Craniospinal Irradiation Project

Introduction:

Medulloblastoma is a form of malignant brain cancer which typically originates in the

cerebellum. Unlike most other brain tumors, medulloblastomas spread through the cerebrospinal
fluid. It is not uncommon for these tumors to metastasize to the spine and other areas of the
brain. This makes craniospinal treatments necessary. By treating the brain and the entire length
of the spinal cord, physicians can attack the full extent of the disease.

When it comes to craniospinal radiation treatments, there are multiple strategies. An “old
school” approach consists of opposing laterals to treat the brains with posterior fields to treat the
thoracic and lumbar spine. These posterior fields are often fixed with a couch kick to match the
divergence of the laterals and avoid hot or cold spots. However, with the advent of IMRT and
VMAT, there are other methods available. VMAT can effectively treat the entire target volume
while significantly sparing the surrounding organs. By using arcs instead of static fields, the
overall treatment time can also be reduced. This assists the radiation therapists in delivering an
effective treatment.

Treatment Setup:

The patient, in my project, was treated in the supine position. His arms were at his side
with his head first towards the gantry. At my site, patients are often fitted with a head and neck
Aquaplast mask to effectively immobilize the patient. A vac-bag is often used as well to fix the
patients legs in position. However, other centers may use different forms of immobilization. This
may include a mask-like fixture for the patient’s abdomen or a knee roll for the patient’s legs.
Whatever devices are used, it is important that the patient is in a fixed, reproducible position.

I chose to treat the patient using an SAD setup with three separate isocenters. One is
located in the brain, with two others placed in the patient’s thoracic and lumbar spine. Each
isocenter is in the same right to left and anterior/posterior location. This was done to provide
simple longitudinal shifts from each isocenter. I fashioned the field borders to include an overlap
region between the inferior edge of one field and the superior border of the other. This was done
to ensure that no section of the PTV would be missed. The image below clearly shows this
overlap effect.

As can be seen in the aforementioned image, the patient was treated using a total of six
full-rotation, 360 degree, arcs. For each isocenter, two arcs were used with counteracting
collimator angles of 30 and 330 degrees. This was done to avoid any overlapping of the MLC
interleaf dose leakage. The primary goal of the field borders was to include the primary target
volumes.

Plan Normalization:

The plan was normalized so that 95 percent of the volume received 100 percent of the
prescription dose. This was done to meet the requirements made by the physician. However, the
plan was very conformal after optimization. Normalization resulted in minimal increased
coverage. Reference points were used to track the dose for each PTV, but they were not used to
normalize the prescription.

Treatment Planning Process:

 All of the beams in this plan used 6 MV energy. Given that this was a VMAT plan,
higher energy beams are not permissible due to neutron contamination. The treatment couch was
not moved at any point. A VMAT plan was chosen due to its ability to provide a conformal dose
distribution. Static field IMRT was considered, however, this would have resulted in a longer
treatment time for the patient.

The plan has a hot spot of 116.8%. This is located superiorly in the brain PTV. While I
would have liked to have reduced this number, I found it difficult to do so without reducing my
PTV coverage. The plan has no noticeable cold spots. However, there is a section of the brain
PTV that is not receiving the full prescription dose. This is due to the proximity of the optic
nerves. In order to spare these critical structures, I had to sacrifice PTV coverage.
 My plan evaluation process was simple. I wanted to cover at least 95% of the PTV with
the prescription dose while sparing the critical structures as best as I could. The resulting plan
provided the coverage I desired while meeting every single OAR constraint. As I create a
treatment plan, I like to make sure that it actually makes sense. The beams were designed to
provide an optimal treatment flow. One arc rotated from 181 to 179 degrees with the next going
from 179 to 181. In my opinion, this craniospinal treatment checks all the boxes.
ProKnow Score Sheet:

I was able to meet all of the ProKnow objectives for this plan. For a majority of them, I
achieved the ideal requirement. The most notable abstentions are the kidneys and optic nerves.
The optic nerves were difficult due to the fact that they were abutting and at times completely
covered by the target volume. I made an executive decision to stop where I did to avoid losing
even more coverage on my brain PTV. When it comes to the kidneys, I believe this can be
attributed to the VMAT treatment method. With VMAT the lower doses tend to bow out more
than with a static field IMRT plan. While I was able to meet the minimum requirements, I was
not able to get the mean kidney doses any lower.

As a side note, it should be noted that the numbers displayed in this ProKnow scorecard
are not completely accurate. For example, it states that I failed my left lens requirement by
delivering a max dose of 1100 cGy. In fact, I actually had a max left lens dose of 830.6 cGy.
This must be due to an algorithm difference between my centers treatment planning system and
ProKnow.

Reflection:

I have very little experience planning craniospinal treatments. I found this assignment
interesting and challenging. The most difficult part is deciding what beam configuration to use.
Unless the patient is treated using tomotherapy or some other helical modality, there will need to
be multiple isocenters. I wanted to make sure that, through all the shifts, the patients PTV was
getting sufficient coverage. Craniospinal treatments are often long and uncomfortable for the
patients. While creating this plan, I tried to think of ways to make it as seamless as possible. As
all dosimetrists know, the best plan on paper is not always the optimal choice. This VMAT
craniospinal plan effectively fulfills the presented objectives while keeping the patients comfort
in mind.