Supine craniospinal irradiation using intrafractional junction shifts and field-in-field dose shaping: early experience at Methodist Hospital

PURPOSE: To describe our preliminary experience with supine craniospinal irradiation. The advantages of the supine position for craniospinal irradiation include patient comfort, easier access to maintain an airway for anesthesia, and reduced variability of the head tilt in the face mask. METHODS AND MATERIALS: The cranial fields were treated with near lateral fields and a table angle to match their divergence to the superior edge of the spinal field. The collimator was rotated to match the divergence from the superior spinal field. The spinal fields were treated using a source to surface distance (SSD) technique with the couch top at 100 cm. When a second spinal field was required, the table and collimator were rotated 90 degrees to allow for the use of the multileaf collimator and so the gantry could be rotated to match the divergence of the superior spinal field. The multileaf collimator was used for daily dynamic featherings and field-in-field dose control. RESULTS: With a median follow-up of 20.2 months, five documented failures and no cases of radiation myelitis occurred in 23 consecutive patients. No failures occurred in the junctions of the spine-spine or brain-spine fields. Two failures occurred in the primary site alone, two in the spinal axis alone, and one primary site failure plus distant metastasis. The median time to recurrence was 17 months. CONCLUSION: The results of our study have shown that supine approach for delivering craniospinal irradiation is not associated with increased relapses at the field junctions. To date, no cases of radiation myelitis have developed.