at

the posterior aspect of the spinal cord (figure5). I did this so that the depth would not have to
change for the lower spine field isocenter in order to keep it in the treatment volume. The
arrangement for the lower spine field was found using the field alignment tool in the Eclipse
treatment planning system.1
This tool will match our beams precisely after you put in the direction and rules. The rules
included the matching of the lower spine field superior border, Y2, to the upper spine field
inferior boarder, Y1. I set the tool to automatically adjust the field, keeping the field size and
isocenter for the Upper Spine field intact by making it the master field (figure 6). After the rules
were set in the field alignment tool I was able to adjust my lower spine field y jaw parameters
without having to reset the gantry or collimator angle each time. I set the lower spine field size
length to 30 so that it included through S2 vertebral body (figure 7).
After all the fields were adjusted and correctly placed I planned each one independently. First I
planned the whole brain lateral fields. I used a calculation point place about mid volume
anterior-posterior and superior-inferior (figure8). I used 6x photons. In order to get good
coverage I ended up with a hot spot of 116%. I was able to bring it down to 107% with the use
of a field in field technique. This is where you are able to lightly weight beams that have MLC
leaves covering up hot spots within the treatment field (figure8). This weighting does not
compromise tumor coverage but does a very good job at lowering your overall high dose regions.
It took three field in field beams from each lateral to get the high dose region down to 107% for a
total of 8 merged fields for the lateral whole brain plan.
Next I planned the upper spine field. This was pretty straight forward. For the blocking I added
2cm margin around the already 7mm margin CSI_PTV volume (figure 9).
The isocenter was placed just anterior to the spinal canal, and the calculation algorithm is set to
deliver 100% of the dose to this point. In order to get a uniform dose distribution to the length of
the cord I planned it with 15 MV photons and placed a 20 degree dynamic wedge heal out to
force some of the dose towards the half beam region (figure 10).
For the lower pelvis plan I set my blocking at the same 2cm margin around the CSI_PTV volume
(figure 11). Due to the maximum length allowance of the field, my field edge just did cover the
thecal sac.

I also planned this field with 15 MV photons. This energy was most beneficial in getting the 95
isodose line to the anterior aspect of the spinal canal. It was also necessary for me to use a
wedge for this plan. Due to the significant gantry angle in order to adequately match the upper
spine fields the dose distribution was unevenly weighted to the superior aspect of the field. In
order to get a more even dose distribution a more enface angle would have been beneficial. The
wedge was able to get the IDL more evenly distributed throughout the field, but there was still a
significant high dose region in the inferior portion of the plan. I was able to easily eliminate this
region with the field in field technique (figure 11).
After all plans were done independently, I summed them together to get a better idea of any
overlapping or gapped areas. I was pleasantly surprised to see that the dose distribution was
uniform throughout the craniospinal region. I got good coverage anterior to the spinal canal
(figure 12)
For this planning technique I was able to give 100% of the prescribed dose to 95% of the
Cord_Brain Sum treatment volume (figure 13). All of the OR were kept below tolerance dose,
but this is mainly due in part by the prescribed dose to the plan.
After I completed the planning process I submitted this plan to the physician I work with for
pointers and critiques. He expressed some concern about the tight blocking on the brain ports.
This was corrected. He also mentioned that the lower spine field was not ideal because it would
create an undesirable dose gradient across the field.2 I took these critiques to heart and decided
the only way I could see the plan difference was to actually do a comparison plan.

Figures

Figure 1: Three dimensional body rendering of all organs drawn including the CSI_PTV
volume

Figure 2: This is the sagittal view of the brain contours. It includes the cord, spinal canal and
brain contour, as well as the planning volume.

Figure 3: This is the transverse view of the spine contours. It includes the cord, spinal canal
and brain contour, as well as the planning volume.

Figure 4: This is the transverse view of the sacral contours. This is the area represented by the
treatment volumes including the thecal sac.

Figure 5: The beam arrangement for the craniospinal half beam technique.

Figure 6: Field Alignment tool in the Eclipse treatment planning system allows the computer to
automatically set you field parameters when beam matching.

Figure 7: These are the field parameters.

Figure 8: Lateral whole brain field. The orange MLC leaves represent the field in field
blocking from the other beams.

Figure 9: Upper Spine port with 2cm blocking margin around the CSI_PTV volume.

Figure 10: Upper spine isodose distribution.

Figure 11: Lower Spine field. Includes the majority of the thoracic spine through S2. The
orange lines represent the field in field blocking used to lower the overall high dose region.

10

Figure 12: This figure represents the summed dose distribution from all three craniospinal
plans.

11

Figure 13: The OR for the treatment plan were kept within tolerance doses and the tumor
volume received therapeutic dose with this technique.
CSI_2 Beam Arrangement
The field alignment was as for CSI_2 plan included parallel whole brain ports, a PA upper spine
field and a lower spine field. First, the PA upper spine field was set at the depth of the vertebral
bodies. The collimator length for the PA upper spine field was adjusted to the maximum setting
of 40 cm. The PA field was the master field when using the alignment tool to set the abutting
fields (figure 16). The brain fields were placed and the inferior jaw (Y1) of both brain fields was
set to abut the superior jaw (Y2) of the PA upper spine field. The result was a gantry, collimator
and table rotation (figure 15). Lastly, the alignment tool was used to set the Lower spine field.
The Y2 jaw of the Lower spine field was set to abut the Y1 jaw of the Upper spine field. The
results of this matching included gantry, collimator and couch rotations to the Lower spine field
(figure 15). The calculation point was set for each field at a depth that would allow 95% isodose
coverage to the planning tumor volume (figure 17).
Upon evaluation of this plan I found it to be comparable in coverage to the CSI_1 plan. When
evaluating the DVH, CSI_2 was superior for the kidneys, liver and heart (figure18, 20). This
dose difference is most likely due to the fact that the bulk of those organs lie outside the
collimated fields (figure 19).
Discussion
From a treatment and patient comfort point of view, I prefer the CSI_1 plan based on fewer
isoshifts. For CSI_2 it will be necessary to feather all fields 1cm every 9-10Gy in order to
minimized hot and cold spots in the treatment fields.2 My preferred plan,CSI_1, will also need
feathering, but only in the most inferior field junctions. I would also want to go in and put in a
cheater block over the cord at the superior boarder of the Upper spine field so there will be no
cause for feathering at this junction.
It was quite interesting putting these techniques into place and seeing the results of each.

12

Figures

Figure 14: Beam arrangement for the CSI_ 2 plan.

Figure 15: Field parameters for CSI_2 plan.

Figure 16: Field alignment tool for Eclipse treatment planning system. This represents the rules
used for CSI_2 plan.

13

Figure 17: Dose distribution for CSI_2 plan.

14

Figure 18: Dose Volume Histogram representing the OR for CSI_2 plan.

15

Figure 19: This figure represents the upper spine blocking as well as visualizing the OR.

Organ

Constraint

CSI_1

CSI_2

Right Lens

5Gy

4.3Gy

3.5Gy

Left Lens

5Gy

3.5Gy

4.3Gy

Total lung

V2030%

24%%

3.5%

Spinal Cord

50Gy

39.6Gy

36.9Gy

Heart

Mean 26Gy

20.2Gy

13.1Gy

Liver

Mean32Gy

8.0Gy

3.8Gy

Right Kidney

Mean15

2.6Gy

.9Gy

Left Kidney

Mean15

2.1Gy

.7Gy

Figure 20: Organ at risk dose constraint comparison for CSI_1 plan and CSI_2 plan.

16

References
1. Athiyaman H, MayilvagananA, Singh D. A simple planning technique of craniospinal
irradiation in the eclipse treatment planning system. J Med Phys. 2014; 39(4): 251-258.
http://dx.doi10.4103/0971-6203.144495
2. Discussion with Dr. Mark Ezekiel, Radiation Oncologist at Cancer Care Institute of

Carolina. October 3, 2016.