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Jonathan Gonzales
DOS 531 Clinical Oncology for Med Dos
June 28, 2015
Craniospinal Irradiation The Prone Setup
The central nervous system (CNS) consists of the parts of the nervous system that are
encased in bone: the brain and the spinal cord. [1] Craniospinal irradiation (CSI) is a treatment
method of delivering a dose of radiation to the entire CNS. Possible CNS tumors include:
medulloblastoma, supratentorial primitive neruoectodermal tumors (PNET), disseminated
ependyoma, pineoblastoma, disseminated germ cell tumors, and other CNS tumors with
metastases. [2] CSI technique is composed of a whole brain treatment in conjunction with spinal
fields. The target of the treatment is to deliver a therapeutic dose to the cerebrospinal fluid within
the CNS. There are a variety of methods in designing a CSI treatment, but for this paper I will be
demonstrating the prone setup used here at the University of Michigan (UM) radiation oncology
department.
Depending on department practice, doses and fractionations may vary from clinic to
clinic. Here at the UM, we prescribe dose based on standard risk and high risk. A standard risk
case would receive a dose of 23.4 Gy at 1.8 Gy fractions to the entire CNS followed by a boost
of 30.6 Gy at 1.8 Gy fractions to the whole posterior fossa. [3] For standard risk patients, a
course of chemotherapy would also be involved during radiation therapy with an additional 36
weeks following radiation. If chemotherapy is not given, then the initial CSI will be given a dose
of 36 Gy. [3] A high risk case would receive a dose of 36 Gy at 1.8 Gy fractions or 39.6 Gy at 1.8
Gy fractions if there is gross disease in the spine. [3] A boost of 18 Gy at 1.8 Gy fractions would
follow. [3] For high risk cases, chemotherapy will definitely be administered during radiation
therapy and for an additional 36 weeks after.
The treatment fields for CSI are essentially two whole brain laterals with posterior spine
fields. The lateral brain fields are unique in that they will try to include as much cervical spine as
possible. When creating a treatment plan for these cases, it is important to abut the fields and
treat the entire CNS uniformly with no gaps or overlaps in dose. [3] The position of the patient
during CT simulation is important to the success of effectively creating a quality treatment plan.

In addition, having a reproducible setup that can be translated by the therapists during daily
treatment is also important to delivering a safe and operational treatment.
When performing a CT simulation for CSI, we try to have our patients in the prone
position. It is important that the therapists have special instructions on how to properly position
the patient prior to scanning. The patient is to lay on the table prone head first. A pad may be
used under the patient for added comfort. A prone head holder is to be used and adjusted to place
the patients head in the neutral position. The reasoning for having the head in the neutral
position is to avoid excessive curvature of cervical spine and skin folds at the back of the neck if
the chin is too extended. [3] If the chin is too low, it will results in exit dose from the upper
posterior spine field that could possibly send dose into the oral cavity. [3] If the prone head
holder is used, one must take notice if it is causing a great change along the curvature of the neck
area. You ideally want the back of the patients spine to be as parallel to the table as much
possible in respect to the head because it will result in a more uniform dose distribution. If there
is a noticeable curvature in the patients back, one can place boards under the patients chest too
build of the torso to help alleviate the curvature and create a much flatter target area. Once the
patients head is in the ideal position, the therapists should then note to what degree the prone
head rest was set. The fabrication of a custom aquaplast mask will then be used to help
immobilize the patients head. The shoulders of the patient must also be pulled down as low as
possible, suggestion of shoulder retractors may be advised. Having the shoulders low allows for
extension of the inferior portion of the whole brain lateral ports to include more of the cervical
spine without passing through shoulder and this will results in a upper spine field that will not
send exit dose into the oral cavity. Prior to scanning the patient, the therapist must make sure that
the chin is in the neutral position, the spine is as straight as possible, the spine is parallel to the
table as much as possible while maintain a similar height to the patients head, and the shoulders
are as low as possible (Figure 1).
During the treatment planning process, the dosimetrist will begin by setting the upper
spine field first. The upper spine field will generally cover C7 to L1 and should be given 1.5 2
cm lateral margins of the vertebral bodies. [3] Having the upper spine field at around C7 helps
avoid sending exit dose into the oral cavity and is the reason why it is important to have the
patients shoulders as low as possible. The isocenter is chosen at a depth that will place the match
plane at the level of the cord, refer to Figure 3. [3] At the University of Michigan, they maintain

the same couch vertical for all treatment fields. They call this a Center-to-Center shift, which
makes for easier daily treatment setups and minimizes setup error. The UM also adjusted the
weighting of each field independently until ideal isodose depths are met. The length of the upper
spine field will determine the collimator rotation of the lateral brain field. A formula can be used
to determine the collimator rotation:
Collimator Rotation [Brain field] = tan-1 (length of upper spine field/200) [3]
*assuming the spine field is asymmetrical. An example of this formula can be seen in Table 1.
Applying this collimator angle to the lateral brain field will make the inferior boarder of
the field abut along the divergence of the upper spine field, refer to Figure 3, and keep in mind
that this is still all at the same couch vertical as the spine fields. The blocking for the lateral brain
fields will be defined by the physician, the treatment area includes the entire brain, spinal cord
down to C7, and 2cm of flash around the patients scalp. To better protect the eyes, a gantry
angle of the cranial ports can be positioned in a way that utilizes the field edge along the
posterior portion of the eye. Using this technique will better protect the eyes from beam
divergence by creating a co-planar field along the posterior side of the eye. A formula can be
used to determine this gantry angle:
Gantry Angle [brain field] = tan-1 (Length of the anterior border of the brain field/SAD) [3]
*SAD of brain field. An example of this formula can be seen in Table 2.
Then there is now the issue of beam divergence from the brain fields into the upper spine
field. Typically, a pedestal angle will be used to again create a coplanar field edge of the inferior
portion of the brain field along the upper spine field. Here at the UM, they have decided not to
use this technique because they have found the area of overlap actually falls outside of the cord.
[3] Using the TPS, they have noted that the divergence from the opposed lateral fields along the
50% isodose line produces a straight line, refer to Figure 4, and when abutted to the upper spine
field create a pretty uniform dose distribution along the junction. [3] For purposes of this paper I
will explain how to employ the use of the couch kick. Here is the formula used to determine the
angle of the couch:

Angle of Couch = tan-1 (Length of the brain inferior jaw / SAD) [3]
*An example of this can be seen on Table 3.
Finally, you can create the lower spine field. This field, again will be at the same couch
vertical as the other fields, and will cross the upper spine field at the depth of the cord. The shape
of this field will stay narrow between the kidney and then flare out to cover the nerve roots in the
cauda equine down to S2/S3, refer to Figure 5. [3] There will be a measure planned-skin gap
determined by dosimetry and that must be physically measured daily for treatment setup
verification. An example of the manual skin gap calculation can be seen on Table 4.
The result of this type of treatment technique will create both hot and cold spots in the
match areas, but the dose in these regions will get smoothed out with intra-fractional feathering.
[3] Figure shows you the regions of hot and cold spots if no feathering is used. Feather the fields
is done by shifting the match lines inferior 1 cm during the course of treatment. This is done by
extending the inferior border of the brain field by 1 cm, decreasing the superior border of the
upper spine field by 1 cm, increasing the inferior border of the upper spine field by 1 cm, and
finally decreasing the superior border of the lower spine field by 1 cm. It is important that during
treatment planning, that you allow yourself enough field extensions to allow for these increasing
field sizes. Feathering will spreads out the hot spots and fills in the cold spots. At the UM, they
use intra-fractional feathering. This is a technique where on a daily treatment the patient will
receive a fractional dose of each feathered field. This results in a daily feathered dose
distribution.
Once the treatment plan is complete, it is important to give special setup instructions to
the therapists for daily treatment. The dosimetrist must give all treatment SSDs, Center-to-Center
shifts, and the measured gap for the lower spine field. The first thing would be to set up the
whole brain field and verify with imaging and check SSDs. [4] You should then mark the inferior
border of the whole brain field on the physical mask and then proceed to setup the upper spine
field. [4] Without changing the couch vertical, use the field light to position the upper spine field
to abut the superior border to the mark on the mask. [4] Images and SSD verification is
compared to planned measurements. Finally, without adjusting couch vertical, you will use the
planned center-to-center shift to set up the lower spine field. [4] The therapists will then have to
verify SSDs and compare the physical gap measurements to what dosimetry planned. The lower

spine field must also be imaged and verified that position is correct. At the UM, the first day of
treatment is extremely long because they have to image all feathered segments of the plan. The
number of the segmented fields can vary from 3 to 4, depending on how the physician wants to
fractionate daily dosage. [4]
CSI is becomes very involved when it comes to treatment planning. A strong knowledge
of beam geometry is very beneficial to have when it comes to figuring optimal beam
arrangements. Using geometric formulas are useful tools in determining these angle and they are
important to use because they help produce a better treatment plan for the patient. The UM has
mastered this type of treatment technique and has simplified it in a way that makes it easy for all
to follow. The use of center-to-center shifts, no couch angles, and intra-fractionated dose regimen
can really make the daily setup a lot easier for both the therapist and patient.

Tables
Table 1.
Example: Upper spine field length = 38 cm
Collimator Rotation [Brain field] = tan-1 (38/200) = 10.8
Table 2.
Example: Length of anterior border (X2) of brain field measure 7cm with a SAD = 100 cm
Gantry Angle [brain field] = tan-1 (7/100) = 4
Table 3.
Example: Length of brain inferior jaw = 18 cm with a SAD = 100 cm
Angle of Couch = tan-1 (18/100) = 10.2
Table 4.
Example: Manual skin gap calculation.

Figures

Figure 1. CT simulation for a CSI case with the patient in the prone position.

Figure 2. Location of the isocenter is at depth that will place the match plane at the level of the
cord

Figure 3. Image of the lateral brain field abutting the divergence of the upper spine field.

Figure 4. Lateral brain fields producing a straight line along the 50% isodose.

Figure 5. Field shape of the lower spine field.

Figure 6. Image of hot and cold spots of CSI without the use of feathering.

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References
1. Bear MF, Connors BW; Paradiso MA. Neuroscience: Exploring the Brain. 3rd edition.
Philadelphia, PA: Lippincott Williams & Wilkins; 2007:171.
2. Chao KS, Perez CA, Brady L. Radiation Oncology Management Decisions. 3rd edition.
Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
3. Conversation with Paul Archer, Certified Medical Dosimetrist. University of Michigan
Radiation Oncology Department. June 9, 2014.
4. Conversation with Ashley Orow, Radiation Therapist. University of Michigan Radiation
Oncology Department. June 25, 2014.