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Heather Maurer
Final Clinical Project
October 18, 2014
Craniospinal Irradiation Using Photons and Electrons
History of Present Illness: Patient CW is a 4 year old boy who present with headaches and
photophobia in November 2012. A CT and MRI revealed a 3.9 cm mass near the third and
fourth ventricles but were negative for metastasis. Pathology suggested a grade IV
pineoblastoma. CW underwent chemotherapy though he showed signs of increased intracranial
pressure. Before his third cycle of chemotherapy a repeat MRI was performed showing lateral
ventricular hydrocephalus and transependymal CSF flow. CW underwent right frontal
ventriculostomy and posterior fossa craniotomy for resection of pinealoblastoma in February
2013. Pathology confirmed it was a Grade IV pineoblastoma. He received a
ventriculoperitoneal shunt in March 2014 and continued chemotherapy. A restaging MRI in July
2014 showed likely tumor recurrence with suggestion of leptomeningeal components, involving
the middle cerebellar peduncles. Due to these results the patient was referred to radiation
oncology for further management recommendations.
Radiation Oncologist Recommendations: With the extent of CWs disease, including a
cerebellar recurrence and the possibility of leptomeningeal disease involvement, salvage
radiation was recommended. Due to the fact that his disease is able to metastasize via the
cerebrospinal fluid (CSF) his radiation fields will include the entire brain and spinal cord.
The Plan (prescription): There has been some controversy regarding the best way to plan
craniospinal irradiation. This particular case was planned using photons for the brain fields and
electrons for the spine fields. The initial brain fields consist of lateral fields each with
intrafractional feathering, creating 3 large whole brain fields per side as well as one segment to
even out dose distribution. The spine has been divided into an upper and lower spine section.
Each spine section consisted of 3 fields in order to help feather the match line. CW was
prescribed 23.4 Gy in 1.8 Gy fractions with these initial fields and completed his treatments with
a posterior fossa boost of 32.4 Gy in 1.8 Gy fractions for a total of 55.8 Gy. The posterior fossa
boost consisted of 2 axial beams as well as 2 off-axis beams conformed to the boost PTV
structure contoured by the physician.

Patient setup/Immobilization: Patient CW had a CT simulation in the prone position lying on
a one inch foam pad with his arms at his sides and shoulders as inferior as possible. His head
was in a prone foam headrest with a custom aquaplast faceplate to aid in the reproducibility of
his head tilt. His head was positioned in a neutral position assuring the chin is not tucked toward
chest in order to keep it out of the feathering spine fields. An aquaplast mask was made over the
posterior portion of his head for immobilization. His feet were also elevated slightly by a rolled
eggcrate under his ankles for comfort and to aid in preventing rotation (Figure 1).
Anatomical Contouring: The data set from the CT simulation was transferred into the Eclipse
treatment planning system (TPS). The staff physician and their resident created structures for the
posterior fossa boost GTV and contoured the brain, optic chiasm, left and right cochleae,
cirbiform plate, and the spinal canal. The dosimetrist then contoured the eyes, lenses, and
kidneys. The brain was used as a PTV and the cribiform plate was drawn to help when shaping
the brain fields. The Optic chiasm had a high priority and was to receive a maximum dose of 54
Gy whereas the cochleaes had a lower priority with a request of ALARA (as low as reasonably
achievable). The eyes had a mid-level priority with the maximum dose being 45 Gy per eye.
Other mid-level structures were the lenses, each able to get a maximum of 10 Gy, and the
kidneys which also had a request to minimize the dose. The Spinal canal was used as the PTV
for the spine fields. The dosimetrist expanded the posterior fossa boost GTV by 1 cm to create
the boost CTV and expanded again by 5 mm and edited within the skull to create the final boost
Beam Isocenter/Arrangement: For this particular case there were 3 technical isocenters.
When using electrons the first isocenter tends to be for the brain fields. The brain fields flash the
anterior, posterior, and superior edges of the skull and MLCs block the facial features and lenses
in the eyes, though it is more important to cover the entire brain than spare the lenses. Ideally
the inferior brain field border should match the upper spine superior border as inferior as
possible without the lateral brain fields treating through the shoulders. Typically if the match
line should be around vertebral body C7 to avoid exit does into the oral cavity.1 Two more brain
fields will be created with the same isocenter and anterior, posterior and superior borders. The
inferior border for each additional field will decrease by 1 cm in order to match to the additional
spine fields made to feather (Figure 2). These brain fields were set without the collimator
rotation you would typically see if you were matching to photon fields. When using electron

fields, the shape of the 50% isodose line, which is the dose at the edge of the field, is almost
vertical (Figure 3). Due to this there is no need to collimate the brain fields to match isodose
lines. This also allows for field matching on the patients skin surface rather than the center to
center shifts and skin gaps you would need to calculate for photon treatments. Matching the
fields on the surface will create a tear drop shaped hot spot caused by the lower isodose lines
bowing out which is smoothed out with feathering (Figure 4).
The second isocenter is for the upper spine field. This field was set at 110 cm SSD and a custom
electron cutout was created using the 25 cone covering as much of the length of the spine as
possible, 23 cm, with a 1.5cm margin on either side. Two other upper spine fields are created to
feather the match lines. The length of each additional spine field changes by 2 cm, 1 cm on each
superior and inferior border (Figure 5). These additional fields will be matched to the additional
brain fields and used for intrafractional feathering.
The third isocenter is for the lower spine fields. These fields are also set at 110 cm SSD, since
the fields will be matched on the skin there is no need to keep the table at a set height as you
would in a standard photon matching treatment. The first field will be designed to match the
largest upper spine field. It will stay narrow between the kidneys and then flare out to cover the
nerve roots in the cauda equina making sure adequate dose is distributed to S2/S3. The
additional lower spine fields used for intrafractional feathering here will increase their superior
border by 1cm in each field to match the additional fields in the upper spine (Figure 6).
Treatment Planning: As requested, according to the planning directive completed by the
physician, 6 MV was used for the brain fields and the adequate electron energy used for
coverage was 16 MeV for the spine fields. The primary constraint on the optic chiasm to receive
less than 54 Gy was met by achieving a maximum dose of 24.143 Gy. The maximum does to
each eye was roughly 25 Gy, meeting the constraint of 45 Gy. The kidney doses were kept to
23.6 Gy on the right and 25.2 Gy on the left and the cochleae received 24.5 Gy to the right and
24.7 Gy to the left, all of which were to be kept to minimal doses. The only constraint not met
was the constraint for the lenses. Ideally they should have been kept to 10 Gy or below, though
it was more important to treat the entire brain which lead to the right lens receiving 24.166 Gy
and the left lens receiving 23.837 Gy. By doing this the 90% isodose line covered 100% of the
brain and they max dose was 109.8% which did not exceed the 110% constraint placed by the
physician. The regions of high dose were mostly posterior spine or in the spinal canal itself.

The maximum dose location was in the spinal canal near L1, which was to be expected since that
was also the match area for the upper and lower spinal fields.
Reflection: While going through the planning on this case many options were discussed.
Craniospinal fields are treated in a variety of ways, some of which include supine, photons,
protons, 3D conformal, IMRT and electrons (which was our choice). There has been
controversy over which treatment is the best, and more specifically, if electron treatments create
more issues due to the increased dose heterogeneity across the vertebral bodies.
Using electrons to treat the spinal fields in a craniospinal case prove to have many advantages
and disadvantages. Some of the disadvantages include customized cutouts for each electron field
that are switched out over the patient in a prone position. If the intrafractional feathering is
involved, there will be multiple cut outs that need to be interchanged over the patient. This
opens up more opportunities for human error and also adds time to each treatment to enter the
room and change the cut-out. Electrons also tend to create slightly higher hot spots in the spinal
canal as well as create increased dose heterogeneity across the vertebral bodies2 (Figure 7).
Advantages of electron treatments include field matching directly on the skin surface. This
eliminates calculation errors for collimation on the brain fields, table kicks, center to center
shifts, gap calculations and skin gap measurements. Taking these opportunities for human error
out of the equation significantly reduces the probability for a treatment variance. The biggest
advantage of electron spine fields though is the reduced exit dose to the anterior thoracic and
abdominal structures (Figure 8).1 Though protons appear to provide the best treatments, when
comparing 3D-CRT electrons to photons, electrons were more effective at sparing dose to the
thyroid, heart, lung, kidney and liver through spinal irradiation.3 There is still the concern about
a change in bone growth due to the increased dose heterogeneity across the vertebral bodies
when treating with electrons. A subset of 19 patients who were post treatment by at least one
year received an MRI to have their vertebral bodies measured at specified levels of the cervical,
thoracic, and lumbar spine. These measurements were compared to the St Jude model of
predicted growth rates and did not correlate with any growth rate differences within the vertebral
body, full results can be seen in Figure 9.
After reviewing the advantages and disadvantages of prone craniospinal irradiation using
electrons I agree this was the best treatment modality given our options for patient CW. He did
not require anesthesia and was able to lay prone without discomfort. His spine was easily

palpable from this posterior surface which allowed for faster and easier alignment for treatment.
The electron fields covered all PTVs adequately and limited dose to other critical structures.

1. Archer, P. Cranio-Spinal Irradiation: Ann Arbor. [softChalk]. University of Michigan
Health Systems Department of Radiation Oncology; 2014
2. Kapadia NS, Archer PG, Oh K, et al. Assessment of bone growth effects among
medulloblastoma (MB) patients treated with electron vs. photon spinal irradiation.
ASTRO poster 2012 # 3104
3. Lee CT, Bilton SD, Famiglietti RM, et al. Treatment planning with protons for pediatric
retinoblastoma, medulloblastoma, and pelvic sarcoma: how do protons compare with
other conformal techniques? Int. J. Radiation Oncology Biol. Phys.2005;63(2):362-372.

Figure 1. Patient during simulation in prone position on foam pad, arms at side, faceplate, mask,
and rolled egg crate under ankles.

Figure 2. Brain fields with inferior boarder decreasing for feathering

Figure 3. Notice the 50% isodose line (Gray/green colored line between the blue and red lines)
is nearly vertical at the superior and inferior ends of the field.1

Figure 4. Teardrop shaped hot spot caused by the bowing out of lower isodose lines.1


Figure 5. Blocks for upper spine isocenter with decreasing superior and inferior borders for
intrafractional feathering.

Figure 6. Lower spine field blocks with increasing superior borders for intrfractional feathering.


Figure 7. Color wash comparisons of a photon plan subtracted from an electron plan. The red
areas indicate regions of higher dose with electron plan while the blue regions indicate lower
dose with electron plan. The kidneys are outlined in yellow.2


Figure 8. Dose distribution a) Electron spinal fields b) Photon spinal fields1


Figure 9. Results of vertebral measurements. ASTRO poster #3104 submitted 20122


Figure 10. DVH of crianospinal treatment prescribed to 23.4 Gy


Figure 11. Transverse slice showing fields with feathering and dose distribution using electron
spine fields


Figure 12. Axial slice showing dose coverage to spinal canal (contoured in yellow) also showing
dose coverage to vertebral body.


Figure 13. Axial slice showing dose distribution with brain fields


Figure 14. Coronal slice showing dose distribution using electron spinal fields