Group 2

DOS 773
Professor Vann

Group 2 Prone CSI Project

Craniospinal irradiation is a common technique used to treat
medulloblastoma. For children, the planning process may only need to utilize
one or two isocenters, but typically 3 isocenters is needed for larger adults.
An adult medulloblastoma case was planned with a prescribed dose of 36Gy
to a 5mm PTV margin of the CNS. For this project I chose to use a dual
isocenter technique proposed by Athiyaman, Mayilvaganan and Singh. 1 This
3D, photon technique reduces treatment time, set up time and chances of
set up error. Hot/cold spots were effectively reduced utilizing field matching
and field-in-field techniques.
1.) Field Descriptions:
a. Borders, seen in Figures 1 and 2.
i. Opposed Cranial Fields: The superior borders were the
most superior aspect of the skull. The inferior borders
extended down to around C3, where isocenter was placed.
A half beam block was used at C3. The lateral borders
extended from the most posterior aspect of the skull to just
posterior the lens of the eyes.
ii. Cervical-Thoracic Field: The superior border matched the
cranial fields near C3 vertebrae with a half beam block,
utilizing the same isocenter as the cranial field. The lateral
borders were extended to be 1cm laterally to encompass
the transverse processes. The inferior border extended
inferiorly 20cm to around the T7 vertebrae.
iii. Lumbar-Thoracic Field: The superior border matches the
inferior border of the cervical-thoracic field at T7. The
inferior border extends down to the superior aspect of the
Sacrum. The lateral borders extend 1cm laterally from the
transverse processes.
b. Blocking
i. Cranial Fields: Blocking was used with multi-leaf collimators
(MLC) to provide some scalp sparing. The leaves also
extended to block the oral cavity and normal tissue outside

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Professor Vann

the PTV. Extra emphasis was placed on blocking the lens of

the eyes.
ii. Spine fields: MLC shielding was fit around the PTV with a .8
cm margin. Blocking was performed more generously near
the lungs, kidneys, liver and heart. This was to prevent
unnecessary dose to these vital organs. The spine has a
minor curve, the MLCs helped to match the curvature and
avoid normal tissue.

Figure 1: Fields superior and inferior borders with isocenters shown as stars.

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Professor Vann

Figure 2. MLC blocking of the thoracic-lumbar spine.

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Professor Vann

Figure 3. MLC blocking for the cervical-thoracic spine.

Table 1: Field Specifics
Field

Gantry
Angle

Collimator
Rotation

Couch
Rotation

Field Size
(X)

Field Size
(Y)

Energy
(MV)

Right
Cranial

87

180

180

17.8

20

Left
Cranial

274

180

180

18.2

20

CervicalThoracic

180

180

180

20

18

LumbarThoracic

202

90

90

8.5

29

18

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Professor Vann

2.) This patient was set up using SAD technique with isocenter set at
100cm. The reason SAD was chose is because this is the way it was
described by Athiyaman.1 Calculation using SAD is less involved than
an extended distance treatment. With extended SSD it would take
more monitor units (MU) to get prescribed dose to our PTV.
3.) Points were placed in the brain, thoracic spine and lumbar spine. These
points were to help with field matching and dose normalization. The
points fell within the middle of the brain and spinal cord. These points
were chosen to help with normalization. For the cranial field I had to
normalize to a value of 88% to get the 95% dose line to cover the
entire PTV within the brain. Since isocenter was in the cervical spine, I
had to normalize to increase the overall dose. For the thoracic spine,
dose was normalized to 99.5% to slightly increase dose to the PTV.
Field-in-field was used to increase dose to the part of the cervical spine
where the depth was greater. Because of this depth and being at the
match line, it was more difficult to get dose to the PTV. This was one of
the slightly cold spots (Figure 4). For the Lumbar-Thoracic field the
normalization value was 105.5. I believe this is because the calculation
point was at a more deep equivalent depth. Since the plan tried to get
100% dose at this deep location, the plan was running hot initially.
However, after using some field in field, this normalization value
provided adequate coverage and less hot areas.

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Professor Vann

Figure 4. Cold spot from the match line and increased depth required for
the PA beam to travel. Sagittal view pictured left, axial view pictured right.

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Professor Vann

4.) For this plan I initially tried a 3 isocenter technique utilizing formulas
couch kicks to match the cranial and cervical-thoracic fields (Figure 5).
I found this match to work well, but was still getting hot spots at the
cervical-thoracic and lumbar-thoracic junction. As opposed to using gap
feathering, I decided to do some research online. I found the two
isocenter technique, which describes saving time and reducing set up
errors by utilizing only two isocenters. Without a direct therapy
background, I am always looking for ways to help out the therapists. I
feel it is something I am obligated to do to overcome this obstacle. I
also believe that easier, simpler treatment techniques lead to a more
reproducible and accurate treatment delivery.

Figure 5. Formulas for traditional couch kick and collimator rotation.

One tool I learned to use from this article was the field alignment tool.
The field alignment tool helps to align fields automatically in Eclipse (Figure
6). I was surprised to find out that none of my preceptors were familiar with
it. This tool automatically incorporates the formulas from Figure 5 and
creates field alignments for dual isocenter plans. I have already incorporated
it into a 3 field breast case I have been working on. The formulas are great,
but I like to think of it in the same way hand calculations were used. This
method is just faster and simpler.

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Professor Vann

Figure 6. Screen shot of Eclipses field alignment tool.

While completing this plan I initially had some difficulty understanding
the field alignment tool and getting conformal dose coverage. I had to reset
my cervical/cranial isocenter several times before finding the optimal
position. My case was different from the example provided by Athiyaman
because the patient was larger and had a protracted chin. Once I found a
good location for isocenter I had a hard time getting the 95% isodose line to
cover the CNS PTV. In order to cover the PTV I needed to increase the energy
for the spine field from 6MV to 18MV. The Athiyaman paper used 6MV and I
was afraid that this would increase the toxicity to normal ORs. However, after
DVH comparison, I realized that the OR dose was very close and that a
significant increase in tumor coverage was worth the minute increase in OR
dose (Figure 7). There was still a bit of hot and cold in regions of overlapping
dose. The hot spot was about 114% and the cold spot had only 80%
coverage. Field-in-field techniques (2-4) for both the cervical-thoracic and
lumbar-thoracic fields allowed for a more homogenous dose distribution
(Figure 8). Tolerance doses were established from Dr. Devisettys
recommended tolerance doses for organs at risk.

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Professor Vann

Figure 7. DVH comparison of the thoracic fields with 6MV (squares) and
18MV (triangles). Green is the heart where the most significant difference
occurred. The max total dose increase was only 1.2Gy. All other OR resulted
in a max increase of less than 1Gy by increasing beam energy to 18MV

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Professor Vann

Figure 8. Field-in-field technique for lumbar-thoracic field used to eliminate

hot spots and increase dose homogeneity.

a. Target Volumes. (Figure 9, 10)

b. Isodose Coverage (Figure 9, 10)
c. Hot spot. (Figure 10) Cold spot was located at the cranial and
cervical field junction. The cold spot was still above 90% so I was

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Professor Vann

happy with this. To prevent the hot/cold spots I carefully aligned

my fields and used field-in-field technique.
d. I was happy with my hot spot value of 109.3% being located in
the lumbar region (Figure 10).
e. I was very satisfied with this technique and can see how it would
be easier for the whole team to perform. I believe that a chin
adducted anteriorly would help move the cranial/cervical
isocenter inferiorly. It appears that the more inferior this point is
the easier it would be to avoid cold spots in the cervical spine.

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Professor Vann

Figure 9. Target volumes had a margin of .5cm for the PTV 36Gy. The .5cm
margin was placed around the brain and spinal cord for planning purposes.

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Professor Vann

Figure 10. Isodose coverage and hot spot located in lower lumbar region.
Hot spot only about 109% and I am happy with its location.

5.) OR tolerance doses from Dr. Devisettys recommend Tolerance doses:

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Professor Vann

Organ

Tolerance Dose

Actual

Did Meet/Did Not

PTV 36

V100%> 90

V100%=95%

Did Meet

Rt Lens

Max<7-10Gy

Max=5.2

Did Meet

Lt Lens

Max <7-10Gy

Max=6.1Gy

Did Meet

Rt Lung

V20Gy<15%
V10Gy<20%

V20Gy=6%
V10Gy=8%

Did Meet
Did Meet

Lt Lung

V20Gy<15%
V10Gy<20%

V20Gy=2.2%
V10Gy=4.5%

Did Meet
Did Meet

Bi lateral Kidney

Mean<18

Mean=1.3Gy

Did Meet

Heart

D30%<50Gy

D30%=21Gy

Did Meet

Liver

Mean<28Gy

Mean=3.8Gy

Did Meet

Brain

V100%>95

V100%=97%

Did Meet

6. DVH

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Professor Vann

Figure 11. DVH of organs at risk and PTV 36 Gy.

References
1. Athiyaman H, Mayilvaganan A, Singh D. A simple planning technique
of craniospinal irradiation in the eclipse treatment planning system.

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Professor Vann

Med Phys. 2014;39(4):251-258. http:// dx.doi.org/10.4103/09716203.144495