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Shands James
DOS 773 Clinical Practicum III
October 5, 2016
Craniospinal Irradiation Project
Technique:
The technique that I chose for this project is a supine CSI with intrafractional junction shifts as
described by Michael South et al with a few adjustments according to the specific practice of
physicians at my facility.1 The patient is in the supine position for the practical purposes of
anesthesia access and preventing patient motion by increasing comfort. Like many other
variations of the CSI, this technique is composed of two lateral whole brain fields and two spine
fields. However, instead of using a gap between each field matching junction there is a 2 cm
overlap where field-in-fields will used to feather junction during each fraction. This technique
eliminates the need manually feather the gap every 9 Gy. In my plan, I used 5mm feathering to
cover the 2 cm field overlap of each junction.

Figure 1: For each field-in-field the junction was feathered 5mm over a 2cm gap.

Figure 2: Field junctions of all three field groups

I chose to put the isocenter for each field on the x and y coordinate. As a result, this treatment
plan uses an SAD technique for all of the fields. The advantage of this is that the only shift
between fields during treatment is longitudinal.
Table 1: Isocenter coordinates for each field set.

Field Name
Whole Brain Fields
Upper Spine Fields
Lower Spine Fields

X
0.5cm
0.5cm
0.5cm

Y
2cm
2cm
2cm

Z
-3.7cm
-31.3cm
-57.8cm

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Lateral Brain Fields:
When setting up the lateral brain fields it is important to account for the divergence of the upper
spine field to prevent hotspots at the junction. To match the lateral brain field to the upper spine
field the collimator and couch must be rotated. Field-in-fields were used to feather the gap with
the two 6 MV brain fields, but not with the 23 MV fields due to neutron contamination. Using 23
MV fields on the lateral brain ports helped to reduce the hotspots in the isodose distribution.
Table 2: Brain Port Set up information

Field Name

Gantry

Collimator

Couch

Beam Energy

LLAT Wh

87 deg.

350.2 deg.

5.0 deg.

6 MV

Brain
RLAT Wh

273 deg.

10.2 deg.

354.8 deg.

6 MV

Brain
LLAT Wh

87 deg.

350.2 deg.

5.0 deg.

23 MV

Brain 23x
RLAT Wh

273 deg.

10.2 deg.

354.8 deg.

23 MV

Brain 23x

The inferior border of the brain field was placed 2 cm inferior to the bottom of the C2 border to
create an overlap with the upper spine field which would be feathered. This also puts the junction
of the brain and spine fields further inferior so the exit dose is not concentrated on the mandible.
The anterior border includes fall off anterior to front bone and blocks just below the cribiform
plate and temporal fossa to ensure adequate coverage of the brain.2

Table 3: Brain Port Borders

Superior border
Inferior border
Posterior Border

Fall off
2 cm inferior to the bottom of C2
Fall off with blocking for back of neck to

Anterior border

reduce hotspot
Fall off in front of cranium

Figure 3:DRR of brain field

The brain fields are calculated using the isocenter location so the isocenter will receiving 100%
of the dose. However, the 100% isodose line for breakup near the center of the brain. This may
seem like a significant changed, but the 95% isodose line (green) shows full coverage of the
brain and spine.

Figure 4: Isodose distribution shows good coverage of the 95% isodose line (green).

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Upper Spine Field:
Table 4 shows the base upper spine field parameters. There are 3 other field-in-fields that are
included in the plan that feather the junction of the upper spine with brain fields and upper spine
fields with the lower spine fields. The collimator is rotated so that the MLC move in the superior
to inferior direction. These fields use 23 MV energy to reduce the hotspot on the plan. Because
the upper spine fields use all 23 MV energy, the field-in-fields were not merged so neutron
contamination can be reduced.
Table 4: Base Upper Spine Field Parameters

Field Name

Gantry

Collimator

Couch

Beam Energy

Upper Spine

180 deg.

90 deg.

0 deg.

23 MV

The superior border meets the brain fields with a 2 cm overlap that is feathered intrafractionally.
The junction between the upper and lower spine fields were designed to meet as low on the
spinal cord as possible which resulted in a junction at the L3 vertebra. However, a 2 cm overlap
is required for the lower and upper spine junctions as well so 2cm was added to the inferior
border. Approximately 1 cm of margin around the vertebral bodies was added to ensure all of the
spinal cord and cerebrospinal fluid is treated.2
Table 5: Upper Spine Borders

Superior border
Inferior border
Lateral borders

C2
L3+2cm for junction overlap
Approximately 1 cm lateral of either side of the
vertebral bodies

Figure 5: Upper Spine DRR- 1 cm margin around vertbral bodies

The upper spine field was calculated using the isocenter of the beam. The depth of the isocenter
was great enough to ensure that all of the spinal canal received at least 95% of the prescription
dose (pink line) while most of the target received 100% of the prescription (yellow line).

Figure 6: Isodose dstribution of upper spine field.

Lower Spine Field:

In order to match the lower spine field with the divergence of the upper spine field the gantry
must be rotated to 195.8 degrees which required a couch rotatation to 90 degrees. The collimator
was positioned so that the MLCs could travel superior to inferior while feathering the junction.
The depth of the spinal cord required a 23 MV beam to reduce the hotspots on the plan which
resulted in not being able to merge the field-in-fields.

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Table 5: Lower Spine Field Parameters

Field Name

Gantry

Collimator

Couch

Beam Energy

Lower Spine

195.8 deg

0 deg

90 deg

23 MV

The superior border of the lower spine field is found at the level of L3 which allows for the 2 cm
overlap of the spine fields as described above. Some sources say that the inferior border of the
lower spine field should be at the level of S2, however our physicians choose to extend the
border to S3. The lateral border of the lower spine expands to encompass the S vertebra as well
as L vertebra. 1
Table 6: Lower Spine Borders

Superior border
Inferior border
Lateral border

L3
S3
Approximately 1 cm lateral of either side of the
vertebral bodies of L spine and S spine

Due to the curvature of the patients spine and the angle of the gantry using the isocenter as the
calculation point is insufficient. Instead a calculation point was placed at midplane of S1 to
ensure the target received adequate coverage. Figure 6 shows the 95% isodose line covering all
of the spinal cord in the field.

Figure 7: Lower Spine Isodose Distribution

Figure 8: Lower Spine DRR

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Final Plan:
All of the dose constraints for this plan were met with the exception of the lenses. I found that it
was important to prioritize matching the upper spine and brain fields over matching the lenses
exactly. Practically this meant choosing to rotate the couch with respect to field matching and not
lens alignment. I believe this was a large part of why the lens dose tolerances did not meet.
Overall, the target cerebrospinal axis received 100% of the dose to approximately 96% of the
volume so the coverage was clinically acceptable.

Figure 9: Isodose lines for the plan

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Table 7: Normal Tissue Tolerance Table

Organ
Spinal Cord
R and L Kidney

Tolerance Dose
45 Gy Max
18Gy Mean

Actual Dose
4052.9 cGy
R:181.4 cGy L:180.4

Met Objective?
Y
Y

Heart
R and L Lung
Liver
Lenses
Mandible

40 Gy Mean
V20>35%
30Gy Mean
7 Gy Max
50 Gy Max

cGy
2151.1 cGy
R:13.2% L:17.8%
675.8 cGy
1168.4 cGy
3721.5 cGy

Y
Y
Y
N
Y

The hotspot for the plan was 4300.7 cGy which is 119.5% of the prescription dose. The location
of the hotspot is at the junction of brain and upper spine fields at the level of C2. The hotspot is
1.44 cm away from the spinal cord so it is in a relatively safe location and is not yet hot enough
to cause serious damage to the spinal cord. Ideally, the hotspot would lower and located further
away from the cervical spine because it more radiosensitive than the thoracic spine.

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Figure 10: The hotspot is located at the junction of the brain and spine fields.

References
1. South M, Chiu JK, Bin ST, Bloch C, Schroeder TM, Paulino AC. Supine Craniospinal
Irradiation Using Intrafractional Junction Shifts and Field-in-Field Dose Shaping: Early
Experience at Methodist Hospital. Int J of Radiat Oncol Biol Phys. 2008; 71(2): 477-483.
http://dx.doi.com/10.1016/j/ijrobp.2007.10.029
2. Vann, AM, Dasher BG, Wiggers NH, Chestnut SK. Portal Design in Radiation Therapy. 3rd
ed. Augusta, GA. Phoenix Printing. 2013: 179-185.