CSI

1. Dr. Abani Kanta Nanda
3rd Year PG Student
AHRCC Cuttack

2.  Craniospinal irradiation (CSI) is a technique
used in radiation therapy to deliver a
prescribed amount of radiation to the entire
cranial-spinal axis to achieve curative
measures in the treatment of intracranial
tumors.
 Craniospinal Irradiation – Treats anywhere
CSF flows – Treatment fields typically include
the brain to the thecal sac

5. The concept of CSI was advanced by Dr Edith Paterson
(wife of Ralston Paterson).
Before this the patients of Medulloblastomas were
treated with posterior fossa or whole brain radiation
She advocated the treatment of
the entire neuraxis – bringing
the concept of CSI
Paterson and Farr reported that
with the use of cranio-spinal
irradiation in 27 patient resulted
in a 3 yr survival of 65% (Acta
Radiologica – 1953)

7.  Medulloblastoma
 Pinealoblastoma
 Ependymoblastoma
 Intracranial Germ cell tumor(germinoma)
 Leukemia/lymphoma(with CNS axis mets)
 Supratentorial PNET

8. Tumours in proximity of CSF drainage
pathways are prone for CSF spread

9.  Medulloblastoma forms the most common
indication for CSI
 In medulloblastoma , CSF Dissemination is
known in 20 - 30 % of cases, producing a risk of
metastases along the neuraxis.
 Posterior fossa, spinal cord, ventricular walls &
supratentorial region including the cribriform
plate form the main sites of relapse
 Being a radiosensitive tumour, RT is curative in
upto 70 % of average risk patients

10.  Patient positioning and immobilization difficult,
especially in paediatric cases (may require anaesthesia).
 Large, irregular target volume.
 Critical structures, with special importance to paediatric
cases, who are potential long term survivors.
 Problems of matching junctions between the divergent
brain and spinal cord fields.

11.  Proper immobilisation
 Dose homogeneity in the planning target volume
 Reducing the dose to organs at risk.
‣Evaluating the integral dose (ID)
received by normal tissue.
‣Reduce the planning time and
waiting time for patients to start
their radiotherapy course.

12.  • Phase I : Craniospinal radiotherapy (two
parallel opposed lateral cranial fields
orthogonally matched with the posterior
spinal field to cover the entire length of the
spinal cord)
 • Phase II : Posterior fossa boost (whole
posterior fossa irradiation or conformal boost
to tumour bed)

13. CSI (Phase I)
 30 - 36 Gy in 18 - 21 fr over 4 weeks to the cranium @ 1.5- 1.8
Gy/fr
(36 Gy in 20# over 4 weeks to the cranium @ 1.8 Gy per #)
 30 - 36 Gy in 18 - 21 fr over 4 weeks to the spine @ 1.5 -1.8
Gy/fr
(36 Gy in 20# over 4 weeks to the spine @ 1.8 Gy per #)
Posterior fossa boost (Phase II)
 18-20 Gy in 10-11 fr over 2 weeks to the posterior fossa
(18 Gy in 10# over 2 weeks to the posterior fossa @ 1.8Gy/#)

14.  The North American intergroup study (CCG-923/POG#8631)-
The use of reduced-dose CSI (23.4 Gy) alone (without
chemotherapy) resulted in a significantly increased risk of
isolated neuraxis failure and an event-free survival at 5 and 8
years of only 52%.(standard risk meduloblastoma)
 CCG pilot study -reduced-dose CSI(23.4 Gy in combination
with weekly vincristine) followed by a boost to the posterior fossa
to a total dose of 55.8 Gy, followed by adjuvant systemic
chemotherapy consisting of vincristine 1.5 mg/m2,
CCNU(Lomustin) 75 mg/m2, and cisplatinum 75 mg/m2).
Progression-free survival was 79% at 5 years.
perez

15.  CCG/POG phase III randomized study (A9961) the
previous regimen was compared to a regimen in which the
CCNU was replaced by cyclophosphamide.
 Event free survival at 4 years was approximately 85% in
both arms.
 Such an approach is now considered to be the standard of
care for children with standard-risk medulloblastoma in
North America.

perez

16.  SFOP pilot study- tested HFRT to a CSI dose of 36 Gy
without chemotherapy, early toxicity was reduced and
progression-free survival at 3 years was 81%.
(Perez)
 HIT-SIOP-PNET4 study- was to compare two radiotherapy
protocols, Standard RT and HFRT. It was hypothesised that
the HFRT regimen used would be superior for survival
without causing more late effects. With a median follow up
time of 7.8 years, the estimated OS at 10 years, remains
not significantly different in the two treatment arms.
(csi-36 Gy/36#/48 days, 1 Gy BID, 8 hrs apart
Tumor Boost: 32 Gy/32#/2.5 wks, 1 Gy BID, 6 hrs apart, 5
days/wk) (2016)

17.  • Pituitary
 • Eyes / Lens
 • Cochlea / Inner ear
 • Parotid
 • Oral cavity
 • Mandible
 • Thyroid
 • Larynx
• Heart
• Lungs
• Oesophagus
• Liver
• Kidneys
• Gonads (Testes / Ovaries)
• Breasts
• Whole Pelvis( marrow)

18.  Detailed history & operative notes.
 General physical & complete neurologic examination
(ophthalmoscopy included)
 Gadolinium enhanced pre-op MRI of the brain & spine.
 Immediate post-op MRI brain for residual disease status.
 Post-op MRI of the spine (if pre-op scans not done).
 CSF cytology
 Anesthetic evaluation before RT .

19. Target Volume:-
 Entire brain and its meningeal coverings with the CSF
 Spinal cord and the leptomeninges with CSF
 Posterior fossa – boost
Energy:-
 4-6 MV linac or Co60
Portals:-
 Whole Brain: Two parallel opposed lateral field.
 Spine: Direct Posterior field
Scheduling of radiotherapy:-
 Starting time : within 28 to 30 days following surgery
 (perez)
 Duration of treatment : 45 to 47 days

20. • Aimed at maximum tumor control with
minimized normal tissue toxicity
 Positioning
 Immobilization
 Simulation
 Target and OAR Delineation
 Treatment Planning
 Junction shift

21. Prone Position:
Advantages :
 • Direct visualization of the field junctions.
 • Good alignment of the spine
Disadvantages :
 • Uncomfortable, and larger scope for patient
movement
 • Technically difficult to reproduce.
 • Difficult anesthetic maneuvers.

22. Supine
 • More comfortable.
 • Better reproducibility
 • Safer for general anaesthesia
BUT
 • Direct visualisation of spinal field is not
possible

23. 1.Orfit (Thermoplastic
devices) for
immobilization of
the head, cervical
spine & shoulder
2.Small children–
inverted full body
plaster cast with
facial area open for
access for
anesthesia

24.  3.Vaclock- is filled with
styroform beads. When air is
removed from the bag, it retains
the shape and contour of the
patient.
 4.Alpha cradle- It uses two
liquids, which when mixed
together creat thermal reaction.
When placed in a plastic bag and
sealed, the chemical expands
and conform to the patient’s
body and then solidify.

25.  5.CSI board: Lucite(polymethyl methacrylate) base
plate fitted on which is a sliding semicircular lucite
structure for head-rest & chin-rest.
 Slots from A to E to allow various degrees of
extension.

26.  Thermocol wedge for supporting the chest wall
 Alignment of the thoracic & lumbar spine parallel to
the couch (to confirm under fluoroscopy)

27. Concern 1
 Divergence of the upper border of the spinal field in case of
single spinal field(and interdivergence of spinal fields in
case of 2 spinal fields)
Concern 2
 Divergence of both cranial fields

28.  Spinal field simulated first (get to know the
divergence of the spinal field)
 SSD technique
 2 spinal fields if the length is > 36 cm
 Upper border at low neck
 Lower border at termination of thecal sac or
S2 whichever is lower
 In case of 2 spinal fields , junction at L2/L3

29.  Traditional
recommendation for lower
border of spinal field is
inferior edge of S2
(myelogram & autopsy
studies).
 8.7% patients have
termination below S2-S3
interspace.
 MRI accurately determines
the level of termination of
the thecal sac & the extent
of neuraxial disease if
present. Int J Radiat Oncol Biol Phys. 1998 Jun 1;41(3):621-4,
scharf et.al.

30.  1. Cranio-spinal junction : various
techniques; described subsequently
 2. Spinal-spinal junction : no gap / fixed gap
/ calculated gap can be employed for
matching as central axes of both the beams
are parallel

31.  Proponents of no gap argue that as medulloblastoma is
radiosensitive tumor, small reduction in dose per fraction or
total dose to part of Target Volume, owing to a gap, may
produce significant difference in cell kill over a fractionated
course of CSI, seen as local recurrences.
 Proponents of gap argue that no gap risks overdose at the
junction & cervical spine & may result in disabling late
toxicity

32.  Many institutes use a fixed gap ranging from <5 mm - 10
mm
 A customized gap calculated for each patient depending
on field length & depth of prescription, is more appropriate
Gap calculation formula

33. CD BC
DE AB
=
Khan’s physics 5th ed pg-246

34.  Spinal field- superior boarder at C3 – C4 junction such that
field is not exiting through oral cavity.
Mark the divergent boundary of
the superior margin of spinal
field (red line) on lateral aspect
of neck to provide a match line
for the lateral cranial field(blue
line).
Open length of field to a
maximum length and mark
inferior border or

35.  Width - vertebral body + 1 cm to include
the intervertebral foramina; usual width 5
- 7 cm.

36. Anterior posterior width includes entire skull with 2cm
clearance.
Superiorly, clearance to allow for symmetric field
reduction while doing junction shift.
Inferiorly, the border is
matched with superior
border of spinal field.

38.  Most important is what not to shield
 Frontal (cribriform plate)
 Temporal region
 In meduloblastoma nearly 15-20% of
recurrences occur at cribriform plate site
which is attributed to overzealous shielding,
because of its proximity to ocular structure it
often get shielded.

39.  SFOP (French society Paediatric
Oncology) Guideline- The
recommended placement of
block is
 0.5cm below orbital roof
 1cm below and 1cm in front of
the lower most portion of the
temporal fossa

47.  Classically described technique.
 Divergence of spinal field into the cranial field is overcome
with collimator rotation.
 Divergence of cranial field into spinal fields is overcome
with couch rotation(rotated so that the foot end moves
towards the gantry).
 Both rotations are performed during irrediation of the
cranial fields.

50. θcoll= Collimator angle to rotate (7-100)
θcoch= Couch angle to ratate (~60)
L1 = the length of the posterior spinal field
L2 = the length of the lateral cranial field,
(SSD is the SSD for the spinal field, and SAD is the source to axis
distance for the cranial fields,
assuming that the SSD technique is used for the spinal field and the
SAD technique for the cranial fields)

51.  5mm overlap at 4mv photons 30 to 40%
overdose (14Gy for 36Gy prescribed dose)
which may exceed cord tolerance. (Hopulka, 1993,
IJROBP)
 Systematic error during radiotherapy
delivery could further lead to an overlap or
gap.
 Feathering after every 5 to 7 fraction
smoothes out any overdose or underdose
over a longer segment of cord

52.  Usually shifted by 1 to 2 cm at each shift
 Done every few fractions( usually 5# to 7#).
 Either in cranially or caudal direction.
 Cranial inferior collimator is closed & spinal
superior collimator is advanced by the same
distance superiorly (if junction to be shifted
cranially).
 Similarly, lower border of superior spinal
field & superior border of inferior spinal field
are also shifted superiorly, maintaining the
calculated gap between them.

56. Advantage
 Single spinal field and circumventing the issue of junction
between two spinal fields
Disadvantage
 Higher percentage depth dose and greater penumbra
results in higher mean doses to all anterior normal
structures,(mandible, esophagus, liver, lungs, heart,
gonads and thyroid gland)

57. Borders
 Anterior: Posterior clinoid process.
 Posterior: Internal occipital
protuberance.
 Inferior: C2-C3 interspace.
 Superior: Midpoint of foramen magnum
& vertex or 1 cm above the tentorium
(as seen on MRI).
Field arrangement
Two lateral opposing fields.

58.  Conventional Simulator films do not define:
• Terminal location of the thecal sac.
• Relationship between the optic globe and the cribriform
plate.
 The cribriform plate may be located below or at the same
level as the superior edge of the lens in 50% patients.
 Shielding the lens – underdosage of the cribriform plate.
 Nearly 25% of all recurrences occur in the supratentorial
region.

59.  • Virtual simulation of treatment fields without the patient.
 • Better definition of critical organs and target volume.
 • Graphical overlays of anatomic CT data onto digitally
reconstructed radiographs (DRRs) and the viewing of all
fields simultaneously in multiple CT-based planes improve
field placement, matching, shielding accuracy & direct
calculation of gap between the fields.

60.  • Patient positioned using all ancillary devices and the
spinal columns aligned with the sagittal external laser.
 • Three-fiducial reference marks placed on the mask in a
transverse plane at the center of the head with the aid of
the external laser.
 • Spiral CT images of 5 mm from the vault of skull – bottom
of sacrum, with 3mm slices through the primary tumor/bed
are acquired.
 • Target volumes and organs at risk are contoured on
images.
 • Co-registered MRI and CT data sets are used for target
volume delineation.

63. Single isocentre for 2 lateral cranial fields and one upper spinal
field.

65. .Field matching using field alignment option

66.  IMRT plans provided better healthy tissue sparing than
either the 2D or the 3D plans.
 IMRT results in better sparing of OARs without a significant
increase in integral dose.

68.  The plan used three field sets, each with a unique
isocenter.
 One field set with seven fields treated the cranium.
 Two field sets treated the spine, each set using three fields.
 Fields from adjacent sets were overlapped, and the
optimization process smoothly integrated the dose inside
the overlapped junction.
•one IMRT plan is required for
the entire target volume.
•The three isocenters were
collinear, requiring only a
longitudinal couch shift to
move from one to the other,
and were placed near the
patient’s midline.

69. Sagittal view shows the dose distribution for one of the patient’s
jagged-junction IMRT plan (i) and the conventional plan (ii) for
the same patient. Regions A and B show the dose distribution in
the cranial-spinal and superior-inferior junctions.

70. •TIOJ IMRT provides a simple and efficient choice for
CSI treatment.
•It helps avoid typical CSI problems, such as over-long
radiation fields and matching between the fields.

71. •A reduction of late sequelae and thus improved quality of life
may be achieved by the use of VMAT.
•A VMAT planning solution for different lengths of craniospinal
axis has been developed, with significant reductions in dose to
the OAR around the brain, neck, and thoracic regions.
•HOWEVER there may be a risk of second malignancy due to
increase of integral dose.

72.  It is a rotational IMRT- no need for junction.
 Helical TomoTherapy delivers continuous arc–based
intensity-modulated radiotherapy that gives high
conformality and excellent dose homogeneity for the target
volumes.
 Helical TomoTherapy allows for differential dosing of
multiple targets, resulting in very good dose distributions.
 The use of pretreatment MVCT imaging with Helical
Tomotherapy allows for increased precision with respect to
patient positioning and use of a reduced PTV margin.

73. Proton therapy-
- Uniform dose distributuon to the posterior fossa and spinal cord
with in the thecal sac.
-Near complete organ sparing, lower probability of developing
secondary hearing, hormonal defects.
-Long term effect of neutron spill- not quantified.

74. • Proton CSI is superior to other CSI modalities in terms of OAR doses
and toxicities.
• There is a decreased risk of radiocarcinogenesis with proton CSI than
with conventional radiation therapy.
•The reduction in risk of toxicity and radiocarcinogenesis offered by
proton craniospinal irradiation appear to outweigh the increased
costs.

75. Posterior spinal field

76. Lateral cranial field

77. Spinal field

78. Single isocentre for 2 lateral cranial fields and one upper spinal field.

79.  • GTV- Tumor bed on MRI
 • CTV = GTV + 15 mm.
 • PTV = CTV + 3-5 mm, modified only at sella.
 • Immobilization accuracy +/- 3-5 mm.
 • 95% of isodose covers 100% of CTV & 95% Of PTV.
 • Constraints:
 • < 70% Supratentorial brain to receive > 50% boost dose.
 • < 80% Left & right cochlea to receive > 80% of boost
dose.
 • < 50% Pituitary to receive > 30% of boost dose.
 • < 10% Left & right optic nerve & chiasma to receive >
50.4 Gy each.

80.  Acute Toxicity
 • Within first few weeks
 • Hair loss, skin
reaction, sore throat,
dysphagia, nausea and
vomiting, fatigue
 • Bone marrow
suppression
 • CNS toxicity
– Acute radiation
encephalopathy
– Early cerebral necrosis
Late Toxicity
• After four weeks
• Bone marrow
suppression
• CNS toxicity
– Delayed cerebral
necrosis
– Delayed cranial nerve
damage
– Delayed radiation
myelopathy
– Delayed motor-neuron
syndrome

81.  Craniospinal Irradiation – Treats anywhere CSF flows –
Treatment fields typically include the brain to the thecal
sac.
 Medulloblastoma forms the most common indication for
CSI.
 There are ongoing trials for alternative dose of CSI to
reduce toxicity- like reduced dosing schiduled with
chemotherapy and HFRT.
 In standard risk meduloblastoma, dose can be reduced to
23.4Gy along with chemotherapy but in high risk
meduloblastoma dose reduction is not recommended.
 Not to shield cribriform plate and Temporal region, as these
are main site of recurrence due to overzealous shielding.

82.  Craniospinal and two spinal fields are matched using
different methods otherwise there may be over dose to
spine and devastrating result will occur.
 Feathering-Usually shifted by 1 to 2 cm at each shift, Done
every 5# to 7#, Either in cranially or caudal direction.
 IMRT, VMAT, IGRT, Tomotherapy, Proton therapy are now
more homogenous treatment plans, where target is
receiving required dose and OARs are having less dose.