Method to plan, administer, and verify supine craniospinal irradiation

Craniospinal irradiation remains an important technique in the management of malignancies of the central nervous system. It is technically demanding, with potential for treatment field overlap or gaps to yield unacceptable dosimetric heterogeneity. A method to accurately simulate and verify the three-field junction is described. We use a comfortable supine position to minimize patient movement. The supine position provides airway access by anesthesiology in patients requiring sedation or anesthesia. Virtual simulation is performed with a dedicated computed tomography (CT) simulator. Multiplanar sagittal and coronal CT reconstructions allow visual confirmation of three-field matching at the cervical region. The placement of isocenters for each field, table position, and collimator angles are determined by calculation of field sizes accommodating for beam divergence. At treatment, exact matching of the three fields is assured using the record and verify confirmation of beam collimator settings and rotation, digital couch readouts, and gantry parameters. Mini-verification silver halide (Kodak XV) films (6x6 cm) are placed behind the patient's neck and are exposed by all treatment fields (posterior flash from the lateral cranial fields and entrance from the PA spine field). These films assess field placement accuracy at the junction of these three fields. Finally, placement of radio-opaque markers at the junction is visualized in each clinical portal radiograph. Patients readily accept the supine position as their treatment setup is eased. Field placement using digital couch settings is efficient and accurate. Daily mini-verification films are simple, inexpensive, and allow verification of each treatment field matching. Field placement errors of greater than 1 mm can be readily identified and corrected at subsequent treatment sessions. Virtual simulation and direct junction verification with mini-verification films allow for simple and quantitative evaluation of the junction associated with the three-field craniospinal irradiation technique. The supine patient position does not present any difficulties in field matching or verification.