SPINE SRT

Ryan Kisamore

 34 year old Male.
 Stage IV Metastatic Colorectal
Adenocarcinoma to the brain, lung,
and adrenal Gland.
 Chemoradiation for locally advanced
rectal cancer in 2016.
 Colostomy with Ileostomy followed.
 Brain SRS in August.
 Spine SRT and Second Brain SRS in
November.
PATIENT SUMMARY
 Family history of Familial Polyposis
Syndrome.
 Mother and Brother both have FAP
and have had colons removed.
 Two maternal uncles diagnosed with
Colon CA at young ages.
 All current and future treatments of
with a Palliative intent to help patient
Quality of Life.
 Patient wants treatment with hopes
that it will lessen or remove his chronic
back pain.
 Increased complexity of immobilization is required to
allow for precise treatment with minimal patient
movement.
 We do not want the target to move internally due to
the high dose and high dose rate of beam.
 Our goal is high dose to target within minimal dose to
surrounding normal tissues
 Use the specialized Civco board on normal table top.
 Wing Board and Red Knee sponge used and indexed
on the Civco board with special T-Vac Bag used for
molding and further immobilization.
 Knee Lock attached to the Civco Board with a small
vac bag that will mold to the upper thighs and knees.
 Compression Plate can also be added at the
Physicians digression and depending on sights of
treatment.

IMMOBILIZATION
 SRT and SRS will require tighter
tolerance doses due to the
increased amount of damage done
per fraction.
 Treating the spine means we will need
to have to have tight margins with the
spinal cord so not to overdose it and
cause major complications.
 95% of the PTV_2700 will receive 27 Gy
 95% of PTV_1800 will receive 18 Gy

PLANNING OBJECTIVES
  Two Complete Arcs
 1 G181-179, C: 85
 2 G178-182, C: 175
 HD Machine used which allows for use
of smaller MLCs.
 Esophagus does not sit on the body,
makes for easier planning and less
constraints.
 Slight Collimator Angles that isn't 0 or
90, this is not typical when treating
spines.

BEAM ARRANGEMENTS
 Depending on location of lesion we
will sometimes include the spinous
process but still normalize to the
body.
 We do not include it in this case.
 Standard 95% of Volume receives
100% of the dose
 We want to maximize dose to PTV
 There should be a 2mm gap
between cord contour and the PTV,
the physician did not do this so the
Dosimetrist had to create a PTV Eval
with this gap for planning.
 Major Optimization Structures for this
plan include:
 Spinal Cord Upper: 1950 cGy
 PTV Lower: 95% to 2659 cGy
 Esophagus Upper: 2000 cGy
 Aorta Upper: 1900 cGy
while limiting dose to Cord and
Esophagus.

OPTIMIZATION
  Stereotactic Radiotherapy
 27 Gy in 3 fractions
 900 cGy per fraction
 Energy: 10x –FFF
 Flattening Filter Free to increase the
dose rate.
 CBCT Daily
 Planning CT was fused with recent
MRIs for use with planning.

PRESCRIPTION
 Hotspot at 126.1%, which is a bit
higher than would normally be
desired.
 Preferably want to push it toward the
centers of the Vertebral Body
 Normally the Collimator would be
used at 0 or 90 to allow for the
possibility of treatment of adjacent
bodies.
 The small angle changes do not
effect this too much.
 Cord needs to be contour 5-6 mm
above and below the treated body.

DOSE
DISTRIBUTION
 • SRS and SRT will have lower tolerances
for normal tissue due to the increase
dose delivered per fraction which
means we are doing much more
damage per fraction.
• Notable Tolerance Changes:
• Spinal Cord +2mm:
• SRS: 10 Gy
• SRT: 18 Gy
• EBRT: 47 Gy
• Esophagus
• SRS:11.9 Gy
• SRT: 17.7 Gy
• EBRT: 55 Gy
• Stomach:
• SRS: 11.2 Gy
• SRT: 16.5 Gy
TOLERANCE DOSES: SRS,SRT, • EBRT: 45 Gy

STANDARD FRACTIONATION
 • Notice the two red PTV lines, one is for the
PTC contour by the physician and on was
set by dosimetrist to allow for the required
2mm gap between it and the cord.
• PTV Eval has mean dose of 2926 cGy.
• Doses to critical structures are well below
tolerances.

DOSE VOLUME HISTOGRAM

FIELDS AND DRRS
 Same Immobilization as created during CT.
 Shifts were made from CT Isocenter to planned
Treatment Isocenter.
 5 CBCTS taken on the first day, consistent following
days.
 6DOF used.
 SSDs on laterals were not consistent due to the
location of isocenter with regards to the bag.
 Physicist is present for all treatments to oversee set
up and treatment, ensuring precision needed for
these treatments.
 They allow overrides as needed.

DAILY SETUP AND

TREATMENT
THANK YOU!
Questions?