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Ryan Clark
DOS 531 Clinical Oncology for Medical Dosimetry
June 26, 2016
1. Is the patient a child or an adult? What might you have to do differently based on the size and
age of your patient?
The patient being treated for the craniospinal irradiation treatment is an adult. This will require that
two spinal fields and two lateral cranial fields be used to encompass the larger patients entire
central nervous system. It should be noted that smaller patients, such as children, can be treated
with a single spinal field when using an extended SSD technique.2

2. How will the patient be positioned? Supine or prone? After describing which orientation,
include all the devices used. Describe head position, chin position, arm position, how will you
assure your patient is aligned? List everything that you would check before leaving the CT.
Sometimes a board is placed under the lower torso, describe if this will be used for your
patient and why or why not?
The patient will simulated and treated in the prone position. An Alpha cradle or Vac-lok bag can be
used to help immobilize the patient in a comfortable position.3 The patient will have their arms
down by their side in comfort and in a way so that their shoulders are in a neutral position. A board
will be placed under the patients body to help with neck positioning and allow the head to fall
forward. This board also helps to extend and straighten the cervical neck and helps flatten the
natural curvature of the lumbar spine.2 A head and chin rest registered to the treatment couch will
be used with a thermoplastic mask, which will be placed on the back of the patients head for
immobilization. The headrest also assists in keeping the neck in a hyperextended position to help
reduce the exit dose to the oral cavity from the posterior spinal fields. During simulation, the
extension of the neck and straightness of the spine should be verified on the CT scan. Over
extension of the neck can cause an unwanted skin fold on the neck which can affect the dose
uniformity.
The following questions are generic CSI questions:
1. How is the spine matched to the head ports for a craniospinal setup? BE SPECIFIC. Give me the
formulas used to determine any angles and give an example of using the formula(s). Provide a
diagram or drawing .
Matching the superior potion of the most cephalad spinal field with the inferior border of the head
port for the craniospinal treatment is an important aspect of the treatment plan. Each field diverges
in different planes, where the lower border of the head port diverges caudal and posteriorly and
the upper portion of the abutting spinal field is diverging cephalad.2 A diagram of the divergence of

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these two beams can be seen in figure 1.4 The collimator for each inferior border of the caudal
fields needs to be rotated so that the border matches the divergence of the superior spinal field.
The couch is also rotated toward the direction of the collimator angle for each brain port so that
fields run evenly and perpendicular through the patients neck. An example of this type of couch
kick can be seen below in figure 2.1 The two equations used to find the optimal collimator and
couch rotations can be derived from the two equations below as follows.2
Collimator Degree(s) = Tan-1 ( 0.5 x L1 x 1/SSD )
Couch Degree(s) = Tan-1 ( 0.5 x L2 x 1/SAD)
Example: 100cm SSD with a field length of 20cm.
Collimator Degree(s) = Tan-1 ( 0.5 x L1 x 1/SSD ): Tan-1 (0.5 x 20 x 1/100)
=5.7 Degree collimator rotation
Example: 114cm SAD with a field length of 20cm.
Couch Degree(s) = Tan-1 ( 0.5 x L2 x 1/SAD): Tan-1 ( 0.5 x 20 x 1/114)
= 5.0 Degree couch rotation

Figure 1.

Figure 2.

2. If you wanted to remove any divergence from the eyes in the cranial port, how would this be
accomplished? Why would you do this? Show a formula and how it can be used. Provide a diagram or
drawing.
To match the divergence of the head ports to run perpendicular through the back of the eyes the gantry
needs to be rotated. Figure three illustrates how rotating the gantry slightly upward can help match to
the divergence of the opposing field.2 This gantry rotation also brings the divergence of the beam
further away from the lens of the eyes while still keeping the same field matching from the couch and
collimator changes.1 The equation used for the gantry rotation is listed below.
Gantry Angle = Tan-1 (0.5 x L x 1/SSD)
Example: Tan-1 (0.5 x 18 x 1/100)
=Gantry angle of 5.0 degrees
Figure 3.

3. For treatment planning, approximately where will you place the isocenter for each field for
the patient above, will the isocenters be moved? Why or why not? What are the approximate
field borders?
A total of three isocenters need to be placed for the craniospinal irradiation treatment plan. One
isocenter will be located in the center of head, and the other two will be in the medial region of the
mid and lower spine. The brain field will encompass the entire brain and will extend inferiorly down
to the C4-C5 vertebrae.3 The two isocenters for the spinal field will be set to 100 SSD on the patients
back and in the same X plane to minimize the need for lateral shifts between the three fields. The
largest field is for the upper spine and will be the first beam set. The lateral border of this field will

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be set 1cm away from each of the pedicles on the spine. The exact location of the isocenter will be
determined by opening up the jaws to a field size of 18cm. The maximum field size for the
treatment machine is 20cm in either direction, but a 2cm margin is left to give room for the
feathering technique. The field will then be shifted so that the caudal border lies just below the
patients shoulders. The gap calculation can then be used to insure that the divergence of the head
and upper spinal fields do not overlap.
The lower spinal field isocenter will also be longitudinally shifted below the upper spinal field. The
isocenter will be placed in a location that allows for a 2cm margin to cover the thecal sac at S2.2 The
inferior portion of this field will also be extended more laterally so that the sacral nerve roots are
covered. These isocenter locations will not be moved throughout the patients course of treatment
as there are now required shifts from these three points.
4. If two spine ports must be matched due to the length of the spine, tell me how you would
accomplish this and how would you assure that there is no overlap?
Because our patient is being treated using two spinal ports in the prone position, the gap calculation
needs to be used to optimize the overlap for each of the beams divergence. The gap calculation will
help reduce potential hot or cold spots between the two fields. The gap calculation that will be used is
listed below.3
Gap Calculation: D/2 (L1/SSD1 + L2/SSD2)

5. If feathering the gap is required between 2 fields, what does that mean? Can you describe how
this could be accomplished? (provide details as if you had to explain exactly what will be done to the
radiation therapist who is treating the patient)
Feathering is required during the course of the patients treatment to help prevent hot and cold spots
from occurring for where the spinal cord fields abut one another.1 It is important during planning that
the initial field lengths can be extended by an additional 4 to 6cm to account for the field junction shifts
by moving the jaws of the linac.3 The junction of the spinal fields are moved 1cm either superiorly or
inferiorly every 9 Gy or about every five fractions if the patient is being treated by 1.8 Gy each fraction.2
An example of how the jaws are moved to perform the feathering technique can be seen below in figure
four.

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Figure 4

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References
1. South, M. Using Composite Planning and Delivery with Feathered Junctions in Craniospinal,
Brain-Spine and Spine-Spine Abutted Fields. [PowerPoint]. Methodist Cancer Center; 2016.
2. Chao K, Perez C, Brady L. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2011.
3. Bentel GC. Radiation Therapy Planning. 2nd ed. Durham, NC: McGraw-Hill Companies, Inc; 1996.
4. Singh V. Diagnosis, treatment & management of medulloblastoma. Slideshare website.
http://www.slideshare.net/vandana_rt/diagnosis-treatment-management-of-medulloblastoma.
Published September 30, 2011. Accessed June 16, 2015.