Peter Hirschi

Clinical Oncology
CNS Project
1. If the patient were positioned prone, a board is usually placed under the chest to build up
the lower torso. What does this accomplish?
By placing a board or sponge under the chest of the patient in the prone position, the patients
posterior aspect has a more uniform SSD along the length of his/her body. This helps create more
uniform isodose distributions down the length of the patients spine.

2. How do you match the spine and head ports for a craniospinal setup? Formulas used to
determine any angles and give an example of using the formulas. Provide a diagram or
drawing.
When treating a cranial spinal field, the entire brain and spine are included. The whole brain is
treated with lateral fields while the spine is treated with PA fields. The lateral fields of the whole
brain allow the collimator to be turned in order to match the divergence of the superior PA beam.
To find the divergence of the superior PA beam, you simply take the treatment length of the
superior jaw and divide it by SAD, then take the inverse tangent.
Treatment Jaw length 15/100 sad = 0.15

0.15Tan-1= 8.53 degrees.

So the divergence of the upper beam is 8.53. The collimator for the lateral brain field is then
rotated to 8.5 to match the divergence of the PA beam creating consistent coverage without any
overlap or gap between the fields.

Pg 352 Bentel
In order to account for the caudal beam divergence of the lateral whole brain fields, the couch is
rotated until the lateral beams divergences runs parallel with the Superior aspect of the PA spine
field, crossing the patients neck in a straight line. To find the couch rotation, the same formula
mentioned above can be used. The treatment length of the lateral brains inferior jaw is divided by
the SAD then the inverse tan of jaw length/SAD is found.

(Washington)
Most adult patients being treated with cranial spinal fields require two separate PA spine fields
due to the long length of the spine. In order to abut the two PA spine fields correctly, divergence
of the beam is taken into account otherwise a very cold spot or very hot spot will occur within
the spine. In order to correct for beam divergence at my clinical site we do not use the gap calc
formula. Rather we find the divergence angle of both PA beams and turn the gantry to match the
divergence. This helps ensure full dosimetric coverage of the spine by eliminating the cold and
hot spots associated with the gap calculation technique.
We match the divergence by using the following formula.

Then we change the gantry angle to match divergence of both beams.

Notice on diagram 2, the inferior PA field is angled causing substantial difference of SSDs along
the spine. At the beam matching point, the SSD is much shorter than the inferior aspect of the
beam at the sacrum. Due to the inverse square law, the superior part of the field will be much
hotter than the inferior part of the field. We use fluencies? to make the beam more homogenous
down the length of the field. This technique has advantages over the gap calc method, but it is
worth noting that this technique is more difficult to implement in the treatment room. Great care
must be taken to avoid making a mistake.
3. If you wanted to remove any divergence from the eyes in the cranial port, how would this
be accomplished? Why would you do this? Show a formula and how it can be used. Show
diagram.
To minimize dose to the lens of the eyes while treating with lateral whole brain fields, the gantry
can be rotated so that the divergence of the beam runs parallel with both eyes. The divergence
formula used to calculate the collimator angle for the lateral whole brain fields can also be
utilized to keep divergence from entering the eyes. To do this, the distance from the CAX of the

beam to the eyes is noted. Then the distance is divided by the SAD. Then the inverse tangent of
that number is found.
Example: 5cm difference from CAX? and eyes= 5/100=.05 and then .0.5TAN-1 = 2.86 degrees.
The angle of the gantry should be slightly RAO and LAO. Therapist should be aware that LPO
and RPO fields will increase dose to the eyes.

4. In your own words describe the setup for a CSI adult patient (specify prone or supine)
where 2 spine ports must be matched that extend to the bottom of S-2.
At my facility, we treat cranial spinal patients in the supine position. This allows us to securely
immobilize their head with a head rest and aquaplast mask. It also helps keep the posterior aspect
of the patient flat and more uniform along the length of their spine. Patients are also more
comfortable in the supine position which helps keep them from moving.
5. State what is needed during the CT simulation.
For CT simulation the following items are needed: S-frame, headrest, aquaplast, indexed knee
sponge, and BB markers.
We place BB markers on the patients mask and place tattoo reference marks on their anterior
chest, anterior lower abdomen, and two lateral tattoos for rotation. All lateral marks are placed on
the same plane Y plane (post/ant). Arms are placed on the side of patient. Knee sponge should
be indexed to table to ensure knee position is reproducible. Knee position has great effect on the
position of the lumbar spine.

6. For treatment planning, approximately where will you place the isocenter for each field
for the patient above, will the isocenters be moved? Why or why not? What are the
approximate field borders?
Three isocenters:
Lateral Brain: Isocenter is placed slightly posterior in the brain so the same depth can be used for
all three isocenters. Sup/Inf the isocenter is placed halfway between the top of the head and the
vertebral interspace? of C4-C5. The isocenter of the brain is never moved throughout treatment.
Because the other two fields will be moved, its easier to keep the isocenter of the brain the same.
Thoracic PA spine: Inferior border around T10 and superior border at vertebral interspace of c4c5. The isocenter is placed midway between superior and inferior borders. The isocenter will be
moved twice during the 20 fraction treatment in order to feather the field junctions to help
minimize hot and cold spots at the field junctions.
Lumbar PA spine: Superior border is around T10 and the inferior border is the L5-S1 vertebral
space. The isocenter is placed midway between the two field borders. Care is taken to ensure that
the jaws of both PA spine fields have room to be expanded in order to enlarge the field when the
isocenters are moved. The isocenter will also be moved twice during the 20 fraction treatment.
Because the L-spine PA field has the gantry angled to match the divergence of the other PA field
the isocenter must be moved when the isocenter of the T-spine PA field is moved in order to keep
the divergent match line the same.
7. Give a detailed description for treatment (feathering the gaps) for the patient. How will
the fields be feathered during treatment?
Feathering helps ensure that hot/cold spots do not occur at field junctions. This is done by
moving the junctions twice in order to spread out possible cold/hot spots at field junctions. For
cranial spinal treatments we move the field junctions twice at 1cm inferior each time?. We do
this by adding 1cm to the inferior border of the lateral brain fields. The collimator angle is kept
the same to match the divergence of the PA spine field. The T-spine fields isocenter is moved
1cm inferior. The superior border doesnt need to change because the lateral brain is now
covering what the T-spine PA field has excluded with the 1 cm shift. The L-spine PA fields
isocenter is also moved inferiorly 1cm. The superior border does not need to be adjusted because

the T-spine/L-spine junction also moved 1cm. The inferior field jaw needs to be shortened 1cm
to keep the inferior field border at the L5-S1 interspace. This 1cm shift is done twice, once on
fraction 8, and again on fraction 15.

References
Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis,
MO: Mosby-Elsevier;2010.
Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996: