Carissa Rivinius

Clinical Practicum III

Treatment Techniques

Craniospinal Irradiation (CSI) patients treated with radiation therapy may be setup in the
supine or prone position. This depends on the physicians preferred treatment technique as well as
the patient’s comfort and ability to be setup reproducibly each day. At my clinical site we have
not had a CSI patient treatment since I have been working here for the past 6 years. After
discussing the variety of treatment techniques of 3D conformal radiation therapy (3DCRT) and
Volumetric Modulated Arc Therapy (VMAT) with my preceptor I decided to create a VMAT
plan utilizing the prone patient position dataset. The main reason being that I wanted to spare as
many organs as risk (OAR) as possible and with the patient in the prone position most of these
organs would naturally fall in the direction of the floor due to gravity. Along with utilizing the
VMAT treatment technique I have found from previous studies throughout this course I am able
to spare OAR better then with 3DCRT.

Planning Process

After researching common techniques utilized for CSI planning, I discussed the typical
beam angles and energies with my preceptor, as well as feathering and matching techniques. In
creating my VMAT plan I decided to use 3 isocenters; one in the center of the brain PTV, one in
the upper (thoracic) spine, and one in the lower (lumbar) spine. All three isocenters are placed at
the same depth and same sagittal plane in order to make planning and actual treatment more
efficient. Allowing the therapists to shift the table longitudinally along just one plane during
treatment. The fields in the brain isocenter overlap with the upper spine fields by about 5cm, as
well as the upper and lower spine fields overlapping by around 5cm. This technique gives a
higher quality plan as it is more robust against junction errors, ultimately gaining a more
homogeneous dose distribution in the overlap region.1
Figure 1. Isocenter Placement-Axial, Coronal and Sagittal views marked with purple crosshair

Since
this is a
VMAT
plan the
energy I
selected
was 6x
due to the depth of the PTVs being more superficial with the patient in the prone position as well
as not wanting the beam to be deeply penetrating to spare more OAR. The first isocenter covers
the brain PTV and is composed of 2 full bounce back arcs rotating in the clockwise and
counterclockwise direction with a collimator angle of 5 degrees for the first and 355 degrees for
the second. This allows the MLC to move across the PTV at slightly different angles to help
prevent interleaf leakage. The couch remains as 0 for the entire plan. My jaws in the Monaco
treatment planning system have a limit of 20cm travel distance but with the isocenter placement I
made sure that would be accounted for so the PTV would be covered sufficiently with a 10cm
overlap total.

Plan Submission
 I was given a score of 125.14 out of 127 total points when I submitted my plan to
ProKnow. I met all ideal constraints for this study expect for the left and right kidney receiving a
mean dose of <2Gy as well as the left and right lens receiving a max dose of <7Gy. Although,
these constraints still met the minimum requirement and were very close to meeting ideal. With
all goals being met for my plan as well as discussing with my preceptor and physician I am
satisfied with the outcome for this case and would be comfortable treating if this was a actual
patients treatment plan.

Figure 20. ProKnow Scorecard

Reflection
 Having now completed my first ever CSI treatment plan it has given me the confidence to
be able to perform this task again if the opportunity arises at my clinical site or future job. At
first, I was intimidated by this case having not planned one before. Although throughout this
process I have shown myself how much I have learned over this year and how to concur my fears
in a challenging case. I have also gained the necessary knowledge and tool set to treat a large
treatment volume with multiple isocenters if need be. I expanded my knowledge through
researching about techniques used for CSI cases, such as feathering and match lines between
fields as well as the tips and tricks utilized to create optimal plans whether treating with 3D or
VMAT treatment techniques. I feel I have a good knowledge base on how to approach planning
a CSI case and the importance of proper simulation and setup from the very start to the end of
treatment. I look forward to more challenging cases in my future career as a medical dosimetrist.

References:

1. Wang K, Meng H, Chen J, Zhang W, Fend Y. Plan quality and robustness in field
junction region for craniospinal irradiation with VMAT. Phys Med. 2018;48(1)21-26.
https://doi.org/10.1016/j.ejmp.2018.03.007