Lisa Stevenson

CSI Project

Craniospinal irradiation is a treatment technique in which the entire

CNS is treated using parallel opposed lateral brain fields in conjunction with 2
direct posterior spine fields.

CSI can be treated in a prone or supine

position. The traditional prone technique, which is utilized at the center

where Im employed, allows for direct visualization of the field junctions.
However, it can be uncomfortable for some patients and does not allow for
easy access to patient airways when anesthesia is used. To remedy this,
patients may be treated in the supine position. The following case is an
adult Medulloblastoma case that will be treated to 36 Gy in 1.8Gy
increments for 20 fractions.
Simulation/ Treatment Planning
Prior to bringing the patient into the CT Simulation area, it is necessary
to prepare the room and all of the immobilization devices necessary to treat
a CSI patient. The table should be equipped with a prone headrest that
extends the neck while supporting the jaw and forehead to allow
unobstructed respiration, a Vac Loc bag for the abdomen, and a knee
support. A thermoplastic mask is also needed along with a pre-heated water
bath.
After retrieving the patient from the waiting room and thoroughly
explaining the simulation procedure, carefully help the patient onto the table
in the prone position. The patients face should fit comfortably into the face
holder while their neck is hyperextended enough to prevent the superior PA
spine field from exiting through the mandible and oral cavity while not flexed
enough to create excess skin folds on the back of the neck. 2 Once the
patients head is in an optimal position, arrange the patients arms by their

sides, place the knee support, and then visually straighten their spine using
the room laser. Once the patient is straight and in a comfortable position,
the compressor can be hooked up to the Vac Loc bag that is positioned under
the patients abdomen. While the air is being removed from the bag, form
the bag around the patient in an effort to create a mold that will support and
aid in immobilizing the patient during daily treatments. The Vac Loc molds
are an essential piece in the patients set up because the prone position is
known to be uncomfortable. Creating a mold greatly increases patient
comfort as well as the likelihood that they will remain in their treatment
position.

In some cases, it is necessary to place a board under the cradle to

build up the lower torso so that the head and torso are on the same plane
and there is less curvature in the spine. After the Vac Loc has been
satisfactorily constructed, the mask can then be heated in the water bath,
fitted onto the back of the patients head, clamped to the table, and allowed
to cool and harden.
After the patient has been positioned and all immobilization devices
have been constructed, the CT images can be acquired. This field needs to
start above the skull and continue all of the way through the mid pelvis using
3mm cuts. The physician and dosimetrist are then called into sim to set the
treatment fields. The superior spinal field is placed first and set to 40 cm.
This is the maximum collimator setting available on the Varian Trilogy Linac
which is used to treat all of our CSI cases.

The superior border should be

extended about 2 cm superior to the shoulders but not high enough to allow
the beam to exit through the mandible/oral cavity. Placing the field border 2
cm above the shoulders allows for the field to be feathered by reducing the
length on each end by 1cm twice (after every 9-10Gy of treatment) without
allowing the cranial beams to treat through the shoulders. The lateral edges
should extend 1 cm from the pedicles of the spine. Once this field is
determined then the isocenter can be locked.

The inferior spinal field is defined next. The superior edge of the field
should intersect the superior spine field at the level of the anterior spinal
cord to prevent the beams from overlapping in the cord creating an
overdose.2 This creates a skin gap on the surface of the patient from The
inferior edge of the field extends to the bottom of S2. My facility uses a half
beam block for the initial phase of this field to further limit dose to areas
beyond the cord due to beam divergence.4 The width of the field should be
extended 1-2 cm to include the sacral nerve roots.

This field is feathered

twice (every 9-10Gy) by extending the superior edge of this field 1cm while
leaving the inferior edge stationary. The 1cm increase in the superior border
of this field always corresponds with a 1cm decrease in the inferior border of
the superior spine field. The gap measurement does not change. To find the
gap calculation the following formula is used3:
(Length of field1 /2)(depth of dose specification/SSD1)=S1
(40/2)(6/100)= 1.2
Length of field 2 /2)(depth of dose Specification/SSD2)=S2
(11/2)(6/100)=.33
S1 + S2 = Field gap on skin surface
1.2+.33+=1.53cm

Now that the spine fields have been defined, the parallel opposed
cranial fields can be set up. The cranial fields require a collimator rotation of
9-11 degrees to match the divergence of the spine field thus preventing
overlapping dose in the spine. The collimator is easily calculated using the
following equation4:
tan-1= half of field length/100

tan-1=20/100=11 degree collimator rotation off axis.

After the collimator angle is applied to the spine fields, my facility also uses a
table kick to avoid divergence of the whole brain fields and the superior
spine field. The degree of the couch kick is found using the following
equation4:
tan-1= half field length/100= 10/100= 6 degree couch rotation

After calculating the beam and table angles, the field edges can be
defined. The lower border of the whole brain fields are extended to abut the
superior edge of the spine field. This border is feathered every 9-10 Gy by
increasing the inferior cranial border by 1cm while decreasing the superior
spine border by 1cm.4 Furthermore, the gantry can be angled up a few
degrees on each lateral field until the contoured eyes align, limiting dose to
the contralateral eye.2 The physician then draws blocks. The anteriorly the
block begins .5cm inferior to the projection of the cribriform place, 3cm
posterior to the ipsilateral eyelid surface, and extends 1 cm inferior of the
middle cranial fossa floor. Once this field is defined, the isocenter can then
be marked.
Once all of the fields are defined and isocenters have been marked, the
isocenter coordinates can be sent to the lasers in the CT sim and the
isocenters can be marked on the patients skin and mask for daily set up. Set
up photos must be taken and detailed notes regarding the patient set up
must be documented for the therapists to use on the first day of treatment.
Treatment Planning:
Once the treatment fields have been marked and defined in CT
simulation, treatment planning can begin. Three isocenters were defined in
simulation. These included the brain isocenter assigned to the lateral brain
fields, superior spinal field isocenter, and inferior spinal field isocenter. A
prescription was assigned to each area for 3.6Gy delivered in 1.8Gy daily
increments for 20 fractions. The brain field was calculate to the brain field
isocenter. The spine fields were prescribed to their respective calculation
points and the calculation points were adjusted until the desired coverage
was achieved while limiting the maximum dose as much as possible. The
beams were then calculated.

The brain fields was normalized to 100% and hot spots were forward
planned out using the field in field technique. The maximum dose point after
forward planning was less than 105%. All OR tolerances were met as
reflected in the chart below.
The superior and inferior spine fields were very hot so to reduce
maximum dose points, both plans were increased from 6x to 20x, normalized
to 105%, and then maximum dose regions were decreased through the use
of a field in field technique. The maximum point dose was 108% and all dose
constraints were met.

105% (red)

100%
(cobalt)

98%
(turquois)

95% (yellow)

90% (green)

80%
(orange)

60%
(maroon)

Organ

Constraint

Dose Achieved

Right Lens
Left Lens
Total lung
Spinal Cord
Heart
Liver
Right Kidney
Left Kidney

5Gy
5Gy
V2030%
50Gy
Mean 26Gy
Mean32Gy
Mean15-18
Mean15-18

3.6Gy
3.5Gy
22.3%
38.6Gy
19.8Gy
9.2Gy
5.9Gy
1.8Gy

Spinal
Cord
R Lens
L Lens
Heart
Liver
R Kidney

Treatment
The first day of treatment, the therapists must place all immobilization
devices (head holder, mask, Vac-loc abdominal cradle, knee support) on the
treatment table and position the patient the same way they were simulated.
The treatment position can be verified via the set up photos and set up page.
Once the patient has been placed in the immobilization devices, the
therapists must use the room lasers to line up the isocenters on the spine
and the mask to ensure the patient is completely straight prior to treating
any area. The brain field should be set up first and portfilms should be taken
to verify blocks and the isocenter. Once these fields have been approved,
the lower border of the brain field should be marked on the patients skin for

reference. Next, the superior spine field should be set to the isocenter tattoo
and appropriate SSD. GHCI always uses 100cm SSD for each spine field for
continuity, ease of calculation and to decrease the risk of set up error. The
superior field border of the upper spine should then be verified to ensure it
matches the lower brain border. The lower border of the upper spine field
should also be marked for reference after the portal images have been
verified. This will will be the upper edge of the skin gap. Lastly, the inferior
spine field should be set up using its isocenter and set to 100 SSD. The
Superior border should be marked and the gap should be measured to
ensure it matches the value calculated by dosimetry. In this case the gap
calculation shown above indicates a gap measurement of 1.53 cm. Once the
portal images and measurements have been verified, the patient can be
treated.
As previously described, these fields must be feathered every 9-10 Gy
which would equate to 2 junction shifts during the course of treatment. Each
junction shift would need to be verified using the same procedure used to
verify blocks and isocenters on the first day of treatment. The isocenters will
not change, however the field borders will so the reference marks on the
patient will need to be updated.
Discussion
Although my center treats patients only with a prone technique, I was
very interested reading all of the information about the supine set ups. One
article of particular interest treated the patient in the supine position with a
posterior field that was set to 118 SSD which allowed the entire spine field to
be treated at the same time. This only left the craniospinal match line and
dramatically cut back on treatment time.

I was also interested to learn

about the different methods of prone CSI that can be used since Ive only
seen it treated using the method described in this paper.

Work Cited
1. Kahn FM. The Physics of Radiation Therapy. Third Edition. Philadelphia, PA: Lippincott,
Williams, and Wilkins; 2003
2. Chao, Clifford KS. Radiation Oncology Management Decisions. Third Edition. Philadelphia,
PA: Lippincott, Williams, and Wilkins; 2011
3. Bentel GC. Radiation Therapy Planning. McGraw Hill Professional; 1996.

4. Discussion with Leslie Boulay, Medical Physicist at Genesys Hurley Cancer Institute.
September 12, 2016
5. Cagle, Susan. Supine Adult Craniospinal Irradiation: A Case Study. Retrieved from online
web site: http://www.medicaldosimetry.org/pub/dd8a9fd0-ccd2-e86b-f842-79a28d93bbee
Accessed September 12, 2016