Steven Yorio

DOS 733
10/6/21
Craniospinal Irradiation

There are many types of brain tumors that can lead to the need for craniospinal
irradiation. A few primary examples include astrocytoma, ependymoma, oligodendroglioma, and
medulloblastoma. The most aggressive and fast-growing malignant brain tumor in adults is a
form of astrocytoma known as glioblastoma multiforme (GBM). Medulloblastomas are more
common in children and most frequently the cause of leptomeningeal spread throughout the
central nervous system. These tumors begin their development in the cerebellum and are one
type of primitive neuroectodermal tumor (PNET).1
If the tumor metastasizes throughout the spinal cord and spreads into the cerebrospinal
fluid (CSF), full cranio-spinal irradiation is indicated. Since CSF is a free-floating fluid, the
entirety of the thecal sac contents must be dosed uniformly due to the potential of microscopic
disease being present throughout. This type of treatment seeks to generate a homogeneous dose
distribution to encompass the brain and spinal canal to eliminate this disease, although multiple
side effects may present due to the large volume being treated. Toxicities can present during or
after treatment in the form of fatigue, nausea, emesis, esophagitis, and an increased risk of
secondary cancers as there is a wide region receiving lower doses from this type of treatment.1
Historically, these treatments have been planned using a 3D conformal radiation
technique with three isocenters and feathering the junctions of each field after a certain number
of fractions. The brain and cervical spinal cord fields were treated to the isocenter in the middle
of the brain and using opposed lateral beams which blocked the lenses of the eyes, and a field-in-
field technique to block the high dose regions within the beams. The spine fields are treated
using single PA fields with isocenters being placed in the midthoracic and midlumbar regions of
the spinal canal to treat through the cauda equina down to the S3 vertebra. Using a 3D technique
for this treatment does little in terms of sparing organs at risk (OAR) and thus other sequelae
tend present at later stages after treatment. This is primarily seen as neurocognitive and
endocrine impairment, but other morbidities such as cardiac disease, cataracts, thyroid disease,
and gastrointestinal toxicities can present after this type of treatment.2 The effects of these
toxicities when using a 3D conformal radation therapy technique for craniospinal irradiation led
to the more novel volumetrically modulated arc therapy (VMAT) being used to seek the potential
benefit of this type of treatment.

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DOS 733
10/6/21
Simulation, Patient Setup, and Planning

The computed tomography (CT) simulation scan was performed with patient in the
headfirst supine position with their arms placed at their sides. A vaclok bag was placed under the
patient extending from their pelvis to their shoulders and an aquaplast mask was fixed to an S-
frame head support for immobilization of the head and neck. Three-point metal ball bearings
were placed on the anterior and lateral surfaces of the aquaplast mask for setup and reference
purposes, with additional marks on the upper and lower spine for straightening.
Target structures included two planning target volumes (PTV) that were each prescribed
to 36 Gy in 20 fractions. Prescriptions called for 95% coverage at 36 Gy for both PTV_Brian and
PTV_Spine structures and limiting the volume within these structures receiving 39.6 Gy (110%
of RadRx) to less than 3%. Contours for OAR consisted of the bladder, bowel, brainstem,
esophagus, eyes, lenses, femoral heads, glottis, heart, kidneys, liver, lungs, mandible, optic
nerves, parotid and submandibular glands, rectum, stomach, and thyroid gland. Additional target
contours were created by cloning the PTV_Spine contour and creating separate structures for the
upper and lower spine due to length of PTV_Spine. Also, a gap of three CT slices was created
between the brain and upper spine contours, as well as the upper and lower spine structures as a
proactive method to limit dose overlap between the two fields and prevent the creation of a
hotspot in these overlap regions.
Contours were drawn using the MIM Software Inc. program and Monaco for a treatment
planning system (TPS). After transferring the planning CT and structure set to the TPS, three
isocenters with an SAD setup were place in the PTV_Brain, PTV_SpineUpper, and
PTV_SpineLower contours to prescribe the 36 Gy dose to all respective volumes (Figure 1, 2, &
3). Two 360o counterclockwise arcs with two rotations per arc were used to dose all three PTV
structures. 6MV photons were used, and the collimators were rotated at 10o and 350o for each arc
respectively to reduce low-dose overlap caused by inter-leaf leakage in the same regions for both
arcs. Double and full arcs are superior to single and partial arcs in terms of organs at risk sparing
even for unilateral target volumes. The collimator position was found as an additional setup
parameter, which can further improve the target coverage and sparing of organs at risk.3

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Figures 1 & 2. Arc configurations at associated isocenters.

Figure 3. Beam’s eye view of isocenters with MLC configurations removed.

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DOS 733
10/6/21
Dose Constraints

Planning objectives were derived from the instructions list within the plan study on the
ProKnow website (Figure 4). A target penalty of 36 Gy was assigned to the PTV_Brain structure
to ensure prescription dose coverage was met while constraining the max dose to 37.8 Gy and
the dose to the lenses, optic nerves, parotid and submandibular glands to their ideal limits. An
additional maximum dose constraint was placed on the PTV_Spine at 10 Gy in order to prevent
dose build up in the field overlap when treating the second set of beams for the upper spine.
Dose constraints to the respective OAR in this structure had to be loosened from the ideal
numbers in order to maintain 95% coverage of PTV_Brain at 36 Gy.
When treating the upper spine in the subsequent prescription, 36 Gy was also prescribed
to this region. The pertinent OAR in this region were the lungs, heart, thyroid, kidneys, and
esophagus. Again, constraints were added to the brain and lower spine structures to prevent
hotspots in the overlap regions. The same paradigm was utilized for the lower spine while adding
constraints for rectum and bowel.

Figure 4. ProKnow wish list.

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DOS 733
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Plan Analysis

While all constraints were met without needing to normalize the plan, there were still
resultant hot and cold spots within the PTV_Brain and PTV_Spine. It is evident from the sagittal
view in figure 5 that the method utilized in this case to prevent dose overlap between the upper
and lower spine fields resulted in a cold spot at the junction, although without this measure in
place the relative volume within the PTV_Spine receiving 39.6 Gy<0.03cc was around 12%
when the maximum relative volume allowed at this dose level was 3%. The global maximum
dose was located at the junction of the brain and upper spine and was considered acceptable
because it is located within the PTV.
Generating a faux gap in the spine field by cloning and splitting the structure kept the
maximum dose in this region to an acceptable level. All metrics of this plan were evaluated
based on the dose volume histogram (DVH) and the DVH statistics (Figures 5,6, 7, & 8).
Regardless of the low dose region of the spine, all plan metrics were successfully achieved and
conformality was vastly improved when compared to a 3D conformal plan as is evident be the
DVH statistics provided and the ProKnow scoring evaluation (Figure 9). This method proved
beneficial in that creating anatomical structures can drive dose away from regions that become
saturated when using the standard structure set and techniques.

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Figure 5. Final Dose Distribution. Note hotspot between Brain and upper spine, and cold spot
between upper and lower spine.

Figure 6. DVH of Brain OAR.

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DOS 733
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Figure 7. DVH of Spine OAR.

Figure 8. DVH statistics for target volumes and all OAR.

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Figure 9. ProKnow plan evaluation score.

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References

1. Cadieux C. Medical Dosimetry Pubs. Hybrid VMAT/IMRT Approach to Traditional

Cranio-Spinal Irradiation (CSI): A Case Study on Planning Techniques and Delivery.
http://pubs.medicaldosimetry.org/pub/8c04019f-782b-cb6e-2763-b5e18707f715.
Published 2017. Accessed October 7, 2021.

2. Studenski MT, Shen X, Yu Y, et al. Intensity-modulated radiation therapy

and volumetric- modulated arc therapy for adult craniospinal irradiation – a
comparison with traditional techniques. Med Dosim. 2013;38(1):48-54.
https://doi.org/10.16/j.meddos.2012.05.006

3. Richter, A., Exner, F., Bratengeier, K. et al. Impact of beam configuration on VMAT
plan quality for Pinnacle3Auto-Planning for head and neck cases. Radiat Oncol 14, 12
(2019). https://doi.org/10.1186/s13014-019-1211-6