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Rodger Williams
DOS 793: Fieldwork III
October 11, 2018

CSI planning project

Cranial-Spinal axis planning is a very specialized planning process. For this treatment the entire
cavity where the cerebral spinal fluid flows is covered by the treatment fields. One of the most
concerning aspects of this type of planning is not only the coverage to the PTV, but the low dose
given to the rest of the body as a result of plan delivery. When I first started this project, I
planned the case with ‘old school’ fields: right and left lateral whole brain with couch rotations
to create the geometry to match the spinal fields from the posterior aspect of the spine. The
spine, if it was longer that the field length that the accelerator could achieve, was spliced together
using a gap calculation. The plan I created looked pretty good, but it failed miserably when
submitted to the ProKnow scoring matrix. With the research that I found, VMAT and
Tomotherapy were the accelerators of choice to deliver the treatments. At our facility we have a
Varian TureBeam. Myers et al1 states that either Tomotherapy or VMAT are the accelerator of
choice for planning this type of case. These techniques produced the least amount of secondary
malignancy risk due to low doses to the surrounding organs at risk.
Case Information
We had the choice to plan either a supine or prone patient. I chose the supine patient due to the
consistent reproducibility for treatment delivery. The patient has medulloblastoma. He is a
pediatric case. His head was placed on a positioning sponge in an immobilization mask. His
arms are at his sides. A CT simulation was performed from the top of the calvarium to
approximately one third of the proximal femurs.
Target Volumes
The target volumes were broken into two separate volumes: PTV_Brain and PTV_Spine. Both
of the PTV’s were expanded from the CTV by 0.5 cm.
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Organs at Risk
The following organs are a listing of the surrounding tissues that were monitored during the
planning process. They are not listed in any order of importance.
Heart, Right & Left Kidney, Liver, Right & Left Lung, Right & Left Lens, Right & Left Optic
Nerve, Right & Left Parotid glands, Right & Left Submandibular glands, Thyroid, Esophagus
and Small Bowel. A complete table listing the target volume or the organ at risk and their
planning constraints is displayed in the planning dose constraints section.
Prescription
100% of the prescription dose will cover 95% of both PTV_Brain and PTV_Spine. Both PTV
volumes covered by 39.6 Gy, or 110% maximum, should be less than 3%.
Beam Arrangements
The two PTV’s were combined to create one PTV labeled Total PTV. This was the addition of
the PTV_Brain and PTV_Spine. A Varian TrueBeam was used for treatment planning. The
energy used was 6 MV. The planning algorithm used is version 13.6, AAA (Analytical
Anisotropic Algorithm). Unlike the 3D planning process, the software has an arc geometry
planning tool that assists the placement of the isocenters. Two isocenters were placed by the use
of the planning tool. It split the Total PTV into two sections. The first encompassed the brain
and the superior portion of the spine. The first arc started at 181 and went to 179. The second arc
for the cranial portion went counter clockwise, from 179 to 181. The isocenter was then shifted
to the lower portion of the spine and the arc rotated from 181 to 179. This arrangement saves the
patient time while under treatment so that movement during treatment is kept to a minimum.
This arrangement also allows for the patient to be treated at all times when the gantry is rotating.
There is not a need to rotate back to a starting position to begin the next arc. Three arcs were
used, one clockwise and counter clockwise for the brain and upper spine and the other clockwise
for the lower spine. Collimator rotation of 10 degree and 350 degree were use two upper arcs
and 10 degree for the lower spine field. Field sizes were checked to be sure that the target
volumes stayed within the field dimensions during the rotation of the accelerator. This was done
for all 3 fields. The blocking of the organs at risk are done by the dynamic movements of the
multileaf collimator as part of the planning algorithm. Constraints were entered at the
optimization process that defined the target volumes and the organs at risk.
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Above are images of the two superior cranial-spinal ports and the lower image is of the lower
spine port.

Plan Normalization
The plan was optimized without any plan normalization. When the final plan was reviewed, a
plan normalization value of 99.5% was used to maximize the coverage to the target volumes and
keep the organs at risk within the stated constraints. This increase or 0.5% allowed for me to
meet the planning criteria.
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Planning Dose Coverage

Below are the dose coverage image for the Total PTV. It also demonstrates the beam placement
on the supine setup used for planning this case. The 95% coverage is illustrated with the color
wash option to display coverage.
The plan was evaluated against the constraints from the planning protocol provided by ProKnow.
Each organ at risk was evaluated to see if the percentage, the mean or the maximum dose was
achieved or exceeded. After each revision of the plan was optimized, these constraints were
again evaluated to see where improvements could be gained. The planning process is a give and
take where one structure has increased coverage or lowered dose to obtain the best possible
solution. There becomes a tradeoff for which structures are protected and which structures are
relaxed to gain the maximum benefits.
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Planning Dose Constraints

OAR metric Minimum Ideal
Required
Heart, mean dose 30 26
Kidney_Rt, mean dose 4 2
Kidney_Lt, mean dose 4 2
Liver, mean dose 8 6
Lung_Rt, volume % covered by 20 Gy 35 30
Lung_Lt, volume % covered be 20 Gy 35 30
Lens_Lt, maximum dose 10 7
Lens_Rt, maximum dose 10 7
Optic Nerve_Lt, maximum dose 36 34
Optic Nerve_Rt, maximum dose 36 34
Parotid_Lt, mean dose 20 15
Parotid_Rt, mean dose 20 15
Submandibular gland_Lt, mean dose 20 15
Submandibular gland_Rt, mean dose 20 15
Thyroid, maximum dose 30 25
Esophagus, volume % covered by 18 Gy 35 34
Bowel, volume (cc) covered by 25 Gy 180 179
PTV Brain, volume % covered by 36 Gy 90 95
PTV Brain, volume % covered by 39.6 Gy 3 0
PTV Spine, volume % covered by 36 Gy 90 95
PTV Spine, volume % covered by 39.6 Gy 3 0

These constraints were given as part of the planning protocol.

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Planning outcomes
The DVH is for the planning process outcomes.
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This is the scoresheet from ProKnow.

Conclusions
As with any planning done, there is always something to learn. I have treated these cases in the
past, but no longer being at an academic facility, I have not seen a CSI in over 20 years. This is
the first time that I had the opportunity to plan this type of case. The process of learning what
was done when Bentel2 wrote her book in the 1990’s to the technology of today gives remarkable
results. The dose distribution using VMAT is extremely conforming to the PTV and definitely a
savings to the organs at risk.
I did have a hot spot that was in the very top slice of the PTV_Brain. The location of the hot
spot was not in any critical structures, but the concern would be that hair growth in the future
would be affected. This would require that I work with a physicist or a senior dosimetrist that
had experience in planning these cases before I would feel comfortable taking this case to clinic
for treatment. I would not feel comfortable taking this case to treatment due to the hot spot
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location and that the patient’s kidneys and optic nerves did not meet constraints. The lens of
both eyes were marginally acceptable, so I would not favor treating this patient with this plan.
I also consulted with two physicians that gave me their thoughts on treating medulloblastoma.
One warned me of the low dose risk to the rest of the body for future malignancies and the other
gave advice that either a tomotherapy unit or a proton unit would be the treatment machine of
choice.
The exercise of planning this case caused me to think outside of box. As I approach a multitude
of other anatomical sites for planning, I have a comfort level of where to start. With this case I
started at the beginning trying to emulate what I had used in the past and quickly realized that
was not going to work. Researching the current technology and how to use current techniques
within our planning software quickly helped me to reach a feasible solution. I believe that in
order to become proficient in this type of planning, practice would be of utmost importance.
Additional planning of this type of treatment would move me from skeptical to confident that I
could produce a quality plan that could be treated in the clinic.

References
1. Myers P.A. et al. Pediatric Cranio-spinal Axis Irradiation: Comparison of Radiation-
induced Secondary Malignancy Estimations Based on Three Methods of Analysis for
Three Different Treatment Modalities. Technol Cancer Res Treat. 2015 April, 14(2):
169-180. https://doi.org/10.7785/tert.2012.500413.
2. Bentel G.C. Radiation Therapy Planning. Treatment planning-Central Nervous System
and Pituitary Gland. 2nd ed. New York, NY: McGraw-Hill Companies, Inc.; 1996:550-
557. https://doi.org/10.1118/1.596806.