Radiotherapy

Treatment Planning 1
FRCR
Matt Clarke
May 2013
 Radiotherapy
Treatment Planning
Lecture 1
– Concepts of ICRU reports 50 & 62

SHORT BREAK

Lecture 2
– Changing the variables
(i.e. the treatment parameters)
– Assessment tools
(e.g. DVH)
 Introduction

• “The tumour is clearly visible”

• “Please treat tumour with X amount of radiation”

» Ideally, 100% dose in tumour & 0% everywhere else

BUT this is not achievable in practice…

which leads on to a number of questions…

 Introduction

• How big is the tumour?

• Will the tumour move during treatment?
• If the patient is in the right position, will the
tumour be in the right position?
Introduction
 Introduction

• Is this a good plan? When is a plan good enough?

• What is the aim of this treatment?
• Dose will inevitably be delivered to surrounding
tissue – how much is acceptable?
• Does it matter what the surrounding tissue is?
• Which is better: ‘small’ area of ‘high’ dose or larger
region of medium dose?
• How do plans from one centre compare with those
from another?
 ICRU 50 & 62
The information contained in these ICRU reports
help to address the previous questions.

• ICRU Report 50 – 1993

• ICRU Report 62 – Supplement Nov 1999
• Contain recommendations on how to report a treatment
in external beam XRT
• Introduce common terminology for reporting and
prescribing that can be followed in all centres worldwide
• Intended to standardise prescribing practice!
 ICRU 50
Aim of Therapy
• Define clearly and concisely the aim of the
treatment:
Radical or Palliative
• Volume to be treated
• Radiation Dose
• Treatment technique
 ICRU 50
Volumes
• GTV: Gross Tumour Volume
How big is the tumour?

• CTV: Clinical Target Volume

How big is the tumour?

• PTV: Planning Target Volume

Will the tumour move during treatment?
If the patient is in the right position will
the tumour be in the right position?
 ICRU 50
Volumes
• GTV: Gross Tumour Volume
Palpable or visible/demonstrable extent and
location of malignant growth

• CTV: Clinical Target Volume

Margin that encompasses subclinical
microscopic malignant disease
i.e. CTV is a pure anatomic-clinical concept

• PTV: Planning Target Volume

Concept that accounts for geometrical variations
in the CTV (e.g. organ motion and inaccuracies
in treatment delivery).
The PTV ensures that the CTV receives the
prescribed dose
 ICRU 50
Volumes
• Treated and Irradiated
Volume
Dose will inevitably be delivered to
surrounding tissue – how much is
acceptable?

• Organs at Risk
Does it matter what the
surrounding tissue is?
 ICRU 50
Volumes
• Treated and Irradiated
Volume
Volume that receives a dose considered
significant in relation to normal tissue
tolerance

• Organs at Risk
Tissues whose radiation sensitivity may
influence a treatment plan (i.e. spinal
cord)

More on organs at risk in ICRU 62…

 ICRU 50
Absorbed Dose Distribution

Is this a good plan? When is a plan good enough?

Dose will inevitably be delivered to surrounding

tissue – how much is acceptable?

How do plans from one centre compare those from

another?
 ICRU 50
Absorbed Dose Distribution
• Dose Variation
– Homogeneous as possible: Should be within+7% and -5%
WittKamper et al 1987, Brahme et al 1988, Mijnheer et al 1987
– Values extending outside this range must be noted
– For palliative patients it is noted that a greater heterogeneity in
the dose distribution is inevitable
• Spatial representation
– Isodose display accuracy accordance with ICRU 42.
– Documentation at a minimum should outline transaxial
samples of isodoses and PTV volume, as well as isodoses
adjacent to OARs
• Maximum Dose
– Report/Document the maximum dose within specified ROIs
(in particular PTV and OARs)
 ICRU 50
Absorbed Dose Distribution
• Minimum Dose
– Report/Document the minimum dose within specified ROIs (in
particular PTV)
• Hotspots
– Represents hotspots outside the PTV which receive doses >
100% of the prescribed dose
– Only significant if 15mm (unless considering small OARs i.e.
eye. Optic nerve etc)
 ICRU 50
Dose Evaluation for Reporting
How do plans from one centre compare those from
another?
3 Levels of Reporting
Level 1 : Basic level of reporting
-Minimum requirement
Level 2 : Advanced techniques
-CT planning + heterogeneity correction
Level 3 : Developmental techniques (incl. research)
-3D dose computation + Dose Volume Histograms

*Note these levels were written in 1993, thus 3D

computation and DVH are now routinely used in this and
many other centres
 ICRU 50
Dose Reference Point
Criteria:
• Selection is based on a point within the PTV
• Clinically relevant and representative of the dose throughout the
PTV
• The point should be easy to define in a clear and unambiguous way
• The point should be selected where the dose can be accurately
determined
• The point should be selected in a region where there are no dose
gradients

The criteria for the location of the ICRU reference point are also
those required for the prescription point (sometimes identified as the
‘isocentre’). Hence often the ICRU reference point and the
prescription point are the same thing. However, they serve two
different purposes – one for reporting and the other for prescribing.
 ICRU 50
Dose Reference Point
The dose reference point criteria are, in the majority of 3D
conformal plans, fulfilled if the ICRU point is at the
gravitational centre of the PTV and on/near the central axis of
the beams.

Exception: Centre of gravity of the PTV is outside the PTV

(e.g. chest wall, where the resulting reference point may be in
shielded, healthy lung)

In such cases the reference point should be moved to a

position within the PTV which retains dosimetric stability.
 ICRU 50
Concepts Summary 1
Standard Definition
• Aim of treatment
• Diagnosis
• Dose and fractionation
• Volumes
• GTV, CTV, PTV
• Treated & Irradiated Volumes
• Organs at Risk (OAR)
• Absorbed dose distribution
• Representation of spatial variation
• Min and Max dose, etc
• Hotspots
 ICRU 50
Concepts Summary 2
Recommendations for reporting
• Reporting volumes
• GTV, CTV, PTV
• Reporting Dose
• ICRU Reference point
• ICRU reference dose
• Dose variation throughout treatment volume
• Levels of dose evaluation for reporting
• Single planning target volume
• Complex treatment volumes
• Organs at risk
• Hot spots
 ICRU 62
Supplement – WHY?
• Since the publication of ICRU Report 50 new and
improved irradiation techniques that have become
available.
• The new techniques rely on the ability of modern
imaging procedures to provide more complete
information on the location, shape and limits of target
volumes and organs at risk.
• Margins around the target volumes become more critical
in this situation and Report 62 addresses this question in
some detail, introducing new concepts and refining
previous recommendations.
 ICRU 62
So What’s New?

• OARs are now characterised as;

Serial, parallel and serial-parallel
• Planning organ at risk volumes (PRV) – i.e. margins on
OARs
• Margins are discussed
• Conformality index introduced
• Dose specification for reporting –DVHs
• Reporting dose in a series of patients
• Levels of dose evaluation for reporting have altered
• Proposes Graphical volume colours
• 3D Coordinate system
 ICRU 62
OARs & parallel-serial model
Which is better: ‘small’ area of ‘high’ dose or larger
region of medium dose?
 ICRU 62
OARs & parallel-serial model
Serial, parallel and serial-parallel classification
introduced for OARs:

• A “serial” string of subunits

(e.g. the spinal cord)
An organ with a high ‘relative’
seriality, implies that a dose above
the tolerance limit, even to a small
volume can totally impair the
function of that organ

Schematic examples of tissue organization

Structures in the parallel serial Model
 ICRU 62
OARs & parallel-serial model
Serial, parallel and serial-parallel classification
introduced for OARs:

• A “parallel” string of subunits

(e.g. the lungs)
An organ which has low seriality
(e.g. the lung), implies that the
main parameter impairing its
function is the proportion of the
organ that receives a dose above a
specified tolerance

Schematic examples of tissue organization

Structures in the parallel serial Model
 ICRU 62
OARs & parallel-serial model
Serial, parallel and serial-parallel classification
introduced for OARs:

• A “serial-parallel” string of
subunits (e.g. the heart)
The heart is a combination; the
serial component of the coronary
arteries combined with the parallel
component of the mycardium.

Schematic examples of tissue organization

Structures in the parallel serial Model
 ICRU 62
OARs & parallel-serial model
Serial, parallel and serial-parallel classification
introduced for OARs:

• a combination of “parallel”
and “serial” structures (e.g. a
nephron)

Schematic examples of tissue organization

Structures in the parallel serial Model
 ICRU 62
Additional Concepts

• CTV to PTV margin is now divided into two parameters

(Internal and Set up Margin)
• Derives a planning Organ at Risk Volume (PRV) which is
analogous to the PTV (margin dependant of OAR)
• Conformity Index (CI) - Defined as the quotient of the
treated volume and the volume of the PTV (used to
compare techniques)
 ICRU 62
Dose Specification

• Adopts the same specification as ICRU 50

• Suggests documentation of min and max PTV doses
• The use of DVHs recommended (if available)
• Absorbed dose to OARs should be given
 ICRU 50 & 62
Problems!
• IMRT
– ICRU only recommends prescribing to a point dose
– IMRT plans prescribe a mean dose to a PTV
• GTV, CTV, PTV –not always delineated
– e.g. post operative radiotherapy
• Point dose specification
– min and max dose quoted for 1cc i.e. not a point measurement
• New ICRU 83 report published in 2010 which addresses
the changes needed for IMRT
Outlining and Margins
Things to consider…
 Outlining and Margins
Uniform Margins?

Uniform margins Different margins

A/P, L/R S/I
Outlining and Margins
Different Margins?
 Outlining and Margins
Volume-Growing Tools
• Used in planning systems to create PTV & PRV
• Algorithms can be 2D or 3D
– 2D: adds margin to each individual transverse section
– 3D: rolling ball method is commonly used
• Expansions are important
– Define PTV i.e. radiation area
– Define PRV i.e. protection for OARs

N.B.
• Deciding between 2D or 3D doesn’t just affect the superior and
inferior borders.
• Using rolling ball will alter the lateral extent of the volume as well
• This may affect the dose constraints i.e. plan acceptability
for example…
 Outlining and Margins
Volume-Growing Tools
• Used in planning systems to create PTV
• Algorithms can be 2D or 3D
• 2D: adds margin to each individual transverse section
• 3D: rolling ball method is commonly used

2D 3D

Comparison:
 Outlining and Margins
Volume-Growing Tools: Affecting PTV
2D 3D

Sagittal view
 Outlining and Margins
Volume-Growing Tools: Affecting PTV
2D 3D

Transaxial view
 Outlining and Margins
Volume-Growing Tools: Affecting PRV

Head & Neck IMRT

patient
Blue area is PTV
Red contour is spinal canal
Coloured isodose lines show
region of dose
 Outlining and Margins
Volume-Growing Tools: Affecting PRV

2D expansion 3D rolling ball expansion

 Outlining and Margins
Volume-Growing Tools: Affecting PRV

Effect on SC PRV dose

Consultant requested max dose
to 1cc of sc PRV <4400 cGy.

2D expansion: 4294 cGy

3D expansion: 4670 cGy
 Outlining and Margins
Volume-Growing Tools: Affecting PRV

Elderly patient who could not lie horizontal

 Outlining and Margins
Volume-Growing Tools: Affecting PRV

2D expansion 3D rolling ball expansion

 Outlining and Margins
Volume-Growing Tools: Affecting PRV

This 3D expansion
causes overlap
between PRVs
(here, spinal canal &
brainstem).
However, this is
consistent with
concept of PRV
including motion of
organs.