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Purpose: Proton vertebral body sparing craniospinal irradiation (VBS CSI)treats the thecal sac while avoiding the anterior vertebral bodies in effort toreduce myelosuppression and growth inhibition. However, robust treatmentplanning needs to compensate proton range uncertainty, contributing unwanteddoses within the vertebral bodies. This work aims to develop an early in vivoradiation damage quantification method using longitudinal magnetic resonance(MR) scans to quantify dose effect during fractionated CSI. Materials andmethods: Ten pediatric patients were enrolled in a prospective clinical trialof proton VBS CSI receiving 23.4-36 Gy. Monte Carlo robust planning was usedwith spinal clinical target volumes defined as the thecal sac and neuralforamina. T1/T2-weighted MR scans were acquired before, during, and aftertreatments to detect transition from hematopoietic to less metabolically activefatty marrow. MR signal intensity histograms at each time point were analyzedand fitted by multi-Gaussian models to quantify radiation damages. Results:Fatty marrow filtration was observed on MR images as early as the fifthfraction of treatment. Maximum radiation-induced marrow damage occurred 40-50days from the treatment start, followed by marrow regeneration. The mean damageratios were 0.23, 0.41, 0.59, and 0.54 corresponding to 10, 20, 40, and 60 daysfrom the treatment start. Conclusions: We demonstrated a non-invasive method toidentify early vertebral marrow damage based on radiation-induced fatty marrowreplacement. The proposed method can be potentially used to quantify thequality of CSI vertebral sparing to preserve metabolically active hematopoieticbone marrow.

Early in vivo Radiation Damage Quantification for Pediatric Craniospinal Irradiation Using Longitudinal MRI for Intensity Modulated Proton Therapy