Bianca Tester

October 13, 2018

Supine Craniospinal Irradiation Treatment Plan

Medulloblastoma, the most common form of malignant brain tumor found in children,
consists of 18% of all pediatric tumors.1 These tumors arise in the posterior fossa, and are
typically found in the midline of the cerebellum. They have a high likelihood to spread
throughout the ventricular system and into the cerebrospinal fluid (CSF) pathway. Surgery is
done initially for tissue pathology, tumor debulking and decompression, but this is not a curative
approach. If the patient is 5 years old or younger, chemotherapy can be given to delay, or
replace the need for radiation therapy. For all other patients, postoperative craniospinal
irradiation with adjuvant chemotherapy is recommended.1
In the past, craniospinal irradiation (CSI) was done using three-dimensional conformal
radiotherapy (3DCRT) with couch kicks, collimator rotations, and gap calculations to avoid areas
of overlap.2 As technology has advanced in radiation oncology, newer techniques have emerged,
such as intensity-modulated radiation therapy (IMRT) and volumetric-modulated radiation
therapy (VMAT). VMAT has grown in popularity over the years due to the increased
conformity around the planned target volume (PTV), as well as maintaining a steep dose gradient
to avoid dose to nearby organs at risk (OAR).
CSI is a highly complex plan and treatment due to many factors, these include: a large
treatment volume which proves challenging to maintain uniform dose distribution, as well as
avoiding dose to several critical structures (which is imperative, especially when treating such
young patients, whose bodies have not fully developed). Patient position and immobilization is
another tricky piece of the puzzle when dealing with a CSI case. Patients can either be treated
prone or supine, with both providing different advantages. If the patient is prone, this helps
therapists by being able to visualize the light fields for the spine setups (for the 3DCRT
technique). If the patient is supine, they are more likely to be comfortable, and also allows for
easier monitoring for a patient under anesthesia. For immobilization, alpha cradles, vac lok’s,
and orfit thermoplastic masks are typically used.2
For this assignment, a CT dataset was provided by ProKnow, a software program for
measuring contouring accuracy, as well as a structure set, so all classmates were graded based
off of the same metrics. ProKnow also provided a list of objectives focusing on OAR such as the
heart, kidneys, liver, lungs, and thyroid. A treatment plan was produced using a Pinnacle
treatment planning system (TPS), and a Trilogy linear accelerator was selected for the delivery
of the plan. The prescription dose was prescribed to deliver 180 cGy daily, for 20 fractions, for a
total dose of 3,600 cGy.
The treatment technique I utilized was a VMAT auto plan, with 2 full arcs for the brain
and a portion of the upper C-spine, 2 full arcs for the mid spine, and 2 full arcs for the lower
spine (with all fields overlapping on purpose) with all fields using 6 MV. The overlapping of the
fields isn’t a problem when using inverse planning, because the TPS takes the dose from the
other fields into account when optimizing the plan. I chose a VMAT auto plan because both
dosimetrists at my clinic agreed that this technique would deliver the best possible outcome,
based off of the machine capabilities available to our department. If proton radiation therapy
(PRT) were an option, I would have planned the CSI with proton’s instead, because studies have
shown PRT to have more favorable outcomes of limiting dose to normal OAR compared with
IMRT.3
The treatment fields and borders were determined by first measuring the entire length of
the combined treatment PTV’s (PTV brain and PTV spine) – essentially the entire brain and
spinal cord needed to be irradiated. Once that was measured, I created 3 separate isocenters, and
attempted to place them somewhat equidistant from each other. I did this so that all my field
lengths would be roughly around the same size. The field length for the brain fields were done
in such a way to avoid treating through the shoulders, seen in Figure 1. I thought about doing
partial arcs to avoid dose through the arms, but since I hadn’t planned a CSI before I didn’t want
to limit my gantry angles, for fear of under or over dosing an area (in hindsight now, I will try a
plan with partial arcs next time). The gantry positions are seen in Figure 2, while the collimator
angles and field sizes are found in Figure 3.
Figure 1. Coronal view of beam orientation and shown areas of overlap.

Figure 2. Gantry positions for CSI plan utilizing a VMAT technique.

Figure 3. Collimator angles and field sizes for CSI plan using a VMAT technique.
 A source-to-axis distance (SAD) setup was chosen to avoid setup errors, such as setting
an incorrect source-to-skin distance (SSD) and also reduce the time the patient is on the
treatment table (less likely to move and have to be re-positioned). Blocking of OAR was
achieved by the multi-leaf collimator (MLC) inside the head of the gantry, and was
accomplished according to the objectives I outlined in the optimizer. The lens of the eye, optic
nerves, heart, and kidneys were some of the OAR I focused on, to limit dose to, due to their
highly radiosensitive tissue. Once the field sizes were set and the gantry and collimator angles
were chosen, I was ready to begin the optimization process. Figure 4 shows the list of objectives
I used for limiting dose to the OAR.

Figure 4. Initial OAR optimization goals.

It took roughly about 2 hours for the plan to finish optimizing, but most objectives were
met. The PTV’s, esophagus, optic nerves, and kidneys did not meet the objectives on the first
try, so I began to chip away at the dose by reviewing the DVH and re-optimizing the plan.
Figure 5 shows part of my optimization goals, trying to chip away at the dose to the optic nerves
and kidneys, while maintaining solid coverage to the PTV.

Figure 5. Additional OAR optimization goals after initial run.

After re-optimizing 2-3 more times, I was able to get the PTV’s, esophagus, and right kidney to
meet the objectives, but was unsuccessful with the left kidney and optic nerves. In hindsight, I
could have pushed the left kidney harder to meet the objective, however, I didn’t want to push
the optic nerves any further because I was afraid I was going to lose coverage to the brain and
have a larger cold spot, seen in Figure 6.

Figure 6. 100% (red isodose line) coverage pulling away from left optic nerve.

I normalized my plan to 97.5% to the PTV 3600 volume that I created (which was just the PTV
brain plus PTV spine volumes combined). I normalized my plan to maintain solid 95% coverage
(receiving 100% prescription dose) to the PTV brain, and 94.6% to the PTV spine, while keeping
the majority of the OAR doses within an acceptable limit, seen in Figure 7-10. Again, I didn’t
want to push on the optic nerves any further, because the optic nerves are partially included in
the PTV brain volume (which needed to receive a dose of 3600 cGy).
Figure 7. Sagittal view of isodose distribution to the PTV. The red isodose line represents the
100% line, while the yellow isodose line represents 95%.

Figure 8. DVH of clinical target volumes (CTV) and PTVs.

Figure 9. DVH of normal OAR.
Figure 10. DVH of normal OAR.

The maximum hot spot was located near the coccyx, and had a total dose of 3,961 cGy,
which made the hot spot 110% to a point, seen in Figure 11. This is an acceptable hot spot,
because it was still located inside the PTV volume, and when comparing this to the ProKnow
objective, they allow up to 3% of the PTV spine volume to receive 110%, and my plan only had
110% to a point.
Figure 11. Transverse view of maximum dose to a point.

Overall, I was pleased with how my plan turned out. I did encounter a few bumps in the
road, with Pinnacle crashing a few times, losing my work and having to start again (the entire
plans file got corrupted at one point in time). In spite of all of the road blocks, I enjoyed doing
this plan project because it made me think outside the box, and try different ways to push the
TPS. Below is my scorecard, seen in Figure 12, provided by ProKnow, grading how my plan did
against their objectives.
Figure 12. ProKnow plan study results for a supine CSI treatment plan.

Self-Reflection:
This assignment was very challenging at first, because I have never seen nor treated a
CSI patient before in my 8 years as a radiation therapist. I kept remembering the “old school”
CSI technique, with feathering and gap calculations being necessary, but with newer techniques,
it negates the need for gaps and actually benefit from overlap, so this was a new concept for me.
I’m glad we had this assignment, so now I have a much better understanding of CSI treatment
planning, and depending on where I get a job, I will have some experience on how to plan them.
 References

1. Vann AM, Dasher BG, Wiggers NH, Chestnut SK. Portal Design in Radiation Therapy.
3rd ed. Augusta, GA: Phoenix Printing; 2013.
2. Rajan R. Craniospinal Irradiation – Part 1. [PowerPoint]; 2016.
3. Eaton BR, MacDonald SM, Yock TI and Tarbell NJ (2015) Secondary Malignancy Risk
Following Proton Radiation Therapy. Front. Oncol. 5:261. doi: 10.3389/fonc.2015.00261