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Evgenia Nigay
CSI Assignment
October 3, 2017

Case Information
Patient presented with a diagnosis of medulloblastoma and was simulated in the prone
position. The prescription called for 36 Gy to be delivered at 180 cGy per fraction to the targets
PTV Brain and PTV Spine. Eclipse treatment planning system (TPS) was used to create the plan
using 6 MV photons for the brain fields and 15 MV photons for the spine fields. Treatment goals
were to deliver at least 95% of the dose to the PTV and to keep the global maximum dose under
110%. Organ at risk (OR) constraints to follow were listed in the ProKnow plan study.

Setup
Patient was set up in the prone position. The SAD setup was chosen and three isocenters
were used - one for the lateral brain fields, one for the superior spine field and one for the
inferior spine field. Figure 1 shows the field borders and blocking for the two lateral brain fields.

Figure 1. Beams eye view (BEV) of the left and right lateral fields to cover the brain PTV.

The entire brain PTV was included as well as the uppermost portion of the spine PTV with a 0.5
cm margin around. The jaws were opened to account for the 2 cm of flash at the superior and
posterior borders. The few MLCs pushed into the PTV were used in order to shield the lenses
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and the optic nerves. The superior spine field covered the cervical and thoracic portions of the
spine and the inferior spine field covered the remaining lumbar portion of the spine (Figure 2).
The MLC leaves were fitted to leave a 0.5 cm margin around the PTV.

Figure 2. BEV of the superior and inferior fields to cover the spine PTV.

Plan Normalization
Each PTV was normalized individually and volumetrically. The brain PTV was
normalized to have 100% of dose covering 95% of the PTV volume. The total spine PTV was
divided into two segments, one to include only the section covered by the superior spine field
and one for the inferior spine field (Figure 3). The segments were normalized individually to a
value to achieve the best balance between the PTV coverage and hot spots. The values were
adjusted as the plan was created; for the final plan C-T spine segment was normalized to 80%
and L spine segment was normalized to 80.7%.
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Figure 3. Spine PTV divided into segments: green - C-T spine segment covered by superior
field, blue - L spine segment covered by inferior field.

Treatment Planning Process

The superior spine field was placed first. The goal was to cover as much of the spine PTV
as possible, so the Y-jaws were opened to the maximum field size of 40 cm. The isocenter was
placed to avoid the divergence from the Y-2 jaw entering the mandible (Figure 4). The
uppermost part of the spine PTV was omitted in this field and was covered by the lateral brain
fields.

Figure 4. Superior spine field, sagittal view; Y-2 jaw avoiding divergence into the mandible.
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The lateral brain fields and the inferior spine field were placed next. Originally, the
isocenter for the brain fields was placed at the superior edge of the superior spine field to create a
half-beam block for the brain fields. However, the brain PTV extended beyond the limits of the
Y-2 jaw (20 cm) and the isocenter had to be shifted 2 cm superiorly. The isocenter for the
inferior spine field was placed to open Y-1 and Y-2 jaws evenly. The field alignment function of
Eclipse TPS was used to align the lateral brain fields and inferior spine field to match the
divergence from the superior spine field (Figures 5, 6). The gantry, collimator and couch angles
were calculated to match the superior spine field that was set at 0 (Figure 7).

Figure 5. Field Alignment to match the field edges.

Figure 6. All the field edges are aligned and matched to avoid divergence into the fields.
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Figure 7. Field gantry, collimator and couch angles to align the field edges.

Once all the fields were set a plan sum was generated to see the dose from all the fields
simultaneously. The brain PTV was taken care of first. The dose was calculated and the beams
were weighted equally. The PTV coverage was normalized to 95% of the volume to be covered
by 100% of the dose, while keeping the OR constraints within tolerance. The hot spots were
reduced by using field-in-field (FiF) segments - 2 from the right lateral and 1 from the left lateral
fields. The isodose lines show a uniform coverage of the brain PTV (Figure 8).

Figure 8. Transverse, frontal and sagittal views of isodose lines covering brain PTV.

The spinal fields required more work. The highest available energy, 15 MV, was used to
pull the dose deeper and to reduce the volume of the high doses as well as their location near the
surface. The normalization values were adjusted until the desired balance between coverage and
hot spots was achieved for both spine PTV segments (Figure 9, 10). The FiF segments were used
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to bring the volume of the hot spots down. Total of five FiF segments were used for each of the
spine fields to achieve the 90% of the PTV volume coverage by 100% of the dose, while
decreasing the volume of 110% as much as possible. Trying to increase the PTV coverage lead
to excessive volumes of high doses.

Figure 9. Frontal and transverse views of isodose lines covering the superior segment of spine
PTV.
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Figure 10. Sagittal, transverse and frontal views of isodose lines covering the inferior segment of
spine PTV.

Upon evaluation of the final isodose lines the global dose maximum was 4,231 cGy
(117.5%) and was located at the lumbar spine region (Figure 11). It can also be seen that the 80%
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isodose line (dark blue) covers the esophagus (beige contour) almost entirely, which lead to the
constraint for esophagus to not being met. Due to the higher energy used the dose penetrated
deeper, and because the esophagus runs along the spine there was no avoiding delivering the
dose there. Some of the thyroid (purple contour) was also covered by the 80% isodose line with
the maximum dose of 31.3 Gy, exceeding the allowable constraint of 30 Gy. Lowering the dose
to the thyroid reduced the PTV coverage in that region drastically and the compromise had to be
made. Figure 12 shows the cumulative DVH of the PTVs and the OR. Except for the esophagus
and the thyroid all other OR constraints were met. The ProKnow score sheet shows the criteria
and the achieved results (Figure 13).

Figure 11. Sagittal view of isodose lines covering the entire brain and spine PTVs, showing the
location of the global maximum dose.
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Figure 12. DVH.

Figure 13. ProKnow score sheet.

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Prior to completing this assignment I only knew the theory behind the CSI planning from
the textbooks. The dosimetrists at my clinic also did not have any experience planning CSI cases,
and I had to do a lot of research before beginning the planning process. The traditional method
was to leave the gap between the cranial field and the spine field and also to have a calculated
gap in the junction between the two spine fields. Planning this way left a cold spot at the superior
portion of the spine. There was also a cold spot at the gap between the spinal fields and a hot
spot in the area where the beams converged, which would require a feathering technique to
spread out the area of the cold and hot spots. When showing the plan to the physicist, he said that
he'd prefer to avoid the cold spots and not leave the gap between fields. That's when I found a
study on the planning technique using the field alignment tool in Eclipse TPS.1 Setting the fields
according to this technique resulted in a better plan with a more uniform dose distribution.
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References

1. Athiyaman H, Mayilvaganan A, Singh D. A simple planning technique of craniospinal

irradiation in the eclipse treatment planning system. J Med Phys. 2014;39(4):251-258.