TamaraEng

June26,2016
CraniospinalIrradiation(CSI)Assignment
Patientpositionisextremelyimportant.Pretendyouarethedosimetristcalledtogointo
thesimulatorandassistwiththeCSIsetup.Beveryspecificanddescriptiveinyour
answers.
1.Isthepatientachildoranadult?Whatmightyouhavetododifferentlybasedonthe
sizeandageofyourpatient?(5points)
Boththeageandsizeofthepatientcandeterminehowthepatientwillbetreated.Childrenoften
requirespecialconsiderations.Childrenaremuchmorelikelytomoveunintentionally.
Furthermore,iftheyareuncomfortablethelikelihoodthattheywillmoveisincreased.Thus,it
isimperativethatimmobilizationdevicesarebothcomfortableandeffective.Youngerchildren
usuallyneedtobeunderanesthesia.Thisposesachallengebecausetheanesthesiologistmust
haveaccesstothechildsmouthandnose.Therefore,mostsmallerchildrenaretreatedinan
invertedfullbodyplastercastwithafacialareaopening.Thecastincludestheanteriorhalfof
thebodyextendingfromthefacetothekneesexcludingtheeyes,nose,andmouth.Thecast
containssupportsattheforehead,chest,andthighsinamannersuchthatwhenthechildis
positionedpronehisorherdorsalsurfaceisashorizontalaspossible.1Theadultproneface
holderconsistsofachinholder,whichpushesthemandibleintothetreatmentfield.Thechin
holderispaddedandhasasolidplasticstopatthebottom.Thereisalsoaforeheadholder,
whichiscushionedbutdoesnotsecureinthesameplace.Intermsofthespinalfields,adults
generallyaretreatedwith2spinalfields,1superiorfieldand1inferiorfield.Conversely,
childrenareusuallytreatedwithonly1fieldwhichcancovertheentirespinalsubarachnoid
spaceutilizinganextendedsourcetosurfacedistance(SSD),forexample120cm.2

2.Howwillthepatientbepositioned?Supineorprone?Afterdescribingwhichorientation,
includeallthedevicesused.Describeheadposition,chinposition,armposition,howwill
youassureyourpatientisaligned?Listeverythingthatyouwouldcheckbeforeleavingthe
CT.Sometimesaboardisplacedunderthelowertorso,describeifthiswillbeusedfor
yourpatientandwhyorwhynot?(25points)
Therearepositiveandnegativeaspectstoboththeproneandsupinesetups.HereIwilllookat
positioninganadultpatientintheproneposition.Therearemanydisadvantagestotheprone
position.First,forexample,thereisvariabilityinthedailysetup,whichrequiresmoretimeand
clinicaljudgment.Also,themaskisplacedonthebackofthepatientshead.Itisquitelabor
intensivetoflippatientsintotheproneposition.Itisalsomoredifficulttoassessthenoseand
mouthforpatientsthatrequireventilationoranesthesia.Thepronepositionrequiresaspecific
fixationdevice.Lastly,fieldsmustbematchedtopreventgapsandoverlaps.However,the

mainadvantageofthepronepositionisthattheentranceofalltreatmentfieldscanbedirectly
visualizedonthepatient.3
Forthetreatmentsimulation,thepatientispositionedproneinatotalplastershelloranAlpha
Cradle.TheAlphaCradleismoreuserfriendlyasitrequiresamuchshorteramountoftimeto
harden.TheAlphaCradleismadeofaStyrofoamform,whichfitstheshapeofthepatients
headandtorso.Itiscoveredbyapolyvinylsheet,whichistapedaroundtheperipheryofthe
headsupport.Thisformsachannelaroundthepatientsface.Thefoamingagentsaremixed
andpreparedthenpouredintotheform.Thepatientliesdownflatinthepronepositionwith
armsdownathisorhersidesonthepolyvinylsheetandshouldersdepressed.Aspongemaybe
placedunderthepatientsanklesforcomfort.Thepatientshouldbepositionedasstraightas
possiblewiththelasers.Ittakesafewminutesforthefoamtoexpandandfillthespacebetween
thepatientandtheStyrofoamformwalls.Thepatientsheadrestsonthechannelwherethe
foamwaspoured.Thefoamexpandsaroundthepatientsface.Anareaisleftopenforthe
patientseyes,nose,andmouth.ThepolyvinylsheetcoveringthebodypartoftheAlphaCradle
ispulledupbetweenthepatientstorsoandarms,thusallowingthefoamtoriseandformamold
ofthearmsandtorso.Somepatientsbodyhabitusrequiresthetorsotobeelevatedinorderto
placethetorsoandheadinahorizontallineorinthesameplane.Thisisaccomplishedby
placingapieceofStyrofoamofagiventhickness(oraboardunderthepatientsbody)inthe
bodypartoftheAlphaCradlebeforepouringthefoamingagents.Oncethefoamishardened,
thetherapistshavethepatientlifthisorherheadandtheyplaceasoftenedthermoplasticsheet
acrosstheheadsupport.Thenthepatientisinstructedtoplacehisorherheadbackintoposition.
Atthistimeatherapistsupportsthepatientsheadsothatitisstraightandthechinisextendedin
ordertopreventtheposteriorspinalfieldfromexitingthroughtheoralcavityormandible.
However,careshouldbetakentonothyperextendtheneck,whichwouldleadtoexcessive
posteriorneckcreasingandthuscompromisedoseuniformityforthespinalfield.Next,the
thermoplasticsheetiscontouredtothepatientsfacialprominencestoformatightlyfitting
mask.Also,duringthesimulation,thetherapistscreateopeningsintheStyrofoamand
thermoplasticsheetsothatthepatientseyesmaybevisualized.Theyplaceradiopaquemakers
onthelateralcanthusofeacheye.Thesagittallaseralignmentlineshouldbemarkedonthe
immobilizationdevicebothcephaladofthepatientsheadandbetweenhisorherlegs.The
positionofthetreatmentfieldrelativetotheeyesshouldbecheckeddaily.Thepatientis
positionedinthispronepositiondailyfortreatment.ThetherapistcreatesaCTscanwhich
capturesthetopofthepatientsheaddownthroughhisorherpelvis.Duringthesimulation,the
brainfieldisocenterismarked,aswellas,straighteninglinesalongthespinalaxis.
ThefollowingquestionsaregenericCSIquestions:
1.Howisthespinematchedtotheheadportsforacraniospinalsetup?BESPECIFIC.
Givemetheformulasusedtodetermineanyanglesandgiveanexampleofusingthe
formula(s).Provideadiagramordrawing.
Craniospinalirradiationiscomplexasitutilizesseveraladjacentfields.Usually,thebrainsetup
consistsoflateralopposedfieldsandthespinalaxissetupconsistsof1or2posteriorfields

(giventhatthepatientisprone),dependingonthelengthofthepatientsspine.Matchingthe
inferiorborderofthelateralcranialfieldswithsuperiorborderofthemostcephaladposterior
field(oronlyposteriorfield,ifthereisonly1)iscomplicatedbecausethecephaladaspectofthe
posteriorspinefielddivergescephaladandthecaudalaspectofthebrainfieldsdivergecaudal
andposteriorly.Thus,itisnecessarytofirstrotatethecollimatorofbothlateralfieldsinsucha
waythatitsinferiorborderisparalleltothedivergenceofthesuperioraspectofthespinefield.
Thiskeepsthesuperioraspectofthespinefieldfromexitingintotheanteriorsuperioraspectof
thebrainfields.Inotherwords,theanteriorportionofthelateralbrainfieldsismovedcephalad
andoutofthepathofthespinefield.Theformulatocalculatethenecessarycollimatorangleis
givenby:
coll=arctan

( 12L 11
SSD )

Reprinted from Radiation Therapy Planning. 2nd ed., 19951

Reprinted from Managementofmedulloblastomas.4

Second,topreventoverlapasaresultofinferiordivergenceofthecaudalborderofthelateral
fieldsintothecephaladaspectoftheposteriorspinalfield,acouchrotationisneeded.
Specifically,thefootofthecouchisrotatedtowardthecollimatorinordertomakethecaudal
fieldmarginsofthetwofieldsbecomeparallelandcrossthepatientsneckinastraightline
perpendiculartothepatientssagittalaxis.Thenumberofdegreesthecouchisrotateddepends
onthelengthofthelateralcranialfieldsinthedirectionofthegap,aswellas,thedistanceat
whichthefieldsizeisdefined.Theformulatocalculatetheneededcouchrotationisgivenby:
1
21
couch=arctan L
2
SAD

Reprinted from Radiation Therapy Planning. 2nd ed., 19951

Reprinted from Managementofmedulloblastomas.4

Thefollowingexampledemonstratestheseconcepts.

Example:ForaCSItreatmentplan,thepatientispositionedprone.Thetotallengthoftheupper
spinefieldis28cmandtheSSDis100cm.Thelengthofthebrainfieldis12cmat100SAD.
Findthecollimatorrotationandcouchrotationneededtopreventdivergence.
Tofindthecollimatorangleforthebrainfield,usethecollimatorangleformula:
coll=arctan

( 12L 11
SSD )

L1isthetotallengthoftheupperspinefield,giventhatthejawsaresymmetric.Inthecasethat
theyarenotsymmetric,thewouldberemovedandthelengthofthesinglejawnearesttothe
brainfieldwouldbeusedinplaceofL1).TheSSDisthesourcetoskindistanceofthesame
field.Thus,
1
281
2
coll=arctan
=arctan ( 0.14 )=8.0
100
Therefore,thecollimatormustberotated8.0degreesfromzerotomatchthedivergenceofthe
spinefield.Sincethetwolateralfieldsareopposed,theleftlateralcollimatorwouldbe352.

Tosolveforthecouchrotation,usethecouchangleformula:
couch=arctan

21
( 12L SAD
)

Inthisformula,L2isthelengthofthebrainfieldasmeasuredontheaxis,whichintersectsthe
spinefieldandthesourcetoaxisdistance(SAD).

1
121
2
couch=arctan
= arctan ( 0.07 ) =3.4
100

Thus,thecouchmustberotated3.4towardthegantrypreventoverlapfortheleftlateralfield
Fortherightlateralfieldthecouchwouldberotatedto363.5.
2.Ifyouwantedtoremoveanydivergencefromtheeyesinthecranialport,howwouldthis
beaccomplished?Whywouldyoudothis?Showaformulaandhowitcanbeused.Provide
adiagramordrawing.
Itischallengingtotreattheentirebrainwithoutdivergenceintothecontralateraleye.However,
itisimportanttoprotecttheeyes.Specifically,thelensoftheeyehasatissuetoleranceof10Gy
foraslittleavolumeas1/3ofthelens.Exceedingthisnormaltissuetolerancecouldresultin

damagetotheeye,forexamplethepatientcoulddevelopacataract.5Duringthesimulation,lead
markersareputonthelateralcanthusofbotheyestoaidthedosimetristindesigningthebeam
shapingblocksinamannertoblocktheanterioraspectoftheeyes.1Inordertoremove
divergencefromtheeyesinthecranialportthegantrymustberotatedtowardtheanterior
surfaceofthepatient.Thiscreatesastraightlinebehindthepatientseyes.Solvingthe
followingequationforthetagantrygivesthenumberofdegreestobeaddedtothegantryangle
tocompensateforthebeamdivergence.Listhelengthofthefield,whichassumesa
symmetricalfield.Thus,xLrepresentsthedistancefromtheisocentertothecanthus.SADis
thesourcetoaxisdistance.6Theanglecalculatedcanbeverifiedbyrotatingthegantryuntilthe
canthusmarkersaresuperimposed,thusdisplayingthecorrectangle.
gantry=arctan

11
( 12L SAD
)

Reprinted from Radiation Therapy Planning. 2nd ed., 19951

Example: A patient will receive CSI treatment. The physician states that he or she would like no
divergence to travel through the eyes. The machine SAD is 100 cm and the length of the Y axis
is 16 cm. What gantry angle is needed to remove the divergence from the eyes?
.
1
161
2
gantry=arctan
=arctan ( 0.08 )=4.6
100

With the patient in the prone position, the right lateral field is at 90 . Thus, to remove the
divergence the gantry should be rotated to 94.5. The left lateral field is at 270. To move the
gantry anterior in relation to the patient, the gantry should be rotated to 265.4. These gantry
positions will place the divergence of both fields in a line parallel and behind the eyes.

3.Fortreatmentplanning,approximatelywherewillyouplacetheisocenterforeachfield
forthepatientabove,willtheisocentersbemoved?Whyorwhynot?Whatarethe
approximatefieldborders?
Ifpossible,allisocentersshouldbeplacedonthesamelateralcouchpositiontominimizeor
eliminatingtheneedforshifts.Thebrainisocenteriscreatedinthesimulationtakinginto
accountthemaximumdistancethemultileafcollimators(MLCs)cantravel.Allotherisocenters,
1or2spinalfieldisocenters,willbeatthesamelateralpositionasthebrainisocenter.The
spinalisocenterswillbeplacedinthemiddleofthegivenspinalfield.Theisocenterswillnot
moveunlessthephysiciandeemsshiftsarenecessaryafterreviewingtheportsonthefirstdayof
treatment.CSItreatmentsareveryinvolved;nothavingshiftshelpstodecreasethelikelihoodof
errors.3
Theapproximatefieldbordersaredemonstratedintheimagebelow.Thecranialfieldsaretwo
parallelopposedlateralwholebrainorhelmetfieldswithblocking,representedbythestripes.
Thecranialfieldscentralrayisstationary,whichwillallowthemovingjunctionof
approximately1cmforevery9Gydeliveredtothepatient.Theinferiorcranialfieldborder
shouldtraversethelowestpossiblecervicalvertebrawhileavoidingtraversingtheipsilateral
shoulder.Theinferiorcranialfieldborderabutsthesuperiorspinalfieldborder.Inordertoabut
thesefields,thecollimatorofthecranialfieldsshouldberotatedby9to11degreesagainstthe
transverseplanethroughthepatientsbody.Thecranialanteriorblockbordershouldbe
approximately0.5cminferiortotheprojectionofthecribiformplate,3cmposteriortothe
ipsilateraleyelidsurface,and1cminferiortothemiddlecranialfossafloor.Ingeneral,the
spinalfieldswillabutthecranialfieldswitha0.5cmskingap.Thesuperiorspinalfieldhasan
initialsuperioredgegenerallyimmediatelyabovetheleveloftheshoulders.Thesuperiorspinal
fieldshouldhaveastationarycentralrayinatransverseplaneofthebody.Thisallowsthebest
reproducibilityofsimultaneousmovementofthesuperior,aswellas,theinferiorjunctions.The
superiorborderistypicallymovedcraniallybyapproximately1cmafterevery9Gy.The
inferiorborderofthewholebrainfieldsshouldmovecraniallyby1cmaswell.Theinferior
borderofthesuperiorspinalfieldwillhaveaskingapwiththesuperiorborderoftheinferior
spinalfield,thuspreventingtheedgesofthesefieldsfromoverlappingwithinthespinalcord.
Optimally,toavoidjunctionsovertheinferiorpartofthespinalcord,thesuperiorspinalfield
shouldextendcaudallytotheL1L2interspace.Theinferiorspinalfieldhasastationary
inferiorborder,whichislocatedatapproximatelythelevelofS3.Thisallowsforcoverageof
thethecalsac,whichusuallyendsatS2,withamarginofabout2cm.Assuming,symmetrical
jaws,thecentralray,aswellas,thesuperiorbordermoveswithstepjunctions.2

Reprinted from RadiationOncologyManagementDecisions, 20022

4.Iftwospineportsmustbematchedduetothelengthofthespine,tellmehowyouwould
accomplishthisandhowwouldyouassurethatthereisnooverlap?
Ifthelengthofthespinerequirestheuseoftwospineports,theyneedtobematched.Thisis
typicallydonebycalculatingtheseparationbetweenthetwospinefieldsontheskinsurface.1
Theinferiorborderofthesuperiorspinalfieldwillhaveaskingapwiththesuperiorborderof
theinferiorspinalfield.Thisgapwillassuretheedgesofthetwospinalfieldswillnotoverlap
withinthespinalcord.Inotherwords,thegapshouldbecalculatedinsuchamannerthatthe
fieldedgesintersectatanteriorspinalcordandposteriorvertebralbody.2Definingtheexact
depthofthespinalcordalongitsaxiscanbechallenging.Duringthesimulation,withthepatient
inthetreatmentposition,aradiopaquemarkerisplacedalongtheskinsurfaceoverthespine.
ThenacrosstableradiographiscapturedfromtheCTscanner.Thisimagecanbeenlargedand
utilizedtofindthedepthofthespinalcord,aswellas,thedepthatwhichthetwospinalbeams
shouldconvergewithoutcausinganoverlapinthespinalcanal.Thefollowingformulaisused
todeterminetheneededgapfieldseparationonthesurface.Where,Sisthefieldseparationon
surface;disthedepthofthedosespecification;L1isthelengthofthesuperiorspinalfield;L2is
thelengthoftheinferiorspinalfield;SSD1isthesourcetosurfacedistanceforthesuperior
spinalfield;andSSD2isthesourcetosurfacedistancefortheinferiorspinalfield.
S= [L1/2 ( d / SSD1)]

+ L2/2 ( d / SSD2)]

Reprinted from Radiation Therapy Planning. 2nd ed., 19951

Example:Findthenecessaryfieldseparationonsurfacebetweenasuperiorspinalfieldandan
inferiorspinalfieldtoassurethereisnooverlap.Thesuperiorspinalfieldhasalengthof30cm,
theinferiorspinalfieldhasalengthof24cm,theSSDofboththesuperiorspinalfieldandthe
inferiorspinalfieldis100cm,andthedepthwherethefieldswillbematchedis5.5cm.
S= [L1/2 ( d / SSD1)]

+ L2/2 ( d / SSD2)]

S= [30/2 ( 5.5/100)] + 24/2 ( 5.5/100)] = 0.825 + 0.66 = 1.485 cm

S = 1.5 cm skin gap
Thus, there should be a 1.5 cm gap on the surface between the superior spine field and the
inferior spine field.

5.Iffeatheringthegapisrequiredbetween2fields,whatdoesthatmean?Canyou
describehowthiscouldbeaccomplished?(providedetailsasifyouhadtoexplainexactly
whatwillbedonetotheradiationtherapistwhoistreatingthepatient)
Featheringisthemovementofthejunctionoftwofieldsacrossthetreatmentlength.4Inother
words,featheringisthemigrationofagapbetweentreatmentfieldsthroughoutatreatment
course.Usuallya00.5cmgapisusedbetweenthespinalfieldsandthelateralbrainfields.7
Forexample,thisjunction,aswellas,theonebetweenthe2spinefieldsaremovedsuperiorly
andinferiorly0.5cm1cmeitherdailyorweeklydependingontheclinicsprotocol.One
purposeoffeatheringistopreventexcessivedosegradientsatthefieldjunctions.Another
benefitoffeatheringistheeliminationofpotentialtooverdosethespinalcordoranarea
receivingalowdoseallowingtumorcellstosurvive.Overdosesarecausedbyoverlap,while
underdosesarearesultofagap.Featheringallowsalongersegmentofthespinalcordtobe
exposedtoamorehomogeneousdose.Furthermore,featheringcanreducethenegativeimpact
ofsetuperrors.4

Thetherapistswillpositionthepatientinthesameexactsetupthatwasestablishedinthe
simulation.First,thetherapistswillsetupthe2lateralbrainfieldswithbothcouchrotationand
collimatorrotation.Afterportverification,theinferiorborderofthebrainfieldsismarkedon
thepatientsmaskusingtape.Next,followingthetreatmentplan,thetherapistsperformshifts
fromthebrainisocenterlongitudinally.TheSSDshouldbe100cmattheisocenter.The
superiorborderofthesuperiorspinalfieldismatchedtothemarkthatwasmadeonthetapeof
lateralbrainfield.Again,portfilmsaretakentoconfirmthepatientsetup,aswellas,the
patientsanatomyinthetreatmentarea.Oncethetherapistshaveverifiedthepatientsposition,
theisocenterandinferiorportionofthatfieldaremarked.Thenlongitudinalshiftsareperformed
totheinferiorspinalfieldsisocenter.Again,theSSDshouldbeverifiedas100cm.The
therapistsshouldvisualizeagapbetweenthelightfieldoftheinferiorspinalfieldandthe
superiorspinalfieldmark.Thisgapshouldbeequaltotheskingap,whichwascalculated
duringtreatmentplanning.Afterthetherapistsverifypositioningviaportfilms,theisocenter
andsuperiorportionofthefieldaremarkedfordailysetup.Thefrequencyoffeatheringis
dependentonthephysiciansdirective.Thedosimetristplannedthefields,labeledthemas
prime,doubleprime,etc.nexttothegivenfield.Thislabelingsignifiesthefieldsizechangesto
bemadethroughoutthefeatheringprocess.Theincreasingordecreasingoffieldsizeisverified
viapreportfilms.Eachfieldjunctionisadjustedby0.5cm1cmeachstepofthefeathering
process.TheonlyborderthatremainsthesameistheborderatS2.Usually, the superior spine
field will increase by 0.5cm1cmon each end with the other two fields shortening by 0.5cm
1cmto feather the junction. The isocenters positions do not change throughout the treatment
duration.

References
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LippincottWilliams&Scott;2002.
3.South M. Using Composite Planning and Delivery with Feathered Junctions in Craniospinal,
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Dosimetry Program;2016.
4.Managementofmedulloblastomas.In@SlideShareWebsite.
http://www.slideshare.net/santam/medulloblastomas.AccessedJune18,2016.
5.VannA,LenardsN,WeegeM.BrainandCentralNervousSystemTumors. [SoftChalk]. La
Crosse, WI: UW-L Medical Dosimetry Program;2016.

6.LevittS,PurdyJ,PerezC.TechnicalBasisofRadiationTherapy:PracticalClinical
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