Robert Hale

CSI Assignment

Treatment Planning Process

I used a VMAT three isocenter technique with 6x energy, two arcs per isocenter, and no couch kick
rotations.1 There are six fields total, all six fields were full arcs with gantry angles 179.9-180.1
degrees and 180.1-179.9 degrees.1 Isocenter group I includes Field 01 and Field 02 and was placed
for the PTV-Brain Target as close to the center of the PTV-Brain I could estimate using Collimator
angles of 15 degrees and 345 degrees. Isocenter group II includes Field 03 and Field 04 and were
placed for target PTV-Spine Mid and Isocenter group III includes Field 05 and Field 06 were placed
for PTV-Spine Low; the collimator angles for the second & third isocenter groups for PTV-Spine were
5 degrees and 355 degrees. I chose those collimator angles to be able to maximize the field length
(Y1, Y2) for the PTV-Spine fields. I chose a slightly larger angle for PTV-Brain due to the width (X1,
X2) limitations of the X field but also to still be able to utilize most of the length of the field (Y1, Y2).

Field borders for the 1st Isocenter were set at 15cm in the X direction, which is the maximum width
for our machine, with 0.5cm margin on the targets PTV Brain & PTV Spine, superior to the top of the
Brain, lateral borders encompass the width of the brain, and the inferior border goes ~10cm below
base of skull. Field borders for the second & third isocenter were set using the same margin of
0.5cm, with the middle isocenter fields at 30cm for the Y borders and ensuring there was a region of
overlap of 5cm between the fields from isocenter both above & below; the overlap is to address the
dose feathering between the isocenter fields along with the auto-feathering option within eclipse.1
Had this option not existed, I would have needed to setup gradient structures within the match lines
to receive 80%, 60%, 40%, and 20% dose, both for the fields above & below.1 The X-border was set
to maintain the 0.5cm margin during the arc. For the third isocenter, the superior border was set for
a region of 5cm overlap with the above fields, inferior border is at the bottom of the PTV Spine Low
target with a 0.5cm margin, and again the lateral borders were set to maintain the 0.5cm margin
during the arc on the target.1 There was no normalization done on the plan and there were three
calc points used, one placed for each isocenter, within the target volume and within the field.
Beams-Eye-View of these fields can be seen in the figures below along with figures of the field
geometry:

Field Geometry Information:

Shifts & SSD:

Field Size Information:

Field 01 – PTV Brain Field – Gantry: 179.9 – 180.1 CCW, Collimator: 15

Field 02 – PTV Brain Field – Gantry: 180.1 – 179.9 CW, Collimator: 345

Field 03 – PTV Spine-Mid Field – Gantry: 179.9-180.1 CCW, Collimator: 5

Field 04 – PTV Spine-Mid Field – Gantry: 180.1-179.9 CW, Collimator: 355

Field 05 PTV Spine Low Field – Gantry: 179.9-180.1 CCW, Collimator: 5

Field 06 PTV Spine Low Field – Gantry: 180.1-179.9 CW, Collimator: 355

3D View of Beams/Arcs:
Auto-Feathering Option:

Plan Evaluation

The 100% Isodose line covers the target with 100% dose to 95% of the volume, the dose maximum is
116.5%, and the cold spot is located at the match lines. When I discussed this plan with my
preceptor, we discussed that the 116.5% max dose that was located within bone in the first
isocenter fields and was a high max dose, but he said it was acceptable. During the planning process,
to address the hot spot I used a 108% Dose structure and dose constraints to attempt to bring it
lower. To address the cold spot at the match points, I made target structures at those locations to
push within optimization and improved these areas. Below are figures showing the Hot Spot
information, a sagittal view showing the isodose lines, hot spot location, cold spot location, and the
108% structure used to lower the hot spots throughout both target volumes.

Hot Spot:

Isodose Coverage - Hot Spot – Cold Spot – 108% Structure Locations:

During the evaluation process, the OAR constraints I was struggling with were Liver, Kidneys, Lens R
& L, Parotid R1 & L, and Optic Nerve R & L. I was able to meet the constraints for the Liver & the
Parotids by using upper and mean dose constraints to bring down the mean dose to the ideal metric
for each. The OAR’s that failed, but met the minimum requirements were the mean dose for both
Kidneys, the mean dose for both lens’, and max dose point for both optic nerves. The dose
constraints for the lens’ (mean dose constraint range 700-1000 cGy), & optic nerves (max dose
constraint range 3400-3600 cGy) were difficult to meet due to the proximity of PTV Brain (dose of
3600 cGy). The kidneys were difficult to meet because the constraint is low (mean dose constrain
range 200-400 cGy) and any dose delivered in the arc laterally will give some dose to the kidneys. I
tried a version that blocked entry dose into the kidneys, but as I expected, it hurt coverage too
much. The other plan metric I was not able to meet the ideal standards was the percentage of
volume covered by 3960 cGy for both PTV Brain and PTV Spine, I tried to address this using the
108% Dose structure in the optimization process. Below are the evaluation tools I used to evaluate
these OAR constraints, ClearCheck report, DVH statistics, DVH, and my ProKnow Report with a score
of 122.53/127.

ClearCheck Report:

DVH Statistics:
DVH:
ProKnow Report on Critical Structures:

One of the experiences from this assignment that I took away was the growth I have experienced
learning how to use contours, dose structures, and multiple isocenters within the optimizer while
evaluating dose constraints at many different sites in the body to build a complex CSI plan. I think
one of the fun parts about this project was I was to try and use some of the tips from other
discussions from our peers, all successful to varying degrees. Some examples being for the hotspot I
used the dose structure contour and 4th stage optimization to reduce the hotspot by a few percent
or the optimization structure I built to address the cold areas at the match lines. Overall, it was fun
to put together a lot of what I have learned for this project and I also found a great reference for any
future CSI cases that I may have to plan.
References

1. Prabhu RS, Dhakal R, Piantino M, et al. Volumetric Modulated Arc Therapy (VMAT) Craniospinal
Irradiation (CSI) for Children and Adults: A Practical Guide for Implementation. Pract Radiat
Oncol. 2022;12(2):e101-e109. doi:10.1016/j.prro.2021.11.005