Benjamin

n Smith
ProKnow
w CSI Plan Discussion
D
DOS 773
3: Clinical Prracticum III

Craniospinal
C irradiation (CSI)
( is a speecialized treeatment involving the treeatment of thhe
whole brrain and spinnal cord for patients
p diagnosed with ccentral nervoous system ((CNS)
malignanncies such ass medulloblaastoma. For my m ProKnow w CSI plan sstudy, I chosse the UWLA AX
Supine CSI.
C I decideed to use vollumetric mod dulated arc ttherapy (VM MAT) as my treatment
techniquee. This is a modern
m apprroach to the standard
s 3D conformal ttechnique whhich incorpoorates
overlapping fields an nd featheringg using MLC C segments. I was able too find some research on
dosimetric planning using
u VMAT T for CSI caases. Takahaashi et al1 disscussed the pprocess and
format off using 2 full arcs for thee brain and 1 full arc forr each of the 2 spinal fiellds. Using
avoidancce sectors forr the lateral aspect
a of thee beam (225--315° and 455-135°), the dose to the llungs
will be decreased wh mately help with its dos e constraint..1 This also pprevents treaating
hich will ultim
through the
t arms of the T was the starting poiint I used forr my CSI plaan.
t patient. This

For this plan, the dose preescription was

w 180 cGy x 20 Fx = 36600 cGy (366 Gy). I usedd
6MV eneergy for all my
m arcs. In order
o to creatte my fields,, I used the aarc geometryy tool in Ecliipse.
I selected
d Total PTV as the targeet and selecteed 3 isocenteers with 3 fuull rotations uusing a 0.5cm m
target maargin and 10° collimator angle. I now w had 3 isoc enter groupss generated ffor the brainn,
upper spiine and loweer spine fieldds. This proccess creates aan SAD treaatment plan. Each isocennter
group had 1 arc afterr the initial creation. I theen duplicate d each arc too have 2 arcss for the 3
different isos. I manually pluggeed in the colllimator to 3550° for each of the suppllemental arccs to
avoid anyy MLC leakaage. Found belowb on thee left is the aarc geometryy tool showccasing how I
selected 3 isocenters with 3 full rotations.
r Onn the right, aare the total ffields for thee 3 isocenterr
groups affter duplicating each arcc.

I also manuallly typed in whole

w numbers for the X
X, Y, and Z ddirections inn order to havve
simpler shifts
s for when this patieent would be treated. At my clinical facility, shiffts made from
the brain isocenter arre in incremeents of 20cm
m which I waanted to replicate for myy plan. I typeed in
20cm infferior (Z) to the
t brain isoocenter for th
he upper spinne isocenter and 40cm innferior (Z) fo
for
the lowerr spine isoceenter. Found below is my
y arc creatio n scheme inncluding the X, Y, and Z
parameteers.

Under
U the Fin
ne-tune Fieldds tab in arc geometry toool, I de-seleected the “addjust isocenteer
while fittting in X, Y,, Z direction” and clicked Fit Collim
mator to Targget. By doinng so, I kept m my
current X,
X Y, and Z coordinates
c with
w the arc geometry toool adjustingg to encompaass the PTV
Total.

This
T tool has an auto-featthering featu ure which meeans the arc fields autom matically oveerlap
to avoid hot
h and cold d spots as weell as decreasse the chancces of setup eerror and missing the tarrget
completeely. When measuring
m thee overlap, th
he brain and upper spine junction hadd a 4cm oveerlap
and the 2 spine fieldss had an overlap of 3cm.. At my clinnical site, 2cm m is typicallly the standaard
but anythhing more on nly benefits the
t setup. Found
F below
w is a 3D renddering of thee PTV Total and
the 6 arcss feathering (overlappingg) one anoth her with commplementary 10° collimaator angles.
 Before
B I optim
mized my pllan, I first creeated some ppseudo strucctures. I creaated a remaiining
volume ata risk (RVR R) structure which
w will aiid in dose coonformality. For this plann, I generateed a
RVR31 where
w I crop
pped the body y from enterring the PTV V Total with a 5mm marggin. It is an
unspoken n rule that do
ose falls off around 1 Gy y per 1 mm. Therefore, I can put 2 uupper constraaints
on my RV VR31 includ ding: 0.1% allowing
a a max
m of 31 Gyy and 0.0% w with a max oof 35 Gy withh a
priority of
o 75% for each. Found belowb is the RVR31 struucture for a vvisual aid.

I also needed to create a Planning

P PTV as the opttic nerves haad an ideal m
max constrainnt of
34 Gy. Within
W conto
ouring, I crop
pped the PTVV_Brain froom entering iinside the opptic nerves w
with a
3mm margin and useed this as my y Planning PTV. This deepiction can be found beelow.

Lastly,
L beforee optimizatio
on, I created a clinical prrotocol tempplate with eaach of the plaan
objectivees provided for
f this lab. I used this as
a a reference while in opptimization as I can see in
real time if I’m meeting my plan objectives or o which onees I still needd to work onn. Once in
optimizattion, I needeed to create mym avoidancce sectors. A As mentionedd towards thee beginning of
this papeer, I referenced an articlee which used d lateral avoiidance sectorrs for both spine isos wiith
dose stilll entering thee anterior asppect of the patient.
p In the beginning,, I had createed a plan usiing
their exacct parameterrs and met alll the constraaints as welll as PTV covverage. How wever, it was after
consultinng the chief dosimetrist
d at
a my clinic as well as a physicist thaat we agreedd to have mee try
to plan using the 2 arrcs for each of o the spine fields and onnly deliver ddose in the pposter aspectt of
the patien voidance secctors for the entire laterall/anterior asppect of the ppatient. This is
nt, setting av
method described
d thu
us far in this paper. My current
c avoiddance sectorrs were 225--135° and 1335-
225° for each of the spinal
s arc fieelds. Found below
b is myy avoidance ssectors within the plan
informatiion tab in op ptimization.

I proceeded too input all my

m uppers an nd lowers forr each of thee structures bbased on the
goals I neeed to meet. Unlike 3D planning wh hich uses larrger field borrders and OA AR blockingg, I
am usingg a 0.5mm margin
m aroundd the PTV Total
T which fforgoes the nneed to blockk critical
structures. I am ablee to use inverrse planning to limit dosse to the critiical structurees while
achievingg optimal tarrget coveragge. Found below are my ffinal optimizzation objecctives.
 After
A optimizzation, I was able to meeet all my plann objectives I had createed except forr
PTV cov verage. I re-nnormalized to
t 99.25% fo or my plan nnormalizationn value whicch increasedd my
PTV cov verage for bo
oth brain andd spine abovee 95% whilee maintainingg my OAR cconstraints.
Listed beelow are the plan objectives with acttual dose outtcomes for each.

As
A for the acttual ProKnoww metric con nstraints wh en I importeed my treatmment plan, I wwas
able to meet
m 17/21 id deal metric objectives.
o In
n the Eclipsee TPS, I did mmeet all the ideal objecttives
but whenn imported in
n ProKnow, it determineed that I did nnot meet thee ideal objecctives for Lenns
Lt, Lens Rt, Volume (%) of the PTV_Brain
P covered
c by 336 (Gy) and Volume (%)) of PTV_Sppine
covered by
b 39.6 (Gy)). I was welll able to meeet the minim
mum requirem ment for thesse, however. My
ProKnow w score card can be found at the end of this papeer.

My
M isodose distribution
d was
w very con nformal to thhe PTV Totaal. Found bellow is my
isodose distribution
d showing
s my prescription
n with plan nnormalization value. Thee yellow isoddose
line repreesents the 36
6 Gy prescrip
ption dose. The sagittal really depiccts the confoormity of dosse.
 The
T hotspot forf my plan was
w 113.4% which is muuch lower thhan standard CSI plans w which
can have a hotspot up pwards of 12
25%. My ho otspot was foound just skiimming the posterior poortion
of the PT
TV Spine. This
T is accepttable as it is preferable nnot to have thhe hotspot ddirectly withiin the
spinal co
ord itself. Fo
ound below is
i my hotspo ot and its loccation.

The
T cold spott for my plann was 77.8%
% of the presccription dosee (28 Gy) annd was foundd in
the lateraal aspect of the
t PTV Spin
ne in bone. This
T is an accceptable loccation as welll due to the
attenuatioon of bone. Found
F below
w is my cold
d spot and itss location.
 Found below is the DVH for my plan n with all thee OAR and targets labeleed. I also
included the dose staatistics for eaach of the strructures, dispplaying theirr min, max aand mean dooses.
 Planning CSI patients using VMAT is a great technique based on several factors. Not
only do you have better dose conformality to the PTV but also lowered hotspots. With
optimization, we can better limit dose to the OAR without compromising coverage.
Furthermore, with the auto-feathering feature in arc geometry, there is no need for couch kicks
and matching fields with specific collimator angles. The optimizer knows where the auto-
feathering takes place and accounts for this, preventing major hotspots. Therapists do not need to
enter the room once initial treatment begins which shortens the amount of time the patient is on
the table, improving accuracy. Using avoidance sectors for both spine fields reduces dose not
only to the lungs but also the kidneys as well as avoiding the arms. Only treating in the posterior
aspect vastly improved the V5 lung dose (radiation pneumonitis) as well as the Bowel_Total
dose. I believe this treatment scheme should be implemented when possible for adult CSI
patients. For pediatric patients, we want to treat the entire vertebral body to prevent growth
defects from only treating half a growth plate. It would be interesting to see if VMAT could also
treat the entire vertebral body effectively for pediatric cases. This technique resonated well with
the dosimetrists and physicists at my facility to where they are moving to implement it for future
CSI cases.
 References

1. Takahashi I, Imano N, Takeuchi Y, Kimura T, Murakami Y, Nagata Y. A simplified

three-isocenter VMAT for craniospinal irradiation. Int J Radiat Oncol Biol Phys. 2018;
102(3): 356. http://doi.org/10.1016/j.ijrobp.2018.07.1076