CSI project

Ashley Coffey
Fall 2016
The technique used for this supine craniospinal is MLC junctions between all of the
fields. This eliminates the need to manually shift the patient and feather the junction through the
course of treatment. It makes the dose more conformal; it also makes it easier for the therapists
so they do not have to make a shift to gap the fields during treatment. One study performed by
Verma et al1 reported that supine position craniospinal treatment has the same survival benefits
as prone but less rejected set up films. This demonstrates that supine treatments do have a benefit
over prone in terms of reproducibility. At Virginia Commonwealth University Health Systems,
they work with the protocol ACNS0331 from the Childrens Oncology Group.2 Even if the
patient is not on the protocol, they follow the guidelines for radiation planning as if they were.

Machine Setup
At Massey Cancer Center, we position our patients supine if possible. It is easier for the
anesthesia team to work with and more comfortable for the patient. A thick styrofoam block is
placed under a VacLok and the patients body (excluding head) to help align the entire spine.
The cervical and thoracic spines have a natural curve to them and the block will help to get the
spine all on the same level to make the dose more evenly distributed. The patient is placed on
large, body length VacLok bag that is on top of the styrofoam and the patient is straightened with
the laser midline before making any immobilization. It is important to ensure the laser is
traveling down the nose, sternal notch, and umbilicus before proceeding any further. The
VacLok is formed around the body with the arms down by the sides. It is abutting the headframe
and an aquaplast mask is formed around the head and shoulders. The chin is tilted upwards and
the head is looking straight towards the ceiling before making the mask. A knee roll or cushion is
allowed under the knees but more common for older children/adults than young children.
Although we were given this data set and I cannot confirm exactly how the patient was set up,
below is how VCU will set up pediatric craniospinal treatments in supine.

Figurre 1 and 2: Patient

P
setup
p in simulation with styrrofoam blockks, body VaccLok bag, annd
head/sshoulder massk.
Selecting thiss position do
oes not requirre SSD set uup or a changge in dose caalculations ffrom
the typicaal conformal plan in the treatment pllanning proggram (SAD). The treatm
ment team
consistin
ng of therapissts, a dosimeetrist, and ph
hysicist are iin simulationn and place tthe isocenterrs by
measurem
ments. The brain
b
isocentter (green) iss placed nearr the ear andd in line withh the spine inn the
anterior/p
posterior dirrection. Then
n 20 cm is measured
m
from
m the brain iisocenter to mark the uppper
spine fielld (blue). An
nother 20 cm
m is measured from the uupper spine iisocenter andd is placed fo
for
the lowerr spine (yello
ow). All of these
t
points are in the saame coordinaates anteriorr/posterior annd
laterally; the only varriant is the superior/infer
s
rior coordinates. Since tthe dosimetrist is in
simulatio
on, there is no
n need to move
m
the isocenter. It is im
mportant to m
maintain onee directionall
shift (lon
ngitudinally) to keep the treatment frrom becominng overwhelm
mingly com
mplex. There is
also no need
n
for otheer shifts sincee the spine is centrally loocated.

Figure 3: Three isocenters placed in simulaation

Figurre 4: The beaam arrangem

ment used forr supine cranniospinal treeatments. Thhe 2cm overlap
junctio
ons can be seeen.

Target Delineation
D
According
A
to the protocoll, the CTV must
m containn the entire ccraniospinal aaxis. Althouugh
the spinee terminates around
a
L2, the
t canal witth cerebrosppinal fluid shhould be inclluded in the CTV
due to the nature of the
t disease. The
T PTV is an
a expansionn of the spinnal cord by 33mm; the braain
w then co
ombined in order
o
to evaluuate the covverage on thee DVH. The
and expaanded spine were
protocol allows for th
he spine to be
b expanded by 3mm to 1cm in totall. This allow
ws for some rroom
e
At leaast 95% of th
he 36 Gray dose
d
(34.2 G
Gy) should enncompass 955% of the PT
TV. It
in setup error.
also shou
uld be no hottter than 110
0% hot (39.6
6 Gy) in 5% of the PTV vvolume. Thiis plan meetss
both of th
hese criteria.2

Percent volume
v
of PT
TV receiving
g 100% dosee (36Gy)

93.13%

95% of th
he PTV receeiving 95% of
o the dose (34.2Gy)

99.75%

Less than
n 5% volumee of PTV recceiving 110%
% dose (39.66Gy)

0.01%

5 The isodosse line viewss from all th

hree planes. T
The red coloorwash repreesents the PT
TV of
Figure 5:
the brain
n plus spine//CSF with a 3mm expansion.

g
Planning
For planning,, I used four total fields: two for the brain, an uppper spine, annd a lower sppine.
The isoceenter for the brain fields is placed at about C2 annd laterally iin the middlee of the spinnal
canal. Th
his was the best
b location in order to encompass
e
thhe entire braain field as w
well as miss most
of the maandible. The jaws are op
pened anterio
orly and supeeriorly to flaash the entiree brain. The eyes

are blocked out inferior to the cribriform plate, diagonally through the external auditory canal,
and just anterior to the vertebral bodies. The collimators on the brain fields are also 11 degrees
offset in order to match the divergence of the spine field. The brain fields are nearly half beam
blocked; for supine setups with MLC intrafractionated junctions, the bottom of the field is
extended two centimeters in order to create the junction. This bottom couple centimeters
overlaps with the upper spine field, which is also has a junction of two centimeters at the
superior and inferior borders. The upper spine isocenter is placed 20 centimeters inferior to the
brain field and is opened to a 20x20cm field length from inferior to superior. The upper spine
then covers the entire vertebral bodies with a one centimeter margin on both sides. The superior
border is the brain junction and inferior is the lower spine field. The lower spine isocenter is then
placed 20 centimeters inferior to the upper spine isocenter and encompasses the spine to S2 and
the sacroiliac joints. The lower spine field utilizes a 90 degree table kick so the gantry can reach
under the patient in the supine position. The lower spine field also contains a two centimeter
junction at the superior aspect of the field. The only blocks used on the spine are the kidneys on
the lower spine field.
With these MLC junctions, the main block is copied twice (so there are three total,
identical blocks) and each block is equally weighted with 33.33% of the dose. The original block
is maintained, the second has one centimeter of MLCs completely closed outside of the field,
and the third has two centimeters of MLCs closed also outside of the field. It is important to
close the MLCs outside of the field in order to eliminate any MLC dose leakage. Making the
MLCs junction the abutting fields like this creates a smooth and acceptable dose distribution
across the field edges.

FIGU
URE 6-9: Allthough hard
d to see, the first
f
segment
nt is the origiinal block annd the last tw
wo
segmentss are blocked
d with 1cm and
a 2cm leav
ves. Any seggments in beetween were control poinnts to
push and
a cool dow
wn dose. It iss also noticed
d the weightting on the innitial and lasst two fields all
equ
ual 33.33%.

Calculation
C
points
p
were placed
p
in eacch field and aaway from aany blocked area. The
calculatio
on points aree placed in th
hese areas in
n order to recceive an acccurate dose reeading for thhese
fields. I calculated
c
my
m plan to a volume
v
insteead of to a pooint. At VCU
U, most of thhe plans are
calculated to a volum
me. When wee calculate to
o a volume, w
we choose thhe isodose liine that bestt
encompaasses the areaa of treatmen
nt. In this meethod, we noormalize thee prescriptionn dose to thaat
chosen issodose line (such
(
as 92%
% with the brrain fields) aand convert tthat to the noormal dose. This
makes th
he brain field
d 8% hot (100% of the do
ose at 92% iisodose line equals 8% ddifference orr hot
spot).

Figure
F
10: The
T prescrip
ption and cho
osen isodosee lines to norrmalize to arre above.

There
T
are a feew hot spots in the most posterior sooft tissue of tthe patient. T
They are in tthe
upper necck, near the junction
j
of the
t brain and
d supine, andd in the loweer lumbar sppine. Due to the
large brain fields and
d the junction
n of those MLCs,
M
the hoot spot was uunavoidablee. The MLCs can
only trav
vel 14.5cm accross a field, which meaant they closeed the junctiion inside thhe field but inn the
posteriorr neck. At thiis junction, the
t plan is where
w
the hotttest spot is llocated. Thee lumbar hot spot
is due to the natural curve
c
of the spine and haaving to presscribe to a loower isodosee line to receeive
verage. Afteer discussion
n with Ed Bu
ump (Septem
mber 28, 2016), these hott spots are
target cov
acceptable and in dessirable placees. It is comm
mon to have hot spots off up to 25% iin the posterrior
ue. The physiician preferss the hot spots to be locaated outside oof the spine and in the sooft
soft tissu

tissue in order to min

nimize damaage. In this plan, the hotttest pixel poiint in the PT
TV is only 100%
pared to the pixel
p
point outside
o
the tiissue (0.03ccc at 39.9Gy)).
hot comp

Figure 11: Many isodose levelss are represented here inccluded the hhottest spot. T
The 95% shoould
be huggin
ng the PTV and
a the hot spot should bbe kept out oof the spinal canal.

a Risk
Organs at
The
T organs att risk accord
ding to the prrotocol are thhe brain, cocchlea, hypothhalamus,
pituitary,, eyes, optic nerves and chiasm,
c
cerv
vical spine (fforamen maggnum to the top of C2), and
skin. Theey must be contoured bu
ut the protoco
ol does not ggive constraiints; it statess that these
structures should nott have a max
ximum dose that
t exceedss the PTV prrescription ddose.2 These
f a brain bboost of 54 G
Gy, which wee are not
organs att risk are maainly for wheen planning for
including
g.

Afterr discussion with

w Dr. Harrris, our ped
diatric and CN
NS specialisst (October 44, 2015), thee
organs to
o be aware of in planning
g the initial craniospinal
c
are bilaterall kidney andd lens. The
bilateral kidneys shou
uld not exceeed a mean of
o 14.4Gy annd the lensess should not rreceive more
than 6 Gy
y. Everythin
ng met on my
y constraintss and were appproved by the doctor annd dosimetrist. I
would lik
ke to decreasse the lens to
o 6Gy insteaad of 7Gy buut that could sacrifice myy brain coverrage.
Dose to any
a critical structure
s
in the
t body of a child shoulld be kept ass minimal ass possible.
Howeverr, with that being
b
said, th
he PTV coveerage shouldd not be comp
mpromised inn order to spaare
these stru
uctures. Thiss statement comes
c
from Dr.
D Harris annd can be foound in the ppediatric
CNS/cran
niospinal pro
otocol, ACN
NS1123, which he also foollows with his pediatricc patients.3

Figuree 12: DVH for

f PTV andd organs at riisk

Resources
1. Verma J, Mazloom A, Teh BS, et al. Comparison of supine and prone craniospinal irradiation
in children with medulloblastoma. Pract Radiat Oncol. Houston, TX: 2015;5(2):93-98.
http://dx.doi.org/10.1016/j.prro.2014.05.004
2. Bell E. ACNS Protocol ACNS0331. Childrens Oncology Group.
https://www.childrensoncologygroup.org/index.php/acns0331. Published June 28, 2013.
Updated January 27, 2016.
3. Leonard M, Dhall G, Bartels U. ACNS Protocol ACNS1123. Childrens Oncology Group.
https://www.childrensoncologygroup.org/index.php/acns1123. Published May 29, 2013.
Updated 2015.