Bijoy Anand CSI Project October 04, 2017

Introduction:
Medulloblastomas and other primitive neuro-ectodermal tumors, high grade ependymomas, etc.
need treatment to the entire craniospinal axis.1 This technique is known as Cranio-spinal
Irradiation (CSI). The treatment field encompasses the whole brain and spine. It is typically so
large that it cannot fit even in the largest jaw size available; so we need to split the fields and use
multiple isocenters. The various fields have to be matched precisely at the junctions to avoid hot
spots and cold spots. Typically, the match-lines have to be staggered over the course of the entire
treatment to smooth out the dose overlap at the junctions. All these considerations make the CSI
treatment planning a challenging project.

There are many different treatment modalities available for delivering CSI: (1) 3D Conformal
matching fields (Traditional method), (2) IMRT/VMAT, (3) Tomotherapy, and (4) Proton
therapy.2 My preceptor did not recommend IMRT/VMAT for the simple reason that one would
not want to irradiate the entire circumference of the torso when a simple PA field would suffice
for treating the spine. The IMRT technique leads to a much higher integral dose. We do not have
Tomotherapy here at our clinic, but if we did, it would not be the chosen modality for the same
reason.

At our clinic, The University of Florida Health Proton Therapy Institute, proton therapy is the
preferred method for treating CSI cases. For completeness of my training, my preceptor initially
directed me to learn the traditional 3D conformal method. I tried that and will present the details
in a separate section below. She also taught me how to make a CSI plan using proton beams. I
will present this as well. The main advantage of treating with proton beams is that we get very
little exit dose. Thus, it is better at sparing the organs at risk (OR).

After deciding which method, next I had to choose which position Supine or Prone. Each
technique has its merits. I chose the prone position because:
1) Therapists have easier access to the spine, and can physically palpate the spinous
processes and verify that the patient is lying straight.
 2) The therapists can see the field outlines on the patients skin, hence it would be easier for
them to verify the line matching.
3) In prone position, gravity causes several critical organs (e.g., heart, bowel, etc) to fall
away from the target volume (the spine in this case). This additional separation helps us
achieve better dose sparing to the OR.
4) This is the way we treat CSI patients in our clinic.

The main advantage of the supine position is that it is more comfortable for the patient, thus this
may lead to a more reproducible set-up. Also, supine position is better for pediatric patients who
require anesthesia, because the intubation is a lot easier when the patient is face-up.

Planning Details (Fields, energy, blocks, set-up gantry angles, couch-kick, etc.) :

The prescription was 36 Gy in 20 fractions. Two target volumes were provided: PTV_Brain and
PTV_Spine. For planning purposes, I had to split PTV_Spine into two segments Superior
spine and Inferior spine. Their boundary was chosen just below the second lumbar spine, L2. My
preceptor advised me that we should choose the match-line below where the spinal cord ends to
avoid under-dosing or over-dosing the cord this typically can happen at the junctions if the
matching of the fields is not perfect.

A) 3D conformal photons

I measured the field lengths first to determine whether we could use the newer TrueBeam
with thinner collimator leaves. But, due to the limitation of the maximum jaw sizes available
it was discarded. The photon plan was made on an Elekta Synergy machine using
RayStation treatment planning system (TPS).

Two opposed lateral fields were used to treat the cranial volume and two PA fields were
used to treat the spine. Care was taken to choose the inferior border of the cranial field so
that it was extended below the second cervical vertebra, C2. We also want to make sure the
field does not pass through the patients face (i.e., goes below the chin). The choice of
isocenter for the cranial field was such that it was at the mid-point of the line joining the two
canthii. This was done to eliminate any divergence at the lenses.
In order to minimize the patients treatment time, we want as few isocenters as possible. We
definitely need one for the cranial field. This was chosen as described above. For the two
spinal fields, the location of the isocenter in the Sup-Inf direction was set to be the near mid-
point of each segment. In the L-R direction, they were kept at the same value as the cranial
isocenter.

The superior spinal field was too large to fit in the jaw size (30x40 cm) at 100 SSD. So,
extended SSD set-up was necessary. By measuring the length of the superior spine segment,
I was able to determine that 110 SSD would suffice. Accordingly, the location of the
isocenter in the Ant-Post direction was determined. The inferior spinal field was set to 100
SSD. This was for the ease of set-up for the therapists as they can just set the laser at the
skin surface for this.

For the 2 opposed cranial fields, an energy of 6MV was selected. But, for the spinal fields,
we chose higher energy to cool the plan. 10 MV was still giving a hot plan, so we went to 15
MV beams for these. Couch kick was calculated from knowing the field length of the cranial
field using the tangent formula. This couch rotation helped us eliminate the caudal beam
divergence of the lateral cranial fields. After putting in these values into the TPS, their
accuracy was verified on the screen images and fine tuning adjustments were made to match
the beams.

Please note that the technique of rotating the collimator to help reduce dose to the eyes as a
result of beam divergence was not needed since we had selected the isocenter at the mid-
point of the two canthii. However, we did use this technique when planning the proton
beam where the brain isocenter was taken to be the center of PTV_Brain.

I should mention one other thing: whenever possible, we try to choose the isocenter such
that the shifts are in whole numbers, e.g., 31 cm, 6 cm, etc; and not 4.7 cm, 11.3 cm etc.
This is done to help the therapists. It helps prevent human errors. For the same reason, I am
advised to choose numbers with bigger hash marks on the ODI such as 110 cm, 115 cm etc.
 Table 1: Showing the Fields and their respective gantry angle, couch and collimator
positions.
Fields Gantry Collimator Couch Energy
1A1 L_Lat 100 SAD 266 351.0 6 6 MV
1B1 R_Lat 100 SAD 86 10 352 6 MV
2A1 Sup Spine 110 SSD 0 0 0 15MV
3A1 Inf Spine 100 SSD 0 0 0 15MV

Figure 1: DRRs showing the 2 lateral brain fields and the MLC blocking used for these fields.
Superior PA spine field: Gap calculations were performed for the fields to meet at the anterior
aspect of the spine. The superior spine field was matched superiorly with the 2 lateral cranial
fields and inferiorly with the inferior spine field. Then this match-line was shifted by 1 cm
inferiorly, and then again a third match-line was created by shifting another 1 cm inferiorly.
Images showing the matching are provided.

Figure 2: DRR showing the superior spine field. There are no blocks necessary for kidneys,
liver, or any other OR.
Inferior PA Spine field: The superior border of this field matches with the inferior border of the
superior spine field. As mentioned above, the 3 match-lines (each 1 cm apart) were utilized to
smooth out the dose at the junctions. The inferior border of this field was at 1 cm below
PTV_Spine.

Figure 3: DRR showing the inferior PA spine field.

Figure 4: Matching of the inferior lateral cranial fields with the superior border of the Superior
spine field
Match-line

In the cranial fields, blocking was done very tightly to reduce the dose to the lens. However, the
target volume should never be blocked. A block margin of 1 cm was made for the spine fields.
Care was taken to ensure that the MLCs were not blocking the field borders in order to allow for
proper dose at the field junctions.

Calc points were chosen for all field in such a way that they were in the coldest region. This way,
later on when I applied the field-in-field technique to carve out the dose from the hot spots, it
would not be blocking the calc points.
Figure 5: Coronal image of the cranial lateral fields showing non-divergence:

Match-line

The treatment goals were that both PTVs should receive the prescription dose of 3600 cGy to at
least 95% of the volume. Also, we were to keep the global maximum dose to less than 110% to
no more than 5% of the volume. When the dose was first computed after setting up the field
matches, I found that the junction were colder than the rest of the volume. So, one of the two the
field border was opened up slightly (1mm) and dose was recomputed. This eliminated the cold
spots at the junctions.

Initially, there were hot areas exceeding 120%; one such notable area was in the posterior side
near the base of skull. I used field-in-field technique to carve out the dose from hot spots. For
this I had to add a few more segments to each beam. I did this till the hot spots came close to the
calc points.
Figure 6: Axial image of the brain showing the isodose distribution - at the level of Calc Point.

Figure 7: Sagittal image of entire treatment volume showing the isodose distribution
Some other planning notes:

Earlier I had mentioned that three match-lines were created - each 1 cm apart to feather the
joins. I would like to clarify that for the superior spine field this adjustment was less than 1cm
because of the extended SSD; in reality it was 0.9 cm (1 cm *100/110 = 0.9cm).

The MUs for each fraction was split into 3 nearly even parts and allocated between the 3
segments for the each of the match-lines. These segments along with the field-in-field segments
were then combined into one beam. All 20 fractions will deliver the same fields, and the
feathering is being done within the segments of each beam.

Some small adjustments were made to each of the fields wherever necessary in order to improve
coverage and reduce dose to OR. This was done by making manual changes to the blocks, i.e,
moving collimator leaves by hand.

B) 3D conformal using Proton beams

This technique was very similar to the photons. One change was that the brain isocenter was
chosen in the center of the brain. So, the collimator rotation was utilized to match the beam
divergence at the eyes. The other major difference was that we added a cranial PA beam to the 2
cranial lateral beams. This was done to cool off the plan; without this the dose levels in the
PTV_Brain were much higher.

Given the large treatment volume, we chose the largest snout size available 30x40 cm.
Uniform scanning proton beam was used as double scattering could not accommodate this large
size. There are no MLCs in the snout; the blocking is done by milled brass apertures and acrylic
range compensators are used to adjust for tissue thickness and density variation. For the same
reason (since there are no MLCs), we cannot have a Field-in-Field technique for proton therapy.

(Since the system has shut down for upgrade, I could not get screenshots from Eclipse today. I
will get them tomorrow and add them to this report.)
4. Embed your ProKnow plan score sheet. Discuss if tolerances could be achieved, and if not,
why not? :

All required tolerances were achieved except:

The dose to left and right lenses we used distal blocking and were able to get these
down to ~ 14 Gy still a far ways off from 7 Gy.
The dose to the left and right optic nerves these were hard to distal-block as they are
within the target volume.
The minimum requirement for the hotness 110% isodose line covering PTV_Brain (<
5%) was met, but not the ideal (0%).
The same for PTV_Spine.
Ideally, we wanted > 95% of the target volume covered by the prescription dose. We
achieved this for PTV_Brain, but fell a little short for PTV_Spine (94.02%), still meeting
the minimum requirement of 90% coverage.
5) Provide a DVH with the CTV/PTV and all surrounding critical structures.

I have pasted a screen-shot of the DVH from Eclipse. I have turned the orientation to landscape
to better fit in the page; sadly, I was not able to resize the column widths in Eclipse (not sure if
the facility is available).

Lens_Lt Lens_Rt

PTV_Spine

PTV_Brain

OpticN_Lt

OpticN_Rt

Lungs Lt & Rt
6) Provide a reflection on what you learned from this planning assignment.

This was a really good learning exercise. I started with the traditional method where I learned
how to make matching field borders for the first time. I had to apply this concept when I did the
proton fields next. I also learned about feathering.

It was my first experience in planning with proton beams. The sharpness of the distal penumbra
is really something! It makes dose to OR much easier to control. For example, I was able to get
the thyroid and esophagus dose to within the desired constraints; this was something I was not
able to achieve with 3D conformal photons.

I also started learning how to use Eclipse for the first time as we use Eclipse for proton planning
here at UFHPTI.
References:

1. Stieber VW, McMullen KP, Munley MT, et al. Central nervous system tumors. In: Levitt
SH, Purdy JA, Perez CA, et al. eds. Technical Basis of Radiation Therapy. 4th revised ed.
Berlin, Germany: Springer-Verlag; 2006: 444-452.

2. Brain and spinal cord tumors in adults. American Cancer Society.

https://www.cancer.org/cancer/brain-spinal-cord-tumors-adults/treating/radiation-
therapy.html Last revised January 21, 2016. Accessed 10/03/2017.