Nicole Peckham 1

DOS 773 Clinical Internship III

CSI Plan Study

Craniospinal Irradiation Plan Study

Thanks to improvements in treatment planning techniques, treatment planning systems
(TPS), and treatment delivery capabilities there are now multiple ways to treat patients who
require craniospinal irradiation (CSI). The traditional technique for CSI is with the patient in
prone position, utilizing three-dimensional conformal radiation therapy (3D-CRT) fields for the
brain and spine. This is complex because it requires both the collimator and couch to be rotated
for the cranial fields so there is no divergence between the cranial and spinal fields. This also
requires abutting spine fields to be able to treat the length of the spine. 1 A gap calculation is
required between the spine fields to control the hot spot that occurs between the abutting fields.
Newer technology now allows for CSI irradiation to be performed with intensity modulated
radiation therapy (IMRT) as well as volumetric arc modulated radiation therapy (VMAT). 1 I
chose a hybrid planning technique, utilizing 3D-CRT opposed laterals for the cranial planning
target volume (PTV) and VMAT for the spine (PTV). The description of my planning process
and final outcomes are described at length below.
To start I marked the simulation reference points found on the outside of the mask for the
cranial fields. I ended up using this as the localization point for all beam sets because I could not
identify any reference points on the rest of the body. This resulted in large shifts from the
simulation reference point to the superior spine fields and the inferior spine fields as seen in the
Figure 1.

Figure 1. Patient set-up directions from simulation reference.

Nicole Peckham 2
DOS 773 Clinical Internship III
CSI Plan Study

After marking simulation reference, I determined how I would treat theses volumes. As
mentioned above, I split the PTVspine into superior and inferior portions due to the field size
limitation at my clinic of 40 x 40 cm2. This resulted in 3 beams sets, one for the PTVcranial, one
for PTVspine_Sup, and one for PTVspine_Inf. The TPS used at my clinic is RayStation, in
which I can create a single plan with multiple beam sets. By setting up the plan this way I can
use one scorecard for the entire plan, and I can evaluate the plan sum dose or individual beam set
doses while I am planning. This also allows for each beam set to have it’s own prescription. I set-
up the plan with each beam set and I created my scorecard based on the ProKnow metrics. In
addition to the combined PTVspine metric, I added individual metrics for my PTVspine_Sup and
PTVspine_Inf to make sure that they were individually receiving full coverage as well.
I started with my 3D-CRT cranial beam set. I added a single lateral beam at 270 degrees
centered on the PTVcranial. Utilizing the BEV with the lens structures visualized, I rotated the
gantry until both the right and left lens were lined up. I created an opposed field and performed
the same step to align the lenses. The resulting beam angles were 273 and 82 respectively, as
seen in Figure 2.

Figure 2. Beam data for the cranial 3D-CRT beam set.

I then used the treat and protect function to set a uniform margin of 1.0 cm to the
PTVcranial (Figure 3). I chose 10 MV because that is standard for 3D-CRT whole brain at my
clinic. Because I had already done several iterations of this plan, I knew right away that I wanted
to completely block the optic nerves, parotid glands, and the intersection of the PTVcranial with
the PTVspine to avoid a hot spot. The resulting initial block is show in Figure 4 for both beams
01 and 02.
Nicole Peckham 3
DOS 773 Clinical Internship III
CSI Plan Study

Figure 3. Treat and protect margin on PTVcranial.

Figure 4. BEV of Field 01 and 02, segment 1, showing the optic nerve block, the parotid block,
and the PTV junction block.
Nicole Peckham 4
DOS 773 Clinical Internship III
CSI Plan Study

I next proceeded to create segments for field-in-field (FIF) to remove the 110% dose of
3960 centigray (cGy), resulting in 3 additional segments per beam. The segments for field 01 are
shown in Figure 5 and the segments for field 02 are shown in Figure 6.

Figure 5. Segments for field 01.

Nicole Peckham 5
DOS 773 Clinical Internship III
CSI Plan Study

Figure 6. Segments for field 02.

Nicole Peckham 6
DOS 773 Clinical Internship III
CSI Plan Study

At this point I had the required coverage for the PTVcranial and the hot spot was under
110% so I proceeded to start working on my spine fields. Even though I split the PTVspine into
two segments and two beam sets for treatment, several of the organs at risk (OAR) would be
getting dose from both beam sets so I decided upfront to co-optimize the superior and inferior
spine beam sets, this allowed me to optimize to the entire PTVspine at once as well. For both the
PTVspine_Sup and the PTVspine_Inf I added 2 full symmetric arcs using 6 MV energy centered
to the respective PTV volumes. I chose to keep the collimator angles at zero to keep the leaves
perpendicular to the target for less interleaf leakage.1 Beam data for PTVspine_Sup and
PTVspine_Inf beam sets are shown in Figure 7. The BEV for these beam sets are shown in
Figure 8.

Figure 7.Beam data for PTVspine_Sup beams 03-04, and PTVspine_Inf beams 05-06.
Nicole Peckham 7
DOS 773 Clinical Internship III
CSI Plan Study

Figure 8. BEV of beam set 03-04 for PTVspine_Sup and 05-06 for PTVspine_Inf.

I then created my optimization structures. I created an optimization PTV_spine that was

cropped 1 cm away from the PTVcranial, called fOpt_PTV_Spine, which can be visualized 1n
dark blue in Figure 9. During planning I was struggling to meet the average dose to the kidneys,
so I also ended up making an optimization spine structure that was in the region of the kidneys,
called fOpt_Spine_Kid, this is visualized in yellow in Figure 9. This structure allowed me to
Nicole Peckham 8
DOS 773 Clinical Internship III
CSI Plan Study

keep full coverage of 3600 cGy on the rest of the PTVspine, while only covering the PTVspine
to 3420 cGy in the region of the kidneys to allow the average dose to be as low as possible. The
fOpt_PTV_spine was given a max dose, min dose, and a uniform dose objective, and the
fOpt_Spine_Kid was given a min DVH and max dose function. I also gave the PTVspine a min
and max dose function as well. Finally, even though I blocked the inferior PTVcranial and
created a gap with the fOpt_PTV_Spine, I was still getting a hot matchline so I also created a
PTVspine_ovlpCran to try and force the optimizer to control the 110% in this region. This is the
small yellow structure visualized in Figure 9 at the base of the PTVcranial.

Figure 9. Visualization of the target optimization structures from superior to inferior: PTVcranial
(green color wash), PTVspine_ovlpCran (yellow), PTVspine (cyan color wash),
fOpt_PTV_Spine (dark blue), and fOpt_Spind_Kid (yellow).
Nicole Peckham 9
DOS 773 Clinical Internship III
CSI Plan Study

To control the dose spread and shape I created 4 different rings; fRingTight, fRing97,
fRing75, and fRing50. Each ring received a max dose function with 99%, 97%, 75%, and 50% of
the prescription respectively. For the OAR I either did a MAX EUD function or a max DVH
function. Towards the end of optimization, I added some additional structures to control heat and
fill cold spots. My final objective functions can be seen in Figure 10.

Figure 10. Objective functions for the VMAT beams 03-06 treating PTVspine.
Nicole Peckham 10
DOS 773 Clinical Internship III
CSI Plan Study

I stopped optimization when I was satisfied with the PTVspine coverage and
visualization overall, as well as the dose to the OAR. The only thing that was not acceptable at
this point was the hot spot. The hot spot was still over 110% and was located in the dose spill
overlap region of the PTVcranial and superior most aspect of the PTVspine. To bring the hot spot
below 110%, I visualized the dose cloud and just moved individual leaves on both beam sets for
the PTVcranial and the PTVspine_Sup until the hot spot was under 110%. The final hot spot was
3959 cGy and was located within the PTVcranial as seen in Figure 11. I felt this was an
acceptable location for the hot spot because it is in the PTV, and it is not located within any
critical OAR. If you look closely at Figures 5 and 6 you will see that the inferior jaw (Y1) moves
between segments, in addition if I was able to scroll through the beam set for the PTVspine_Sup
you would also see the superior jaw (Y2) moving up and down, this essentially feathers the dose.
The junction region seen in Figure 12 has a dose of 3350 cGy, which is 93% of the prescription
and I was satisfied with the overall PTVcranial and PTVspine_Sup coverage so I accepted this.

Figure 11. Location of hot spot.

Nicole Peckham 11
DOS 773 Clinical Internship III
CSI Plan Study

Figure 12. Visualization of the junction between the PTVcranial and PTVspine with an isodose
key.

Finally, I had to address meeting the prescriptions for each beam set. The ProKnow
metric to meet was 95% of the volume receiving 3420 cGy but the prescription was 3600 cGy.
So to track my individual volumes I created my own metric on my scorecard of PTVspine_Sup
and PTVspine_Inf so that 90% of the volume received 3600 cGy, this was roughly the same as
the Proknow metric. If I was able to meet this then I normalized my prescription to this and if I
was below 90% then I used a calculation point, in RayStation these are call dose specification
points (DSP). For the PTVcranial, 92.6% of the volume was covered by 3600 cGy so I
normalized the prescription to this value, as seen in Figure 13. I also normalized volumetrically
for the PTVspine_Sup, which had 92.2% coverage at 3600 cGy. Because I purposely underdosed
the PTVspine_Inf to meet kidney constraints I had less than 90% coverage at 3600 cGy so I
chose to normalize that beam set with a DSP. The DSP was placed within the PTVspine in a
location that had adequate coverage at 3600 cGy, as seen in Figure 14.
Nicole Peckham 12
DOS 773 Clinical Internship III
CSI Plan Study

Figure 13. Volumetric coverage of PTVcranial and PTVspine_Sup

Figure 14. Prescription coverage of PTVspine_Inf and DSP location.

The final plan resulted in meeting all ProKnow metrics with an ideal score except for the
right kidney, which had an average dose of 334 cGy, refer to Figure 15. The ProKnow scorecard
shown in Figure 15 shows the hot spot being marginal for both the PTVcranial and PTVspine,
however, the value is 0.001 % and 0.005 % respectively, and you will notice that I did receive
full points.
Nicole Peckham 13
DOS 773 Clinical Internship III
CSI Plan Study

Figure 15. Final ProKnow scorecard submitted to Canvas.

During optimization I attempted to reduce both kidneys to an average dose less than 300
cGy. However, I noticed it was going to be easier to meet the left kidney so I opted to meet the
left kidney and let the right kidney go so that I could still maintain coverage of 3420 cGy to the
PTVspine in this region, as seen in Figure 16 with the yellow isodose line.
Nicole Peckham 14
DOS 773 Clinical Internship III
CSI Plan Study

Figure 16. PTVspine coverage at the level of the kidneys.

In addition to the junction area, and the kidneys, the only other place that was cold was in
the PTVCranial to block the optic nerves. The final dose distributions for the PTVcranial volume
in axial, coronal, and sagittal planes are shown in Figure 17. In hindsight, I could probably have
covered more of the cranial PTV in the region of the optic nerves and still maintained the ideal
ProKnow metric of 3600 cGy max dose, by only blocking part of the nerves. However, I still had
great volumetric coverage, so I was satisfied with this outcome.
Nicole Peckham 15
DOS 773 Clinical Internship III
CSI Plan Study
Nicole Peckham 16
DOS 773 Clinical Internship III
CSI Plan Study

Figure 17. Final dose distribution for PTVcranial in axial, coronal, and sagittal planes.
Nicole Peckham 17
DOS 773 Clinical Internship III
CSI Plan Study

There were more structures to spare with the PTVspine beam sets. Figure 18 is a display
of several axial slices showing the sparing of the submandibular glands, the lungs, the heart, the
liver, and the bowel. Along with a coronal and sagittal display of the dose distribution. I was
much more satisfied with my PTVspine outcome than my PTVcranial outcome. The major
difference that is seen is the ability to spare the OAR while getting a more conformal dose
distribution than with 3D-CRT.
Nicole Peckham 18
DOS 773 Clinical Internship III
CSI Plan Study
Nicole Peckham 19
DOS 773 Clinical Internship III
CSI Plan Study
Nicole Peckham 20
DOS 773 Clinical Internship III
CSI Plan Study

Figure 18. Final dose distribution for the PTVspine in axial, coronal, and sagittal planes.

In addition to the ProKnow metrics, and the visual outcome I have included a dose
volume histogram (DVH) displaying the OAR and the target volumes in Figure 19. To better
visualize the lines, I provided a combined structure for anything that was left and right sided.
Ideally, I would have had higher coverage of the PTV volumes with sharper fall-off. On the other
hand, I am happy with the dose to the OAR given that we are treating such a large volume
involving so many critical organs.
Nicole Peckham 21
DOS 773 Clinical Internship III
CSI Plan Study

Figure 19. Dose volume histogram.

This planning study was a fun but difficult challenge. We do not treat CSI at my clinic,
and I have not seen CSI treated since I was a radiation therapy student over 12 years ago, so this
was a fun challenge. I had never co-optimized two beam sets before completing this plan study,
so that was a new experience for me. While it does take longer to optimize, I did enjoy and found
it easier to be able to work with one scorecard and one set of objectives in the optimizer for the
entire plan. Something else I learned, almost by accident, is the importance of ring structures in
not only getting adequate coverage but shaping the dose. My first attempt at this plan I only used
2 rings, one with a max dose of 98% and one with a max dose of 50%. I was having trouble
getting coverage and shaping it around the PTVspine, which is a fairly symmetric volume. My
preceptor suggested my rings might be the problem and to put more weight on them. However,
by my final attempt during which I also co-optimized, I used 4 rings. I chose 4 not just to shape
the dose but to try and control the spread since I was trying to spare so many OAR. While it
seems like a lot of rings, it did a great job. Also, in reading the article from Studenski et al 1 I
learned there are several ways to approach planning and treatment for CSI cases. If I had more
Nicole Peckham 22
DOS 773 Clinical Internship III
CSI Plan Study

time for this assignment, I probably would have tried a fifth version of the plan using entirely
VMAT. I think that VMAT for the PTVcranial could have provided better target volume coverage
while sparing the optic nerves and parotid glands better. Also, in using VMAT you can use the
optimizer to control the hot spots between the regions better. 1 Overall, this was a great learning
experience, and I am glad to have done all the other case studies first because I felt they gave me
the tools to be able to tackle such a complex plan.
Nicole Peckham 23
DOS 773 Clinical Internship III
CSI Plan Study

References

1. Studenski MT, Shen X, Yu Y, et al. Intensity-modulated radiation therapy and volumetric-

modulated arc therapy for adult craniospinal irradiation—A comparison with traditional
techniques. Medical Dosimetry. 2013;38(1):48-54.
doi:https://doi.org/10.1016/j.meddos.2012.05.006