1

Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

For this assignment, a craniospinal irradiation (CSI) plan study was assigned through
ProKnow. Treatment planning CT, planning target volumes (PTV) and organs at risk (OAR)
were provided via download from ProKnow. A choice was given to plan a patient either in the
supine or prone position. I chose to plan the patient supine, per the department standard. The
patient was simulated supine with arms at sides utilizing a thermoplastic mask to immobilize the
head and neck. The prescription dose was 180 cGy per fraction for 20 fractions for a total dose of
3600 cGy to PTV_Brain and PTV_Spine (Figure 1). A total of 17 OAR structures were included
in the plan study for evaluation and plan scoring (Figure 2).
Upon researching current methods, I came across an interesting article in the Red Journal
which studied multiple isocenter CSI delivery with volumetric modulated arc therapy (VMAT).
Lee et al1 compared conventional three-dimensional (3D) CSI plans consisting of matching
lateral brain and posteroanterior (PA) spine fields to those planned with VMAT. The study found
VMAT to be superior in significantly reducing OAR doses. The caveat of utilizing VMAT rather
than traditional 3D planning was discovered to be the unfavorable increase of non-PTV integral
dose inherent to arc therapy. The treatment plan technique chosen for the ProKnow CSI plan
study was multiple-isocenter VMAT.
 2
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

nER

Figure 1. PTV_Brain (green) and PTV_Spine (orange).

 3
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Figure 2. OAR included in the plan study.

 4
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Treatment Planning
My initial planning approach was to review PTV and OAR along their relationship with
each other. After review of PTV_BRAIN and PTV_SPINE, I placed the first isocenter
approximately mid-brain. The second isocenter was set 26 cm inferior to isocenter 1 in the
thoracic spine. Isocenter 3 was then placed 22.5 cm inferior to isocenter 2 in the lumbosacral
spine. To aid in isocenter placement and beam geometries, I combined PTV_BRAIN and
PTV_SPINE and split into 3 sub volumes consisting of PTV_Upper, PTV_Mid, and PTV_Lower
(Figure 3). Each plan isocenter delivered 2 full arcs with gantry angles of 181° to 179° clockwise
and 179° to 181° counterclockwise. Collimator angles were offset to avoid leakage in common
planes. To optimize the collimator settings, I added MLC for each arc and set a 0.6 cm margin to
fit each PTV sub volume. I then fine-tuned the collimator lengths to ensure there was a 2 cm
overlap at the junctions of PTV_Upper, PTV_Mid, and PTV_Lower structures (Figure 4).
Treatment planning and dose calculations were performed using Eclipse version 13.6.
The algorithms used for optimization and dose calculations respectively were Photon Optimizer
and AcurosXB. The plan was created utilizing 6 MV photons to be delivered on Varian 21iX
linear accelerator with Millennium 120 MLC system. Prescription was set for 180 cGy per
fraction to a total dose of 3600 cGy. For plan optimization, lower objectives were placed for
CTV_ BRAIN, PTV_BRAIN, CTV_SPINE, PTV_SPINE, and opt_Brain_MinON. The
opt_Brain_MinON was PTV_BRAIN with optic nerves subtracted to help steer high doses out of
the optic structures. The normal tissue objective (NTO) and upper objectives were set for all
OAR using both dose volume and gEUD constraints (Figure 5). Given the tight constraints to
kidney and lens OAR, I felt utilizing upper gEUD constraints would be beneficial to help limit
dose to these structures.
During the optimization process I set high priorities to the kidneys and lens, as I
attempted to keep these OAR doses to within acceptable limits. The NTO setting used resulted in
a highly conformal plan, so I did not have much issue with meeting the remaining OAR
constraints. Coverage to PTV_BRAIN and PTV_SPINE was adversely affected when attempting
 5
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

to reduce doses to mainly the kidney and lens OAR, so constraints were adjusted to best balance
PTV coverage and OAR sparing. When pushing on the kidney and lens OAR, hot spots were
present in the PTV volumes. In an attempt to meet the plan global maximum dose requirement of
3960 cGy or less, I converted isodose lines to structures with upper constraints to incorporate
into subsequent optimizations.
Plan Outcome and Evaluation
After multiple plan optimizations, I arrived at a plan that met most of the plan metrics.
With having adequate coverage to PTV_SPINE, the prescription was normalized such that
95.1% of PTV_BRAIN was covered by prescription dose of 3600 cGy (Figure 6). The global
maximum dose was 4050 cGy located on the edge of PTV_SPINE (Figure 7). In the lens and
kidney regions, both the PTV_BRAIN and PTV_SPINE were not well covered with prescription
dose of 3600 cGy (Figures 8, 9). Due to the stringent constraints to the lens and kidney OAR, the
minimum dose to PTV_BRAIN and PTV_SPINE were 1302.4 cGy and 1662.1 cGy respectively.
I found the ProKnow CSI plan to be challenging. I met or mostly met all OAR plan
constraints with the exception of the kidneys and optic nerves. I struggled with reducing doses to
these OAR to meet ideal levels in this ProKnow CSI plan challenge. In retrospect, I think by
reducing the lower objective weights to the CTV_BRAIN and CTV_SPINE the high doses
observed in PTV_BRAIN would have been reduced. No minimum dose to any CTV or PTV was
required in this plan study. By allowing much lower doses to the target volumes, OAR dose
reduction most likely would have improved. Additionally, by allowing more time during
optimization, I may have had better results. Isodose display, dose volume histogram, plan
objectives, and ProKnow CSI plan scorecard are found below.
 6
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Figure 3. PTV_Upper (Cyan), PTV_Mid (Green), PTV_Lower (Magenta)

 7
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Figure 4. BEV and collimator settings for arcs 1, 2, and 3.

 8
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Figure 5. Optimization objectives and NTO settings

 9
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Figure 6. Prescription and plan normalization

Figure 7. Global maximum dose

 10
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Figure 8. Suboptimal PTV_Brain coverage in lens region

Figure 9. Suboptimal PTV_Spine coverage at level of kidneys

 11
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Dose Volume Histogram

 12
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Plan Study Objectives and Results

 13
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study

Colorwash Isodose Display

 14
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study
References

1. Lee YK, Brooks CJ, Bedford JL, et al. Development and evaluation of multiple isocentric
volumetric modulated arc therapy technique for craniospinal axis radiotherapy planning. Int J
Radiat Oncol Biol Phys. 2012;82(2):1006-1012.
http://dx.doi.org/10.1016/j.ijrobp.2010.12.033
 15
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study
 16
Neil Joyce
October 20, 2019
DOS 793 ProKnow CSI Plan Study