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Clinical Project: Craniospinal Irradiation with TomoTherapy

Introduction
The use of helical TomoTherapy has several advantages in both planning and delivering
craniospinal radiation over traditional treatment techniques. The main advantage that we had
using the TomoTherapy planning system, was the ability to treat the entire length of the patient
using only one beam on period.This is done as the treatment table is translated continuously,
moving the patient into the machine's bore while delivering helical IMRT treatment. This ability
allowed for less complexity for the upfront planning process because beam matching and beam
gaps are rarely needed in TomoTherapy helical IMRT planning. This overall less complex
planning process can then be translated toward the ability for the patient to be treated supine.
Treating patients in the supine position allows for clinical benefits such as less discomfort for the
patient, less potential movement, and better setup reproducibility.1 The ability for having a daily
MVCT for treatment setups has a large advantage of potentially being more accurate over
standard treatment setups as well. In addition to this, multiple prospective studies done by
different institutions show that CSI plans using TomoTherapy are dosimetrically superior in both
target volume and tissue sparing as well.2,3
Contours
To begin the planning process, the organs at risk (OAR) and target volumes were
contoured on the supine data set using the Varian Eclipse treatment planning system. The OAR
that were contoured consisted of the lens, eyes, liver, kidneys, lungs, heart, thyroid gland,
lacrimal glands, trachea, bowel cavity and esophagus. The CTV consisted of both the spinal cord
and the brain of the CT data set. The spinal cord contour consisted of the cerebrum of the spinal
canal and the lateral spinal roots. The total extent of the cord volume goes cranially to the
posterior fossa of the brain and caudally to thecal sac. A 0.5cm margin was then placed around
the CTV to create the PTV that was used for target optimization in the treatment planning
system. A ring structure with a margin of 2.5cm was then expanded off of the PTV, which is
later used to increase dose conformity to the target. Examples of the contoured target structures
and OAR can be seen in figures 1-3 below.

Figure 1. The contoured CTV, PTV, and ring structure of the spinal cord.

Figure 2. The contoured CTV, PTV, and ring structure of the sacral region.

Figure 3. The contoured CTV, PTV, and ring structure in the brain

Planning
The CT data set and contoured structure set were then exported to the helical
TomoTherapy planning system. A pitch of 0.287 was selected to determine the amount of beam
overlap that will occur along the long axis of the patient as the table moves. A larger pitch causes
greater couch speed and longer gantry period while decreasing the amount of beam overlap. A
modulation factor of 2.0 and a field width of 2.51cm with dynamic jaws in the superior to
inferior direction were used to provide adequate coverage while helping to meet target
constraints. The modulation factor is used to calculate the range of beam intensity values during
optimization. By increasing the modulation factor, the treatment time will increase but the
optimizer has a greater ability to modulate the total beamlet intensities. A 6MV energy was used
throughout the entire treatment. A table of these optimization parameters used for the CSI plan
can be seen in figure 4 below.

Figure 4. Initial optimization parameters

A total dose of 36 Gy in 20 fractions was prescribed to the PTV in the treatment planning
system. The PTV was placed within the target parameter area while the remaining OAR and
PRVs were placed within the OAR parameter area. The PTV was then given the highest
importance with an arbitrary number of 100 within the optimizer. The PTV was then set so
that 100%, or 36Gy, was prescribed to cover at least 95% of the PTV. The maximum dose
penalty was set so that this volume would have constraints to receive no more than 105% of the
dose within the PTV. At the beginning of dose optimization, none of the OAR were assigned
with any values for dose constraints. The plan was then calculated out for over 100 iterations so
that optimum coverage and dose conformity were met for the PTV without sacrificing any initial
coverage to spare normal tissues.
We then worked on bringing down and penalizing only the maximum dose that each of
the OAR received. We would try to reduce each of these dose maximums by values of roughly
2Gy for every 20 iterations. The amount of each maximum dose for these tissues depended
largely on the location and proximity to that of the PTV. Some examples of areas that could not
be modified as much included regions of the bowel cavity and optic nerves. Once the maximum
doses were pushed to lower doses without sacrificing coverage or causing hotpots, the regions of

low doses in the OAR were then changed by placing optimization points. Such as reducing the
dose maximums, these points were also modified by roughly 2Gy and 2.5% of tissue volume
every 20 iterations. Examples of these dose optimization points can be seen in figure 5. We felt
that the plan was complete when parts of the PTV coverage began to be lost and the low doses
within the OAR could no longer be pulled away.

Figure 5. Illustration of the dose optimization window

The final part of the dose optimization plan includes drastically increasing the dose
minimum and maximum penalties by 5000 for the PTV to remove any last hot and cold spots
that may be within the volume. To further improve the dose conformity around the PTV, the
constraints and optimization points for the ring structure were placed. The optimization points
looked to reduce the amount of area that the 18 and 25Gy isodose lines were converting within
the ring. Once the ring volumes could no longer be reduced, the final calculation was completed
for the plan.

Figure 6. Orthogonal view of dose coverage in the treatment planning system

Evaluation
The maximum hotspot of 3790Gy occurs within the PTV just posterior to the optics. We
suspected that the hotspot would occur in this general region due to the amount the lens and eyes
were pushed during the optimization phase. The location of this hotspot can be seen below in
figure 7.

Figure 7. Area of maximum dose hotspot

The table of dose constraints that were used to base the plan off of are listed below. Although
these tolerance doses would be reviewed after a boost plan was complete, they were still a good
reference.
Organ
Rt Kidney
Lt Kidney
Rt Lung
Lt Lung
Heart
Esophagus
Cord
Cauda Equina
Lens

Tolerances
V15 <33%
V15 <33%
V5 <33%
V5 <33%
V20 <25%
Mean dose <50% of
Rx dose
0.5cc <55cGy
0.5cc <55cGy
<10cGy

Achieved
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes

All of these dose constraints were met except for achieving V5 <33% for both of the lungs. This
can be attributed to the nature in which TomoTherapy creates higher integral dose throughout the
whole patient by using full gantry rotation. Having the V5 <33% for the lungs is more feasible in
proton treatment plans due to not only having rapid dose fall off, but from also only using one
beam angle when treating the spinal cord fields. An example illustrating the amount of low dose
that contributes to the lungs from my treatment plan can be seen in the figure below.

Figure 8. Shows the low dose (20%) represented by the white IDL.

Based on the results from this plan, there are still some factors that We felt could improve the
plan further. While we did make sure there were no areas of overlap between the PTV and OAR,
We felt that having PRVs of a 3mm margin around some of the critical structures could have
helped me to better optimize and control the low doses around these structures. We also could
have made the plan more intricate by splitting up my PTV into four optimization volumes of the
brain, cervical, thoracic, and lumbar cord. This would have allowed for better optimization of hot
or cold spots that occurred during planning. The treatment time could also be reduced from its
current 19 minute mark by increasing the amount of pitch in the plan. Increasing the amount of
pitch would also reduce the possibility of the treatment plan not passing QA due to a decreased
possibility of deviations in MLC latency. Since the target is located centrally, the amount of
pitch could be increased without losing too much sparing of critical structures. Lastly, the
patient's arms could have been contoured and used as avoidance structures to account for the
changes that could occur in arm positioning on a day to day basis.

Figure 9. Sagittal view of dose distribution

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Figure 10. DVH for the thoracic critical structures and targets.

Figure 11. DVH for the cranial critical structures and targets.

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Figure 12. DVH for the abdominal critical structures and targets.

Deleted:

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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. Parker W, Brodeur M, Roberge D, Freeman C. Standard and Nonstandard Craniospinal
Radiotherapy Using Helical TomoTherapy. Int J Radiat Oncol Biol Phys.
2010;77(3):926-931. doi:10.1016/j.ijrobp.2009.09.020.
3. Sharma DS, Gupta T, Jalali R, Master Z, Phurailatpam RD, Sarin R. High-precision
radiotherapy for craniospinal irradiation: evaluation of three-dimensional conformal
radiotherapy, intensity-modulated radiation therapy and helical TomoTherapy. Br J
Radiol . 2009;82(984):1000-1009. doi:10.1259/bjr/13776022.