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Jenny Huang
Clinical Practicum III
October 17, 2018
Craniospinal Irradiation
Introduction
Craniospinal irradiation (CSI) is a form of radiation treatment for the management of
intracranial tumors to the entire cranial-spinal axis, where the cerebrospinal fluid (CSF) flow that
includes the brain and the entire spine. In radiation oncology, CSI is considered one of the
technically challenging treatment techniques, with the potential for treatment field overlap and
gaps to yield unacceptable dosimetric heterogeneity.1
There are many treatment approaches that can be used such as 3D conformal radiation
therapy (3DCRT), intensity-modulated radiation therapy (IMRT), volumetric modulated arc
therapy (VMAT) or proton therapy. At Austin Cancer Center (ACC), we prefer to treat patients
in the prone position when possible. The advantage of treating in prone position is so that the
junction between the lateral brain fields and posterior spine fields can be directly and easily
visualize. The disadvantages of prone position are patient discomfort, dose inhomogeneity and
not easily reproducible. Prone position is not possible for patients requiring anesthesia and
causes restriction to airway and oral cavity. For this assignment, I chose to use the traditional 3D
conformal because it is the most commonly approach used in my clinical site and also well
documented in the literature.
Patient Setup/ Beam Geometry
Immobilization of patient is essential for consistent and accurate setup. Patient in prone
position was setup using a vac-lock bag with the head supported by face rest and an aquaplast
mask. A thin wedge was place under pelvis to reduce lumbar curvature (figure 1).
The treatment fields for CSI required two parallel opposed lateral brain fields, upper
spine and lower spine. The anatomy for the brain fields encompass the whole brain, cribriform
plate, and superior orbital tissue. Cribriform plate is the most important structure and should not
be shielded.2 In medulloblastoma, nearly 15-20% recurrence occur in cribriform plate because of
over shielding.3 In addition, the attempt to spare the lenses from developing future cataract may
result in under-dosage in this region and lead to treatment failure.2,4 Anatomy for the spine
encompasses the entire spine and thecal sac, which ends usually around S2.
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Figure 1. Prone position with aquaplast mask and vac-lock bag for immobilization.
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Whole Brain Irradiation

Patient’s head was slightly extended with the shoulder down to avoid the beam
divergence into the mandible and oral cavity. The whole brain irradiation consisted of two
parallel opposed lateral brain fields with 6 MV photon beam. The isocenter was placed near
center of the brain to minimize the divergence in the region of the eye and the cribriform plate.
Dose was prescribed and normalized to the reference point near the frontal lobe (figure 2). A
SAD setup was used for the brain fields where the right lateral SSD is 92.38 cm and the left
lateral SSD is 91.98 cm. The treatment field was 22 x 24 cm. The inferior border extends to C2
and C3.
Collimator and couch rotation were necessary to align the divergence of the brain lateral
beams with the divergence of the spine fields. The calculation for the angle of collimator rotation
θcoll = arc tan (0.5 x L1 x (1/SSD)) and couch rotation is θcouch = arc tan (0.5x L2 x (1/SAD)),
where L1 is the length of the upper spine and L2 is the length of the cranial field. The right and
left lateral beams had collimator of 169° and 191° respectively. This is determined in the sagittal
plane (figure 2). The couch angles were set so that the inferior borders of the cranial field
produced a straight line across patient’s neck in coronal view. The right and left lateral fields had
couch rotation of 174° and 186° respectively. The right lateral field had a gantry of 90°, while
the left lateral field had a gantry of 270°. Blocks were drawn to confirm the field to the PTV, to
block the lens of the eye, the optic nerve, and the posterior neck and to reduce the hotspots
(figure 2).
Multiple segments were applied to manage the hotspots. The hotspots tend to occur in the
anterior and posterior portion of the skull. Two field-in-fields for each beam were added to
reduce the hotspots.
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Figure 2. Right and left lateral brain with collimator angle of 169° and 191°. The lenses of the
eyes and optic nerves are blocked and the head is slightly extended. The magenta marker is the
isocenter and the green marker is the normalization point.

Upper Spine Irradiation

The depth of the spinal cord column was around 6 cm, and I decided to use 18 MV
photon beam to provide adequate PTV coverage and to reduce hotspots. The disadvantages of 18
MV are higher dose to anterior structures such as the esophagus, liver and bowel. The field size
for the upper spine was 6.5 x 40 cm, in which x1 at 2.7 cm, x2 at 3.8 cm, y1 at 20 cm and y2 at 20
cm. Blocks were drawn to block both kidneys, a portion of the liver and thyroid. The superior
border passed approximately at the level of C2and C3 and skimmed below the mandible. The
inferior border was placed between L2 and L3. The couch, gantry, and collimator were all set at
180°. The upper spine field was setup with SSD at 100 cm and the normalization point was at the
depth near the anterior/ superior surface of the spinal cord (figure 7).
I used MLC with 1.5 cm margin as the initial field (figure 3). Multiple segments were
applied to manage the hotspots at different depths of the spinal cord and also to block the thyroid
andboth right and left kidneys (figure 4,5). Once the plan was normalized, I kept adjusting the
location of the normalization point to achieve the best possible coverage.
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Figure 3. Upper spine irradiation. The spinal column was given MLC with 1.5 cm margin.
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Figure 4. Field-in-field to block both kidneys, thyroid and to reduce hotspots

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Figure 5. Field-in-field (control point 3) to block both kidneys, thyroid and to reduce hotspots
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Lower Spine Irradiation

To cover the entire length of the spine, the couch and collimator were rotated to 270°.
The gantry was rotated to 169° to match the diverging beam of inferior border of the upper spine.
The lower border of this lower spine covered the thecal sac around at the level of S2. This
position can be verified in the sagittal plane. The field size for the lower spine was 15 x 7.5 cm,
in which x1 at 6 cm, x2 at 9 cm, y1 at 4 cm and y2 at 3.5 cm. SSD setup was also used where
the isocenter was placed on the skin, and the normalization point was near the curve of anterior
portion of the sacrum (figure 7).
I also used 18 MV photon beam for lower spine because of the depth of the cord. By
looking at concavity of the sacrum, I was planning to apply an electronic dynamic wedge (EDW)
to obtain dose homogeneity. Since the EDW resulted in bigger amount of hotspot, I decided to
remove the dynamic wedge and instead I created a static field and blocked a small portion of the
lateral fields (figure 6)

Figure 6. Lower spine with partial blocked static field

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Figure 7. Isocenter, normalization point and Dmax

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Feathering
Junction between cranial-spine and spine-spine were moved feathered to spread the uncertainty.
Since there were 20 fractions, feathering was done every 7 fractions to smooth out any overdose
or underdose over a longer segment of the cord. This feathering was done caudally 1 cm every 7
fractions. The isocenter remained the same while the field size and the gap were adjusted (figure
8).

Right lateral brain

Right lateral brain, feather 1

Right lateral brain, feather 2

Figure 8. The feathered plan of the right lateral brain
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Result
Traditional CSI 3DCRT requires the development of multiple feathered plans to
distribute the dose throughout the spine. This consumes a lot of planning and delivery time.
Every few fractions a new plan must be delivered to match the lines.
The maximum dose of 5030 cGy (140%) was located anterior to C3 vertebrae, which was
not an ideal location but it was a better location than in the spinal cord itself (figure 9). The
cribriform plate was blocked while attempting to reduce dose to the optic nerves and lenses.
I met the ProKnow ideal requirements for the heart,left kidney, liver, right and left lung,
right and left lens, right and left optic nerve (figure 9). I could not met the ideal requirement for
right kidney and PTV spine V39.6 cGy < 3% that could be due to 3DCRT and 18 MV photon
beam. The DVH with OAR is provided in figure 10 to 13.
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Figure 9. Maximum dose of 5030 cGy at C4 as shown in this sagittal view

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Figure 10. ProKnow scoring sheet with PTV, OAR objectives and constraints

Figure 11. DVH of PTV brain and PTV spine

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Figure 12. DVH for PTV brain with OAR objectives and constraints
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Figure 13. DVH for PTV spine with OAR objectives and constraints
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Reflection
The outcome of this CSI assignment met the treatment goals (100% prescription dose to
cover 95% of both PTV brain and PTV spine). The goal for the PTV brain (V39.6 Gy < 3%) was
almost met at 0.101. I was unable to meet the PTV spine (V39.6 Gy < 3%) as my final result was
41.544%. This could be due to 3D-CRT with 18 MV. I also failed to meet the objectives for the
esophagus, bowel and thyroid. I would think the high exit dose of the18 MV caused the anterior
push of the dose coverage to those anterior critical organs. I would conclude that 3D-CRT do not
spare critical organ and result in patient toxicity.
If I were to plan another CSI assignment again, I would use either IMRT or VMAT
technique. Both IMRT and VMAT produce highly conformal dose, homogeneous dose
distribution, and patient can be easily treated supine or prone. The inverse planning incorporates
junction into optimization. Thus, both of these techniques provide the best PTV coverage and
OAR sparing.
For this assignment, I did not have the opportunity to discuss it with our physicians due
to our busy patient load and short staff. In the past, our clinic used 3D-CRT and for future
planning, they would like to use either IMRT or VMAT technique.
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References:
1. Jeff M. Michalski, Eric E. Klein, and Russell Gerber. Methods to plan, administer, and
verify supine craniospinal irradiation. J Appl Clin Med Phys. 2002;3(4):310–316. https://
doi: 10.1120/jacmp.v3i4.2555. Accessed October 13, 2018
2. Discussion with Ed McPadden, Chief Medical Dosimetrist at Austin Cancer Centers.
October 15, 2018
3. Jereb B, Krishnaswami S, Reud A, et al. Radiation for medulloblastoma adjusted to
prevent recurrence to the cribriform plate region. Cancer. 1984:54(3):602-604. PMID:
6733691. Accessed October 12, 2018
4. Parker WA, Freeman CR. A simple technique for craniospinal radiotherapy in the supine
position. Radiotherapy and Oncology. 2006:78;217-222. Accessed October 13, 2018
5. Craniospinal radiation therapy. Pediatric Oncology Education Materials Website.
http://www.pedsoncologyeducation.com/images/clip_image004_001.jpg. Accessed
October 13, 2018