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Teri Burrier
CSI Plan Study
October 14, 2018
CSI Plan Study
Positioning and Setup: For our CSI plan study I chose to use the prone data set. If a patient
were to be treated for craniospinal irradiation (CSI) in our clinic, I was told they would be placed
in the prone position for their CT simulation. Immobilization is a key component for a
successful CSI treatment due to the long field that needs to be treated. In order to minimize head
rotation and/or movement during treatment, a prone head holder and thermoplastic mask should
be used. Additionally, a Vac-Lock cushion is used for body immobilization.
Although CSI treatments are not given at the facility where I am doing my training, I was
told that Tomotherapy would be the treatment planning method of choice. With this treatment
method no field borders are placed, and no fields need to be abutted, which allows for a much
more even isodose distribution. Instead of fields, normal structures, as well as optimization
structures, are contoured and then given specific criteria to meet within the planning software.
One drawback to this method is that the treatment time can be close to 30 minutes, which is why
proper immobilization is so important.
Optimization: No reference points or fields are used with Tomotherapy planning, instead
volume constraints are placed on each structure. Figure 1 below shows an image of the
optimization page within Tomotherapy. All PTV structures that will be treated are placed under
“Target Constraints” while normal structures to be avoided are placed under “Regions at Risk
Constraints”
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Figure 1. Image of optimization page within Tomotherapy software.

At the top of Figure 1 it shows that the plan was prescribed to a volume, which in this
case was the brain PTV with the optic nerves cropped out. This structure is shown in red under
“Target Constraints”. For each structure an importance value, maximum dose, maximum dose
penalty, minimum dose, and minimum dose penalty must be chosen. In addition to this, a dose
must be entered and the percentage of the structure that can receive that dose. For the “PTV
Brain sub optic nerves” I put that I wanted 96% of the structure to receive the prescription dose
of 36 Gy. Even though only one PTV structure will show up at the top under “Prescription” in
the optimization page, multiple structures can be used and prescribed to. Although it cannot be
viewed in Figure 1, the PTV Spine structure is also listed under “Target Constraints” with the
same criteria of 96% of the volume being covered by 36Gy.
Treatment Planning Process: Tomotherapy treatments use a 6MV beam and are delivered in a
helical fashion. The internal gantry moves around the patient continuously while the couch
gradually moves through the open bore of the machine. Due to this unique treatment delivery,
the pitch, modulation factor, and jaw width must be chosen before treatment planning can begin.
The pitch in Tomotherapy is related to the couch speed and how much overlap of the field there
will be with each rotation of the gantry. Using a pitch of 1 will result in a faster couch speed and
almost no overlap while a smaller pitch allows more overlap and thus a slower couch, which
increases treatment time. The modulation factor refers to the MLC’s and how much modulation
will be allowed, the larger the number the more modulation that will be allowed. The jaw width
is chosen from three options, 1cm, 2.5cm, and 5cm. For this plan I chose to use a jaw width of
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2.5cm, a pitch of 0.3, and a modulation factor of 3.0 based on a previous study by Sharma et al.1
that used these parameters in the treatment of CSI using Tomotherapy.
After choosing the initial settings and assigning criteria for the PTV’s to meet, normal
structures were considered. When starting a Tomotherapy plan, I have found that it works best
to set very loose constrain on the normal structures initially to allow the PTV to get the best
possible coverage and from there gradually begin to decrease the dose allowed to the organs at
risk. After starting the optimizer, I found that the PTV coverage to both the brain and the spinal
cord were very good and I was meeting the majority of the given ideal dose constraints;
however, I was not meeting the minimum lens, optic nerves, or kidney constraints given. Prior to
starting the plan, I created lens optimization structures with a margin of 0.5cm around each lens
to help increase the structure size and give myself more room to manipulate the dose to the
actual lens. Using this larger structure, I was able to reduce the dose to the actual lens below the
desired dose of 7Gy. Figure 2 shows the right lens in green and the lens optimization structure in
yellow.

Figure 2. Right lens (green) and optimization structure (yellow).

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The optic nerves overlapped into the brain PTV. To control dose to the optic nerves, I
chose to separate the Brain PTV into two structures: PTV brain sub optic nerves and an overlap
structure, which was the area that occupied both the Brain PTV and optic nerves. I then
prescribed the overlap region to 34 Gy to try and achieve the desired dose constraint. Figure 3
shows how this affected the dose within the brain PTV. Even using this technique, I was only
able to limit the maximum dose to the optic nerves to 35.8 Gy, which is just under the minimum
requirement of 36 Gy and exceeds the ideal requirement of 34 Gy. When I pushed on these
constraints more by placing a higher priority on the optic nerves or increasing the dose penalty, I
created unsatisfactory high dose regions within the eyes and areas of low dose within the Brain
PTV.

Figure 3. Decrease in 100% coverage from limiting dose to optic nerves.

An average dose of 2 Gy was the ideal kidney dose for this plan and 4 Gy was the
minimum requirement. Due to the close proximity of the kidneys to the spine, this was difficult
to achieve with Tomotherapy. I was unable to achieve the minimum requirement allowing all
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beam angles to be used. I thought a complete block may be able to be used in this area, which
would not allow entrance or exit dose to the kidneys; however, Figure 4 shows the high dose that
resulted (in blue) from this option.

Figure 4. Area in blue showing dose exceeding 105% of the prescription using a complete block
on the kidneys.
After seeing that a complete block was not ideal, I chose to place a directional block on the
kidneys, which only allows exit dose to reach the kidneys. This resulted in much better dose
distribution throughout the target, limited the areas of 105%, and decreased dose to the nearby
kidneys. The resulting isodose lines can be seen in Figure 5.
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Figure 5. Isodose coverage using a directional block on the left and right kidney.

Using a directional block on the kidneys made an impact on the dose homogeneity within
the spine PTV near that area; however, I feel it was the right choice to limit dose to the kidneys.
Figure 6 shows an example of isodose washes that were achieved for the spine in an area where
there were no directional blocks.
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Figure 6. Ideal spine coverage without the use of directional blocking.

In the final plan I created the overall hotspot was 39.23Gy (108.9%) and was located between the
eyes as a result of trying to limit dose to the optic nerves. Figure 7 shows the area of maximum
dose within the plan.

Figure 7. Area of maximum dose (108.9%) within the plan.

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Figure 8 shows my ProKnow plan score sheet demonstrating the constraints I was able to
achieve.

Figure 8. ProKnow plan score sheet.

In evaluating my overall plan, I worked to balance PTV coverage, while also working to
ensure the dose to normal structures was as low as possible without causing excessive hot spots
or decreased coverage to the PTVs. I feel I achieved a plan that was a good balance of this
because both PTV structures were covered by more than 95%, hot spots were minimal, and I met
the ideal dose constraints for all of the organs at risk except the optic nerves and kidneys, which
still met the minimum constraints. The optic nerve structures, as well as the kidneys, were
unable to meet ideal dose criteria due to the increase in hot spot volume that resulted from trying
to decrease dose to those areas. In the optic nerve structures constraining on the organ at risk
significantly increased the area of maximum dose and did not satisfactorily limit the dose to the
structure. For the kidneys using a complete block on the structure did limit the average dose to
the ideal amount of 2 Gy; however, it caused the entire section of spine in that area to be covered
by dose greater than 105%, which is not acceptable. Figure 9a and 9b show the dose volume
histogram (DVH) of the critical structures and PTVs and CTV’s evaluated in this plan.
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Figure 9a. Dose Volume Histogram of organs at risk and PTV’s with labels.

Figure 9b. Close up of DVH showing CTV coverage

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Reflection: I felt that this assignment was very beneficial to me. The clinic where I am doing my
training does not do CSI, and this was the first plan I have done like this. From our previous
classes, I know that it can be challenging to achieve homogeneous dose distributions due to the
long field size and the necessity to abut treatment fields, as well as the varying depths of the
target volumes. I feel that Tomotherapy was an optimal choice for this type of treatment and
provided very nice coverage of the PTV volumes. The previously mentioned study by Sharma et
al1 found that Tomotherapy, when compared to IMRT using a conventional accelerator and
three-dimensional conformal radiation therapy (3DCRT), was superior in dose homogeneity and
conformity. I found this study to be accurate, especially when considering the initial results I was
able to achieve with Tomotherapy, which met the optimal liver, bowel, esophagus, heart, and
lung constraints without issue due to the conformity of the treatment beam. One drawback to the
use of IMRT for the treatment of CSI is the higher integral dose that results, which could
increase the likelihood of a second malignancy in the future. A study done by Peñagarícano et al2
found that the integral dose for a patient treated with IMRT versus 3DCRT increased 6.5%.
Further study will need to be done to determine long-term effects for these patients. As long as
integral dose is not of concern, I believe Tomotherapy is an excellent option for CSI treatments
due to the superior dose conformity and homogeneity that results.
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References

1. Sharma DS, Gupta T, Jalali R, et al. High-precision radiotherapy for craniospinal

irradiation: evaluation of three-dimensional conformal radiotherapy, intensity-modulated
radiation therapy and helical TomoTherapy. Br J Radiol. 2009;82(984):1000-1009.
http://dx.doi.org/10.1259/bjr/13776022
2. Peñagarícano JA, Papanikolaou N, Yan Y, Youssef E, Ratanatharathorn V. Feasibility of
cranio-spinal axis radiation with the Hi-Art tomotherapy system. Radiother Oncol.
2005;76(1):72-8. http://dx.doi.org/10.1016/j.radonc.2005.06.013