Stacey Song

DOS 773 - Dosimetry Clinical Practicum III

November 7, 2023

ProKnow Craniospinal Irradiation Plan Study

Craniospinal Irradiation (CSI) is one of the options to treat craniospinal diseases such as

Medulloblastoma. Due to the nature of this disease, it can spread through the cerebrospinal fluid.

The first treatment choice for non-metastatic MB is surgery followed by CSI. Improvements in

CSI therapy has improved over the years with survival rates more than 80%, but long-term

survivors have experienced late effects which seem to be directly related to the irradiated volume

which is extensively applied in CSI.1 In the past, the classic 3D Conformal Radiation Therapy

(3DCRT) was used as the CSI treatment which rarely spared any organs which led to acute and

late morbidities. Since then, Volumetric Modulated Arc Therapy (VMAT) was introduced which

provides better homogeneity and conformal doses to the Planning Target Volume (PTV) while

reducing the dose to the other organs. 1

For this assignment, 36Gy in 20 fractions was prescribed in supine position. I chose the

VMAT to plan this assignment due to the benefits mentioned above. To prepare for optimization,

I created additional optimization structures such as arms and a ring for PTVspine. Since the

patient was positioned supine with both arms on the side, the arms would have received

unnecessary radiation during the treatment. In order to avoid this, I contoured both a right arm

and a left arm, then used them as avoidance structures during the optimization (Figure 1). Also, a

ring for PTVspine was created which was 3mm away from the PTVspine with a width of 1cm to

have dose conformality (Figure 2).

Figure 1. Both arms were contoured to be used as avoidance structures during the optimization.

Figure 2. Sagittal (left) and coronal(right) views of the ring for PTVspine.

After reviewing additional optimization structures, I set up the fields. Using Fogliata et

al2 as a starting point, I set up the fields using two full arcs for each of the three isocenters. I used

the Arc Geometry Tool to target the entire PTVall with a complement 10° and 350° collimator

rotation (Figure 3). Only 6MV energy was selected since VMAT was used for this plan. The X

and Z coordinates were kept the same to minimize the couch shift (Figure 4).
Figure 3. The Arc Geometric Tool was used to create fields.

Figure 4. The arc geometry for the plan.

The first arc field 1 and 2 included the entire brain to the C6, and the second arc field 3

and 4 included the C5 to C12. The last third arc field 5 and 6 included the C11 to the rest of the

PTVspine (Figure 5). There was a 3.63cm of overlapping area between the first arc and the

second one, a 3.79cm overlapping area between the second arc and the third one to reduce cold

or hot spots between the junctions.

Figure 5. The sagittal view of the overlapping areas between the junctions.
Figure 6. Beam’s Eye View of the treatment fields.

Normal Tissue Objective (NTO) was set as 100 priority, 0.3cm distance from the target

border, the start dose at 100%, the end dose at 60% and the dose fall off was 0.3 (Figure 7) .

Also, both arms and lenses were set as beam avoidances to avoid any direct dose (Figure 8).

Figure 7. Normal Tissue Objective set up.

Figure 8. The avoidance for both arms and lenses used during the optimization.

Once the optimization was done, I reviewed the plan. I decided not to normalize the plan

since the coverage and the OAR constraints were met (Figure 9). Figures 10 and 11 show the

axial images of isodose coverage of both PTVcranial and PTVspine. The global max dose was

110.1% which is in the middle of the PTVspine (Figure 12).

Figure 9. The outcome of CSI plan with no plan normalization.

Figure 10. Axial images showing the isodose coverage of PTVcranial.
Figure 11. Axial images showing the isodose coverage of PTVspine.
Figure 12. Axial image showing the location of the global max dose in the PTVspine.

Figure 13. ProKnow Metric Score Card.

Figure 14. DVH for PTVspine and constraints.

Figure 15. DVH for PTVcranial and constraints.

Figure 16. Axial image showing the area of underdosed.

After I uploaded my plan to the ProKnow metric system to be graded, I was able to get a

scorecard which indicated this plan met most of the requirements (Figure 13). However, I was

not satisfied with my plan because I could not get ideal coverage for PTVspine. I tried to spare

the kidneys and the eyes, but as a result failed to provide full coverage and delivered an

underdose to those areas (Figure 16). In my opinion I do not think this is clinically treatable due

to the lack of PTVspine coverage. Due to the busy schedule of the doctor, I was not able to get

his feedback on my plan, however I was able to talk with the physicist and he agreed with me

that this was not treatable. I just accepted it as it is, because at my current skill level, this was the

best I was able to achieve.

This CSI planning was very challenging to me, but it also provided me with greater

exposure to the types of plans I will need to encounter in the future. A big part of this challenge

was since we rarely treat CSI patients and I have not seen any at my clinical site since I started

my internship as a dosimetry student. Additionally, I have not had any experience treating multi-

isocentric treatment yet. However, this plan provided me a great opportunity to practice this type

of treatment. And it has made me more aware of different scenarios that might come up and how

I need to continue to push myself to be prepared for such situations.

 References

1. Nourreddine, Abdelati, et al. A dosimetric comparison between three-dimensional

conformal radiation therapy and volumetric -modulated arc therapy for medulloblastoma
craniospinal irradiation. Oncology and Radiotherapy. Vol.16 Iss.1:10-14.
https://www.oncologyradiotherapy.com/articles/a-dosimetric-comparison-between-
threedimensional-conformal-radiation-therapy-and-volumetricmodulated-arc-therapy-for-
med.pdf
2. Fogliata A, Bergström S, Cafaro I, et al. Cranio-spinal irradiation with volumetric
modulated arc therapy: a multi-institutional treatment experience. Radiother Oncol.
2011;99(1):79-85. http://doi.org/10.1016/j.radonc.2011.01.023