Shands James

6/26/2016
Clinical Oncology
Craniospinal Irradiation (CSI) Assignment
Patient Demographic and Positioning Questions:
1. Is the patient a child or an adult? What might you have to do differently based on the
size and age of the patient?
The patient is a 6 year old male. If the patient was larger and/or was an adult that could lay prone
then a prone set up could be more appropriate because the spine field may have to be split into
two fields. When using 2 spine fields the fields have to be matched using radiopaque skin
markers and imaging. Markers could be placed on the neck to match the superior spine port and
the lateral brain ports and on the patients back to match the 2 spinal ports.
2. How will the patient be positioned? Supine or Prone? After describing which orientation
include all of the devices used. Describe the head position, chin position, arm position how
will you ensure the 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. Why or why not?
The patient will be positioned in the supine position due the patients age. There is concern that
the child will not lie still so a more reproducible set up will be required as well as anesthesia.
The daily setup will require an aquaplast holder and mask, a headrest, and a knee cushion. The
headrest will serve to angle the patients chin for a more neutral position. A neutral position keeps
the mandible out of the treatment field and helps to prevent skin folds in the neck (reducing the
skin reaction). Furthermore, due to the patients size a Styrofoam board was used to build up the
torso so that the spine was in a more level position (shown in image below). The patients hands
and arms should be by their side (possibly with a strap to prevent arms from falling off of table)
for anesthesia access. Positioning marks will placed on the patients skin and face mask so that
the therapists can align the patient using the room lasers.

Image 1: The styrofoam board helps to level all of the vertebrae of the spine.

Generic CSI Questions:

1. How is the spine field matched to the head ports for a craniospinal setup? BE
SPECIFIC. Include formulas used to determine any angles and give an example of using
the formula(s). Provide a diagram or drawing.
Matching the spine field and the brain fields requires that each beams divergence aligned.
Because there are two different kinds of beams diverging in different directions, each direction
must be accounted for. The first direction the divergence of the spine field along the neck and the
divergence of the brain field in the same location. Figure 1 shows the brain field correctly
collimated so that its divergence matches that of the upper spine field.

Figure 2: Correct collimator angle for brain field.

The angle that should be used for the collimator on the brain field can be calculated from the
formula1:
1
Y [upper spine]
1 2
[ brain field ] =tan (
)
SSD
For example, the Y2 jaw setting on the patient is set to 20 cm so to calculate the collimator
rotation for the brain field the above equation can be used:
[ brain field ] =tan 1

10 cm
=5.7 degrees
( 100
cm )

The next divergence that must be accounted for is from the overlap of the two lateral brain fields.
This is fixed by kicking the table towards the gantry for each field. Figure 2 shows the
divergence of the lateral brain fields prior to kicking the table.

Figure 3: Divergence of brain ports overlap in same area as upper spine.

Equation 2 can be used to calculate the angle the table should be kicked to match the divergence
of the brain ports.1
1
Y [brain field]
1 2
[ couch rotation ] =tan (
)
SAD
So if the brain fields were set to 18 x18 cm fields then this equation could be used to determine
that:
[ couch rotation ] =tan 1

( 1009 cmcm )=5.1 degrees

The couch should be kicked 5.1 degrees toward the gantry to adequately account for the
divergence of the brain field as show in figure 3.

Figure 4: Gantry kicked to match divergence of spine field.

2. If you wanted to remove any divergence from the eyes in the cranial port, how would this
be accomplished? Why would you do this? Show a formula and how it can be used. Provide
a diagram or drawing.
The brain fields can be further adjusted to account for the divergence at the eyes. The purpose
for this is to spare the lenses which have a TD 5/5 of 1000cGy. To match the divergence at the
eyes the gantry must be angles so that the divergence of each field aligns behind the lenses of the
eyes. The formula that can be used to determine this angle is below:
1

[ Gantry ] =tan [

D
]
SAD

Where D is the distance measured from the bony orbit (in line with the lenses) to the central
axis. Using the angle provided by the formula, the gantry will be adjusted to block the lenses in
each port as shown in figure 4.

Figure 5: Angling the gantry enables the divergence of the brain ports to match and spare the lenses of the patient.

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 borders?
All isocenters should be placed near midline and on the same longitudinal plane. This will ensure
that shifts will be minimized. To further ensure shifting errors are reduced only whole number
shifts should be used whenever possible. There will three total isocenters- 1 for the lateral brain
ports, 1 for upper spine port, and 1 for lower spine port.
The brain ports should extend posteriorly and superiorly to provide flash around the whole head.
The anterior border should approximately follow the base of skull to include all of the CNS
tissue. The inferior border should extend to approximately C2. Whole brain fields are typically
treated with an SAD technique so the SSD will not be 100. The isocenter must be placed so that
the MLC can travel an adequate distance to correctly shape the field. It is also important that the
MLCs travel inferior to superior to make matching the brain fields with the spine fields easier.
If the patient is being treated with an SSD technique the isocenter will be placed on the patients
skin at an SSD of 100cm. When the patient is the supine position this puts the isocenter on the
table which can reduce the effects of table sag. The superior border of the spine field should
match with the brain field at the C2 vertebra. The inferior border should extend to the

termination of the thecal sac or S2. The lateral borders should extend 1-2 cm past the vertebral
bodies. The collimator should be turned so that the MLC travel laterally so dose shaping is more
convenient.
4. If two 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?
For larger patients, the spine field should be split into two separate fields. These fields will have
a gap near the posterior skin surface and an overlap deeper into the patient. The fields must be
matched so that adequate coverage can be achieved while still protecting the spinal cord. To do
this, you must calculate the depth at which the beams are to be matched so that there is no
overlap. The gap calculation formula can be found below2:
1
Depth 1
Depth
Gap= L1
+ L 2(
)
2
SSD 1 2
SSD 2

Where L1 is the length of the upper spine field and L2 is the length of the lower spine field. The
figure below can provide a visual depiction of a gap calculation on a patient lying prone. If one
of the ports was treated with isocentric technique then the depth would be subjected from the
SAD to find the SSD needed for the equation.

Figure 6: Prone gap calculation diagram.

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 what will
be done to the radiation therapists who is treating the patient].
As discussed in question 4, matching spine fields can leave gaps in coverage which lead to cold
spots and overlap in coverage which cause hotspots. One way to smooth out the hot and cold
spots is by feathering. Feathering means that the location of the junction between the upper
and lower spine field will be moved periodically so the coverage improves and the hotspot is
reduced. The junction is shifted by adjusting the jaws of each field, but the isocenter remains in
the same place. For example, you would add1-2 cm (per plan) of length to the upper spine field
and subtracting the same amount of the lower spine field at a prescribed interval of fractions (say
3-5 fractions for example). The total length of spine treated doesnt change but the junction of
the spine fields changes location thus moving the hot and cold spots. After shifting the junction a
few times the fields go back to their original size and the process starts over. The figure below
provides a visual depiction of the process.

Figure 7: The process of feathering shifts the junction of the two spine fields.

As shown in Figure 6, the length of spine stays the same (40 cm) while the individual field sizes
will adjust. After the upper spine field reaches 24 cm, the fields will go back to 20 cm for the
next feathering day. Visual marks should be placed on the patient so that the shift can be made
accurately each feathering day. This process can also be used at the junction of the upper spine
and brain fields as well.
References
1. Michalski JM, Klein EE, Gerber R. Method to plan, administer, and verify supine craniospinal
irradiation. J Appl Clin Med Phys. 2002; 3(4):310-316.
2. Munshi A. RT Techniques in Medulloblastoma. [PowerPoint]. Tallahassee Memorial
Healthcare Radiation Oncology Department.
3. South, M. Using Composite Planning and Delivery with Feathered Junctions in Craniospinal,
Brain-spine and Spine-spine Abutted Fields. [PowerPoint]. Methodist Cancer Center. 2012.