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Adam Schwartz
October 17, 2018
DOS 773 Craniospinal Project
Craniospinal Radiotherapy

Craniospinal irradiation (CSI) is an important technique in radiation therapy designed to

manage malignant disease with potential progression and involvement in the entirety of the brain

and cerebrospinal fluid (CSF) drainage pathway. This complicated technique can be performed

using a variety of techniques and methodologies, all with the intention of distributing uniform

dose coverage to the cranial space, subarachnoid space, and spinal canal. CSI planning requires a

methodical approach, as it is common to encounter difficulties related to the minimization of

dose to critical structures in close proximity to large target volumes, creating complex plans with

reasonable treatment times, and matching a number of divergent fields to avoid under and

overdosing treatment volumes. Integral dose to organs at risk is highly considered when treating

pediatric patients and those patients with likely extended survival in order to prevent any

unnecessary complications.

This patient presented diagnosed with medulloblastoma, which is a common brain tumor

in adolescents often located posterior in the brain. The risk for developing this particular

diagnosis decreases with age, as nearly 70% of all cases are seen in patients younger than 10

years old.1 These tumors often metastasize to other parts of the brain or spinal cord and patients

are commonly treated using a craniospinal technique. This methodology has proven to net

positive treatment outcomes and has helped to increase the survivability of patients with this

disease. In this ProKnow plan study, the aim was to treat 95% of the spinal and brain PTV

volumes with 100% of 36Gy at 1.8Gy per fraction, while also maintaining a volume of less than
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3% receiving 39.6 Gy (110% dose). I selected the supine patient dataset for planning and

analysis of my selected treatment technique.

Froedtert Hospital in Milwaukee WI. employs a unique approach to CSI refined in-house

by a team of physicians and physicists. Patients are typically simulated in the supine position

using an appropriate head-rest to keep their head and neck extended, which is then held in place

using an aquaplast mask. The patient is immobilized using a Vaclock where their arms are

positioned down and next to their body, held in place by wrist straps also helping to also pull the

patients shoulders out of the treatment fields. A knee wedge is inserted beneath the patient’s legs

to increase comfort and aid them in remaining still. 3pt BB marks are placed on the patients

mask and abdomen to be used for daily positioning of the patient, which can be visualized using

an example of a similar patient setup seen in Figure 1.

Following simulation and contouring, 3D treatment plans are designed to deliver a total

of 36 Gy in 20 fractions at 1.8 Gy per day to the entirety of the patient’s cranial target and spinal

target volumes. Dosimetrists initially design posterior spinal fields, attempting to treat the

entirety of the spine above the inferior border of S2 with one beam. If this is not possible, a

second spinal field is added and matched to the other posterior field anterior to the spinal canal

using calc points to drive prescription dose into the targets. These fields, along with the cranial

fields, are then feathered in order to decrease any dose heterogeneity across the treatment fields.3

Feathering has been shown to be effective in decreasing the effect of cold and hot-spots caused

as a result of a change in patient habitus or set-up inconsistencies. In order to feather the spinal

fields, the superior border of the lower PA and inferior border of the upper PA beams are moved

superiorly 1cm after every 5 treatments. The cranial fields are designed following the posterior

spinal fields using parallel opposed beams with 2cm flash surrounding the skull, as seen in
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Figure 2. Collimator rotations are used and intended to match the divergence of the PA fields to

avoid overlap of treatment fields. A simple schematic illustrating the entirety of the field design

can be seen in Figure 3. When analyzing dose distributions and altering beam

weighting/energies, the dosimetrist assesses dose heterogeneities and overall isodose line

coverage of the target. In the event of a pediatric case, the dosimetrist ensures that the spinal

column is entirely covered with homogenous prescription dose in order to prevent future

complications including, but not limited to, lordosis and kyphosis. These conditions have

indicated by uneven growth caused by differing levels of radiation exposure. In general, the

dosimetrist aims to cover the target volume with homogenous dose and limit dose to normal

tissues using a simple, but effective approach.

I began the treatment planning process using the methodology used at Froedtert Hospital,

as this technique has proven to be clinically effective and is used frequently. From the beginning

of the process, I was hesitant about using this method because organ at risk (OAR) and target

values at Froedtert Hospital are not assessed in the same manner required by the ProKnow

planning study, seen in Figure 4. Physicians at Froedtert Hospital often check isodose lines

rather than DVH data and far less critical structure contours are drawn, as they understand that

3D planning does not allow the planner to meet these constraints as easily.

In my attempt to make use of this technique, I began by creating a cranial isocenter mid-

brain, followed by spinal isocenters at the same position in the Z and X planes. Initially, upper

and lower PA spinal fields were designed to treat from the inferior border of S2 to a position near

the lower border of the C-spine. These fields made use of 6MV photon beams and were ported to

create a 2 cm margin around the spinal column to avoid dose to the kidneys, bowel structures,

and lungs. Each spinal field was copied 4 times, as the superior border of the lower PA beams
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and inferior border of the upper PA beams were moved superiorly 1cm per copy, carefully

ensuring the match point between the beams remained anterior to the spinal canal. Each beam

copy used the same isocenter but possessed a unique calc point to maintain prescription dose

coverage to the target. Cranial fields were then designed using 6MV photon fields with 2 cm

flash surrounding the skull and with the intention of treating into the spinal PTV as inferior as

possible. The collimator was rotated 7 degrees in each lateral field to match divergence seen in

the upper PA field and cranial fields were then copied in a similar manner as the spinal fields to

increase the inferior border by 1 cm at a time, creating an adjustable junction that ended before

beams would enter into the patient’s shoulders. The varying length of the cranial and spinal

fields was intended to create movable junctions designed to feather the dose and avoid dose

heterogeneities. A total of 4 left lateral cranial beams, 4 right lateral cranial beams, 4 lower PA

spinal fields, and 4 upper PA spinal fields were created.

Planning the ProKnow case study using this version of a 3D technique prevented me

from achieving dose parameters to almost all of the critical structures, especially those either

encapsulated by, or in very close proximity to the PTVs. In order to decrease dose to these

tissues, I employed the use of field-in-fields and modified block edges to balance coverage of

targets and dose to OARs. PTV coverage was highly compromised as a result of doing so and the

complexity of the treatment plan would not have been acceptable according to the ProKnow or

clinical criteria.

Alternatively, I decided to attempt this plan study using Accuray’s Precision planning

system, which makes use of helical IMRT technology. My rationale for employing this technique

was that with consistent daily setup, a highly conformal plan not requiring any junction matching

could be created to treat the spinal and brain target volumes simultaneously using a single field.
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This technique works by positioning patients on a couch that slowly moves through a treatment

bore as a linear accelerator rotates 360 degrees around the patient creating a helical delivery. As

a single 6MV photon beam rotates, fields are shaped and modulated into smaller fields referred

to beamlets.4 This technique allows for dose to be delivered isocentrically using varying angles

couch speeds, and beam shapes, effectively decreasing dose to surrounding tissues and creating

conformal dose distributions.

Following the import of the CT and structure set into the planning system, I created a

combined PTV structure that included both the spinal and brain PTVs. Optimization structures

are entered into an optimization counsel in a similar manner as other IMRT planning systems.

The combined PTV structure was entered as the primary target for optimization, where it was the

highest ranking placeholder in the optimization counsel. The structure was set to receive 96%

percent coverage at 36 Gy while maintaining a hot-spot less than 39 Gy. These values were

designed to push the system to create a high degree of target coverage while maintaining a very

low hot-spot, as I predicted that other downstream structures would fight these constraints. I then

identified critical structures that were near, or within the target volumes. In doing so, I created

optimization structures to assist the planning system in achieving dose parameters that would

fulfill those requested by the plan study. I created ring structures that extended 1 cm and 3 cm

from the PTV in order to drive plan conformality. The 1 cm ring asked the planning system to

only allow 30 Gy to 50% of the structure, while the 3 cm ring asked the system to allow less than

20 Gy to 40% of the structure. 1 cm rings were also added to each of the kidneys, asking to allow

less than 6 Gy to 40% of the structure, while 1 cm rings to the optic nerves requested the

planning system to maintain a max dose less than 36 Gy to those structures. Mean percentages

were entered by setting the system to allow only 40% of the ideal dose requirement and max
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doses were entered 1-2 Gy below the ideal requirement into the optimization counsel for each of

the other OARs. Selecting appropriate layering priorities was important when designing the

optimization plan as incorrect order could prevent optimization or disallow the system from

recognizing a constraint.

In order to further adjust plan quality, the field width, pitch, and modulation factor are

able to be modified in the Accuray Precision planning system. I initially ran the plan with

constraints listed above at the default field width, pitch, and modulation factor to get an idea of

the complexity required to achieve a deliverable plan. The modulation factor is designed to

adjust the range of leaf open times and the pitch adjusts the table travel per gantry rotation, both

leading to increased treatment time but also increased plan quality. These values must be finely

tuned to create effective plans that do not exceed outlandish treatment times. Following the first

optimization, I was unhappy with the maximum dose indicated and PTV coverage falling lower

than the minimum requirement. In order to increase the plan effectiveness, I was required to

increase both the modulation factor and pitch to their maximum values, which in-turn created a

plan that was able to achieve all ProKnow values, as seen in Figure 5. All structures were given

a reasonable maximum and mean dose and can be seen in table format in Figure 6. Target

volumes easily met the minimum study requirements, but the PTV_Brain missed ideal criteria as

it was just below 95% coverage with the 100% isodose line, seen in Figure 7. DVH data can be

visualized in Figure 8, where it is shown that the maximum plan dose of 39.15 Gy (108.75%)

was within the PTV_Brain. The downside of doing so was the increase in treatment time, which

will be further discussed.

The largest struggles throughout the planning process involved maintaining overall PTV

coverage at a value above 95% and maintaining maximum doses below 36 Gy to the optic
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nerves. Following several unsuccessful attempts, I created a PTV-Optic Nerves +1cm ring

contour and added maximum doses of 34Gy to each individual optic nerve. I believe that the

system was struggling to balance PTV coverage and maximum dose constraints to the optic

nerves and this technique seemed to take stress off of the planning system, allowing me to

achieve either ideal or acceptable criteria for each of the listed structures. Although the

parameters were met, the hottest portion of the plan remained in the anterior region of the

PTV_Brain, resulting from the optimization structures requesting decreased dose to the optic

nerves. The system attempted to fill in the PTV coverage by dumping more MUs through beam

angles not directed at the nerves, causing hot-spots as well as cold spots directly surrounding the

optic nerves. Another difficulty presented as a result of a limitation in the Accuray Precision

planning system, as the software does not allow for scaling following the final dose calculation,

making the selection of optimization parameters even more important. Any desired changes must

be generated by editing constraints, field width, modulation factor, or pitch which then requires a

complete re-calculation of dose. Complex cases often require multiple modifications and an

extended amount of time to complete. Delivery time became an issue as a result of the size and

complexity of the target volume, along with increased modulation factor and machine pitch.

These modifications caused the table to move slower and take more time creating complex beam

shapes. Although this improved plan quality, treatments of this length are not practical for any

patients other than those that are safely sedated and anesthetized for the duration of the

treatment.

Medulloblastoma is the most common pediatric brain malignancy, often metastasizing to

other areas of the brain and CSF. Varying CSI treatment methods have been the choice of

physicians in these scenarios, as positive results are often observed. As our understanding of
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disease progression and normal tissue tolerance continues to advance, we must continue to

evolve our approach to planning in order to create more effective plans. The 3D approach

required junction matching and a high number of treatment fields, only to result in major

sacrifices in target coverage to achieve normal tissue parameters. Instead, I employed helical

IMRT to treat the target volumes simultaneously with a single field. AS seen in Figures 9 and

10, Accuray-s Precision software allowed me to create a highly conformal plan. Although this

method allowed me to achieve all dosimetric parameters and decrease the daily treatment

complexity, the patient would have been on the table for nearly an hour. Similar to other IMRT

methods, this technique also presents worry in regard to the effects low dose spray across a large

volume of the patients body, as there is evidence that low-dose exposure may increase the

likelihood of secondary malignancy in patients expecting extended survival.5 This case study is

an example of a comparison between a traditional technique and one that, with some tweaking

and improvement, has the potential to improve our ability to treat patients requiring craniospinal

irradiation. The main teaching point I took away from this study was to continually seek out new

and improved methodologies and not to become stagnant with simple techniques. Our main goal

as medical dosimetrists is to create the most effective treatment plans we are capable of and it is

our duty to continually improve our technique.

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Figure 1. Immobilization of a craniospinal patient using immobilization devices designed to

create a reproducible and comfortable patient setup.2

Figure 2. A transverse image shows cranial fields created using opposed lateral beams. Gantry
angles are selected in order to align the patient’s right and left patient lens.

Figure 3. Sagittal view of a typical craniospinal beam arrangement at Froedtert Hospital. PA

beams are matched and feathered to treat the spine and opposing lateral fields are used to treat
the cranial region of the patient.
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Figure 4. The ProKnow plan study parameters for CSI.

Figure 5. The ProKnow generated score card indicated that each parameter met either minimum
or ideal criteria for a final total of 123.15 points out of 127.
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Figure 6. Final plan maximum, minimum, and mean doses to all OARs and target volumes.
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Figure 7. Final plan DVH analyses for all OAR and target volumes requiring specific volumetric
dose limits or minimums.

Figure 8. Final plan DVH graph for absolute dose to all relevant OAR and target volumes.
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Figure 9. Final plan transverse images illustrating isodose lines and OARs. The pertinent
isodose colors are listed in the top right corner of each of the transverse images.
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Figure 10. Final plan sagittal and coronal images illustrating isodose lines and OARs. The
pertinent isodose colors are listed in the top right corner of each of the transverse images.
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References

1. Medulloblastoma - Childhood - Statistics. Cancer.Net. https://www.cancer.net/cancer-

types/medulloblastoma-childhood/statistics. Published April 3, 2018. Accessed October
16, 2018.
2. Cagle S. Supine Adult Craniospinal Irradiation: A Case Study.
http://pubs.medicaldosimetry.org/pub/dd8a9fd0-ccd2-e86b-f842-79a28d93bbee.
Accessed October 15, 2018.
3. Athiyaman H, Mayilvaganan A, Singh D. Journal of Medical Physics / Association of
Medical Physicists of India. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258734/.
Published 2014. Accessed October 14, 2018.
4. Technology. Technology | Accuray TomoTherapy.
https://www.tomotherapy.com/technology. Accessed October 17, 2018.
5. Paganetti H. Health physics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464436/.
Published November 2012. Accessed October 16, 2018.