SBRT SPINE

KATELYN LARGER
 • Non-small cell carcinoma of the lung
PATIENT MEDICAL • Stage IV

HISTORY • Now presents with bone metastasis to T1-T2 and L4

 • Treating a small volume to a high dose
SBRT SPINE • Used for re-treats and spine metastasis
PURPOSE • Limits the amount of normal tissue treated
 • Special immobilization has to be used because we are
using such a high dose to treat a small area
IMMOBILIZATION • Tight margins, movement could cause high dose to
critical structures/normal tissue
 IMMOBILIZATION
CONT.
• Dosemax board and arm
shuttle used for T-spine
treatment
• SBRT vac bag
• Iso placed with marks 5cm
sup. and inf.
• Tattoos placed at iso
• Knee sponge with strap used
for extra immobilization
PLANNING OBJECTIVES
 • VMAT
• 2 full arcs
• Full arcs keep the dose conformal
BEAM
• 0 and 90 degree collimator angles used
ARRANGEMENT • Helps to get a straighter edge so we can easily retreat
if more metastasis
 • Use inverse planning
• Create optimization structures
• Take into account critical structures and planning
OPTIMIZATION objectives
• Optimization structures:
PROCESS AND
• Cauda equina (Use MRI to contour)
STRUCTURES • Kidneys
• Ring 100
• Ring 50
OPTIMIZATION RINGS
DOSE DISTRIBUTION
PRESCRIPTION
• 6FFF gives quicker treatment
time, less time for patient to
move
• Usually prescribe to 95%-100%
• 99.3% isodose curve is
getting 100% of the dose
SBRT 1 FRACTION VS 3 FRACTIONS VS STANDARD

1 Fraction 3 Fractions Standard Fractionation

• Cauda Equina • Cauda Equina • Cauda Equina
• <5cc, max 14Gy • <5cc, max 21.9Gy • max 60Gy
• Kidneys • Kidneys • Kidneys
• 200cc, max 8.4Gy • 200cc, max 16Gy • 100% <23Gy
 • First day patient is set up to CT marks, shifts applied, patient is
remarked
• Daily CBCT used to verify patient position
• Shifts are applied from CBCT and recorded by physicist
• Physicist verifies the treatment plan
DAILY SETUP
• Energy, gantry, collimator, rotation, MUs, etc.
 • 1-2 vertebral bodies 6 DOF is used
• > 2 vertebral bodies 4 DOF is used (rotation only)
• SRS
• ≤ 2.5 apply shifts and reimage
• If shifts ≤ 1mm/1degree, no need to apply shifts, can treat
patient

CBCT TOLERANCES • If shifts > 1mm/1degree, apply shifts and repeat imaging
• > 2.5 must re-set up patient and reimage
• If shifts ≤ 1mm/1degree, no need to apply shifts, can treat
patient
• If shifts > 1mm/1degree, apply shifts and repeat imaging
• SBRT
• ≤ 1.5 apply shifts and treat
• >1.5, ≤ 2.5 apply and reimage
• > 2.5 must re-set up patient and reimage