Jenn DeWeese

Dos 773 Clinical Practicum III

November 7, 2023
CSI Plan Study

The way I was taught to plan a CSI for my internship was to combine two planning approaches
with photons; forward and inverse planning. This will ensure a consistent distribution of radiation dosage
within the specific area of treatment.
First, a three-dimensional (3-D) forward plan is developed for the regions involving the brain and
the upper spine. This plan incorporates a method called the "feather dose gradient" in the overlapping
region where the brain and upper spine meet.1
Additional plans are created for the upper spine and a "false" lower spine field. The lower spine
field plan also includes a feathered gradient in the region where it overlaps with the upper spine field.
The lower spine's false field is combined with the 3-D brain plan, creating a foundational plan for
the optimization process of the upper spine field. This inclusion ensures that the feathered gradients are
accounted for both above and below this region.
Once the optimization for the upper spine's intensity-modulated radiation therapy (IMRT) is
completed, a sum plan is generated by combining the 3-D brain and upper spine plans. This sum plan is
then utilized in the optimization process for the lower spine field.
A plan sum is created by summing the plans for the brain, upper spine, and lower spine, providing
an assessment of the total radiation dosage across the entire treatment volume.

After I completed these steps my ProKnow score was a C and not much room for improvement.
The constraints in the brain were impossible to meet with the 3D plan, so I changed that to an IMRT plan
that utilized 4 full arcs and was able to achieve an A in ProKnow.

My clinical site treats very few CSIs in the photon practice. Most of these patients are treated
with protons. I have not had my rotation through that department yet, but I can only image how great the
plans turn out!

Field Design Steps

The initial stage of the planning process involved selecting the location for the isocenter in each
segment of the plan. Three separate isocenters will be utilized for the treatment plan, corresponding to the
brain, upper spine, and lower spine. All three isocenters will share identical lateral and vertical
coordinates, with the only adjustment being a longitudinal shift between them. Figure 1 represents the
entire PTV (PTV_All).
 Figure 1

Brain Field

• Two lateral fields will target the brain region. The Y1 is set to 10 cm and placed so the lower part
of the jaw is located just above the shoulders, see Figure 2. Using a 0.5 cm dosimetric margin,
the MLC’s are fit to the PTV_all structure within the lateral fields. The X jaws and Y2 Jaw are
adjusted to meet the edges of the fit MLC’s. The eyes and optic nerves are manually blocked to
limit dose.

Figure 2
 • To establish the X-axis position, ensure that it is aligned along the spine's central axis. Similarly,
the Y-axis should run along the entire length of the spine's center to ensure that our other
isocenters are predominantly located at the center of the PTV. See Figures 3 and 4.

Figure 3 Figure 4

Upper Spine Field

• To begin the next isocenter, replicate the brain isocenter configuration established for the upper
spine field, positioning the gantry at 180 degrees. Scroll down to approximately the estimated
location for the upper spine isocenter. For this setup, set the Y2 and Y1 jaws at 20 cm and shift
the isocenter so that the Y2 jaw aligns with the Y1 jaw of the brain field, with an overlap of 5-6
cm, preferably 6 cm. Maintain identical X and Y jaw settings as those used for the brain fields.
See Figure 5.

Figure 5
Lower Spine

• Duplicate the isocenter set from the upper spine with gantry still at 180 degrees. Set isocenter so
the Y2 jaw overlaps with the Y1 jaw of the upper spine field by 12-15 cm. (This may vary
depending on how long the PTV is drawn) See Figure 6.

Figure 6

• Below are the final isocenter coordinates used for the CSI “all fields” plan in Figure 7. Notice
how the X and Y remained the same.

Figure 7

PTV Optimization Structure Design

• A new structure called "PTV upper" was created. To do this, identify the specific z-coordinate
range within the CT scan that corresponds to the area covered by the upper spine field's Y2 and
Y1 jaws. Then, when contouring, set the Volume of Interest (VOI) to encompass this range,
defining the upper limit (superior z value) and the lower limit (inferior z value). This will
 establish the optimization structure for "PTV upper." Additionally, perform a Boolean operation
to combine "PTV upper" with the "ptv_all" structure, which is used in planning the upper spine
treatment.
• Repeat this same process for the “PTV lower” by identifying the z-coordinate range from the Y2
and Y1 jaws of the lower spine field. See Figure 8.
• In addition to creating the optimization structures, create 2 corresponding DLAs. One for PTV
Upper and PTV Lower. Each DLA is created by expanding the PTV for each region by 2 cm and
then trimming it from the PTV with a 2 mm margin.

Figure 8. Optimization PTV

structures with overlap

A plan is then created for each isocenter individually, with the intent of creating a plan sum at the
end.

Create Brain & C-Spine Plan

• Energy: 6 MV
• Prescribed Dose: 300 cGy x 10 fx = 3000cGy
• Technique: Isocentric, 3-D, Photons, Supine
• Fields: Right and left lateral beams to avoid treating through the eyes (I used an A80L and A88R
for this plan) Figure 9.
• Field Boarders: The MLC’s are fit to a PTV_all structure within the lateral fields with a .5cm
dosimetric margin. The X jaws and Y2 Jaw are adjusted to meet the edges of the fit MLC’s. The
eyes and optic nerves are manually blocked. Figure 10
• Planning: A 3D brain plan was created using a field in field (FIF) technique. The goal for target
coverage was 95% of the volume to receive > or = 100% of the prescription dose.(Figure 11)
Normalization is not typically used to achieve coverage in my clinic.

Figure 9 Figure 10

Figure 11

• Before finishing the brain field, a feathered dose gradient is created for the inferior portion of
plan. A single field in field (FIF) segment is created to close the inferior 6 cm of leaves. One leaf
is closed at a time for a total length of 6 cm on both the right and left lateral fields. This results in
multiple FIF segments. This technique is demonstrated below in figures 12-15.
 Figure Figure 13

Figure 14 Figure 15

• The original weighting of the right and left lateral brain/cranial spinal fields are divided and
redistributed to each FIF to achieve the final dose gradient pictured below. For example, the main
beam of the left lateral beam was 0.544 and there were 16 segments including the main beam.
Divide 0.544 divided by 16 which is equal to 0.034. Enter this amount in all the fields excluding
any FIF segments created to reduce hot spots/increase coverage. This process was repeated for
the right lateral beam as well. (To double check your work you can look at the dose profile in
that feathered area.)

Figure 16

Create Lower “false” field plan

 • A single posterior false field operates only as a component of the base plan dose used in the
optimizer. It is weighted and calculated so that the 95% isodose line covers the most anterior
portion of the PTV while the 100% isodose line covers the entire thecal sac.
• Field Borders: Copy the “All fields” plan and create a false field using only the field from the
lower spine. The superior border (Y2 jaw) of the lower spine field should overlap the upper spine
fields by same amount given 12 cm. Another dose gradient, on the upper portion of the field, will
be created by moving one MLC at a time (Figure 19).

Figure 17 Figure 18

Feather
ed area

Figure 19

Create Upper Spine Plan

• Energy: 6 MV
• Prescribed Dose: 300cGy x 10 fx = 3000cGy
• Technique: Isocentric, VMAT IMRT, photons
• 4 Fields: Two posterior arcs are created for the right and left side, both with a slight collimator
angle (Figure 20). For the left side of the treatment, the arc was started at 179 and stopped before
it entered the left arm (Figure 21). On the right side of the patient the arc started at 181 and
stopped before entering the patient's right arm. This plan utilized 179-132 and 228-181. See
Figure 20.

Figure 20

Figure 21

• The same Y2 and Y1 jaws used in the “All Fields” plan that was created previously.
 Figure 22

Optimization –Upper Spine Plan

• The Brain fields + False plan sum is used as base plan in the optimizer (Figure 23)

Figure 23

• The optimizer was asked for 100% of the PTV to receive 95% of the dose and 0 to receive 103%
of the dose. I had to be mindful of getting my constraints met for the esophagus as well as the
thyroid, I had to push fairly hard.
 Figure 24

• After optimization of the upper spine, a plan sum is created with the brain and the upper spine
plan.

• I did move a few of the brain MLCs to help with hot and cold spots in the overlap.
Create Lower Spine Plan

• Energy: 6 MV
• Prescribed Dose: 300cGy x 10 fx = 3000cGy
• Technique: Isocentric, VMAT IMRT, photons
• 4 Fields: Two partial arcs are created for the right and left side. The arc start angle on left side
was 179 and the stop angle was determined by the location of the arm, 132. The right side of the
plan utilized a start angle of 181-228 (in hindsight I could have gone much further than 132 and
228.)
• Field Borders: The superior border (Y2 jaw) of the lower spine fields should overlap the upper
spine fields by 12-15 cm. The inferior border (Y1 jaw) should be set at 19.5 cm or to include the
entire PTV.
 • Planning. Upper and lower objectives were placed on PTV. I used a DLA to limit the dose in the
area of the PTV and I had to really push to get the kidneys within tolerance. I also made a cold
structure to help with dose and a hot structure to keep out the 110.
• Optimization. The Brain + Upper sum plan is used as a base plan in the optimizer and the same
process is followed to calculate dose.

Figure 25

Figure 26

Final Sum Plan

• Following the completion of the lower spine optimization, proceed by merging the fields of the
brain plan.
• Sum the Brain, UpperSpine, and LowerSpine to create plan sum CSI total.
 After submitting my plan sum to Proknow, there were many constraints in the brain that I wasn’t
meeting at all, and I felt with the 3D technique that I had used, there was no possible way of getting any
better. See Figure 27.

Figure 27
So, this is when I decided to change my planning approach to IMRT for the brain also. I ended
up using 4 full arcs and was able to achieve marginal to ideal coverage on the optic nerves, parotoid and
submandibular constraints. The following figures are of my final plan used.

Figure
28
Figure 28. 4 arcs used for the IMRT planning. Notice how I used an upper and lower configuration for
the fields with the 90 degree collimator angle.
 Figure 29

Figure 29 is a sagittal view of the final merged plan.

Figure 30

Figure 30. What was used in the brain IMRT plan. This had the same feathering technique and same
field borders as the 3D plan. A plan sum was made with the IMRT brain, upper and lower spine fields.
 Figure 31

Figure 31. Final Proknow score with the IMRT brain arcs.

Figure 32
 Figure 33

Figure 32 and 33 are a few slices of the entire plan.

Figure 34

Figure 34. DVH

Cold Spot

• The coldest spot in my PTV was located close to the right eye. I was pushing on a few different
structures here and feel like this is an ok place for it to land. The portion of the PTV in Figure 35
shows where the 95% dips a little to help on sparing the right eye.
 cold location

Figure 35

Hot spot

• The hot spot in my plan was located in the body of my lumbar spine at a dose of 4089 (113%).
My goal was to stay under 110%, which I did for the most part. There this one location with a
point dose of 113% shown in Figure

hot spot

My second attempt at planning this CSI was no means perfect, but I believed it was an
improvement over the initial plan. I lost some points on the PTV of the spine because I was pushing so
hard in the optimizer for the kidneys to receive less dose. I also received a marginal score on the lenses of
my eyes and thyroid, but I felt like the coverage was my priority. If I attempted this plan again I would
have made my spine arcs a little wider. I was worried about getting dose into the arms, but now see I had
plenty of room for wider arcs.
In summary, this lab proved to be quite intricate. I acquired some valuable new techniques,
including the ability to set up match lines and employ a feathering technique between them. Additionally,
I gained experience in utilizing a base plan during the optimization process. I'm enthusiastic about
applying these new techniques in the future.

Reference
1. Ahmed S., Kruse J, Bradley T, Beltran C, Laack N. Clinical efficacy and safety of a highly
conformal, supine, hybrid forward and inverse planned intensity modulated radiation therapy
technique for craniospinal irradiation. Acta Oncologica. 2018;57(5): 629-636.