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