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Katelyn Fischer
Clinical Internship III
Craniospinal Irradiation Assignment
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This case was a supine craniospinal patient receiving 36 Gray (Gy) at 180 centigray
(cGy) per day to both the brain and spine (PTV Cranial & PTV Spine). I used a photon
volumetric modulated radiation therapy (VMAT) technique with 6 MV energy. I used 3
isocenters for treatment planning, with the cranial field utilizing 2 coplanar 358 degree arcs
while each spine field utilized only one 358 degree arc.1-2 This approach of the three isocenter
VMAT planning technique and beam design for this craniospinal case was influenced by Prabhu
et al.1 The three isocenters used were labeled as brain, upper spine, and lower spine; the brain
isocenter was placed centrally and then the spine isocenters were placed inferiorly to ensure the
collimator jaws could treat the entire length of the central nervous system. I have an image
showing my isocenter and beam arrangement for this plan, with the PTV Combined volume
illustrated in peach. The number of arcs is delineated by the circle(s) surrounding each isocenter.

Beam Arrangement Utilizing 3 Isocenters

For the cranial field, the first arc originated with the gantry in the posterior position at
181° and traveled clockwise completely around the patient to a gantry position of 179°, with a
collimator angle set to 345° rotation. The second arc originated at the gantry position of 179°,
traveling counterclockwise around the patient to a gantry position of 181°, with the collimator
angle set to 15°. For the upper spine field, I used one full arc with the gantry in the posterior
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position at 181° traveling clockwise completely around the patient to a gantry position of 179°,
with a collimator angle set to 345° rotation. For the lower spine field, I again used only full arc
with the gantry position of 179°, traveling counterclockwise around the patient to a gantry
position of 181°, with the collimator angle set to 15°. Utilizing full arcs with 2 degree gantry
spacing allowed for 180 control points to be used in each arc for treatment planning.
For the cranial fields (Fields #1 & 2), the field borders were 20.0 cm for the Y1 and 8.50
cm for the Y2. For the upper spine field (Field #3), Y1 and Y2 were 20.0 cm and for the lower
spine field (Field #4) Y1 and Y2 were 18.50 cm and 20.0 cm, respectively. By using this VMAT
technique, a uniform dose gradient was achieved by feathering the multileaf collimator (MLC)
leaves over a long length on the junction side of the field’s edge.2 This technique has been shown
to have significant dosimetric advantage over 3-dimensional conformal radiation therapy
(3DCRT) including dose homogeneity and robustness to setup errors.1 I have the gantry, couch,
and collimator angles listed below for each arc, along with the Y1 and Y2 jaw sizes.

The plan was normalized volumetrically to both the PTV Cranial & PTV Spine, as one
structure labeled PTV Combined, so that 95% of the prescription dose covered 100% of the PTV
Combined. The total volume for the PTV Combined was 3565.89 cm3, with the PTV Cranial at
2189.58 cm3 and the PTV Spine at 1376.31 cm3. Per the given metrics, at least 95% of the PTV
Cranial and PTV Spine volumes were to be at 3420 cGy while 0% of the volume could receive
3960 cGy, which is 110% of the prescription dose. The PTV cranial volume was 99.1% covered
by 3420 cGy, while the PTV spine was 97.65% covered by 3420 cGy. I was also able to have 0%
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of either PTV volume receive 3960 cGy, as shown below. I was able to adjust target coverage by
manipulating the prescription percentage, but was able to keep it at 95% for both volumes.

For treatment planning, I was able to use the combined PTV structure to create rings
around both PTVs, but I knew they were going to mainly help with limiting dose to the
surrounding organs at risk (OARs). Ring 1 (light blue) was 0.50 cm away from the PTV, creating
a 1.0 cm ring that I used a max DVH of 3240 to 0% of the volume. Rings 2 (dark blue) & 3
(maroon) were 2.0 cm rings, while the External ring (purple) was 6 cm to cover most of the
normal external tissue. I have an image below showing how these rings were able to shape the
isodose lines and also provide OAR avoidance. My optimization targets were set up so that I
could optimize for both planning target volumes at the same time. The optimizer was able to use
the maximum collimator jaw movement in the craniocaudal direction to utilize all available
MLCs for dose modulation, creating a low dose gradient.2 Similar to the technique used by
Sarkar et al2 this dose gradient is formed as the optimizer accounts for dose contribution from the
adjacent fields.

Color Objective
Ring 1 Light Blue Max DVH 3420 cGy to 0%
Ring 2 Dark Blue Max DVH 2430 cGy to 0%
Ring 3 Maroon Max DVH 1823 cGy to 0%
Ext Ring Purple Max DVH 1367 cGy to 0%
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Below are images of the isodose distribution in all three planes for all structures,
including all targets and OARS. The isodose key is located to the right of the images.

Sagittal view of PTV Cranial & PTV Spine Coronal view of PTV Cranial & PTV Spine

Axial view of PTV Cranial & PTV Spine

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The next three images show the 100% (3600 cGy shown in red), 95% (3420 cGy shown
in green), and 50% (1800 cGy shown in yellow) isodose lines specifically at the brain, upper
spine, and lower spine isocenters, respectively.

Brain

Upper
Spine
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Lower
Spine

By using this multi-isocenter VMAT technique, I did not have any cold spots where less
than 95% of the dose covered the PTVs. As shown above, 100% of the prescription dose does
not cover both PTVs but 95% of the dose covers both PTVs. During plan optimization, the
combination of treatment fields complement each other with equal and opposite dose gradients
creating the uniform dose gradient across the field junctions.2 The maximum dose was 3883 cGy
and was located within the PTV spine. I have an axial and sagittal view of the maximum dose
shown below. I was satisfied with this as it was 108% of the prescription dose and located within
the PTV. My main concerns were to ensure the hot spot was not in any OARs and was within
110% of the prescription dose, which I was able to achieve.
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Maximum Dose = 3883 cGy

I was able to meet all metrics for this craniospinal case by incrementally lowering the
dose to the OARs. The hardest metrics to meet were the optic nerves and lenses of the eyes as
they were encompassed in the PTV Cranial. The kidney metrics also required more manipulation
to get within constraints. I was able to use a max EUD objective on the liver, submandibular
glands, and parotid glands as they were completely out of the treatment fields. I was able to keep
a weighting of 1 on these OARs. I then incrementally lowered the max EUD value by 50 cGy to
meet the given metrics. I used 5 max DVH points on the esophagus, thyroid, and optic nerves to
incrementally lower them while maintaining PTV coverage. I did this by gradually decreasing by
about 10% when I had met the objective from the previous iteration. I used a combination of max
DVH and max EUD objectives for both kidneys and lenses of the eyes, as these were the hardest
metrics to meet.
Below is the labeled dose-volume histogram (DVH) including the target volumes and
surrounding critical structures. The target volumes included the CTV Cranial, CTV Spinal, PTV
Cranial, and PTV Spinal. The organs at risk for this case included the heart, esophagus, bowel,
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kidneys, thyroid, liver, lungs, optic nerves, parotid glands, submandibular glands, and the lenses
of the eyes. Each has a corresponding label and color displayed on the DVH.

My ProKnow scorecard is attached below.

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In conclusion, this was a very interesting planning assignment that challenged me, while
also introducing me to more complex treatment planning techniques. Craniospinal cases are very
rare in my clinic and are mostly treated using protons today or using 3DCRT historically. The
conventional method of feathering to prevent hot and/or cold spots at the junction of the fields
was not needed using this technique and my preceptor appreciated this VMAT approach for
craniospinal irradiation. My preceptor was able to show me the 3DCRT approach for
craniospinal irradiation too, which was quite complicated. I personally think in that the 3DCRT
approach there is more room for setup & treatment errors, along with a more complicated
planning process. Therefore, I think this VMAT approach is beneficial over 3DCRT. I would be
interested in seeing a proton plan for this craniospinal case.
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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
2. Sarkar B, Munshi A, Manikandan A, et al. A low gradient junction technique of
craniospinal irradiation using volumetric-modulated arc therapy and its advantages over
the conventional therapy. Cancer Radiother. 2018;22(1):62-72.
doi:10.1016/j.canrad.2017.07.047