April Hardman

Clinical Practicum III

CSI ProKnow Plan

1. Provide an in-depth description of the treatment planning process.

I used a VMAT/IMRT treatment planning technique to plan the supine CSI treatment.
The length of this treatment field alerted me to treat this patient on one of our larger
linacs, which is capable of a 40x40cm jaw size. All fields were planned with 6x energy to
avoid neutron contamination with this treatment method. Due to the length of the target
volume, I chose to place 3 separate isocenter field groups. I reviewed several articles
discussing comparisons in CSI planning and chose to combine ideas from multiple
articles to create this plan, as well as discuss options and ideas with my clinical
preceptors. As suggested in a review of static IMRT CSI planning, if the length of the
PTVcns was less than 80 cm, B and C were set to make A, B, and C 25 cm apart to each
other.1 Since the length of the PTV volume was just over 70cm I placed the isocenters at -
5,-30, and -55cm in the z plane and applied a 1cm shift to create as parallel of a line as
possible with consideration of the natural curvature of the spine.
April Hardman
Clinical Practicum III
CSI ProKnow Plan

Each isocenter section had one field with a 3-degree collimator angle with a clockwise arc
travel direction from 181.0-179.0 degrees. Each field also had an opposing reverse arc field
with a 357-collimator angle with arc degrees of 179.0-181.0 degrees.

Field borders included a 2 cm flash around the brain field and a 2-3cm overlap of field in the
Y-direction to the adjacent inferior field below. The 2nd field encompassed both the superior
and inferior fields with a 2-3cm overlap, and the 3rd field extended to 2 cm beyond the border
of the most inferior portion of the PTV. X jaws on all fields were adjusted to allow adequate
dose to the treatment area, but to also minimize dose to the surrounding tissue, keeping in
mind the maximum distance of leaf travel.
April Hardman
Clinical Practicum III
CSI ProKnow Plan

Within the optimizer calculation models, selection of the photon optimizer will launch a
window where auto feathering can be turned on. This helped to taper the dose from each field
to avoid a hard match line.

2. Describe how your plan was normalized.

The plan was normalized to the 99% isodose line so that 95% of target volume was
receiving 100% of the prescription dose. With IMRT we normalize to a volume. So, I
created a PTV total volume by combining all the PTV’s and normalized the PTV total
volume to the 99% isodose line.
3. Give a detailed summary of your plan evaluation process.
After my first optimization, I noticed that there some areas with prescription dose
extending outside the PTV volume and some areas within the spinal canal that were
lacking dose. This occurred because I placed a hard constraint on the kidney volumes and
forced too much dose outside of the PTV volume which was in-between these two areas.
To remedy this, I created a hot structure out of the prescription dose spilling outside the
volume, and a cold structure for the areas inside the PTV that were lacking coverage. I
placed a lower constraint on the cold structure equal to 80cGy above the prescription
dose and I placed an upper constraint of 100cGy below the prescription dose on the hot
structure. I used upper gEUD’s with high priorities to gradually reduce OAR that were
exceeding the dose constraints. I adjusted the priorities as needed. The D-max within this
plan was 110.5% after normalization, and was found between T12-L1. This is an
appropriate location since it is inside the PTV volume. We would also expect its location
based on the hard constraints placed on the kidneys.
April Hardman
Clinical Practicum III
CSI ProKnow Plan
April Hardman
Clinical Practicum III
CSI ProKnow Plan
April Hardman
Clinical Practicum III
CSI ProKnow Plan
April Hardman
Clinical Practicum III
CSI ProKnow Plan

Dose Distribution Isodose Group I

Dose Distribution Isodose Group II

April Hardman
Clinical Practicum III
CSI ProKnow Plan

Dose Distribution Isodose Group III

DVH
April Hardman
Clinical Practicum III
CSI ProKnow Plan

4. Embed your ProKnow plan score sheet and discuss if goals could be achieved.
Overall, I was able to achieve most of the OAR goals in the ideal range, however, the
liver and kidneys were only able to meet the minimum requirement. The kidney
constraints are hard to meet based on their proximity to the target volume. Based on my
beam geometry, I could not find an optimization that could achieve those goals, even
despite an attempt to place an entrance and exit block on the organs.
April Hardman
Clinical Practicum III
CSI ProKnow Plan

5. What did you learn from this planning assignment?

This was challenging to plan, as they are not common within the clinic. After researching
and many trial-and-error attempts, I was able to find a technique that worked sufficiently
for me. I found the multiple isocenters and field overlapping to be advanced, but I am
very grateful I had the opportunity to work on this project as a student, as it will serve as
a great learning tool with future planning on complex cases. I also was unaware of the
auto feathering feature that is built into eclipse for inverse planning.

References:

1. Wang Z, Jiang W, Feng Y. A simple approach of three-isocenter IMRT planning for

craniospinal irradiation. Radiat Oncol 8, 217 (2013). https://doi.org/10.1186/1748-717X-8-217.
Published: September 17, 2003. Accessed: September 28, 2021.
2. Young L, Brooks C, Bedford J, Warrington A, Saran F. Development and evaluation of
multiple isocentric volumetric modulated arc therapy technique for craniospinal axis
radiotherapy planning. Int Onc Phys 2,82 (2012). https://doi.org/10.1016/j.ijrobp.2010.12.033.
Published: February 2012. Accessed: September 28, 2021.