Craniospinal irradiation (CSI) is utilized for disease that has spread throughout the central nervous

system (CNS). Pediatric patients with medulloblastomas are the most common cases of CSI. Historically
speaking patients were treated in the prone position with opposed laterals used for the brain, similar to
a whole brain treatment, and a single PA field used for the spine. If the patient is taller the PA spine
field may need to be split into two functioned fields, due to field size limitations. A gap junction is used
in these cases to reduce the hotspot cause by two abutting fields.

In my clinical experience I had only seen these cases treated on a Tomotherapy unit with a brain boost
to follow, until recently. My clinic does not treat many CSI cases. A few years ago, we did treat a CSI
and it was treated in the supine position using opposed laterals for the brain and 4 arcs for the spine,
with two separate isocenters. In total the plan had 3 isocenters. I discussed this plan with the
dosimetrist that planned it as well as the conventional way of a prone set up with gap junctions. After
my discussions I decided to try the supine position for this assignment. The tradiational gap treatment
seemed to have more hotspots and a much longer treatment time. I decided to try and see if I could
improve upon this by using supine set up.

Students were asked to download a data set from ProKnow in either the supine or prone position. The
supine set up seems to be a more reproducible set up and I like the idea of trying a newer technique
using VMAT planning. I downloaded the supine CT data set and starting brainstorming ideas of how to
start this.

After reviewing the planning target volumes (PTV) for the brain and spine I wasn’t sure what my best
approach for the brain would be. With opposed laterals I knew that I would not meet constraints for the
optic nerves. However, with VMAT planning I wasn’t sure if how hard it would be to get the superficial
coverage that the PTV required. I was also concerned with how to reduce the hotspot I knew I would
have between the brain fields and the spinal fields.

I decided to try doing a 3 isocenter plan using all VMAT arcs. Two arcs for the brain and 4 arcs for the
spine. Two arcs would be superior and 2 would be inferior. I created an expansion for both the brain
and the spine PTVs. I did notice that the inferior portion of the spine PTV was very superficial as well as
a few spots in the brain. This eventually made coverage harder to obtain in these areas. I optimized this
plan a few times and unfortunately, I just did not like how the Brain plan was coming out. It was always
to hot. I then decided to create an opposed lateral brain plan and then optimize the VMAT arcs for the
spine using the opposed lateral brain plan as a base dose plan. This plan came out with a hot spot at the
junction. Looking back after completing my final plan I would like to go back and try the base dose plan
again. I believe if I were to use by PTVTarget structures that I created for optimization the base dose
plan may have been a good option.

I then decided to try an opposed lateral plan using irregular surface compensator (ISC) for the brain and
then 4 VMAT arcs for the spinal plan. My thought was that using ISC I could reduce the dose near the
junction if needed to reduce the hot spots. The following description is how I arrived with my final plan.

A few things I did before starting the optimization.

 Created an expansion for the spinal cord using a 1mm margin from the spine PTV. There was no
expansion at the superior end of the spine PTV due to concern of hotspots. I also created 2 rings
at 1cm and 2cm away from the spine PTV.
  Used Arc Geometry Tool to pick isocenter for the two spinal fields. I used the expansion as the
target with collimator offsets of 10 and 350.
 I then evened out my shifts. If this was a real patient plan this is helpful for the treating
therapists. It can reduce the chance of shifting errors as well as cut down on an already long
treatment time. My shifts were only in the superior to inferior direction for all fields. No field
required a shift in the right/left direction or the anterior/posterior direction. The brain iso
center was left at Dicom. (Figure 1)
 The brain plan has a 5-degree table for each field. I did this to create a half beam without
shifting iso to the junction. I chose to do this so I would have more control with the dose
painting the in ISC Brain plan.
 Add avoidance sectors to avoid treating through the arms. Although the patient would be
immobilized it is still hard to ensure the arms are in the exact position same every day. Once I
started planning, I realized how much the avoidance sectors also helped reduce the dose to the
kidneys. (Figure 2)
 Turned Jaw tracking on and arc parameters can be seen in Figure 3

Figure 1- Isocenter placement

Figure 2- Avoidance Sectors

Figure 3- Arc Parameters

I began optimizing plans. I ran a few optimizations and realized that the hot spot and the dose to the
kidneys was going to be the tricky part. After the first optimization I created a plan summary with the
Brain and the Spine plans. I wanted to see exactly where and to what level the hot spot was at the
junction of the brain and spine. With my first plan I had a hot spot of 130%.

I then went back and created a PTVSpineTarget. I deleted the top slices one by one of the Spine PTV
with an optimization in between each deleted slice. I wanted to use the scatter from both plans to fill
the gap I had created. In total I deleted 3 slices of the PTV and CTV for the spine to create the target PTV
and target CTV. I then optimized again and had a hot spot of 111%, so I knew I was getting much closer.
Going back and forth between optimizing and editing the target PTV took a little time but it was
reducing the hotspot quite well. I have included my optimization constraints. These are not what I
started with but what I ended with after the final optimization. I did go back and start in MR 4 a to
reduce any hotspots by converting the 108% isodose line into a structure and then using that to reduce
any hotspots. These values reflect that. I have also included a copy of the script that I made for
checking this plan in Eclipse. I used and automatic NTO of 150 in optimizing the spine plan. The brain
plan was normalized to 93.2% of the PTV volume receiving 100% of the dose and the spine plan was
normalized to 95.03% of the PTV volume receiving 100% of the volume. I was able to reduce the
normalization on the brain plan due to the scatter from the arcs. Both plans still had coverage of 95% of
the PTV receiving 100% of the dose. I chose 95.03 for the spine simply because I know when
transferring plans to proknow the coverage can change slightly.
DVH- Showing significant structures. I chose not to turn on all structures as it was very difficult to see
any defined lines. I turned on one CTV to demonstrate where the full dose fell on the DVH

Optimization objectives. As I stated earlier, these are the values I ended with after tweaking during the
different MR levels. You can also see I added in a few structures only used of optimization, such as the
expansion and ring structures.
Figure 4- Script in Eclipse
Figure 5 – Spine Isodose lines
One thing I found interesting while doing this plan is the PTV for both the Brain and the Spine. It is clear
that a CTV was drawn and the PTV was created with a 3D margin. I think there are a few slices within
this data set where the PTV would normally have been altered slightly if this patient were being treated
in clinic. Near the inferior end of the spine PTV it is almost abutting the skin. The same goes for the
Brain PTV that is extending outside of the skull into the nasal cavity. While this made in interesting to
plan I do wonder what a few of my dose outcomes would have been if the PTV was similar to what I
would normally see in my clinic.
The following is my final score card. I was slightly disappointed that my doses did change when I
uploaded my plan. In my original plan I had my lens passing. My hotspot in the spine was not as low has
I would have like but I do believe it is still clinically treatable plan.

Overall, I think this plan turned out to be a plan that could be treated in clinic. I learned a lot from trial
in error with a plan like this. I am pleased that I was able to reduce the kidneys enough to be passing. I
would have liked to see my hot spot reduced further, however this is something I can continue to work
on. The optic nerves were close to passing however in the end they did not pass. In looking at other
doses that are used for brain treatments I still find that this would be an acceptable dose to the optic
nerves for a treatment plan. I general, think utilizing this technique would allow for a much shorter
treatment time. In a case of a craniospinal, especially if it is a child, it is essential to have a stable,
comfortable set up that can be treated quickly and efficiently. I think plan allows for quick treatment
with minimal shifts and a short treatment time.