Jenna Cimmiyotti

September 27, 2021

Clinical Practicum III
Craniospinal Irradiation Assignment
Craniospinal irradiation (CSI) is used for treatment for several central nervous system
tumors such as medulloblastoma, ependymomas, gliomas or leukemias that tend to seed via the
cerebrospinal fluid.1,2 The intended target for these treatments is the entire neuroaxis. Classically,
CSI treatment is delivered using 2 lateral brain fields abutting 1-2 posterior spine fields with the
patient in the prone position1. The collimator and couch is rotated on the lateral brain fields in
order to match the divergence of the inferior jaw of the brain fields with the superior jaw of the
PA spine field. Other techniques used for CSI include 3D conformal, intensity modulated
radiation therapy, volumetric modulated radiation therapy, tomotherapy, and proton therapy.3
Proton therapy has a clear dosimetric advantage over other modalities, but is not widely
available.4,5 Furthermore, patients can be treated in either the supine or prone position, each
having its own advantages. The supine position is preferred when anesthesia is used and is often
considered more comfortable for the patient. However, the prone position allows for direct
visualization of the junction between fields.
For this assignment, students were asked to generate a CSI plan on either the provided
supine or prone data set. Planning goals were provided using the ProKnow software. My
treatment planning technique consisted of a combination of forward and inverse planning on the
supine data set. This is consistent with our standard of practice at my clinical site. The
prescription for both the PTV_Brain and PTV_Spine was set to receive 36 Gy delivered at 1.8
Gy per day over 20 fractions.

Treatment Technique Overview

As mentioned, a combination of forward and inverse planning is utilized in this technique
which is described in depth by Ahmed et al5. First, a 3D conformal plan using opposed lateral
fields is created to treat the brain and c-spine target. The inferior portion of the plan utilizes a
feathering technique creating a dose gradient to blend the dose distribution at the junction of the
brain/c-spine and upper spine plan. Next, an upper spine plan utilizing static IMRT is created as
well as a lower “false” spine field. A plan sum of the brain/c-spine and lower “false” spine plan
is created and used as a base plan in the optimizer for the upper spine plan. The purpose of the
lower “false” spine plan ensures a dose gradient is created during the optimization of the upper
spine plan. Next, the brain/c-spine and upper spine plan are summed together and used as a base
plan for lower spine plan optimization. Lastly, a plan sum is created using all 3 plans (brain/c-
spine, upper spine, and lower spine) to assess the final dose distribution. The following sections
will further describe the details regarding each plan involved in this technique.

Brain and C-Spine Plan

An isocentric, 3D conformal plan utilizing opposed lateral fields was used to treat the
brain and c-spine. I began by setting up the fields using 6 MV and the isocenter was placed so
the inferior jaw (Y1) is set to 10.0 cm and positioned just superior to the top of the patient’s
shoulders (figure 1). The MLCs were fit to a PTV_all structure using 0.5 cm dosimetric margin.
The PTV_all structure was created using the boolean tool in Eclipse to combine PTV_Brain and
PTV_Spine. The X1, X2, and Y2 jaws were manually adjusted to align with the edges of the
fitted MLCs (figure 2). Finally, the optic nerves and lenses of the eyes were manually blocked
with the MLCs to spare these organs at risk.

Figure 1: Beam geometry of the left and right lateral brain and c-spine fields
Figure 2: Right and left lateral brain and c-spine fields

I used a field in field technique to generate a plan that met the target coverage constraints
while also minimizing the dose to the OAR and reducing the areas of 105%. The target coverage
goal was at least 95% of the target receiving 100% of the prescription dose. After I was satisfied
with the coverage and overall dose distribution, I created the feathered dose gradient at the
inferior portion of the plan. The gradient is achieved by adding additional field in field segments
to close one MLC leaf at a time for a total length of 6 cm from both the left and right lateral
fields. Figure 3 below demonstrates 4 of the multiple field in field segments used to create the
dose gradient.
Figure 3: Example of the field in field segments used to create the dose distribution at the
inferior portion of the brain and cervical spine plan.

1. 2.

3. 4.
Once the field in field segments were created, I divided the weighting of the original left and
right lateral parent fields and redistributed it evenly to each field in field segment. In this specific
case, the left lateral parent field was originally weighted 0.471. There was a total of 6 field in
field segments created from the left lateral field when creating the dose gradient. Therefore,
0.471 was divided by 7 to account for each segment and the main left lateral field. Each of the
field weight was changed to be 0.067. The same process was repeated for the right lateral field
resulting in an even dose gradient (figure 4).

Figure 4: Dose gradient at inferior portion of brain and cervical spine plan.
I used the dose profile tool to ensure the area of the dose gradient had the proper dose falloff
(figure 5). Ideally, the dose profile will resemble a 45° angle when measuring from the inferior
prescription isodose line to the inferior field edge.

Figure 5: Dose profile of the dose gradient area.

Create Upper Spine Fields

The next step was to create the fields for the upper spine plan. This plan utilized an
isocentric, static IMRT technique using 3 beams with 6 MV beam energy. The field angles
included a posterior beam and 2 posterior obliques (figure 6). The oblique beam angles were
selected by evaluating the OAR such as the kidneys and posterior arm tissue in the beam’s eye
view. The isocenter placement was shifted inferiorly from the Brain/c-spine plan, and was
positioned so that the inferior jaw (Y1) was set to 19.5 cm and the superior jaw (Y2) overlapped
the brain and cervical spine fields by 6 cm to take into account the 6 cm dose gradient that was
previously created (figure 7). The MLCs were fitted with 0.5 cm dosimetric margin to the
PTV_Spine structure, and the X jaws were manually adjusted to the edges of the MLCs (figures
8, 9).
Figure 6: Beam geometry of the upper spine plan

Figure 7: Overlap of upper spine fields and brain/c-spine fields

Figure 8: Beam’s eye view of the P45L beam.

Figure 9: Axial view of 3 beams used for upper spine plan.

Create Lower “False” Spine Field

Next, I created the lower “false” spine plan. The sole purpose of this plan is to serve as a
component of the base plan that will be used when optimizing the upper spine plan. This plan
consists of a single isocentric posterior field using 6 MV beam energy. The superior border (Y2)
was set to overlap the upper spine plan by 12 cm. The inferior jaw (Y1) was set to include the
entirety of the PTV inferiorly (figure 10). Next, MLCs were added and fit to the PTV_Spine
structure using a 0.5 cm dosimetric margin. The X jaws were again manually fit to the edges of
the MLCs (figure 11). Next, I added weight to the posterior beam until the 95% isodose line
covered the most anterior portion of the PTV and the 100% isodose line covered the thecal sac
(figure 12).
Figure 10: This demonstrates the 12 cm overlap between the lower “false” spine plan and the
upper spine plan to achieve a dose gradient that will be used as a base plan during optimization
of the upper spine plan.
Figure 11: Demonstrates the beam’s eye view of the posterior field of the lower “false” spine
plan.

Figure 12: Initial coverage of lower “false” spine plan with 95% (green) covering the most
anterior portion of the PTV (magenta).
After obtaining adequate coverage on the lower “false” spine field, I created another dose
gradient at the superior edge of the field where the lower spine fields and upper spine fields
overlap. The dose gradient was produced in the same fashion as done previously. That is,
multiple field in field segments were created, closing one leaf at a time for a total length of 12
cm. The MLC leaves were closed starting with the most superior leaf on the lower “false” spine
field and working inferiorly for the entire 12 cm area of overlap (figure 12).

Figure 12: Demonstrates 4 of the 18 total FIF segments used to create a dose gradient on the
superior aspect of the lower “false” spine field.

1. 2.

3. 4.
 After creating the field in field segments, the initial weighting of the single posterior field
used in the plan was redistributed evenly to each of the segments. This creates a smooth dose
gradient at the junction of the upper and lower spine fields. The dose profile tool was again used
to confirm this process was successful. If done properly, the dose profile will result in a 45°
angle as shown in figure 13.

Figure 13: Dose gradient on the superior portion of the lower “false” spine plan

Creation of Lower True Spine Fields

Similar to the upper spine plan, the fields for the lower “true” spine plan consisted of 3
beams using an isocentric static IMRT technique with 6 MV beam energy. The beams that were
used included a posterior, right posterior oblique, and left posterior oblique. The beam angles
were determined by assessing the OAR, including the kidneys, in the beam’s eye view (figure
14). The jaws were set to the same parameters as in the lower “false” spine plan; the superior jaw
(Y2) was set to overlap the upper spine plan by 12 cm and the inferior jaw (Y1) was set to
include the entirety of the PTV (figure 15). Next, MLCs were fit to the PTV_Spine structure
using a 0.5 cm dosimetric margin. The X jaws were manually fit to align with the edges of the
MLCs.
Figure 14: Beam’s eye view of the posterior, left posterior oblique, and right posterior oblique
beams. Notice the beam angle is selected to minimize dose to the left kidney (magenta) and right
kidney (green)

Posterior beam Left posterior oblique

Right posterior oblique

Figure 15: Demonstrates the overlap between the upper spine and lower “true” spine fields.

Optimization
Upper Spine Plan
At this point, I have created a finished plan that encompasses the brain and cervical spine.
Additionally, I have setup the fields on the upper spine plan, lower “false” spine plan, and the
lower “true” spine plan. Next, I moved on to optimizing on the upper spine. Prior to entering the
optimizer, I created a plan sum that combined the Brain&Cspine and lower “false” spine plans to
use as a base plan (figure 16). I also created 2 target optimization structures. The z_PTVOpt
Upper structure consisted of the PTV_spine extending from the area of the C-spine dose gradient
and continues inferiorly into the lower spine dose gradient (figure 17). Similarly, the z_PTVOpt
Lower structure consisted of the PTV_Spine structure within the lower spine fields and extends
into overlap between the upper and lower spine fields (figure 18). Finally, I created 2 dose
limiting annulus (DLA) structures that functioned to help conform the dose. The zDLA upper
and zDLA lower structures are created by expanding the upper and lower z_PTVOpt structures
by 2 cm, respectively, and then cropping it away by 0.2 cm (figure 18).

Figure 16: Plan sum of the Brain&Cspine and Lower “false” spine fields that is used as a base
plan during optimization of the upper spine plan.
Figure 17: z_PTVOpt Upper structure used for optimization of the upper spine plan.

Figure 18: z_PTVOpt Upper structure used for optimization of the lower spine plan.
Figure 19: zDLA upper (green) and zDLA lower (red) optimization structures. zPTVOpt upper
(blue), zPTVOpt lower (orange).

Upon entering the optimizer, I selected the Brain&Cspine and Lower “false” spine plan
sum as the base plan and selected the fixed jaws option under the plan information tab. (figures
20-21).

Figure 20: Base plan in the optimizer.

Figure 21: Selected fixed jaws on all fields of the plan.

Next, I added upper and lower objectives on the z_PTVOpt Upper structure, upper
constraints on both kidneys, and an upper constraint on the zDLA Upper structure (figure 22).
After the first optimization, I created additional structures to fill in areas that were lacking
prescription coverage and to reduce areas of 105%. Once I was satisfied with the dose
distribution of the Brain&Cspine plan combined with the upper spine plan, I moved on to the
lower “true” spine plan.

Figure 22: Optimization objectives for the upper spine plan.

 Lower “True” Spine Plan
Next, I opened the lower “true” spine plan that I had previously created the fields for. As
described previously, this plan consists of 3 static IMRT fields. At this point, I created a plan
sum using the Brain&Cspine and Upper Spine plan that I just completed, which will now be used
as the base plan during optimization of the lower “true” spine (figure 23). In the optimizer, I
selected the base plan and ensured the jaws were fixed. I placed upper and lower objectives on
the z_PTVOpt Lower structure, as well as upper objectives on the kidneys and zDLA lower
structure (figure 24). I chose to optimize this plan a second time in hopes of reducing the areas of
105% and increasing the 100% coverage. Once the optimization was completed, I evaluated the
total dose distribution using a plan sum consisting of the Brain&Cspine, upper spine, and lower
true spine plans.

Figure 23: Plan sum of the Brain&Cspine and Upper Spine plan that was used as a base plan in
the optimization of the lower “true” spine plan.
Figure 24: Optimization objectives used for the lower “true” spine plan

Plan Evaluation
Although I was happy with the overall dose distribution, I hoped to be able to increase
the uniformity of the 100% isodose line in the areas where 2 plans overlap. Normalization isn’t
always standardly used at my clinical site to achieve target coverage. However, I chose to utilize
volumetric normalization on the upper spine and lower “true” spine plan” to visually smooth out
100% isodose line in the areas that 2 plans overlapped. The upper spine plan used a plan
normalization of 97.5%. This means the dose on the upper spine plan was increased by 2.5%.
Likewise, the lower “true” spine plan was assigned a plan normalization value of 98.3%,
resulting in the overall total dose increased by 1.7%. The Brain&Cspine plan was not
normalized. After visually assessing the dose distribution of the total plan sum consisting of all 3
plans, I exported the plan into the ProKnow software (figure 25). Overall, I was pleased with the
target coverage and acceptable amounts of 105%. An area of cooler coverage was seen in the
Brain&Cspine plan due to intentional MLC blocking to spare the optic structures (figure 26).
The maximum global hot spot in the plan was 3958.8 cGy. This is considered acceptable as it
was located on the edge of the PTV and was less than 110% (figure 27). When comparing the
ProKnow score card to the results calculated in Eclipse, I noticed some discrepancies. This is a
known issue between ProKnow and the Eclipse TPS in which the dose metrics can vary widely
due to the voxelization method used. The inconsistencies of the dose metrics between my plan
and ProKnow are included in table 1 and figure 28 below. One metric I did not meet was the
mean dose for the right kidney. If I were to complete this plan again, perhaps I could try a
different posterior oblique angle to avoid exit dose into the right kidney from the left posterior
oblique beam. Figures 30 and 31 below displays the final dose distribution of my treatment plan
as well as the final dose volume histogram. As medical dosimetrists, we often encounter
circumstances in which we must evaluate the cost versus benefit in our planning decisions. Each
treatment plan and the available treatment techniques has its own benefits. There are many
tradeoffs in the field of medical dosimetry that are inevitable when generating the best treatment
plan for the patient.

Table 1. Dose metrics inconsistencies reported in Eclipse and ProKnow.

Structure Eclipse ProKnow
Left Optic Nerve Maximum (Gy) 34.944 35.931
Right Optic Nerve Maximum (Gy) 34.951 35.709
Right Lens Maximum (Gy) 5.373 8.839
Left Lens Maximum (Gy) 4.370 6.123
Right Parotid Mean Dose (Gy) 14.984 15.188

Figure 28: Maximum and mean doses achieved in the Eclipse TPS.
Figure 25: ProKnow Score Sheet.

Figure 26: Area of cool prescription coverage in the Brain&Cspine plan in order to spare optic
structures. PTV (magenta), Right optic nerve (yellow), Right lens (lime green), Left optic nerve
(purple), Left lens (orange).
Figure 27: Maximum global hot spot in the plan.

Figure 30: Final dose distribution.

Reflection
Overall, this assignment was challenging and taught me some new planning features that
I had not worked with before. Specifically, creating a plan sum and using it as a base plan within
the optimizer was a new experience. I quickly recognized how important it was to correctly set
up each of the field borders and ensure there was adequate field overlap between the plans. One
thing I struggled with was increasing the coverage in the junction areas. After close inspection, I
saw the scan utilized a 0.5 cm slice thickness and the cooler spots on my plan were falling in
between the slices. If the scan had been acquired with thinner slices, it would’ve been easier to
smooth out the 100% dose distribution in these areas. At my clinical site, it is the standard of
practice to acquire CSI planning scans at 2 mm. Although the vast majority of the CSI cases at
my clinical site are planned using protons due to the dosimetric advantage, I feel confident in my
ability to use this technique in the clinical setting if the situation arises.
Figure 31: Final DVH.
References
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craniospinal irradiation. J Appl Clin Med Phys. 2002;3(4):310-316.
http://doi.org/10.1120/jacmp.v3i4.2555
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