1

Patrick Melby
DOS 531
Craniospinal Irradiation
Craniospinal irradiation (CSI) treatments are most commonly used to treat
medulloblastoma. These treatments require multiple fields because both the brain and the spinal
cord need to be treated. The use of multiple fields and isocenters during CSI treatments make
them difficult and time consuming to set-up and treat. Because of this it important to be able to
accurately and efficiently set-up these patients.
At Gundersen Medical Center, CSI treatments are always done in the supine position.
Supine treatment allow for an easier, less time consuming patient set-up along with creating a
more comfortable position for the patient. The patient's comfort is a high priority at our facility.
The more comfortable the patient is, the easier it will be for them to hold still, which in turn
creates a more accurate treatment. The one disadvantage of supine treatment is the therapist will
not be able to see the junctions between fields on the patients skin. But, as I will explain later,
there are ways to verify the patient's treatment fields are in the correct position.
Although my description will be on an adult, supine CSI treatments, the supine
positioning can also be beneficial for younger children undergoing treatment. To assure the
young children stay still, anesthesia may be used. Prone treatments of patients under anesthesia
creates a extremely difficult set-up, so patients under anesthesia are usually supine. For patients
that are not under anesthesia in the prone position, a board or support may be placed under the
patient's chest and lower torso for the patients comfort and to help straighten the patients spine.
Continuing on with our adult patient set-up, as I have stated, they will be supine, formed
into a vac-lok bag, with their arms down and chin up. To assure that their head doesn't move out
of position, a facemask will be placed over their head and shoulders, securing the chin in its
position. After checking that the patient was properly positioned, I would make sure that the
patient was straight on the table by using the laser system used during simulation. Some
institutions may place a board underneath the patient's lower torso to try making the spine
straighter for treatment, but Gundersen does not do this. If the spine is curved slightly, and hot
or cold spots are created, field segmentations will be used to make the dose conformal. Other
things I would check before leaving the room, is that the bee-bees were properly placed and that
the patient was comfortable and properly informed on how the simulation would work. After
taking the computer tomography (CT) scan, I would visually look at the CT images to confirm
that the patient was straight on the table, and that no portions of the patient were being clipped.

Next, onto the planning process for a CSI treatment. These treatments involve two lateral
beams that irradiate the brain with one or two additional fields for the spinal cord depending on
how tall the patient is. This is shown in figure 1.

Figure 1. Three different treatment fields used in CSI treatments.1

Without correcting for the divergence of the separate beams, hot spots would be created.
These hotspots would be within the spinal cord, which with a high enough dose, could paralyze
the patient. To account for this, a series of calculations can be made to figure out the couch and
collimator rotation needed to eliminate any overlap of the beams. First we will start with
rotating the collimator. Rotating the collimator takes into account the divergence from the upper
spinal cord field as shown in Figure 2.

Figure 2. Collimator rotation used to account for spinal cord field.1

This shift rotation can be calculated be using the length (L) and the surface to skin
distance (SSD) of the spinal field. The formula along with an example are as follows:1

1
2
1
)
SSD
Collimator Angle=tan1
( L

Ex. The upper spinal cord field for the CSI treatment is 36cm long with an SSD of 90cm. What
collimator angle is required?
1
2
1
( 36 cm
)
90 cm
Collimator Angle=tan1
Collimator Angle=tan1(0.2)
Collimator Angle=11.3 Degrees

As for the couch rotation, this accounts for the divergence of the brain fields. This can be
shown in Figure 3.

Figure 3. Couch rotation used to account for the divergence of the brain fields.1
Similarly to the collimator rotations, this rotation can be calculated be using the length
and the surface to axis distance (SAD) of the brain fields. The formula along with an example
are as follows:1

1
2
1
)
SAD
Couc h Angle=tan 1
( L

Ex. In a CSI treatment, the brain has a length of 20cm with an SAD of 100cm. What couch
angle is required to line up the divergence?

1
2
1
)
100 cm
Couc h Angle=tan 1
( 20 cm

0.1
()
Couc h Angle=tan 1
Couc h Angle=5.7 Degrees

There are a few different methods used for CSI. In the method that I just displayed, the
couch and collimator rotations allowed for the divergence of each of the beam to match
eliminating large hot or cold spots within the plan. One drawback of this method is that since
you are already rotating the couch to account for divergence, you are not able to use a couch
rotation to try lining up the eyes to the divergence. This can cause the physician to choose
whether they want to spare the lens of the contralateral eye and miss brain tissue or treat all the
brain tissue and the lens possibly causing cataracts.2 Using a different technique to
accommodate for the eye divergence would require the gap between the brain and spinal fields to
be increased. This would allow for the couch rotation to line up the lens of the eye (Figure 4).

Figure 4. Demonstrates the divergence to the eyes with and without a couch rotation.2
For these set-ups, it is important for the isocenter to be on the same axial plane as the
eyes If this was a concern of the physician, the couch rotation can be determined by the
following equation.3

Distance
Isocenter
t h e lens

1
Couc h Angle=tan ( SAD )

Ex. If the distance from isocenter to the lens is 10cm at 100 SAD, what couch rotation will be
required to match divergence in the eyes
10 cm
Couc h Angle=tan 1
100 cm
Couc h Angle=5.7 Degrees
Once these shifts are determine, each of the fields can be defined. For the brain fields,
MLC's were placed similarly to that of a whole brain treatment, with extra portions of the
brainstem being treated. The MLC's would cover the lens, oral cavity, and throat while staying 1
cm away from the brain. The isocenter is placed centrally in the brain to allow for the MLC's to
have a maximum range of travel during segmentation. The isocenter of the lower spinal fields
are then determined from the brain isocenter. The only direction that will changed is the z
direction. Otherwise, both the x and y coordinates will stay the same. The less shifts between
fields the less chance for additional errors to occur.
The upper spinal cord field covers the cervicothoracic spine. This field should cover the
cord with a 1cm margin outside of the pedicles. If the patient is small, like a child, then only one
spinal field may be needed. Otherwise, an additional spinal field will also be needed to cover the
lumbrosacral spine. To again account for the divergences of the two fields an additional
calculation needs to be made. This calculation determines the skin gap needed to ensure that the
beams will not cross each other within the spinal cord. The skin gap is calculated using the SSD
and length of each beam along with the depth which they are prescribed to. A diagram is shown
in figure 5 to help visualize this calculation. Since the patient is supine, it will not be possible to
visualize the gap. So to be confident that we are treating the correct areas, portal images are
taken for each field.

Figure 5. Visualization of the skin gap equation.

This gap can be determined by the following equation:1
L1
d
L2
d
S=S 1+ S 2=

2 SSD 1
2 SSD 2

][

Because of this gap, along with the earlier gaps created between the brain and spinal
fields, there will be cold spots within the spinal cord that will not be receiving the prescribed
dose. To try minimizing this cold area, a technique will be used called feathering the junction.
Gundersen does this by creating 3 separate plans. The first plan is the original plan, the second
plan is the same except the jaws that determine the field edge are moved 1 cm superior. The
third plan is then opposite, and the jaws are moved 1 cm inferior from the original plan. This
helps to minimize the effects of those cold spots throughout the spine. This can be seen in figure
6. Although a diagram of the brain field is not shown in figure 6, the junction between the brain
fields and the spinal cord field is also feathered.

Figure 6. Diagram of feathering the junction

This description of the a CSI treatment shows how intricate that treatments are. Because
of this, it is important to take additional time to properly learn how this process works. Extra
time and practice on difficult set-ups will help to ensure that when a patient needs this treatment
it will run accurately and efficiently.

References
1.Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2014.
2. Athiyaman H, Mayilvaganan A, Singh D. A simple planning technique of craniospinal
irradiation in the eclipse treatment planning system. J Med Phys. 2014;39(4):251.
doi:10.4103/0971-6203.144495.
3. Halperin E, Perez C, Brady L. Perez And Brady's Principles And Practice Of Radiation
Oncology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008.