Dakota Sturgess

Clinical Practicum III

University of Wisconsin- La Crosse

Craniospinal Irradiation

Craniospinal irradiation (CSI) is a radiation technique used to treat central nervous

system malignancies. For this plan study, Proknow provided the CT data set of a supine CSI
patient and the prescription. The plan is to be delivered to 36 Gy in 20 fractions at 1.8 Gy per
day. The targets included PTV_Brain and PTV_Spine.

For this plan, I used a volumetric modulated arc therapy (VMAT) technique. Due to the
length of both PTV’s, I used three isocenters; one for the brain, superior spine, and inferior spine.
For each isocenter, I kept the X and Y values the same but adjusted the Z value that allows for
easier shifts between isocenters for treatment. VMAT technique for CSI simplifies the set up and
eliminates the need for shifting junctions during course of treatment and saves OAR of patients
with CNS relapse of hematological malignancies.1 Conventional CSI is technically very
challenging and field edge matching is needed because of the mechanical limitations of standard
linear accelerators.1

Figure 1. Beam arrangements and isocenters.

 For the brain field, I used three full rotational arcs, two clockwise and one
counterclockwise direction with collimator rotations of 10°, 350°, and 85°. I like to use 85° to
allow the optimizer to block the OAR in the opposite direction. In this case, I think it’s beneficial
because of the optic structures in the field. The multileaf collimators (MLCs) were fit to the
PTV_Brain with a margin of 5 mm. In the X direction, the jaws were set to 15 cm and were
opened to 16.6 cm. For both spine fields, I utilized two full rotations with collimator angles of 10
and 350. The jaws were set to 15 cm in the X direction and opened to the maximum field size of
39 cm in the Y direction. It is important to overlap each field by at least 5 cm to allow the
optimizer to feather the plan. All fields were treated using 6 MV photon beam.

The plan called for 95% of the volume to receive 100% of the dose. At my clinic, we do
not normalize. I structure the optimizer to achieve each constraint. The only Opt structure I
created was for the brain, where I cropped out the optic structures. I created a minimum and
maximum constraints on the Brain_OPT structure and PTV_Spine. The OAR I included in my
optimization were the lens, optic nerves, kidneys, esophagus, and parotids. I used max and mean
doses for the OAR.

Figure 2. Treatment information and beam arrangements

When evaluating my final plan, I had cold spots near the optic structures, but this is
expected to meet the clinical goals. The maximum hotspot in my plan was at the inferior portion
of the PTV_Spine, near the sacrum at 112%. I believe this is due to the separation from the PTV
and the external body. I had 105% hotspots throughout the brain and spine to achieve the optimal
PTV coverage. For the proknow scoresheet, all the minimum constraints were achieved. For the
ideal constraints, I failed to meet the mean doses for the kidneys and the maximum dose to the
lens and optic nerves. It is difficult to meet those due to the location of the OAR and would
sacrifice PTV coverage to achieve these goals.

Figure 3. PTV and CTV Dose Volume Histogram (DVH).

Figure 4. OAR DVH.

 Figure 5. Proknow Scoresheet.

This plan was challenging. As a therapist, I have treated CSI cases, both VMAT and
conventional. There are multiple ways to produce effective treatment plans. The VMAT
approach allows for a single direction shift between isocenters, ultimately, delivering an optimal
plan. This allows for shorter overall time that the patient is on the treatment table.
 Reference:

1. Takahashi I, Lmano N, Takeuchi Y. A Simplified Three-Isocenter VMAT for

Craniospinal Irradiation. International Journal of Radiation Oncology.
https://doi.org/10.1016/j.ijrobp.2018.07.1076