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Melissa Wojno
CSI Treatment Planning

A current craniospinal irradiation (CSI) treatment planning technique that I decided to

use after research and discussion with my preceptor is the VMAT technique. The International
Journal of Radiation Oncology, Biology, Physics (IJROBP) article on a three isocenter technique
was used as a reference for the treatment planning process. The article mentions that the use of
this technique greatly limited dose to surrounding OAR when compared to a conventional 3D
plan.1 This is a common technique that is used at Beaumont health with CSI cases and a variation
of this technique was used. Four beams were used for treatment planning instead of 3.

The first step in the treatment planning process was to create ring structures around the
planning target volume (PTV) contour provided by Proknow. The PTV contours were expanded
by 3mm to provide a buffer between the PTV and the first ring. This buffer allows the treatment
planning system to have space instead of conflicting dose constraints to two voxels next to each
other. Four rings were created, getting larger as they become further from the PTV.

The next step was to place the 3 isocenters on the patient. The goal of the isocenters was
to be in the same lateral and ant/post position so that during treatment delivery, the patient would
only be shifted sup/inf. The middle center axis (CAX) was placed approximately halfway
between the superior and inferior boarder of the patient’s PTV. It was placed at a mid-depth so
that the patient’s arms would not be in the way of the level for setup.
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This midCAX was then copied two times for the other isocenters. The superior and
inferior CAX’s were placed approximately half way to the superior and inferior boarders of the
combined brain and spine PTV. Three static beams were temporarily used for a good
visualization of the isocenter for beam setup. One beam was placed on each of the isocenters and
the gantry was rotated 180 degrees for a PA visualization. The collimation on the beams were
changed to the maximum distance of 40 cm on the Y axis (20cm sup and 20cm inf). The superior
and inferior isocenters were then adjusted so that the boarders overlapped with the medial beam
boarders for approximately 12 cm. The sup/inf CAX were placed equidistant from the midCAX.
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The plan was then copied and changed for treatment use. The 3 beams were changed to a
dynamic arc setting and the superior beam was copied. The 2 superior beams were used as
clockwise (CW) and counterclockwise (CCW) rotation around the brain. The start and stop
gantry angles were staggered so that the control points of the opposing beams would not align,
providing better coverage for the PTV. The collimator was rotated in equal opposite directions so
that the MLC orientation could hug the PTV contour more tightly. The medial spine beam
collimator was rotated 10 degrees so that the angle of the MLC leaves could feather in the
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overlap space with the superior beams. The inferior spine beam collimator was rotated 10
degrees in the opposite direction for the same reason. Our protocol for these cases require at least
5 degrees of collimator rotation for feathering.

The first few optimizations of the plan had the target volumes set at minimum doses of 37
Gy and max doses of 39 Gy. The rings were used and weighted slightly to push dose away from
the normal tissue and create tight coverage. With Pinnacle TPS most cases create the best plans
when the first few optimizations are focused on the target volumes and rings. Once good
coverage is met, OAR start to be added to the objectives slightly between optimizations.
However, the lens were added in on the first optimization to ensure that the maximum dose
would stay low on them. If they were added in later its often difficult to reduce the dose to those
without resetting the beams and parameters.

Hotspots remained low during the optimization process due to the max dose constraint to
the PTV. After a few optimizations, a cold spot region of interest (ROI) was created by creating
an ColdROI. This was made by creating a contour of the 100% isodose line (IDL), then both
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PTVs were copied and the 100%IDL contour was avoided on the inside. This means that the
ColdROI was a contour of the PTV-100%IDL, so that only the PTV receiving less than 100% of
the Rx remained in this contour. This contour ended up not being used because the coverage
increased on its own after a few optimizations.

The final plan had very good overallPTV coverage of 97.96% at 36 Gy and a hostpot of
39.7 Gy to .01 cc. This is considered acceptable at Beaumont. All of the acceptable constraints
from Proknow were met and some of the ideal constraints were met. I made an effort to reach the
“ideal” constraints of all of the OAR, except for 2 of them. The optic nerves had an “ideal” max
dose constraint less than the prescription, though they overlapped with the PTV. This meant that
the PTV would have cold spots to meet these ideal constraints. I did set max dose constraints to
these two volumes to meet the minimum requirement. However, if this were a real-time case, I
would contact the physician to see if they wanted to remove the optic nerves from the PTV
contour, or if they would like to exceed the dose constraint for better coverage. Due to timing
limitations, I was not able to continue optimizing to meet more “ideal” constraints. However, this
plan was exceptional and could be used in treatment. The plan did not have to be normalized due
to the good coverage of the PTV.
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At Beaumont Health we only have 1 dosimetrist that can plan a CSI case. Because we do
not get them often, many of my preceptors were not sure how to plan one. I think this was a
fantastic assignment and gave me the opportunity to plan a CSI case on my own. I have yet to
have a treatment plan that has overlapping sup and inf VMAT fields. This was a great learning
experience and I appreciate having this skill in my bank.
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References

1. Takahashi I, Imano N, Takeuchi Y, et al. A simplified three-isocenter VMAT for

craniospinal irradiation. International Journal of Radiation Oncology*Biology*Physics.
2018;102(3). doi:10.1016/[Link].2018.07.1076