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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
For this specific plan study, I decided to go with the prone position scan as I feel that it is
safer and easier for the patient. This position is more relaxing for the patient, and it enables more
stable markings on the back rather than their front for line up purposes. I’ve only seen a CSI
treatment once in my time and it was scanned and planned prone. After looking online from
other studies, there were several cases where VMAT plans were becoming the go-to for these
types of treatment over using 3D. A study mentioned that the rapid-arc treatments were more
conformal and delivered the treatment in less time over the conventional 3D plans.1

Before I began running and creating the plan, there were some optimization structures
that needed to be created to maximize my plan. After scrolling through the scan, I noticed that
parts of the Optic Nerves were inside the PTV_Brain, this will cause issues as the constraint
sheet wants them to be under 34Gy when we are trying to reach 36Gy to the target. I created a
new PTV_Brain optimizer by cropping it out of the Optic Nerves by 2mm. I then created another
optimizer of the overlap of the PTV_Brain and the Optic Nerves to be able to max just that area
below 36Gy. Beyond this, everything else was fine to begin the treatment planning process.

As big of an area that this is, there needed to be multiple isocenters to be able to cover
this whole area. My thought process for setting this up was to center the first isocenter at the
PTV_Brain, an upper spine iso, and a lower spine iso. Once I had the brain isocenter setup,
whatever the X and Y coordinates were, I kept the same coordinates for the other two isocenters
as this keeps everything in the same plane, of course the Z coordinate was different. To
maximize the coverage and keeping OAR dose down, I proceeded this utilizing a VMAT
treatment technique.

All the fields for this plan were using 6x. For the PTV_Brain setup, I used 2 arcs, the
first field went CCW from 120 to 240 degrees. The collimator angle was 30 degrees with X1
being 6, X2 10, Y1 9, and Y2 14.8. The second field went CW from 240 to 120. The collimator
was at 330 with X1 being 10, X2 6, and Y same as first field. For the Y-axis, I made sure that
there was coverage about the head and went inferiorly to about C2. For the upper spine, 2 arcs
were utilized. The first field went CCW from 100 to 260 degrees. The collimator was at 10
degrees with X1 being 6, X2 10, Y1 15, and Y2 20. The second field went CW from 260 to 110
degrees. The collimator was at 350 degrees with X1 being 10, X2 6, Y1 15, and Y2 20. Lastly,
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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
the lower spine had 2 arcs. The first field went CCW from 100 to 260 degrees. The collimator
was at 10 degrees with X1 being 8, X2 7.3, Y1 15.5, and Y2 17. The last arc went CW from 260
to 100 degrees. The collimator was at 350 with X1 being 8, X2 7.3, Y1 15.5, and Y2 17. Below
you will see the fields and how they looked in the planning software.

As you can see from the images above, there is some overlapping in these fields. A great
feature in the Eclipse system is that it can auto-feather. This will allow for any slight deviation to
not change the dose too much whn it comes to the actual treatment. The brain field went
inferiorly to about C2, the upper spine field went superiorly to about the lower third of the brain
target and inferiorly to about T11, and the lower spine went superiorly to about T8 and inferiorly
0.5cm below the PTV_Spine. I did mostly half arcs on these fields as I did not want to enter the
body from the anterior side. This also helped with the Brain fields as I did not want the fields
going too far around getting more into the Optic Nerves.

During the optimization, I worked on the constraints given from the ProKnow scorecard.
This included the two targets, the optimizer structures I created, Optic Nerves, Kidneys, and lens.
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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
For the two targets, I put 100% volume to reach 36Gy and the optimized target inside the Optic
Nerves to be 33.5Gy. The other OAR were constrained to the recommended values from
ProKnow. Below is an image of what the optimizer looked at.
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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
After the planning was completed and I was satisfied with my outcome, I normalized
based on the volume of the structure. My target was the combination of the PTV_Brain and
PTV_Spine. I set the normalization to be 100% covers 95% of the dose. Below are some images
of the isodose lines and the DVH when this was done.
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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
Once normalized, I ended up with a hot spot of 113.4%. This was located in the brain
near the Optic Nerves. This does make sense because of how hard I was pushing to lower the
dose to them. This is also acceptable for this type of treatment and location. Overall, I did meet
all the minimal requirements of the constraints from the scorecard and almost half of the ideal
targets. The toughest OAR that I dealt with were meeting the Optic Nerves and the kidneys. The
Optic Nerves were difficult since they were near and partly inside the PTV. The kidneys were
difficult as it was hurting coverage to the PTV_Spine trying to lower the mean dose to them. I
had to get a happy medium between those two. Below is my scorecard.

This was a really good case to go over as it allowed me to dabble into multi-isocenter
VMAT techniques. As this was also my first CSI plan, I learned the importance of setup for the
patient and how to maximize doe to the targets and keeping OAR low. Below is my scorecard
from this plan.
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Aaron Ayers
DOS 773-501 Dosimetry Clinical Practicum III
CSI ProKnow Plan Study
Reference

1. Fogliata A, Bergström S, Cafaro I, et al. Cranio-spinal irradiation with volumetric

2011;99(1):79-85. doi:10.1016/j.radonc.2011.01.023