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Sara Long
10/16/2019
Clinical Practicum III
Craniospinal Irraditation

Introduction
Total craniospinal irradiation (CSI) is used to treat cancers of the central nervous system such as
medulloblastoma. Medulloblastoma occurs in the cerebellum and easily spreads along the spinal cord.1
Whole brain and whole spinal cord irradiation through the level of the sacrum are used to achieve CSI
coverage. For this project, a patient was prescribed 36Gy in 20 fractions to the CSI, and a plan was
created for the Siemens Oncor machine. Field feathering was used to reduce the hotspot where the whole
brain fields and spinal fields met.

Patient Positioning
CSI was performed on a patient positioned supine on an 8cm thick, stiff pad. The patient’s head was
positioned in a head holder abutted against the pad with the patient’s arms by the sides.

Treatment Fields
Whole brain irradiation was achieved with right and left lateral fields. Beam energy was selected to be
6MV for each field to ensure superficial coverage. Right and left fields consisted of a field-in-field beam
and three other right or left fields with the inferior border staggered to feather the dose. The collimator
was turned to allow for the field to match with the divergent pattern of the PA spine beam. The couch was
kicked 10 degrees right and left to provide for a straight match line between the right and left beams at the
midline. Image1 displays an example of the match lines used in the plan. Image2 shows the staggered
field configuration with collimator rotation used to achieve dose feathering. The posterior field border
was moved approximately 0.5cm. Each superior border of the spinal fields was also staggered to match
brain fields.
Image1: Match Lines
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Sara Long
10/16/2019
Clinical Practicum III

Image2: Staggered Fields & Collimator Rotation

The whole brain fields were extended inferiorly to the shoulders since the spinal cord was treated with a
single long field and not two matched fields. Inclusion of the lateral neck allowed for less thyroid dose
and easy matching with a single spine field. Image3 shows a typical BEV for the brain fields. Blocking in
the brain was designed to shield the lens, parotids, the face, thyroid and larynx. The field-in-field brain
blocking reduced dose to the optic nerves and cooled hotspots.

Image3: Brain Field BEV

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Sara Long
10/16/2019
Clinical Practicum III
Spinal irradiation was achieved with 5 spinal fields. Four fields were staggered in the same way as the
brain fields and were 6MV. The 5th field was 18MV. One 6MV and the 18MV field were optimized using
an IMRT technique. The length of the spinal volume traversed different depths in the body, and the 6MV
beams provided coverage to superficial cord while the 18MV beam dosed deeper cord while reducing
hotspots in the patient’s back. The spine fields are shown in Image4. Image5 displays the BEV for a spine
field. Blocking was used to shield tissue outside of the spinal cord PTV.

Image4: Spine Fields

Image5: Spine Field BEV

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Sara Long
10/16/2019
Clinical Practicum III
Brain fields were treated at isocenter (100cm SAD). Spine fields were treated at an extended SSD of
109.5 cm. The spine SSD was calculated to the bottom of the pad/top of table. An extended distance was
used to allow the beam enough divergence to use one spine beam.

Normalization
Two prescriptions were written to account for the two separate isocenters used in the plan. The brain was
normalized to a calculation point (isocenter) to the 97.5% IDL. This point was chosen because it allowed
for even distribution of dose and pulled dose deep into the brain. The skull got hot so a field-in-field beam
was used to cool it.

The spine was prescribed to a point at the 105.15% IDL. This selection reduced hotspots that I had trouble
cooling with IMRT. The spine fields were difficult to cool since the fields only approached from the PA
direction and the machine had limited energy options (6MV and 18MV only).

Additional Planning Discussion

Mixed beam energies were selected to provide coverage to the PTV while reducing the hotspots
posteriorly. The gantry was positioned at 180 degrees for the spine fields since the patient was positioned
supine; this reduced dose to the anterior organs. Supine positioning is often considered the most
comfortable for patients to maintain during the treatment but prone positioning could also be performed if
the patient can tolerate it. Prone positioning allows for better visualization of the spine and match line
between spine fields if two adjacent spine fields are used.

Isodose Distribution
Approximately 90% of the PTV was covered by the 36Gy prescription. Most of the OAR dose metrics
were achievable with 90% PTV coverage. An example of the dose distribution is shown in Image6, and
Image7 shows a table of the planning goals.

Image6: Isodose Distribution

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Sara Long
10/16/2019
Clinical Practicum III

Image7: Planning Goals

Image8: Isodose Distribution

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Sara Long
10/16/2019
Clinical Practicum III
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Sara Long
10/16/2019
Clinical Practicum III

The hotspot (~25%) was not within the PTV, it was in the muscular soft tissue in the distal spine.
Positioning of the hotspot into the muscle tissue prevented the PTV from becoming too hot. Cold spots
were mostly around the optic nerves and eyes where dose was constricted to meet OAR constraints.

ProKnow Score Sheet

This plan was scored through ProKnow. The scorecard from the site follows.

Many attempts were made at trying to cover greater than 90% PTV but OAR constraints were not met.
The esophagus constraint was not met. If the machine offered 10MV I would have used this instead of
18MV for the spine field and maybe that would have helped reduce esophagus dose.
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Sara Long
10/16/2019
Clinical Practicum III
DVH

Reflection
This was a difficult plan to create. If I were to really treat this plan I would first ensure the spine SSD
could be achieved. This would require raising the table quite a bit and with the gantry at 180 it should be
achievable. The esophagus dose constraint given by Proknow (V18<35%) seems very hard to achieve.
Different beam energy options could allow for less dose to the esophagus.

References

1. American Brain Tumor Association. Medulloblastoma.

https://www.abta.org/tumor_types/medulloblastoma/. Accessed Oct 16, 2019.