CSI Treatment Plan Report

As I began to create this cranio-spinal treatment plan, I spoke with the physicians,
medical physicists and medical dosimetrists at my clinical site for some guidance. They
provided me with some sources that explained some of the proven strategies to use while
planning CSI treatments. Some of these tips included ways to match the cranial and
spinal fields without a hot or cold spot. They also mentioned that matching the spinal
fields was an critical component of the planning process because you must ensure that no
hot spots are created within critical OAR. I began my planning process with a static
photon plan consisting of one cranial isocenter and two lateral opposed beams, and three
spinal isocenters, each with their own PA field. I used a small collimator rotation between
the cranial and spinal fields to create a proper field match. After calculating these plans
and combining them, I realized that the 18x spine energy was too much and exceeded the
OAR constraints. I decided to reduce the energy to protect the OAR but that led to
insufficient coverage of the spinal PTV without an unacceptably high max point in the
back. In the excerpt written in Radiation Therapy Physics, written by Hendee WR, Ibbott
GS, and Hendee EG, they state that in some instances, high energy electrons can be used
instead of photons. I attempted to use this strategy by increasing the electron beam energy
all the way to 20e. After creating a sum plan, I found that this technique left the spinal
PTV with insufficient coverage. After eliminating these two techniques, I asked the
clinical staff at my site how our CSI treatments have been planned before. They explained
that the last patient treated at our site was planned using IMRT. I decided that I would
attempt to use some of these techniques for this lab.

1. Provide an in-depth description of the treatment planning process (treatment technique,

isocenter placement, energy, gantry, couch, collimator angles, field borders and anatomy
encompassed.).
a. How were the match lines and feathering addressed during planning?
b. Do you have any research to cite that helped you determine beam energy,
beam arrangement and geometry?
c. Provide screen captures of your beam arrangement and include any pertinent
images that help describe your setup

First, I created a single isocenter cranial plan, with the isocenter placed in the center of
the cranial CTV. To enhance the coverage of the cranial PTV, and reduce the dose to
critical OAR, I chose to use four arcs in two pairs. The first pair traveled from 181
degrees to 179 degrees in the clockwise and counterclockwise direction. There was a zero
degree collimator rotation to maintain a straight edge for the field match and there was no
couch rotation. The second pair of treatment arcs traveled on the same plane but were
placed opposite from one another. There was a 90 degree couch rotation for the first and
the gantry traveled from 79 to 315 degrees in the counterclockwise direction. The second
had a 270 degree couch rotation and the gantry traveled from 181 to 15 degrees in the
clockwise direction. Both arcs had zero collimator rotation to make field matching easier.
Allowing the optimizer multiple angles to deliver dose helped to reduce dose to OAR
such as the parotid and submandibular glands, cochleas, eyes, lenses, optic nerves and the
oral cavity.

Sagittal and Axial view of cranial field (Isodose line reference located in center)

After creating the cranial IMRT plan, I created a spinal IMRT plan to combine with it.
This plan consisted of two isocenters located approximately ⅓ and ⅔ along the length of
the spine. Each isocenter had two arcs that rotated around the patient from 181 degrees to
179 degrees in the clockwise direction and then in the reverse direction, also. These fields
did not have any couch or collimator rotations because it provided a better field match
with the cranial field. The superior field was set to be more similar to a half beam to also
help with the field match. In an attempt for uniformity, I chose to use 10x energy for all
the beams in both plans. This seemed to be a good energy for covering the PTVs from all
angles. Because IMRT plans are inherently more precise, I chose to create the plan using
optimization structures to account for dose feathering instead of using shifts throughout
the treatment course. In the IMRT CSI plan that was done at my clinical site, they did
perform three shifts throughout the course of treatment to ensure there were no excessive
hot spots or areas left untreated. This is a great clinical strategy but is difficult to relay to
ProKnow. For this reason, I reduced the inferior portion of the cranial PTV by 0.3 cm and
the superior portion of the Spinal PTV by the same margin. This prevented any overlap of
the PTV but still allowed the CTV to receive dose from the spillage from the adjacent
arcs.
 Sagittal and Axial views of Spinal field (Isodose line reference located in center)

2. Describe how your plan was normalized.

In order to achieve the best target coverage and minimize the dose to the critical OAR, I
normalized the plan by adjusting the maximum dose. Since I used the optimizer to control
dose coverage and avoidance of OAR, the plans were both very close to meeting the
constraints without any normalization. To slightly reduce the hot spot, I normalized the
brain and spine plans’ max dose down until the point where the targets had the best
coverage possible while still keeping the OAR doses below their constraints.
 a. If calc points were used, describe their location and rationale behind their
location.
To monitor the prescription dose, I gave each plan a locationless calc point. This allowed
me to monitor the dose across the plan and ensure that the prescribed dose was actually
delivered. In the clinical setting, when printing plans and performing secondary MU
calculations, I would have also added a calc point at each isocenter to serve as a more
specific report of dose. Since this plan was not being used in the clinical setting, I chose
not to use a calc point at isocenter. However, since both plans (cranial and spinal) had
their own calc point, it allowed me to track the dose on each plan to confirm the
prescription was followed.

3. Give a detailed summary of your plan evaluation process.

After I had completed each plan, and ran them through the optimizer, I created a
combined plan with both the cranial and spinal fields included. Then, after uploading the
plan to ProKnow and receiving a score, I was able to see where I needed to improve.
When I first tried to create a conformal photon and electron plan, my scores showed me
that there was a ton of room for improvement. Once I decided to use IMRT, I was able to
tell which structures I needed to push to make their scores better and which targets might
need more attention. Once I saw the constraints and target metrics that were needed for a
good ProKnow score, I decided to enter these constraints/targets into the optimiser as my
goals. Then, I would review my plan DVH and see if I needed to normalize up or down,
and would adjust accordingly. It only took a few runs through the optimizer to obtain
what I considered an acceptable plan and score.
a. Display images of the plan showing the isodose coverage of your volumes. Label
these images so that they are easy to interpret

Axial, Sagittal, and Frontal images of CSI plan with isodose lines, fields, and dose
key.
b. Are there any hot or cold spots? If so, where are they located and why? If not,
how was this prevented?
There was one cold spot in my plan. At the match between the cranial and spinal field,
the dose was less than the prescription. This was done in order to prevent a hot spot
created from the contribution of each field. If I were to create this plan again, I would
probably decrease the margin that I created in my optimization structures to increase the
dose from each field and eliminate the cold spot. Clinically, the shifts throughout the
treatment course would also account for this cold spot.

c. Identify the maximum dose location and explain if its location was acceptable.
The max dose of this treatment plan was 4246 cGy and was located in between the C2
and C3 transverse processes. While this point does sit on top of the C3 cervical nerve I
believe that this is acceptable because it remains inside the spinal PTV. Also, because we
can reason the C3 cervical nerve has a similar dose constraint to that of the brachial
plexus (which can receive a max point dose of 6600cGy), 4250cGy is well within this
dose limit and is considered acceptable and safe.

d. Provide a DVH with the CTV/PTV and important surrounding OAR with clear
labels.

Dose Volume Histogram of all Target Volumes and OAR assessed by ProKnow
4. Embed your ProKnow plan score sheet within the assignment. Discuss if goals could be
achieved, and if not, why.
Even after working on my plan in the optimizer a few times, I decided that it was acceptable to
finish where I was. In order to achieve good coverage on my target volumes, while still
protecting the OAR. I was able to achieve the minimum requirements on all 20 of the ProKnow
metrics. However, I was only able to achieve 12 of 20 ideal goals. While some of these goals
were not met, I would still consider this plan clinically significant. All of these constraints are
approximately ½ to ⅓ of the constraints provided from RTOG reports/other research and are
accepted clinically so the patient would likely not experience any adverse effects from treatment.
I believe that it would actually be acceptable to increase the dose of the PTV slightly to improve
the coverage at the expense of some of the OAR (provided you remain under the RTOG
constraints) if I was going to use this plan clinically.

ProKnow CSI Plan Scoresheet (Total Score of 143.5/150)

5. Provide a reflection of what you learned from this planning assignment.
Before I started working on this lab assignment, I had not personally worked on a Cranio-Spinal
treatment plan. The only experience I had was what I learned from reading and what I had
discussed with the physicians, physicists, and dosimetrists at my clinical site. This experience has
been really beneficial to me for a number of reasons. First, I feel that challenging plans such as
this force me to think more critically about my planning strategies and do more research than
something like a breast or a prostate. Also, working on plans where various isocenters, field
matches, energies, and techniques are used makes me more comfortable with my skills. After
working on a technical plan like this CSI lab, I always go back and see how I could have made
the plan better. For instance, while I was reviewing the plan to write this review, I noticed that I
could have reduced the margin that I gave my optimization structures to improve coverage. It
also forces me to think about how I plan differently when making a plan that is graded on
ProKnow versus something that is used clinically. Sometimes, I make decisions to get a certain
grade on ProKnow that I would not do if the plan was for a real patient. In the clinical setting, I
can discuss my process, the target coverage and OAR constraints, and make a decision that is
best for the patient. Last, I learned most how difficult some plans such as this one can be. It is
important to rely on others that have more knowledge and experience when attempting/learning
new things so they can share their wisdom. In this case, my radiation oncologists, physicists, and
dosimetrists were able to explain how these plans were previously done, and then tell me how the
approach has changed. They also shared lots of information and resources that helped me
complete this lab but also helped me grow in my personal abilities as a medical dosimetrist. One
comment that my supervisor shared with me was how rare these treatments are and that they
were glad that I was getting some experience with one while in school. Plans such as CSI are not
done very frequently and without continual studying and practice, our skills can become less
polished. I am glad that I was able to learn from this experience and appreciate the challenge.
References:

1. Hendee WR, Ibbott GS, Hendee EG. Radiation Therapy Physics. 3rd ed. Wiley-Liss; 2005.

2. Wang Z, Jiang W, Feng Y, et al. A simple approach of three-isocenter IMRT planning for
craniospinal irradiation. Radiation Oncology. 2013;8(1). doi:10.1186/1748-717x-8-217

3. Yan M, Kong W, Kerr A, Brundage M. The radiation dose tolerance of the brachial plexus: A
systematic review and meta-analysis. Clin Transl Radiat Oncol. 2019;18:23-31. Published 2019
Jun 14. doi:10.1016/j.ctro.2019.06.006