Free full text available from

www.cancerjournal.net

Original Article

Shielding in whole brain irradiation in

the multileaf collimator era: Dosimetric
evaluation of coverage using SFOP
guidelines against in-house guidelines
ABSTRACT
Aim: Compare the planning target volume (PTV) coverage in three different shielding techniques in cranial irradiation.
Settings and Design: Tertiary care center, prospective study.
Materials and Methods: The whole brain and meninges were contoured in ten planning CT scans, and expanded by 5 mm for the PTV.
Shielding was designed using the French Society of Pediatric Oncology (SFOP) guidelines (SFOP plan), in-house recommendation (with
1 cm margin from the orbital roof and sphenoid wing) on a igitally Reconstructed Radiograph (DRR) and a third plan was generated using
a 3D conformal radiation technique (3DCRT). The coverage of the PTV was noted using the isodose covering 95% of the PTV(D95),
minimum dose within the PTV(Dmin), and maximum dose within the PTV(Dmax). The location of PTV not covered by the 95% isodose curve
was noted. The median dose and maximum dose (Dmax) to both eyes and maximum dose Dmax for the lens were noted.
Statistical Analysis: General linear model method repeated the measure of analysis of variance test (ANOVA).
Results: PTV coverage was significantly poorer in the SFOP and in-house plans as compared to 3DCRT plan (P=0.04). Median volume
of PTV not covered by 95% isodose curve was 4.18 cc, 1.01 cc, and 0 cc in SFOP, in-house, and 3DCRT plan, respectively.
Conclusions: In the absence of volumetric planning techniques, SFOP guidelines lead to inadequate coverage and the in-house method
is recommended.
KEY WORDS: Brain metastasis, cranial irradiation, radiotherapy planning

INTRODUCTION
In the management of many malignant neoplasms,
whole brain with its meningeal covering forms a
part of the clinical target volume (CTV).[1-3] Common
indications of conformal whole brain radiation
when administered with curative intent include
craniospinal irradiation for medulloblastomas,
and prophylactic cranial irradiation (PCI) in acute
lymphoblastic lymphoma (ALL), and small cell lung
cancer. While the dose, time, and fractionation in
each setting may differ, the delivery technique
remains essentially the same. Parallel opposed, two
lateral portals are utilized, with added customized
shielding to protect the surrounding critical
structures.[4]
The area around the cribriform plate is considered
to be gravity-related sanctuary site.[5] However, due
to its proximity to the ocular structures, it often gets
shielded in cranial radiation. In medulloblastoma
and ALL, nearly 15-20% of recurrences occur at this
site which is attributed to overzealous shielding.[6-13]
152

This emphasizes the importance of a proper

technique for designing the shield in cranial
radiation. There are various techniques reported in
the literature of designing the shield. The standard
German helmet technique has been criticized as
it leads to inadequate coverage of the cribriform
plate.[2-4] In 1999, SFOP (French Society of Pediatric
Oncology) gave guidelines for design of cranial
shielding in medulloblastoma,[6] which have been
subsequently adapted for use in other indications
where whole brain radiation is required. A similar
but modified guideline for design of cranial shield
is used at our center.

Vijay M. Patil,
Arun S. Oinam,
Santam Chakraborty,
Sushmita Ghoshal,
Suresh C. Sharma
Department of
Radiotherapy and
Regional Cancer Center,
Post Graduate Institute of
Medical Education and
Research, Chandigarh 160 012, India
For correspondence:
Dr. Vijay M. Patil,
Department of
Radiotherapy and
Regional Cancer Center,
Cobalt Block, Nehru
Hospital, Post Graduate
Institute of Medical
Education and Research,
Chandigarh - 160 012,
India.
E-mail: vijaypgi@gmail.
com
DOI: 10.4103/09731482.65238
PMID: *****

The use of 3D conformal radiation technique

(3DCRT) for whole brain radiation has been studied,
as it uses the 3D dataset designing of the beam
portals and the shield in cranial radiation is near
perfect. However, the resources required for this
method of radiation are not widely available.
The study was designed to compare the adequacy
of PTV coverage and dose delivered to the ocular
J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2

Patil, et al.: Shielding design in cranial irradiation

structures by using the shielding technique recommended by

the SFOP, shielding technique developed in-house and that
designed by three-dimensional conformal planning.
MATERIALS AND METHODS

margin was selected based on our departmental assessment

audit and was specific for the patients with brain tumors both
in supine and prone positions. These scans and structure set
were transferred to the Eclipse treatment planning system
version 8 for planning and dose calculation.

Planning CT (computed tomography) scans of whole brain of

ten patients who had been treated for various intra-cranial
malignancies were retrieved from the database. Care was taken
to preserve patient anonymity by copying these CT scans in
a protocol-specific dataset after purging data pertaining to
identification of the patient.

Two parallel opposed lateral cranial portals were placed

using an isocentric technique with the isocenter placed in the
patients midline. Three different types of cranial shielding
were designed in the digitally reconstructed radiographs in
the Eclipse planning system in the lateral cranial fields in each
of these patients for the study purpose.

All planning CT were helical scans with 2.5 mm slices at 120

KvP and 250300 mA, acquired in the CT simulator Light
Speed VFX-16 (GE Health Care Ltd, Waukesha, WI, USA). Six
patients were immobilized with a three-point thermoplastic
cast (Efficast, Meditronix) and the rest with a five-point. Four
scans were acquired in the prone position, while remaining
scans were in the supine position. The neck was in the
extended position in all the scans selected for the purpose
of the study.

1. First technique (SFOP plan): Here the shielding was designed

in accordance with SFOP guidelines. The guidelines specify
a block margin of 0.5 cm below the roof of the orbit, 1 cm
in front of the anterior most projection of the greater wing
of sphenoid, 0.5 cm below the base of skull, 0.5 cm in front
of the anterior edge of the upper two cervical vertebrae
and 1 cm from the outer table of the skull in the remaining
directions[6] [Figure 2].
2. Second technique (in-house plan): In the in-house plan, a
block margin of 1 cm below the roof of the orbit and 1 cm
in front of the anterior most projection of the greater wing
of sphenoid are given. Remaining margins are similar to
SFOP guidelines as mentioned above [Figure 2].
3. Third technique (conformal plan): Shielding designed
by using the multileaf collimators (MLCs) fit and shield
software in the Eclipse treatment planning system with
a block margin of 0.7 cm from the PTV. MLC leaves were
constrained to intersect outside the margin during this
planning process in order to ensure that excess shielding
of the PTV did not occur due to the jagged nature of the
MLC-defined field border.

For the purpose of the study, the CTV delineation was

performed on Advantage Sim Workstation 4.3 (GE Medical
Systems, Waukesha, WI, USA) using setting for Head CT
(window width 100 and Mean 40). Whole of the brain with its
meninges was designated as the CTV. As the meninges are not
visualized in CT, whole of brain till the inner cortex of the skull
was included in the CTV as shown in Figure 1. The CTV was
contoured till second cervical vertebra. The cribriform fossa
was taken as a part of the cranial CTV which also included
the thin bony orbital roof. No special attempt was made to
contour the gross tumor volume (GTV). Both eyes and lens were
also contoured separately as avoidance structures. PTV was
generated from the CTV with an isotropic margin of 5 mm. This

Figure 1: Depicting the delineation of CTV (brain till inner cortex)

and PTV. Note that the PTV has gone nearly as far as the anterior
compartment of the eyes
J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2

All shielding was done with MLC Varian Millennium 80 MLC

Figure 2: (Panel A) SFOP shielding used. (Panel B) In-house shielding

used. The distance of orbital roof from the shielding (A) was 5 mm and
10 mm in SFOP and in-house plan, respectively. The distances B,
C and D were 10 mm,10 mm, and 5 mm, respectively, in both plans
153

Patil, et al.: Shielding design in cranial irradiation

which provides 40 leaves with a projected width of 1 cm at

the isocenter. In all plans, the MLC were placed outbound.
Dose calculation was done in the midline at the plane of
maximum cranial separation and the coordinates of the point
of calculation being kept same for each patient for all the
three techniques.
The minimum isodose surface which covered the 95% of PTV,
minimum dose (Dmin)in PTV, maximum dose (Dmax) in PTV, and
the volume of the PTV which was not covered by 95% of the
prescribed dose were noted.
The volume within the PTV within the 95% isodose envelope
was converted into a dummy structure which then was
subtracted from the PTV using the Boolean operator feature
in the Eclipse treatment planning system. The location of
remaining PTV (PTV miss) was noted for all the three plans. The
Dmax and the median dose to both eyes and lens were recorded
Statistical analysis
Comparison of the dosimetric and volumetric parameters
noted above in between the three plans was done by the GLM
method repeated measure ANOVA test using SPSS version
12. A P value of less than 0.05 was taken as statistically
significant. Greenhouse-Geisser correction and Huynh-Feldt
corrections were performed when the assumption of sphericity
were violated. Corrections were applied when the value of
epsilon, which is a measure of sphericity, was less than 1. The
Greenhouse-Geisser correction was done when the epsilon
value was below 0.75 and Huynh-Feldt correction when it
was more than 0.75.
RESULTS
The median of the percentage isodose curve which covered the
95% of the PTV were 98.11, 98.22, and 98.22 in the SFOP plan,
in-house plan, and conformal plan, respectively. The details
of coverage of the PTV for each patient are given in Table 1.
A repeated measure ANOVA with Greenhouse-Geisser

correction conducted indicated that there was a statistically

significant difference in the percentage isodose curve which
covered 95% of PTV in the three plans with F (1.06,9.55) =
10.95, P=0.008, R2 = 0.55, eta2=.0.55. Means of the percentage
isodose curve which covered the 95% of the PTV was 98.04%,
98.17%, and 98.16% in the SFOP plan, in-house plan, and
conformal plan, respectively, suggesting that the coverage
was poor with the SFOP plan.
The median values of the Dmin in the PTV were 16.35%, 61.55%,
and 95.5% in the SFOP plan, in-house plan, and conformal plan,
respectively. A repeated measure ANOVA with Huynh Feldt
correction indicated that there was a statistically significant
difference in the Dmin in the PTV in the three plans, F (1.52,13.70)
= 4.06, P = 0.04 , R2= 0.31, eta2= 0.31. Means of the Dmin in
the PTV were 22.72, 51.67, and 95.44 in the SFOP plan, inhouse plan and conformal plan, respectively, suggesting that
the minimum dose in the PTV was lower with SFOP plans and
in-house plan.
The median values of the Dmax in the PTV were 107.35% in all
three plans. A repeated measure ANOVA with GreenhouseGeisser correction conducted indicated that there was no
statistically significant difference in the Dmax in the PTV in
the three plans, F (1.00, 9.01) = 0.56, P=0.818, R2=0.006,
eta2=.0.006. Means of the Dmax in the PTV were 107.09, 107.13,
and 106.99 in the SFOP plan, in-house plan, and conformal
plan, respectively, suggesting that the maximum dose in the
PTV was nearly similar in the three plans.
The mean volume of the PTV contoured was 1631.66 cc
(range 1481.90-1887.30). The location of PTV miss is shown
in Figure 3. There was miss in all of SFOP and in-house plans,
while there were none in conformal plans. The PTV miss was
located over and near the cribriform plate in all the SFOP and
in-house plans. The median volumes of the PTV miss were
4.18 cc and 1.01 cc respectively in SFOP and in-house plans. A
repeated measure ANOVA with Greenhouse-Geisser correction
conducted indicated that there was a statistically significant
difference in the volume of the PTV miss in the three plans, F
(1.19, 10.70) = 26.40, P<0.001, R2=0.746, eta2=0.746. Mean

Table 1: Showing the PTV coverage parameters. The values of Dmax and Dmin are in terms of percentage of the prescribed
dose
Patient no.

% isodose covering 95% of PTV

1
2
3
4
5
6
7
8
9
10

SFOP
plan
98.38
98.33
98.11
98.89
97.36
97.36
98.76
97.61
97.54
98.11

154

In-house
plan
98.71
98.50
98.22
98.92
97.57
97.45
98.83
97.67
97.61
98.23

Conformal
plan
98.26
98.60
98.20
98.87
97.78
97.47
98.72
97.61
97.76
98.33

Dmin
SFOP
plan
41.7
33.4
15.1
12.0
17.6
13.6
46.5
13.7
23.4
10.2

In-house
plan
63.9
67.9
65.6
62.4
60.7
22
87.6
22.2
31.6
32.8

Dmax
Conformal
plan
95.00
95.50
95.60
95.50
95.20
95.50
95.30
95.40
95.60
95.80

SFOP
plan
107.6
108.8
109.7
104.9
105.8
107.4
106.5
107.3
105
107.9

In-house
plan
107.6
108.9
109.9
104.9
105.8
107.4
106.6
107.3
105
107.9

Conformal
plan
107.7
108.1
105.5
105.0
106.3
107.4
107.5
107.3
107.2
107.9

J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2

Patil, et al.: Shielding design in cranial irradiation

Figure 3: Area missed shown in RED. Note the position of the miss is around the cribriform plate

volumes of the PTV miss were 3.96 cc, 1.14 cc, and 0 cc in the
SFOP plan, in-house plan, and conformal plan, respectively,
suggesting again that the coverage was poor with the SFOP
plan.
The median dose and the maximum dose received by the
eyeball and lens are shown in Table 2. The conformal plans
as can be seen in the table have lead to an increased dose to
the ocular structures. The median dose and the Dmax is more
in conformal plan. Also the Dmax for lens are higher and well
above the TD5/5 for cataract if a prescription above 18 Gy is
given in the conformal plans.[14]
Comparison of the Dmax and median dose to the eye showed a
statistically significant difference between the three plans with
P values of 0.008 and < 0.001, respectively. The Dmax of the lens
also varied significantly between three plans with a P value
of < 0.001. The examination of the means for doses received
in the ocular structures from Table 2 indicates that higher
dose was received by the ocular structures in conformal plans.
DISCUSSION
The use of whole brain radiation (WBI) in brain metastasis
and as PCI in ALL is associated with improvement in quality
of life and survival.[1,5,15] In medulloblastoma irrespective of
the risk group cranio-spinal irradiation (CSI) with or without
chemotherapy is the standard of treatment in postoperative
setting.[3,4,6-10,13,16-18] In such situations, the use of a proper
technique for the adequate coverage of PTV is of prime
importance.
The use of radiation in medulloblastoma especially is
J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2

technically demanding and biologically unforgiving with

inadequate coverage of PTV leading to high incidences of
neuraxial recurrences which is supported by studies in Table 3.
Similar studies have been reported in ALL too. The importance
of coverage of the cribriform plate has been stressed by
Chatani et al.[19] An improved method of cranial radiation was
proposed by Pla et al, in ALL in which the importance of not
only inclusion of retro-orbital tissue but also treatment of this
region with same dose as whole of the brain was stressed.[11]
It is noticeable that trials post 1999 have used shielding design
similar to that suggested by SFOP[6] for quality assurance
purpose. In some studies distance of the block margin from
the temporal bones was reduced but the distance of orbital
roof from the shielding block was 5 mm.[3,6,13,17]
In the study by Chojanacka et al, out of evaluable patients,
27% of patients had a supratentorial failure in spite of correct
shielding.[7] Similar result can be seen in SIOP/UKCCSG PNET
3 study reported by Taylor et al, where in spite of fields been
labeled accurate in nearly 78% of patients, 15.5% of these
patients failed in the region of the cribriform plate.[13] The
distance of 5 mm between the shielding block and cribriform
plate does lead to under coverage of the PTV as seen in the
present study which may be an explanation for these results.
In our study we have compared plans generated using SFOP
guidelines against an in-house developed shielding and a
conformal plan based on segmentation of the CTV. The SFOP
plan led to inadequate coverage of the PTV in all the patients
with the median isodose covering the 95% PTV being 98.11%.
However, the average minimum target dose (Dmin) in the PTV
for SFOP plans was 22.72% as against 51.67% for the In-house
155

Patil, et al.: Shielding design in cranial irradiation

Table 2: Dose in terms of % of the dose prescribed received. The Dmax and median doses of the eye are average of the Dmax
and median doses received by left and right eye, respectively. The Dmax dose of the lens is an average of the Dmax of left and
right lens
Patient no.

Eye doses
Dmax

1
2
3
4
5
6
7
8
9
10
Mean

SFOP
plan
100.30
99.20
85.25
100.35
91.75
99.80
100.80
100.85
99.20
98.55
97.61

In-house
plan
102.00
101.60
101.35
102.30
100.20
101.45
102.60
101.45
100.20
100.80
101.40

Lens doses
Dmax

Median dose
Conformal
plan
102.55
105.60
107.60
103.45
102.30
104.65
105.05
104.45
102.75
104.65
104.31

SFOP
plan
25.35
26.00
11.25
20.25
10.70
35.65
21.45
45.85
19.25
27.05
24.28

In-house
plan
50.80
45.20
43.00
57.45
32.70
55.55
61.40
67.35
34.80
51.20
49.95

Conformal
plan
87.55
100.25
98.00
94.20
80.90
101.90
97.30
101.55
98.25
98.40
95.83

SFOP
plan
23.50
31.95
6.40
27.45
7.10
29.75
14.25
60.70
15.75
13.00
22.99

In-house
plan
51.10
43.55
11.70
67.15
13.15
58.20
40.50
81.30
26.70
29.55
42.29

Conformal
plan
88.95
101.50
59.45
103.50
57.20
121.45
90.90
104.00
100.15
103.65
93.08

Table 3: Details of various studies dealing with impact of target deviation in cranial portals in medulloblastoma
Author
Jereb et al[10]
Miralbell et al[16]
Chojnacka et al[7]
Carrie et al*[6]
Lal et al*[3]
Uozumi et al[18]
Taylor et al*[13]
Miralbell et al*[17]

Cranial fields with inadequate

portals in the region of the
cribriform plate
40 (100)
36 (47)
48 (43)
68 (40)
24 (77)
2 (22)
29 (22)
131 (63)

Supratentorial
failures
6 (15)
12 (15)
17 (15)
NA
NA
2 (22)
26 (14.5)
15 (7)

Supratentorial failures
in those with inadequate
portals
6 (15)
9 (25)
NA
7 (25)
NA
2 (100)
5 (17)
2 (1.5)

Supratentorial failures in
the region of the cribriform
plate
6 (100)
5 (42)
4 (25)
NA
NA
2 (100)
5 (100)
NA

*Used SFOP shielding design near cribriform plate for quality assurance; Figures within parentheses are percentages; NA: not assessed

plans and 95.44 % for conformal plans. In all patients, the area
of miss was the cribriform plate.
The biological consequences of this miss can be better
appreciated if we consider the dose response curves of
medulloblastoma and ALL cell lines. Halprein et al have
demonstrated that the surviving fraction increases from 0.29
to 0.33 in medulloblastoma human cell line D283(D0=1.2 Gy),
when the dose delivered per fraction is reduced from 1.5 to 1.35
Gy.[9] Extrapolating these to more radioresistant cell lines of
medulloblastoma(D0=1.8 Gy), the impact of this sparing effect
would be further amplified. Use of proper radiotheraputic
techniques is thus of foremost importance in radiosensitive
tumors in order to achieve good clinical results, and cranial
radiation in medulloblastoma and ALL is no exception to this
rule.
The failures caused by the improper technique of radiation
in both medulloblastoma are difficult to salvage. In the
series reported by Lal et al, all seven patients with recurrence
eventually succumbed to it.[3] In a recent analysis by Massimino
et al, it was concluded that cure with second-line myeloablative
schedules still remains a myth, despite the responses which are
obtained by these second line schedules. In this series, out of
14 assessable patients 12 had a response; however, only one
patient survived over 13 months. These responses came at a
156

cost of substantial toxicity as highlighted by the same study

in which grade 4 neutropenia was observed universally.[20]
Bowers et al, have further showed that in children older than 3
years who receive radiation, site of tumor progression was an
independent prognostic factor determining survival. Patients
having recurrence in posterior fossa fared better than those in
the supratentorial region (P=0.017 on log rank analysis).[21] In
ALL, the salvage of cranial recurrence has been more successful
with Kumar et al reporting 10 out of 18 patients successfully
salvaged, however, it came at the cost of substantial toxicity
which were well managed in this trial. The ability of managing
such toxicities in a third world health setup is questionable.[22]
Similar results of successful salvage of isolated CNS relapses
post prophylactic cranial irradiation have been reported by
Ritchey et al, where 100% of patient achieved second remission,
as the 4 year event free survival was 71%.[23] But with due
consideration of the toxicity, the additional cost of repeated
treatment and its psychological impact on the patient and
family it should be a priority to ensure adequate coverage of
the whole brain with its meninges while doing prophylactic
cranial radiation itself.
In our study, MLCs were used for shielding as opposed to
customized shielding blocks. Due to these step ladder pattern
created by MLCs, there was a poor conformity between the
intended area to shield and that achieved. However, care was
J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2

Patil, et al.: Shielding design in cranial irradiation

taken while designing the shields with MLC that minimum

distances required in both SFOP and in-house design from
bone land marks were obtained (outbound placement). The
use of customized blocks is therefore better than use of MLC.
However, use of MLC is a time, resource saving alternative
and is proven to be equal to customized blocks in various
studies.[24,25] In this era of MLCs, most of the institute use
MLCs over customized shielding block due to their advantages
highlighted in the previous line. The shielding in this study was
designed on a digitally reconstructed radiograph. However,
it is difficult to locate the cribriform plate on a digitally
reconstructed radiograph or simulator films.[26] In addition,
anatomical variation if any cannot be guessed from the bony
landmarks. The point is well stressed by a study from Turkey
by Erdem et al, where the variation of the cribriform plate with
respect to the roof of the ethmoids which is in close proximity
to the roof of the orbit can vary from 1 to 15 mm.[27] Use of
conformal planning in these cases is important, especially
in young patients who are treated radically in whom the
consequences of a PTV miss would be disastrous. The authors
are also aware of the fact that using finer MLC might have
resulted better conformity as compared to the use of 1 cm MLC.
However, in our department all machines are equipped with 1
cm MLC, hence all plans were generated using the same MLC.
However, using finer MLC is not likely to change the results
as far as coverage is concerned as all leaves were placed in an
out-bound setting. The benefit resulted from this is likely to
be better shielding of the eyes and lens.
The importance of CT planning in WBRT and in medulloblastoma
has been stressed by Gripp et al, where the geographical miss
in the subfrontal region was reduced from 28% to 0% when CT
planning was done as opposed to 2 D planning.[26] Kortmann
et al too showed that standard German helmet technique used
by 2D planning missed in 52% of patients the CTV near the
subfrontal region and middle cranial fossa, and in addition
the set displacements around a 1 cm in either direction were
noted. It was recommended to do CT examination for these
patients and to give a safety margin of 1 cm for the set up
errors.[28] Mah et al, found that CT-based conformal planning is
less time consuming, more accurate, and provides better dose
homogeneity while planning crainospinal radiation.[29] Andic et
al, has reported a significant improvement in coverage of the
retro-orbital area with 3D conformal radiation as opposed to
the standard German helmet technique and Dmin of 59% with
2D plans as compared to 95% in 3D conformal plans.[30] It is to
be noted that shielding guideline used in this study was not
in accordance with the SFOP.
However, in developing countries, underdeveloped countries
and even in some developed countries the facility of CT
simulator is not often available. [31,32] In the absence of
volumetric planning techniques, SFOP guidelines for shielding
in CSI lead to an inadequate coverage, so the method of
in-house shielding described in the present study may be
recommended. Our recommendation differs from those given
J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2

by Kortmann et al, as a less margin is specified below the base

of the skull and in front of the cervical vertebrae, which can
potentially spare a greater volume of pharyngeal mucosa.
The dose to the lens in conformal and in-house plans was
much higher than the tolerance limits. [14] But with the
advancement in cataract surgery in children, the fear of this
complication should not lead to inadequate coverage of PTV.[33]
The dose delivered into whole brain in CSI in radical setting
for medulloblastoma is in range of 3600 cGy and in metastasis
in range of 4000 cGy. These are well below the tolerance limits
of retina.[14,34] So concern for ocular toxicity is unjustifiable.
REFERENCES
1. Kaal EC, Nil CG, Vecht CJ. Therapeutic management of brain
metastasis. Lancet Neurol 2005;4:289-98.
2. Meshref MM, Elshazly N, Nasr M, Abdelhai R. Effect of prophylactic
cranial irradiation dose on CNS relapse, late cognitive decline and
learning disabilities in children treated for acute lymphoblastic
leukemia. J Clin Oncol (Meeting Abstracts) 2006;24:9032.
3. Lal P, Nagar YS, Kumar S, Singh S, Maria Das KJ, Narayan SL,
et al. Medulloblastomas: Clinical profile, treatment techniques and
outcome - an institutional experience. Indian J Cancer 2002;39:97-105.
4. Weiss E, Krebeck M, Khler B, Pradier O, Hess CF. Does the
standardized helmet technique lead to adequate coverage of the
cribriform plate? An analysis of current practice with respect to the
ICRU 50 report. Int J Radiat Oncol Biol Phys 2001;49:1475-80.
5. Williams MV. The cribriform plate: A sanctuary site for meningeal
leukaemia. Br J Radiol 1987;60:469-75.
6. Carrie C, Hoffstetter S, Gomez F, Moncho V, Doz F, Alapetite C, et al.
Impact of targeting deviations on outcome in medulloblastoma:
Study of the French Society of Pediatric Oncology (SFOP). Int J Radiat
Oncol Biol Phys 1999;45:435-9.
7. Chojnacka M, Skowroska-Gardas A. Medulloblastoma in childhood:
Impact of radiation technique upon the outcome of treatment. Pediatr
Blood Cancer 2004;42:155-60.
8. del Charco JO, Bolek TW, McCollough WM, Maria BL, Kedar A, Braylan
RC, et al. Medulloblastoma: Time-dose relationship based on a 30-year
review. Int J Radiat Oncol Biol Phys 1998;42:147-54.
9. Halperin EC. Impact of radiation technique upon the outcome
of treatment for medulloblastoma. Int J Radiat Oncol Biol Phys
1996;36:233-9.
10. Jereb B, Krishnaswami S, Reid A, Allen JC. Radiation for
medulloblastoma adjusted to prevent recurrence to the cribriform
plate region. Cancer 1984;54:602-4.
11. Pla M, Podgorsak EB, Kim TM, Freeman CR. Improved radiotherapeutic
technique for prophylaxis of the central nervous system in patients
with acute lymphoblastic leukaemia. Br J Radiol 1981;54:412-5.
12. Ridgway EW, Jaffe N, Walton DS. Leukemic ophthalmopathy in
children. Cancer 1976;38:1744-9.
13. Taylor RE, Bailey CC, Robinson KJ, Weston CL, Ellison D, Ironside
J, et al. Impact of radiotherapy parameters on outcome in the
International Society of Paediatric Oncology/United Kingdom
Childrens Cancer Study Group PNET-3 study of preradiotherapy
chemotherapy for M0-M1 medulloblastoma. Int J Radiat Oncol Biol
Phys 2004;58:1184-93.
14. Emami B, Lyman J, Brown A, Coia L, Goitein M, Munzenrider JE,
et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat
Oncol Biol Phys 1991;21:109-22.
15. Tsao MN, Lloyd NS, Wong RK, Rakovitch E, Chow E, Laperriere N.
Radiotherapeutic management of brain metastases: A systematic
review and meta-analysis. Cancer Treat Rev 2005;31:256-73.
157

Patil, et al.: Shielding design in cranial irradiation

16. Miralbell R, Bleher A, Huguenin P, Ries G, Kann R, Mirimanoff RO,

et al. Pediatric medulloblastoma: Radiation treatment technique
and patterns of failure. Int J Radiat Oncol Biol Phys 1997;37:523-9.
17. Miralbell R, Fitzgerald TJ, Laurie F, Kessel S, Glicksman A, Friedman
HS, et al. Radiotherapy in pediatric medulloblastoma: Quality
assessment of Pediatric Oncology Group Trial 9031. Int J Radiat Oncol
Biol Phys 2006;64:1325-30.
18. Uozumi A, Yamaura A, Makino H, Miyoshi T, Arimizu N. A newly
designed radiation port for medulloblastoma to prevent metastasis
to the cribriform plate region. Childs Nerv Syst 1990;6:451-5.
19. Chatani M, Teshim T, Inoue T, Azuma I, Kumano M, Hishikawa Y,
et al. [Central nervous system irradiation for children with leukemia].
Gan No Rinsho 1984;30:152-6.
20. Massimino M, Gandola L, Spreafico F, Biassoni V, Luksch R, Collini
P, et al. No salvage using high-dose chemotherapy plus/minus
reirradiation for relapsing previously irradiated medulloblastoma.
Int J Radiat Oncol Biol Phys 2009;73:1358-63.
21. Bowers DC, Gargan L, Weprin BE, Mulne AF, Elterman RD, Munoz L,
et al. Impact of site of tumor recurrence upon survival for children
with recurrent or progressive medulloblastoma. J Neurosurg
2007;107:5-10.
22. Kumar P, Kun LE, Hustu HO, Mulhern RK, Hancock ML, Coffey D, et al.
Survival outcome following isolated central nervous system relapse
treated with additional chemotherapy and craniospinal irradiation
in childhood acute lymphoblastic leukemia. Int J Radiat Oncol Biol
Phys 1995;31:477-83.
23. Ritchey AK, Pollock BH, Lauer SJ, Andejeski Y, Barredo J, Buchanan
GR. Improved survival of children with isolated CNS relapse of acute
lymphoblastic leukemia: A pediatric oncology group study. J Clin
Oncol 1999;17:3745-52.
24. Fernandez EM, Shentall GS, Mayles WP, Dearnaley DP. The acceptability
of a multileaf collimator as a replacement for conventional blocks.
Radiother Oncol 1995;36:65-74.
25. Helyer SJ, Heisig S. Multileaf collimation versus conventional

26.
27.
28.
29.

30.

31.
32.

33.
34.

shielding blocks: A time and motion study of beam shaping in

radiotherapy. Radiother Oncol 1995;37:61-4.
Gripp S, Doeker R, Glag M, Vogelsang P, Bannach B, Doll T, et al. The
role of CT simulation in whole-brain irradiation. Int J Radiat Oncol
Biol Phys 1999;45:1081-8.
Erdem G, Erdem T, Miman MC, Ozturan O. A radiological anatomic
study of the cribriform plate compared with constant structures.
Rhinology 2004;42:225-9.
Kortmann RD, Hess CF, Hoffmann W, Jany R, Bamberg M. Is the
standardized helmet technique adequate for irradiation of the brain
and the cranial meninges? Int J Radiat Oncol Biol Phys 1995;32:241-4.
Mah K, Danjoux CE, Manship S, Makhani N, Cardoso M, Sixel KE.
Computed tomographic simulation of craniospinal fields in pediatric
patients: Improved treatment accuracy and patient comfort. Int J
Radiat Oncol Biol Phys 1998;41:997-1003.
Andic F, Ors Y, Niang U, Kuzhan A, Dirier A. Dosimetric comparison
of conventional helmet-field whole-brain irradiation with threedimensional conformal radiotherapy: Dose homogeneity and retroorbital area coverage. Br J Radiol 2009;82:118-22.
Yin W, Chen B, Tian F, Yu Y, Kong F. The growth of radiation oncology
in mainland China during the last 10 years. Int J Radiat Oncol Biol
Phys 2008;70:795-8.
Ruggieri-Pignon S, Pignon T, Marty M, Rodde-Dunet MH, Destembert
B, Fritsch B. Infrastructure of radiation oncology in France: A large
survey of evolution of external beam radiotherapy practice. Int J
Radiat Oncol Biol Phys 2005;61:507-16.
Vasavada AR, Nihalani BR. Pediatric cataract surgery. Curr Opin
Ophthalmol 2006;17:54-61.
Parsons JT, Bova FJ, Fitzgerald CR, Mendenhall WM, Million RR.
Radiation retinopathy after external-beam irradiation: Analysis of
time-dose factors. Int J Radiat Oncol Biol Phys 1994;30:765-73.
Source of Support: Nil, Conflict of Interest: None declared.

Author Help: Reference checking facility

The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks
the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal.
The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a
single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference.
Example of a correct style

Sheahan P, Oleary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy.
Otolaryngol Head Neck Surg 2002;127:294-8.
Only the references from journals indexed in PubMed will be checked.
Enter each reference in new line, without a serial number.
Add up to a maximum of 15 references at a time.
If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct
article in PubMed will be given.
If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to
possible articles in PubMed will be given.
158

J Cancer Res Ther - April-June 2010 - Volume 6 - Issue 2