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Seth Crumpton
CSI Written Assignment
October 11, 2017

CSI Treatment Plan

For the purposes of this assignment, I chose to plan on the prone CSI patient data set
using intrafractional junction shifts as discussed by author Rodney Hood in Intrafractional
Junction Shifts Utilizing Multileaf Collimation: A Novel CSI Planning Technique. I chose to go
with intrafractional junction shift planning because of its dosimetric and treatment advantages.
The use of intrafractional shifting is much more forgiving when it comes to patient movement or
errors that might occur during setup and allows the same plan to be used throughout treatment.1
This is especially important when you consider that systematic setup error was determined to be
approximately 2 millimeters in feathered field plans.2 Like most of the other CSI treatments, this
plan includes two lateral whole brain fields, an upper spine field and a lower spine field. For
each of the fields I placed the isocenter in the same plane so the only shift necessary between
fields is longitudinal. I chose the prone data set with simplicity in mind and because that is
traditionally how they are done here at my site. Having the patient in the prone position allows
the therapists to see what theyre treating. This is important to ensure the most accurate treatment
possible and helps combat set up errors.3 It can also help the therapists recognize when a patient
movement has occurred. The supine position seemed more geared for children under anesthesia.
It was just an educated guess but the scan appears to be a more mature patient.
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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 1. Sagittal view of CSI treatment plan on prone patient.

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Lateral Brain Fields:

To treat the brain, two parallel opposed 6MV photon beams were used. The isocenter was
placed as low as possible to maintain a 20 cm Y2 field that still encompasses cranium with a few
centimeters to spare for flash. MLC blocks were drawn to block the facial bones, eyes, optic
nerves, optic lenses and the posterior neck to protect these organs at risk and reduce hotspots.
The anterior border was extended 1cm from the cranium to ensure fall off. The posterior and
superior borders of the field were extended a few cm from the cranium to ensure fall off as well.
The inferior border extends a couple cm below the bottom of C2 to overlap the superior border
of portion of the spine field which is designated to be feathered. Segments were manually
generated to reduce hotspots that occurred when dose was applied to the plan. Each beam also
had a collimator angle of 11 degrees to account for the beam divergence that occurs in the upper
spine field. I arrived at this number by dividing the Y2 field (20cm) by 100 and then taking the
arc tan of that number (.2) to arrive at 11.3 or rounded to 11 degrees. Dose was applied to an off
axis point placed the center of the brain contour and was normalized to 96%. This gave me the
uniform dose coverage I needed to meet the requirements of the assignment.

Figure 2. MLC blocking for lateral brain beams.

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 3. Isodose line coverage for whole brain portion of CSI plan.
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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 4. DVH of lateral brain fields.

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Upper Spine field:

To treat the upper spine I used a single 18MV beam. I would like to have used a 10MV
beam here to limit dose to the lungs, esophagus, heart etc. However, this plan was generated on
our VARIAN 21IX linear accelerator and I was limited to either using a 6MV beam or an 18MV
beam. I created a trial first using the 6MV energy. I was unable to meet the constraints provided
by proknow when using this energy. To get the coverage I needed there were too many hotspots
and it made it impossible to meet keep the 39.6Gy dose below 5%. Using a higher energy beam
gave me the coverage I needed without the excess hotspots. The tradeoff was that does to
anterior structures increased, but it was minor enough to justify the use of a higher energy beam
in this case. To encompass as much of the spine as possible I opened the field size to its
maximum setting at 20x20cm for the Y fields and 4cm for the x fields. When deciding where the
superior border of the field should be it is important to consider the mandible. You dont want
there to exit dose there, so I placed the field low enough that the divergence of the beam would
pass just inferiorly to it on the scan. The inferior border of the field is placed just below L2. Once
again I used custom segments here to limit some of the higher dose regions of the spine until I
found a balance that limited higher dose without compromising dose coverage to the point of
failure. The couch, gantry and collimator were all 180 degrees and dose was delivered to an off
axis point placed more anterior to the isocenter. I was able to achieve the required dose coverage
without normalization in this case.
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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 5. BEV of upper spine field

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 6. Isodose line coverage for upper spine field

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 7. DVH of upper spine field

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Lower Spine Field:

The lower spine proved to be the most difficult to treat. I had to utilize several techniques
to finally achieve the dose coverage I wanted. To treat this portion of the spine, I used a half
beam with Y2 at 0 and Y1 opened to 20cm. The couch was rotated to 272 degrees with a
collimator rotation of 270 degrees and the gantry was rotated to 169 degrees once again utilizing
the 11 degree rotation to account for beam divergence in the upper spine field. Dose was
delivered to an off axis point that I was able to maneuver around to get the coverage where I
wanted. Again, I did not have to normalize to get the coverage I needed in the lower spine. I
blame the curvature of the spine for making my life more difficult on this case. This might have
been a little easier had the patient been positioned supine as the spine would lie more flat. At first
I tried to create segments like I did with the other fields to limit dose. Through countless tedious
attempts I was unable to reach my goal. Then I tried to use the optimizer to help me out using
segment weighting that way. Next, I tried using a 25 degree EDW wedge. At first, this did not
improve the plan but when I switched to the 18MV energy beams it gave me the coverage I
needed without creating coverage that was too hot.
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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 8. BEV of lower spine beam.

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 9. Isodose line coverage of lower spine field.

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Final Plan:

In conclusion, I was able to meet 14 out of the 17 minimum requirements provided by

Proknow for a grade of 113 out of 127. Of those 14, I was able to meet the ideal constraints for 8
of the structures. I failed to meet the esophagus considerably and also failed the bowel and
thyroid. The esophagus dose can be attributed to the anterior push of dose coverage utilizing the
18MV beams. I would say that it is a passable plan, but I would hesitate to say an optimal plan
by these standards. I would not use this plan to treat clinically. I feel with more practice and
having the experience I do now after reading some of the other students treatment assignment
papers I can generate a plan that could limit the dose to those constraints I failed. I did encounter
a dose disparity between what my DVH and proknow for volume (%) of the PTV_SPINE
covered by 39.6Gy. Their result was 6.92 causing me to fail the 5% minimum requirement.
However, after investigating a little more closely I was able to confirm that number should be
just shy of 5% which would pass. I quickly determined that I prefer the supine positioning to the
prone position. Its more comfortable for the patient, you dont have to worry about patient
movement during breathing and the spine is more flat making it more ideal for treatment
planning. The benefits of the supine position just seem to outweigh the benefits of the prone
position. I was not able to try out some of the other treatment techniques I researched. I felt that
VMAT would help me achieve more optimal outcomes, but I wanted to experience treatment
planning that is most applicable to my current situation so I went with 3D conformal. I did not
consult a physician to get their input. I just felt the input from the dosimetrists were adequate
enough and I was provided with several resources that affirmed I was right to feel that way.
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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 10. Cumulative isodose line coverage for CSI plan

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 11. Cumulative DVH of CSI plan.

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Seth Crumpton
CSI Written Assignment
October 11, 2017

Figure 12. Verification that the 39.6Gy<5% dose constraint was met on PTV spine.
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Seth Crumpton
CSI Written Assignment
October 11, 2017

References

1. Hood R, Intrafractional Junction Shifts Utilizing Multileaf Collimation: A Novel CSI

Planning Technique. Duke Cancer Institute.
http://pubs.medicaldosimetry.org/pub/23791a1c-0c7f-1fbf-fa99-fffff49479af. Accessed
on October 2, 2017.
2. Holupka, E.J. et al. Effect of Set-Up Error on the Dose Across the Junction of Matching
Cranial-Spinal Fields in the Treatment of Medulloblastomas. Int. J. Rad. Onc. Biol. Phys.
27:345-352; 1993.
3. Discussion with Ed McPadden, Chief Medical Dosimetrist at Austin Cancer Centers.
October 2, 2017.