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Craniospinal Irradiation (CSI) Assignment Patient position is extremely important.


Pretend you are the dosimetrist called to go into the simulator and assist with the CSI
setup. Be very specific and descriptive in your answers.
1. Is the patient a child or an adult? What might you have to do differently based on the
size and age of your patient? (5 points)
The patient is an adult with normal weight. To directly visualize the cranial-spinal, and spinalspinal junctions, prone position is preferred. If the patient is a child who may need more tolerable
position, easier access for anesthesia, an over-weighted patient, or patient who needs more
comfortable position, supine position should be used.1
2. How will the patient be positioned? Supine or prone? After describing which orientation,
include all the devices used. Describe head position, chin position, arm position, how will
you assure your patient is aligned? List everything that you would check before leaving the
CT. Sometimes a board is placed under the lower torso, describe if this will be used for
your patient and why or why not? (25 points)
The patient will be in prone position head first. The patient will lie with the face down and arms
down by the sides of the body in an immobilization cast or Alpha Cradle that ensures the patient
immobilized and reproducible daily setup.2 A face holder will be used to support patient's head
and allow the patient's respiration. The patients forehead is placed on the forehead rest, and chin
on the chin holder to push mandible into treatment field. 1 The head is extended to prevent the
spine field from exiting through the jaw. The shoulders are positioned as low as possible to
ensure an increased area for cranial and spinal field match. If needed, shoulder retractors may be
used. Thermoplastic mask on back of the head will be used to make the head and shoulder
immobilized and daily setup reproducible. Radiopaque markers are placed on the lateral canthus
of each eye to help align the eyes and prevent the lenses from receiving doses. 3 A radiopaque
wire is placed along the spine on the posterior skin surface to help gap calculations.
If the patients cervical and thoracic spine curvature is obvious, a board needs to be placed under
the patients lower torso to reduce the curvature and make the patients dorsal surface as straight
and flat as possible.

Before the CT scan, it is important to make sure the patient is lying straight and parallel to the
table top as much as possible with the head and chin extended and shoulders pulled down.
A scout scan should be taken to assure the patient is positioned correctly.

The following questions are generic CSI questions:


1. How is the spine matched to the head ports for a craniospinal setup? BE SPECIFIC.
Give me the formulas used to determine any angles and give an example of using the
formula(s). Provide a diagram or drawing (20 points)
Since craniospinal irradiation is composed of lateral parallel-opposed cranial fields and posterior
spinal fields, the junction between the cranial and spinal field must be matched in order to avoid
overlap of the fields and overdose to the spinal cord.4 In a prone position setup, it is implemented
with both the collimator and couch rotation.
As shown in Fig.1, in order to match the inferior border of each cranial field to the divergence of
the superior border of the spinal field, the cranial field collimator needs to be rotated.4

Fig. 1 Cranial fields collimators are rotated to match the diverging border of the spinal field.4
The angle of the collimator rotation (collimator) can be calculated by the following equation:
collimator = arc tan ( L1 1/SSD)
L1 = length of the posterior upper spinal field
SSD = source-to-surface distance for the upper spinal field

Since the cranial fields are divergent as well, in order to match the divergence of each cranial
field with the divergence of the spinal field, the couch also needs to be rotated. (Fig. 2)4

Fig. 2 Couch rotated to match the diverging cranial fields with the diverging spinal field.4
The angle of the couch rotation (couch) can be calculated by the following equation:
couch = arc tan ( L2 1/SAD)
L2 = length of lateral cranial field
SAD= source-to-axis distance for the cranial field
For example, if the upper spinal field length is 30 cm at 100cm SSD and each lateral cranial field
length is 25cm with SAD setup, to match the cranial with the spinal field for a craniospinal
setup, what degrees should the collimator of the cranial field and couch rotate?
To solve this problem, we use the equations above:
collimator = arc tan ( L1 1/SSD) = arc tan (15/100) = 8.5
couch = arc tan ( L2 1/SAD) = arc tan (12.5/100) = 7

2. If you wanted to remove any divergence from the eyes in the cranial port, how would this
be accomplished? Why would you do this? Show a formula and how it can be used. Provide
a diagram or drawing. (10 points)

Radiation to the eyes can cause cataract, and dose > 16.5 Gy may lead to irreversible visual
impairment or blindness.5 The divergence of the cranial field on the block edge results in exit
dose to the contralateral eye. In order to remove divergence from the eyes, the gantry can be
rotated to align the eyes with the block edge of the cranial field and limit the exit dose to the
contralateral eye. Fig. 3 shows how the gantry rotates to prevent divergence into the eyes.

Fig. 3 Beam 1 (blue) rotates to Beam 2 (yellow) to align the eyes with the block edge
Below is the formula for gantry rotation:
gantry = arc tan (L 1/SSD)
L = length of the anterior cranial field
SAD = source-to-axis distance for the cranial field
For example, the length of the anterior cranial field is 10 cm and the machine SAD is 100 cm.
Find the angle to remove the divergence from the eyes.
gantry = arc tan (L 1/SSD) = arc tan (10 / 100) = arc tan (0.1) = 5.7
Another way to minimize the divergence is to place the central axis near the eyes and use half
beam to block the eyes.

3. For treatment planning, approximately where will you place the isocenter for each field
for the patient above, will the isocenters be moved? Why or why not? What are the
approximate field borders? (25 points)
For the craniospinal treatment planning, all isocenters should be at the same lateral couch
position to minimize shifts.1 I will place the isocenter for the superior spinal field first. Usually
the isocenter will be placed at the middle of the length of the spine with SSD set up. The central
beam axis should be perpendicular to the vertebral column, and the superior field should be as
large as possible. In order to prevent acute and late oral toxicity, the superior beam border should
not go through the jaw. The lateral edges should be 1 cm to the pedicles of the spine to ensure
adequate dose coverage to the spinal cord. The inferior border is usually placed at the level of
L2.6 By shifting from the superior spinal isocenter to the caudal direction longitudinally, the
inferior spinal isocenter can be placed. There will be a gap between the inferior border of the
superior spinal field and the superior border of the inferior spinal field so that the two fields
wont overlap at the spinal cord. The inferior border of the inferior spinal beam is usually at the
level of S3 to include the entire lumbar spine and sacrum.
For the cranial fields, I will place the isocenter at the center of the cranium with SAD set up. The
gantry head should be rotated anterior to avoid divergence to the contralateral eye and the couch
table should be rotated to compensate the divergence from the caudal border of the beam and
match with the diverging upper spinal field. The match line for the superior spinal field and
cranial field will be at C4-C5 or be placed as inferior as possible without going through the
shoulders of the patient.
The isocenters will not be moved during the entire treatment process, since they determine the
patient set up and field matching calculations.
4. If two spine ports must be matched due to the length of the spine, tell me how you would
accomplish this and how would you assure that there is no overlap? (10 points)
If one spinal field is not long enough to cover the entire spinal subarchanoid space, two spinal
fields will be used. In order to avoid overlapping of the two diverging beams at the spinal cord, a
skin gap between the superior spinal field and the inferior spinal field should be left. By
separating the two fields with a gap, the divergence of the beams will intersect at anterior spinal

cord and will not cause overdose to the spinal cord. The gap is calculated by the following
equation: 5
Gap = S1 +S2 = L1 d/SSD1 + L2 d/SSD2
d = depth of the two fields junction
L1 = field length of the superior spinal field
L2 = field length of the inferior spinal field
SSD1 = source-surface distance of the superior spinal field
SSD2 = source-surface distance of the inferior spinal field

5. If feathering the gap is required between 2 fields, what does that mean? Can you
describe how this could be accomplished? (provide details as if you had to explain exactly
what will be done to the radiation therapist who is treating the patient) (5 points)
During the craniospinal treatment, field matching may cause incidences of under or over dose
due to the gap or overlap. To prevent this, feathering the gap between 2 fields will be used. There
is a skin gap between the superior spinal field and the inferior spinal field to avoid overlapping
of the two diverging beams at the spinal cord. Therefore the junction between the two spinal
fields should be moved superiorly or inferiorly by 1 cm after each 9 Gy (1.8 Gy 5 fractions) to
prevent hot or cold spots at the junction.6

References
1. South, M. Using Composite Planning and Delivery with Feathered Junctions in
Craniospinal, Brain-Spine and Spine-Spine Abutted Fields. [PowerPoint]. Methodist
Cancer Center; 2015.
2. Bentel GC. Radiation Therapy Planning. 2nd ed. Durham, NC: McGraw-Hill Companies,
Inc; 1996.
3. Scott RL. An overview of craniospinal axis fields and field matching. Med Dosim Off J
Am Assoc Med Dosim. 2013;38(4):424-429. http://dx.doi.10.1016/j.meddos.2013.05.005.
4. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014.
5. Henk JM, Whitelocke RA, Warrington AP, Bessell EM. Radiation dose to the lens and
cataract formation. Int J Radiat Oncol Biol Phys. 1993;25(5):815-820.
6. Chao KS, Perez CA, Brady LW. Radiation Oncology: Management Decisions. 3th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2002.