Aubrie Rice

Clinical Practicum III

October 4, 2017
Craniospinal Irradiation Project

Historically, craniospinal irradiation (CSI) for medulloblastoma patients has been treated
using conformal planning techniques by combining traditional lateral whole brain fields with
posterior spine fields. The posterior spine fields included gaps on the skin surface and a junction
shift every 900 cGy in order to maintain the most minimal dose variation possible.1 In more
recent years than the study by Van Dyk et al1 (1977), other modalities have been examined for
the possibility of treating CSI patients.2 These studies have shown both IMRT and VMAT offer
better conformity and a more homogeneous dose coverage of the target. These techniques can
also offer better sparing of normal structures compared to the traditional CSI approach, but raise
concerns about the increased dose to structures such as the lungs and the kidneys. One specific
problem with any modality used to treat CSI patients are the field junctions which can cause
large over and under doses for setup inaccuracies of just a few millimeters. In order to minimize
the risk of such large over or under dosages for such plans, an idealized dose profile such as the
one mentioned in the study by Strojnik et al should be attained (Figure 1).

Figure 1. Dose profile across an idealized field junction in which the individual field
contributions are shown in red and green, respectively, and the total dose shown in blue.2
Intensity-modulated based plans have employed several techniques to minimize the discrepancy
in the field junction region such as field overlap, hybrid junction and jagged junction.2
At my center specifically, a new technique for treating CSI cases was developed using a
static IMRT/VMAT approach.3 After creating optimization PTVs, static IMRT plans are created
for the spinal fields using posterior beams. In order to achieve an ideal dose profile such as the
one mentioned above, the dose to the superior portion of the most inferior plan is manually
stepped down by decreasing the transmission factor every 1 cm. This plan is then used as a
base dose for optimizing more superior spinal fields. The fluence for the plan before and after
fluence editing can be seen in Figure 2 below.

Figure 2. Dose to most inferior plan before fluence editing (left) and after fluence editing
(right).3

After discussing this technique as well as the assignment details with my preceptor, I
decided on a VMAT approach. Since fluence editing is not an option with VMAT planning, we
discussed other ways of achieving an optimal dose profile with VMAT. We discussed two
different techniques that could be used which included the creation of planning PTV structures in
the overlap region, or the creation of a mock conformal plan where 4 subfields are created. The
border of each subfield would be 1 cm less superior/inferiorly and each would be weighted
equally, creating an even dose fall-off. This plan would then be used as a base dose when
creating the first set of plans. The mock plan technique was what I chose to employ with my
VMAT approach which will be discussed in more detail below.
Patient Setup
The patient was positioned prone with a prone head holder and an aquaplast mask to
stabilize the head. A three-point setup was placed on the brain (user origin set here) as well as
another three-point setup placed half way between the shoulders and the sacrum for patient
alignment. A pad was placed underneath the patient and an ankle sponge is used for patient
comfort. The patient setup can be seen in Figure 3 below.

Figure 3. CSI patient immobilization.

Field setup

Three isocenters were strategically placed within the patient using a SAD setup. An SAD
setup was chosen since a VMAT technique would be used for all plans. Isocenter placement can
be seen below in Figure 4.
 Brain
isocenter

Upper Spine
isocenter

Lower Spine
isocenter

Figure 4. Sagittal and coronal views of isocenter placement for brain, upper spine and lower
spine plans.

To avoid dose discrepancies created with beam divergence, all three isocenters were kept at a
consistent X (left/right) and Y (anterior/posterior) axis, with the only shifts being in the Z plane
(superior/inferior). The shifts for each isoenter from the user origin set in CT simulation can be
seen below in Table 1.

Table 1. Shifts for each isocenter from origin placed in CT simulation.

Isocenter X Y Z
Brain 0.00 -7.00 0.00
Upper Spine 0.00 -7.00 -26.00
Lower Spine 0.00 -7.00 -48.00
Mock Plan Creation

In order to mimic dose fall for each plan within the overlap region and create optimal
dose profiles within these regions that were similar to the idealized profile (Figure 1) that
Strojnik et al2 describes, I created a mock plan for the upper spine that I would be using as a
base dose when optimizing both the brain and lower spine plans. For this plan, I inserted a field
with the superior border intersecting the inferior portion of the brain PTV and inferior border low
enough that the lower spine plan would end up being a similar length (field 1). Four subfields
were then created by reducing the superior and inferior jaws (Y2 and Y1, respectively) by 1 cm
each. The X jaws were set to give a 2 cm margin on each side of the PTV for optimal coverage.
The beams eye view (BEV) of the main field along with the sagittal view of all field borders can
be seen in Figure 5.

Figure 5. Beams eye view of field 1 (left) and sagittal image of field 1-5 superior/inferior
borders.
These fields were calculated 15 MV (to minimize the hotspot) and equal weighting of 0.2 each.
This resulted in 20% dose fall off between each field (Figure 6).

Figure 6. Mock plan dose distribution with 20% dose fall of between each field.

Brain and Lower Spine Plan Creation

Next, the brain and lower spine plans were created together with the intention of using
the upper spine mock plan as a base dose. First, superior and inferior field boarders were set by
overlapping the upper spine mock plan fields to match the border of the smallest subfield (100%
line). Fields are placed in this location so that the optimizer can make up for the lacking PTV
coverage from the mock upper spine plan. The remaining borders of the fields were created to
include the entire PTV within the rotation of the arc. Superior and inferior borders for the brain
and lower spine plan can be seen in Figure 7. Several planning structures were also created
according to the field borders: _PTVbrain, _PTVupperS and _PTVlowerS. These structures can
also be seen in Figure 7.

_PTVbrain

_PTVupperS

_PTVlowerS

Figure 7a. Superior and inferior borders of brain and lower spine plans compared to the mock
upper spine plan (left) and planning structures that were created (right).

My center uses 3 full arcs for the brain plan in their technique.3 I chose to do a partial arc
to avoid entering through the majority of the face and started with 2 arcs (with the intention of
reducing the patients time on the table). In a study by Fogliata et al4 using a VMAT approach to
CSI, gantry angles of 230 to 130 degrees clockwise were used for prone positioned patients and
they used between two and three arcs. I chose to implement 2 arcs with a shorter arc arrangement
of 265 to 95 degrees clockwise for the lower spine fields to avoid entering through the patients
arms. Gantry angles and arc arrangement for the brain and lower spine fields are listed in Figure
7b 7d.
Figure 7b. Gantry, collimator and couch arrangement for brain and lower spine fields.

Figure 7c. Arc arrangement for the brain fields.

Figure 7d. Arc arrangement for the lower spine fields.

Anatomy included in the brain fields were the optic nerves, lenses, globes, brainstem, mandible
and thyroid. For the lower spine fields, anatomy included the kidneys, liver, and small bowel.
Corresponding BEVs for the starting gantry angles of each field are included in Figure 8.

Figure 8. Brain field BEV at 230 degrees (top) and lower spine field BEV at 265 degrees
showing structures included.
Brain and Lower Spine Plan: Treatment Planning Process

I chose to optimize both the brain and the lower spine fields together and this limited me
to using the same energy for both fields. I chose to try 6 MV and this choice was supported by
Fogliata et al4 who used 6 MV for all arcs in their study. My arc arrangements were mentioned
above and can be seen in Figure 7b 7d. The plan was optimized to achieve 100% of the dose to
cover 95% of the _PTVbrian and _PTVlowerS while limiting the dose to normal structures such
as the optic nerves, lenses, kidneys, liver, and bowel. The optimization objectives for the brain
and lower spine plan can be seen in Figure 10. Several objectives were added with a 0 priority for
monitoring. The plan was then normalized to 98.5% to which achieve V100% =95% coverage.
The resulting isodose coverage can be seen in Figure 11 below.

Figure 10. Optimization objectives for brain and lower spine plans
Figure 11. Sagittal and axial views of brain and lower spine plan isodose distribution.
Upper Spine Plan Creation

The previous plan for the brain and lower spine fields was used as a base dose plan when
optimizing for the upper spine plan. The same superior and inferior borders were used as in the
mock plan. The X jaws were expanded to include the entire PTV within the length of the arc.
The same arc arrangement was used for the upper spine plan as for the lower spine fields in the
previous plan. Field borders and arc arrangement can be seen in Figures 12a - 12c below.

Figure 12a. Superior and inferior borders of upper spine plan.

Figure 12b. Arc arrangment for upper spine plan.

Figure 12c. Gantry, collimator and couch arrangement for upper spine plan.

Anatomy included in the upper spine plan included several normal structures such as the heart,
liver, kidneys, thyroid, lungs and bowel. A BEV of the starting gantry angle for the upper spine
fields with included normal structures can be seen in Figure 13 below.

Figure 13. The BEV of starting gantry angle of upper spine arc, showing included anatomy.
Upper Spine Plan: Treatment Planning Process

A 6MV energy was again chosen for the upper spine plan as supported by the study by
Fogliata et al.4 The plan was optimized to achieve 100% of the dose to cover 95% of the
_PTVuppersS while limiting the dose to normal structures such as the the heart, liver, kidneys,
thyroid, lungs and bowel. The optimization objectives for the upper spine plan can be seen in
Figure 14. Several objectives were added with a 0 priority for monitoring. The resulting isodose
coverage can be seen in Figure 15 below.

Figure 14. Optimization objectives for the upper spine plan.

Figure 15. Sagittal, axial, and coronal views of upper spine plan isodose distribution.

Overall Plan Evaluation

Overall, the plan achieved optimal coverage while minimizing dose to critical structures.
An overall isodose distribution can be seen below in Figure 16.
Figure 16. Sagittal view at isocenter of the overall isodose distribution.

The maximum point dose to the plan was 117.6% and was located in the lower spine field in the
same plane as the kidneys. This could have resulted from asking for such a low dose on the
kidneys. Due to this, the optimizer struggled to achieve PTV coverage in this area, resulting in a
budging of the isodose lines and a hot spot in the area. A cold spot also resulted in the region just
below the hot spot most likely due to asking for such low objectives on the optic nerves and the
lenses. Locations of the maximum and minimum doses to the PTV can be seen in Figure 17.

Figure 17. Location of the maximum point dose (left) and minimum dose (right).
 When evaluating this plan, several things were considered. Coverage of the PTVs, dose
to critical structures and dose profile across field junctions. PTV coverage was optimal in that
95% of the targets were receiving 100% of the dose. Although, minimum dose to the brain PTV
was very low at 26%. Maximum dose was also evaluated. The maximum dose was located
anterior to the PTV which is not ideal ideal and was 117.6%. My goal was to keep this below
110 but with only a small percentage (approximately 1%) receiving 110%, this is still an
acceptable plan.
Next, the dose to critical structures was evaluated. A DVH can be seen in Figure 18, along with
my ProKnow score sheet in Figure 19.

Figure 18a. Cumulative DVH of CSI plan in relative dose.

Figure 19. ProKnow plan scoring sheet.

The dose profile across field junctions was also analyzed in evaluating the plan. Both field
junction profiles resembled the idealized dose profile mentioned by Strojnik et al.2 These profiles
can be seen below in Figures 20 and 21.

Figure 20. Dose profile and field sharing of field overlap junction between brain and upper spine
fields.
Figure 21. Dose profile and field sharing of field overlap junction between lower spine and
upper spine fields.

Reflection

This was my first attempt at planning a craniospinal case. Through my research and also
through discussion with my preceptor, I learned a vast amount of information. From new
treatment techniques that are being used for CSI cases, to different ways to achieve an optimal
dose profile in junction regions (including the technique that I used in this assignment), all was
fairly new information to me and extremely helpful for this assignment and for my future career
as a medical dosimetrist.
There are several things that I may have done differently in order to improve my plan.
One thing that I struggled with was my minimum dose to the brain PTV. Trying full arcs for the
brain fields may have helped with this (since coverage was struggling anteriorly and my arc
choices limited this region) or possibly the addition of a third arc.
 References

1. Van Dyk J, Jenkin RDT, Leung PM, Cunningham JR. Medulloblastoma: treatment technique
and radiation dosimetry. Int J Radiat Oncol Biol Phys 1977;2(9):9931005.
http://dx.doi.org/10.1016/0360-3016(77)90202-4.
2. Strojnik A, Mndez I, Peterlin P. Reducing the dosimetric impact of positional errors in field
junctions for craniospinal irradiation using VMAT. Rep Pract Oncol Radiother.
2016;21(3):232-9. https://doi.org/10.1016/j.ror.2016.03.002
3. Cadieux, C. Lecture presented: AAMD 2017 Annual Meeting; June 13, 2017; Indianapolis,
IN.
4. Fogliata A, Bergstrm S, Cafaro I, et al. Cranio-spinal irradiation with volumetric modulated
arc therapy: a multi-institutional treatment experience. Radiother Oncol. 2011;99(1):79-85.
https://doi.org/10.1016/j.radonc.2011.01.023