Sheil

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Pat Sheil

October 4th, 2017

Craniospinal Irradiation Project

Introduction:
Craniospinal irradiation (CSI) is one of the most complex treatment plans
seen in radiation oncology due to the large field size and the numerous organs at
risk (OR) throughout the field. Before I attacked this complex treatment plan, I did
research on the various techniques predominantly used today. During my research I
found an article by Stenski et al1 that compared and contrasted 3 common CSI
treatment techniques: traditional 3D conformal, intensity-modulated radiation
therapy, and volumetric-modulated arc therapy (VMAT). The option of utilizing
VMAT intrigued me the most as I am very comfortable with the technique and it was
a realistic option for my clinic as we often use VMAT technique.
The diagnosis for the assigned case was a medulloblastoma. The prescribed
dose was 3600cGy to be carried out to 180cGy/day for a total of 20 fractions. I used
Varians Eclipse treatment planning system (TPS) version 13.6 to create my plan.
Treatment was planned for a Varian iX accelerator and 6MV photons were the
energy of choice for all fields. I will discuss the setup and planning process that was
put into the final product.

Setup and Fields:
The patient was positioned head first and supine because a study done by Tai
et al2 concluded that it was the superior option due to patient comfort, stability and
reproducibility, airway facilitation, and conduciveness to workload of a busy
radiotherapy department. Utilizing the VMAT technique allowed me to take
advantage of the inverse planning software. Using the arc geometry tool I was able
to tell the software that I wanted my plan to include three separate isocenters with
three separate fields employing full arcs. The isocenters were automatically
established equidistant from each other in the brain, upper spine, and lower spine
(Figure 1/Table 1). The equidistant coordinates and alignment of the isocenters
were advantageous, as therapists would only have to make shifts in the superior and
inferior directions during treatment. The original three fields created contained the
brain, upper spine, and lower spine. Each of these fields was set to rotate in the
clockwise (CW) direction starting at 181 degrees and ending at 179 degrees for a
full arc. I copied and pasted these fields so that their counter fields would go counter
clock-wise (CCW) starting where the CW fields left off at 179 degrees and end back
at 181 degrees. Having 2 full arcs for each of the three sites allowed for a more
homogenous dose distribution. I offset the collimators 10 degrees so that interleaf
leakage was reduced. The field parameters were automatically established using the
arc geometry tool mentioned before. The field parameters for all six fields can be
found in Table 2 below. This plan utilized the source-to-axis distance (SAD) due to
the minimization of possible collision throughout the rotation of the gantry for all
six fields. One perk using VMAT is the overlapping of fields that consequently create
a single gradient dose junction, thus requiring no feathering technique.3
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Figure 1: Isocenter placement (Brain, Upper Spine, Lower Spine)

Table 1: Isocenter Coordinates

X Y Z
ISO BRAIN -0.03cm 45.21cm 3.86cm
ISO UPPER -0.03cm 22.14cm 3.86cm
ISO LOWER -0.03cm -0.94cm 3.86cm

Table 2: Field Parameters

Field Name Weight Gantry Rotation X1 X2 Y1 Y2 SAD MU

A CW Brain Arc 0.764 181.0 CW 179.0 8.8 10.2 12.8 12.6 100 138
A1 CW Brain Arc 0.845 179.0 CCW 181.0 10.2 8.8 12.8 12.6 100 152
B CW Upper Arc 0.751 181.0 CW 179.0 5.5 5.6 12.7 12.7 100 135
B1 CW Upper Arc 0.811 179.0 CCW 181.0 5.6 5.5 12.7 12.7 100 146
C CW Lower Arc 0.996 181.0 CW 179.0 7.3 5.6 13.1 12.8 100 179
C1 CW Lower Arc 0.933 179.0 CCW 181.0 5.6 7.3 13.1 12.8 100 168

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Pre-Planning Process:
Before I could begin optimizing my plan I had to create a planning treatment
volume (PTV) for the brain and entire spinal portion. I was able to create my
PTV_Brain by simply adding a 0.5cm expansion to my brain contour. Creating my
PTV_SpinalCord consisted of using Eclipses boolean function to combine the spinal
cord (starting at C1) and cauda equina (ending at S3) into one structure and then
adding a 0.5cm expansion. My clinic utilizes OPTI structures that act as expansions
to the PTV structures to further ensure adequate coverage during the optimization
process. An OPTI_Brain structure was created by adding 0.1cm margin superior,
inferior, and anterior to the PTV_Brain structure. The same was done for OPTI_Spine
as 0.1cm margin superior, inferior, and anterior was added to the PTV_SpinalCord
structure. The complete list of OR structures created pre-planning included the
following: brain, optic nerves, lenses, parotids, liver, kidneys, heart, lungs, small
bowel, esophagus, thyroid, cauda equina, and spinal cord. A multi-planar view of all
structures can be found in Figure 2 below.

Figure 2: Multi-Planar View of the Organs at Risk
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Planning Process:

The prescription for this CSI plan was 3600cGy to be carried out to
180cGy/day for a total of 20 fractions. The energy I chose to use for this plan was
6MV for all six fields as it is the standard at my clinic in order to avoid neutron
contamination throughout gantry rotation. A calculation point and plan
normalization was not necessary as the plan was created volumetrically.

After all fields, set up and prescriptions were verified; I was able to start the
optimization process. The first task I complete when in optimization is to make sure
my normal tissue objective (NTO) settings are correct. For this particular plan I
made my NTO priority 150 and checked the automatic box. I then remove all ORs
that I know are out of the field or unnecessary. My OPTI structures that I mentioned
before are my highest priorities. For the OPTI_Brain I gave it an upper objective of
0% to receive 3680cGy with a priority of 135 and a lower objective of 100% to
receive 3640cGy with a priority of 130. For the OPTI_Spine I gave it an upper
objective of 0% to receive 3680cGy with a priority of 135 and a lower objective of
100% to receive 3650cGy with a priority of 125. I initially added a mean objective of
50 priority to the following structures due to their constraints and close proximity
to the treatment field: liver, right/left kidney, right/left lung, esophagus, stomach
and parotids. As I began to optimize in phase 1 I noticed that my optic nerves and
lenses were very hot so I added an upper objective for both. For the right and left
optic nerves I placed an upper objective of 0% to receive 3150cGy and 3200cGy
respectively with a priorities eventually being 100. For both the right and left lens I
placed an upper objective of 0% to receive 500cGy and 550cGy respectively with
priorities eventually being 100. I placed such high priorities for the lens and optic
nerves because I knew they were only contoured on a few slices and would not
severely affect the plan. They are also very sensitive structures that could severely
impact the patients quality of life (QoL) so meeting those constraints was vital.
Throughout the optimization I noticed certain structures such as left/right lungs,
stomach, esophagus and thyroid were well under their constraints so I took them off
in order to focus on the structures that were in proximity. After really focusing on
the optic nerves and lenses I ended up with an ideal plan that met all constraints
(Table 3). My final optimization objective can be seen on Figure 3.

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Figure 3: Optimization Objectives

Table 3: OR Constraints

Organ TD 5/5 TD 5/5 Max Dose Mean Dose Tolerence

Max Dose Mean Dose Achieved Achieved Met?
(Gy) (Gy) (Gy) (Gy)
Rt Lens 10 N/A 7.0 5.9 Yes
Lt Lens 10 N/A 7.5 6.1 Yes
Lt Parotid 32 N/A 18.4 9.8 Yes
Rt Parotid 32 N/A 17.8 9.4 Yes
Rt Optic 50 N/A 35.4 29.7 Yes
Nerve
Lt Optic 50 N/A 35.5 29.4 Yes
Nerve
Heart 40 N/A 11.0 5.6 Yes
Total Lungs V20<35% N/A 26.02 7.7 V20Gy=2.3%,
Yes
Lt Kidney 23 N/A 14.8 3.3 Yes
Rt Kidney 23 N/A 15.1 3.5 Yes
Small Bowel 45 N/A 36.9 7.9 Yes

Liver 30 N/A 19.7 5.9 Yes

Esophagus 55 N/A 22.4 12.5 Yes

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Isodose Coverage:
My final plan had a global max of 4032cGy (112%), which exceeded my
target goal of the global max being less than 110%. The hot spot was located at the
most superior aspect of the brain in the skull region. Upon review I deemed this to
be an ideal location for the hot spot and one that I expected. The bone density of
skull shifts the isodose curves towards the surface of the skin which is why the hot
spot occurs at the thickest, most superior portion of the skull as seen in Figure 5. I
also found this to be an ideal spot rather than the spinal cord because the spinal
cord is a serial structure and cannot tolerate higher doses to a small volume. In the
case that the patient has to be retreated to the spinal cord in the future, this gives
some extra flexibility to the treatment planner.
My upper objectives did their job during optimization, as there was no cold
spots found throughout my plan. This coverage was obtained due to the dynamic
MLCs movement as the gantry continuously rotated around the patient (Figure 5).
The dynamic MLCs were able to modulate beam intensity to structures that I
prioritized while lowering dose to ORs based on the objectives that I placed during
the optimization portion. The isodose coverage of plan can be seen in Figures 6 and
7.
The PTV objective for both the brain and spinal cord were met as coverage
exceeded 95% of the prescription dose. All OR constraints were met as well and can
seen on Figures 8 & 9.

Figure 4: Hot Spot located in the cranium
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Figure 5: Field Border with Dynamic MLC
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Figure 6: Colorwash Dose (Red=95-112%, Green=50-95%, Blue=0-50%)
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Figure 7: Isodose Lines (Red=3960cGy, Green=3600cGy, Yellow=3420cGy)
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Figure 8: DVH Brain

Figure 9: DVH Spine

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Final Thoughts:
I was able to step out of my comfort zone with VMAT while coming up with
this plan. This complex plan forced me to think critically and outside of the box. It
was also a great way to utilize multiple aspects that I have learned throughout this
year into one plan. My preceptor was very impressed with my work, as she has
never done a CSI before using VMAT so this is something that I have been able to
show her and possibly have it implemented at my clinic in the future. This final
outcome did not come easy and took multiple plans t reach my desired outcome but
I have learned a great deal throughout the process and for that I am thankful. This
project definitely enhanced my skills as a medical dosimetrist.





































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References:

1. Studenski MT, Shen X, Yu Y, et al. Intensity-modulated radiation therapy and
volumetric-modulated arc therapy for adult craniospinal irradiation: A
comparison with traditional techniques. Med Dos. Philadelphia, PA: 2013;
38(1):48-54. http://dx.doi.org/10.1016/j.meddos.2012.05.00
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. Muacevic A, Adler JR,
eds. Cureus. 2015;7(12):e404. doi:10.7759/cureus.404.
3. Athiyaman H, Mayilvaganan A, Singh D. A simple planning technique of
craniospinal irradiation in the eclipse treatment planning system. Journal of
Medical Physics / Association of Medical Physicists of India. 2014;39(4):251-
258. doi:10.4103/0971-6203.144495.