Amanda Tabar

CSI Case Study Report

The challenges of treating primary intracranial tumors with craniospinal irradiation (CSI)

include the large and irregular target volume, technical difficulties, and the sensitivity of critical

structures. Conventional three-dimensional conformal radiotherapy (3DCRT) for CSI often

results in dose inhomogeneity and inaccuracies at field junctions. To address these issues in 3D

planning, manual shifts of field junctions are commonly used, but this approach includes the

potential for dose errors, patient discomfort in the prone position, and increased treatment

complexity.

In an article written for the Journal of Radiation Oncology, Chen et al1 discusses

volumetric modulated arc therapy (VMAT) as a treatment planning technique for CSI cases. The

utilization of VMAT has shown advantages in target coverage, treatment efficiency, and sparing

critical organs for various cancer sites. The study aimed to evaluate a practical VMAT technique

for supine CSI to improve planning target volume (PTV) coverage, minimize organ at risk

(OAR) exposure, and reduce the potential uncertainties of field junctions, in beam setup and

patient motion.

I created a VMAT plan that included multiple isocenters with overlapping fields,

illustrated in figure 1. Multiple field junctions were used to control dose gradient2, with a total of

three fields created due to the length of the patient. Isocenter 1 (red) was placed in the brain,

isocenter 2 (green) was placed in the upper spine, and isocenter 3 (blue) was placed in the lower

spine; along the z axis, only differing in the superior/inferior direction. My rationale behind the

location of each point was to ensure roughly a 10cm overlap for each field, to create junctional

fields, as was recommended in the article. Three full arcs were used, and the collimator angles
were adjusted to 5° and 355°, as in the article, to prevent multi-leaf collimator (MLC) leakage;

along with the use of 6 MV energy.

Figure 1

Multiple isocenter setup

I created ring structures and a control max structure based off of the PTV total, to

increase dose conformality; and dose maximum constraints were put on both. I also contoured
both arms, and collectively used them to create a protect margin, where I put avoidance

constraints on the entrance dose (figure 2). Additional margins around OAR were created to

produce planning organ at risk volumes (PRVs) to account for geometric uncertainties and aid in

meeting dose constraints and I felt would be more difficult to reach; such as the kidneys.

Figure 2

Protect margin used to prevent entrance dose into arms

Clinical goals were added into the Raystation treatment planning system (TPS) with the

constraints given by the ProKnow platform; and constraints were also added into TPS that

correlated with the ProKnow plan requirements. I created a PTV total structure of both the PTV

Cranial and PTV spinal, and added constraints that included a DVH minimum, uniform dose,

dose maximum, and minimum dose; and can be seen in Figure 3.

Figure 3

Dose constraints used for PTV

I also added in constraints for all OAR and PRV as pertained to the plan guidelines,

created a dose fall off on the external, and added in my rings and control max. I pushed hardest

on my dose max constraints during the first optimization, to ensure dose stayed within

reasonable constraints, and also pushed on maintaining an appropriate dose coverage of the

target volumes.

Final isodose coverage can be seen in figure 4, with pink outlining the PTV total and

yellow representing coverage of the 95% isodose line of 3420cGy.

Figure 4

95% of 3420cGy coverage of the PTV total

 To control both hot and cold spots, I created regions of interest (ROI) structures out of

the dose I was focused on and added constraints onto my plan. For example, when I had an area

within my target volume that was missing dose, I created an ROI of the cold spot, found where it

intersected with my target volume, and created a structure. I then added this new structure to my

objectives list with a dose minimum constraint, to increase dose to the area. This same concept

was also used for hot spots, with a dose maximum, to ensure hot spots stayed appropriate within

target volumes. The maximum dose, at 4289 cGy, is located within the clinical target volume

(CTV), which is ideal and can be seen on figure 5.

Figure 5

Location of the hot spot within the CTV

A DVH can be seen below, in figure 6, illustrating the dose statistics of both target

volumes and OAR. An important observation to be noted on this DVH is the arms dose, which

can be seen minimally due to the avoid structure that had been created.
Figure 6

DVH comparison of targets and OAR

The structures that I found most challenging to achieve an ideal dose on were the

kidneys, the liver, and the submandibular glands. I also found it difficult it keep my hot spots

below 3960cGy at 0% volume; and found that by attempting to decrease my hot spots in the end

began to negatively affect my dose coverage. In order to help with doses to my OAR listed

above, I tried multiple different methods to reduce dose. Some examples of OAR I had a hard

time meeting, but was close with, were the liver, R submandibular gland and thyroid. The liver,

was 601cGy, with ideal at 600cGy; the R submandibular gland was at 1510cGy, with ideal at

1500, and the thyroid was at 2507cGy with ideal at 2500cGy.

 A few other structures, however, remained higher than I would have liked. For example,

my kidneys remained at 489cGy and 464cGy, with ideal at 300cGy, regardless of my creation of

PRV structures and dose fall off constraints. My ProKnow scorecard can be seen in figure 7,

with scoring for all required metrics. Full and final dose distribution can be seen on figure 8.

Figure 7

ProKnow scorecard
Figure 8

Final dose distribution

What I learned in from this planning assignment was how to use multiple fields, and

isocenters, to cover a target volume that is too large for a single field. This assignment

emphasized the importance of field junctions, and how to use them to allow for dose gradient

control. This assignment was difficult with achieving all OAR sparing, but required me to try

new techniques, such as creating PRVs or splitting targets into sections to control dose areas

individually. It is important as a Medical Dosimetrist that we stay up to date on the new

technologies and techniques that are regularly emerging, and utilizing VMAT for a CSI case is

the perfect example.

 References

1.Chen J, Chen C, Atwood TF, et al. Volumetric modulated arc therapy planning method for

supine craniospinal irradiation. Journal of Radiation Oncology. 2012;1(3):291-297.

doi:https://doi.org/10.1007/s13566-012-0028-9

2. Strojnik A, Méndez I, Peterlin P. Reducing the dosimetric impact of positional errors in field

junctions for craniospinal irradiation using VMAT. Reports of Practical Oncology and

Radiotherapy. 2016;21(3):232-239. doi:https://doi.org/10.1016/j.rpor.2016.03.002