Craniospinal Irradiation (CSI) Assignment

Patient positon is extremely important. Pretend I am the dosimetrist called to go into the
simulator and assist with the CSI setup.
1. Is the patient a child or an adult? What might you have to do differently based on the size
and age of your patient?
The positions, field planning, immobilization setting and devices are different based on
the size and age of the patient. So starting in simulation room, I have to evaluate the
situation to get good setup for the planning process.
Typically, a prone positon is used for CSI.1 However, many patients with the disease
could not tolerate prone positions or may need anesthesia access, so patients can only be
simulated and treated with a supine position. There are pros and cons between supine and
prone positions. The treatment time should be considered with the two positions as the
patient must maintain the stable position for longer time with prone position during
treatment. Mostly supine position is more preferable than prone position in general. Due
to the limitation of the collimators and maximum field size (40x40cm), adult patients are
treated with two spine fields while the pediatric patients can be treated with one spine
field at typical 100 cm TSD or at extended distance. Additional immobilization device
may be also needed for pediatric patients.
Other than a thermoplastic head mask for all patients with CIS irradiation, an additional
customized thermoplastic headrest for pediatric patient may be used for better control of
head rotation and chin extension.2
2. How will the patient be positioned? Supine or prone? After describing which orientation,
include all the devices used. Describe head position, chin position, arm position, how will
you assure your patient is aligned? List everything that you would check before leaving
the CT. sometimes a board is placed under the lower torso, describe if this will be used
for your patient and why or why not?
My patient was an adult male in a supine position with head to gantry first. He did not
need anesthesia access which makes more flexible for simulation. Based on his body
length, cranial, upper spine and lower spine fields would be needed. He was placed on an
indexed head and shoulder board on the table with head and neck aquaplast mask. The
head and neck mask pulls down the shoulders to give more room for field planning. His
lower torso (legs and feet) were immobilized on a Vac-Loc bag registered to the table to
keep a reproducible straight axial alignment. Head is at neutral position with chin slightly

extended. Here the chin extension should be considered to avoid the exit divergence
between cranial field and superior boarder of upper spine field. Arms were down at the
sides of body. Three laser lights: sagittal and bilateral lights to align the body in a straight
alignment. The patient was marked with three tattoo dots at each field setting point: head,
chest, and pelvis. The head is marked over vast. Find the level of C2 possible for brainspine match location, and the L2-L3 insterspace level where is the splitting spine field
area. Before I leave the room, I should check the right position, right immobilization
devices, right isocenter setup, the patients condition on the table for treatment with that
position, patients approximate length for planning, and the obtained adequate CT
scanning images for planning. I also need to check if the patient has pacemaker or some
metal rods in spine, and if the patient has claustrophobia with the mask on.
In an uncommon situation, a higher energy (16 MV) may need to be considered if the
patient size is large with deep treatment depth.

Figure1: simulation settings (image from TPS at Strong Memorial Hospital Radiation
Oncology Department)3

The following questions are generic CSI questions?

1. How is the spine matched to the head ports for a craniospinal setup? Give the formula
used to determine any angles and give an example of using the formula. Provide a
diagram or drawing.
After creating the fields to brain and upper spine, I manually moved the spine field to
make the superior boarder of the field to abut to the inferior boarder of the brain field.
I checked the frontal and sagittal views to make sure all alignment matched well. I
then calculated the brain collimator angles and couch rotation angles by using the
formulas: 1,3,4
Brain coll angle = arc tan [ length of spine x (1/SAD)]
34 cm
2
=arc tan
=9.6
100 cm
Spine couch angle = arc tan [ length of brain x (1/SAD)]
25 cm
2
=arc tan
=7.1
100 cm

Figure 2: Sagittal view of a brain field. The inferior boarder of brain field is set as low in neck as possible
without touching the shoulders but has enough space for shifting (1.5 cm for total of 3 cm with two shifts
in my case) where is usually at C2.

Figure 3: Collimator and couch rotation to align diverging boarders. 3

Figure 4: Sagittal view of brain, upper spine, and lower spine fields match.

Figure 5: coronal view of brain, upper and lower spine fields match after adjusting collimator and couch
angles.

Figure 6: transversal, frontal, and sagittal view of field match.

2. If you wanted to remove and divergence from the eyes in the cranial port, how would
this be accomplished? Why would you to this? Show a formula and how it can be
used? Provide a diagram or drawing.
In my plan, I just used MLC to block the lens to protect the eyes. If I need to remove
and divergence from eyes, I can manually move the isocenter to the eyes area with
minimal divergence at isocenter and blocking the lens with MLC to protect eyes.
Another way is to move the gantry angles by calculating the angles:3
Gantry angle = arc tan [ length of brain field width x (1/SAD)]

=arc tan

7.58 cm
100 cm

=4.3

Then the new gantry angle for right lateral field is 270 +4.3=274.3
The same calculation to the left lateral field but reversed way: 90-4.3=85.7.

Figure 7: the distance from the eyes to isocenter.

3. For treatment planning, approximately where will you place the isocenter for each
field for the patient above, will the isocenters be moved? Why or why not? What are
the approximate field boarders?
The isocenters were set with the same lateral couch position if the isocenter shifting
technique was used.1 The brain isocenter was placed in the simulation as the reference
point for planning the isocenters in spine fields. I initially put the isocenters for each
field at the geometric center of each field. I did not move the isocenter through the
planning process because I used junction shifting technique to feather the
gap/junctions without moving isocenters. The approximate field boarder for brain
field is 2 cm margin of brain and inferior boarder for brain-spine match at C2, and the
upper spine field is superiorly abutted to brain boarder, bilateral 2 cm margin frim
spinal cord and inferiorly at the upper-lower spine was at L2-L3 interspace where is
the end of the spinal cord, the lower spine field is superiorly abutted to upper spine
boarder, inferiorly 2 cm beyond PTV which is approximate at S2, and bilateral 2 cm
margin to spinal canal which makes the field wider than upper spine field.

Figure 8: coronal view of the field match and boarders.

Figure 9: sagittal view of field match and boarders.

4. If low spine ports must be matched due to the length of the spine, tell me how you
would accomplish this and how would you assure that there is no overlap?
I created a lower spine field right below the upper spine field and locate the isocenter
where the superior boarder overlaps with the upper field at a point in front of the
spinal cord to avoid possible hot spot in spinal cord. I measured the depth of the
overlap from skin surface which was 7 cm. I then calculated the gap by using the
formula:3
LupperD
34 cm
7 cm
2
2
Gupper=
=
=1.19cm
SAD
100 cm

LlowerD
22 cm
7 cm
2
2
Glower=
=
=0.77cm
SAD
100 cm
So total gap is Gupper +Glower=1.96 cm
I magnified the sagittal view of the spine fields. was then adjusted with the gap. I
measured the skin surface1.96 cm vertically down below the inferior boarder of the upper
field, and then adjusted the superior boarder of lower spine (Y2) to that point. I used a
plastic ruler along with the inferior boarder of the upper field to see if the line overlaps
with the superior boarder of the lower field right at the point I planned, which it matched
well.
5. If feathering the gap is required between 2 fields, what does that mean? Can you
describe how this could be accomplished? (provide details as if you had to explain
exactly what will be done to the radiation therapist who is treating the patient)
The dose at gap area is inhomogeneity which the dose is cold before overlap and
hot after overlap. So feathering the gap between the brain-spine and spine-spine
fields to smooth the dose in junction area between fields for the purpose of conformal
dose distribution in the body. I used the junction technique which shifts 1.5 cm for
two shifts with total 3 cm shift inferiorly to superiorly with no change of superior
boarder of brain field and inferior boarder of lower spine field. For each shift change,
I copied and pasted the previous plan to track any changes and possible mistakes.

Figure 10: feathering shifts.3

Figure 11: The final result of feathering after two shift.

References:
1. South M. Using composite planning and delivery with feathered junctions in
craniospinal, Brain-Spine and spine-spine abutted fields. [PowerPoint]. La Crosse,
WI: UW-L Medical Dosimetry Program; 2016. Accessed June 24, 2016.
2. Peterson JL, Vallow LA, Kim S, et al. A smart setup for craniospinal irradiation. Progress
in Medical Physics. 2013;24(4): 230-237. http://dx.doi.org/10.14316/pmp.2013.24.4.230
3. Donatello R. Gap caculations & Divergence corrections. [PowerPoint]. Rochester, NY:
Strong Memorial Hospital Resident Radiation Oncology Department Education
Program. 2016. Accessed June 24, 2016.
4. Stupski M, Donatello R. Craniospinal irradiation & Planning. [PowerPoint]. Rochester,
NY: Strong Memorial Hospital Resident Radiation Oncology Department Education
Program. 2016. Accessed June 24, 2016.
5. All process was guided and evaluated by MDS Mary Henry from Strong Memorial
Hospital Radiation Department on June 24, 2016.