ICRU - 50 - Prescribing, Recording and Reporting Photon Beam Therapy

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ICRU REPORT 50
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Library of Congress Cataloging-ill-Publication Data
Prescribing, recording, and reporting photon beam therapy.
p. cm.-(lCRU report; 50)
Includes bibliographical references and index.
ISBN 0-913394-48-3
1. Cancer-Radiotherapy. 2. Radiation-Dosimetry.
I. International Commission on Radiation Units and Measure-
ments.
II. Series.
RA1231.R2I55 no. 50
[RC271.R31
616.07'57 s-dc20
1616.99 ' 40642J 93-3633
CIP
This report was prepared by the International Commission on Radiation Units and Measurements, Inc. (ICRU). The Commission strives to
provide accurate, complete and useful information in its reports. However, neither the ICRU, the members of ICRU, other persons
contributing to or assisting in the preparation of this report, nor any person acting on the behalf of any of these parties: (a) makes any
warranty or representation , express or implied, with respect to the accuracy, completeness or usefulness of the information contained in this
report, or that the use of any information, method or process disclosed in this report may not infringe on privately owned rights; or (b)
assumes any liability with respect to the use of, or for damages resulting from the use of any information, method or process disclosed in this
report.
ICRU REPORT 50
Prescribing, Recording,
and Reporting Photon

Beam Therapy
Issued: 1 September 1993
INTERNATIONAL COMMISSION ON RADIATION

UNITS AND MEASUREMENTS
7910 WOODMONT AVENUE
BETHESDA, MARYLAND 20814
U.S.A.
THE INTERNATIONAL COMMISSION
ON RADIATION UNITS AND MEASUREMENTS
INDIVIDUALS PARTICIPATING IN THE PREPARATION OF THIS REPORT

Commission Members Report Committee
A ALLlSY,Chairman Chairman
T. LANDBERG,
A M. KELLERER, Vice Chairman Malmo General Hospital
R. S . CASWELL, Secretary Malmo, Sweden
G.E.D.ADAMs J. CHAVAUDRA,

K. DOl Institut Gustave-Roussy
L. FEINENDEGEN Villejuif, France
M.INOKUTI J. DOBBS
I. ISHERWOOD King's College Hospital
J. R. MALLARD London, England
H. PARETZKE G. HANKS
H . H. ROSSI Fox Chase Cancer Center
A W AMBERSIE Philadelphia, Pennsylvania, US.A.
G. F. WHITMORE K.-A JOHANSSON
L. S. TAYLOR,Honorary Chairman and Sahlgrenska Sjukhuset
Member Emeritus Goteborg, Sweden
T. MOLLER
Principal Scientific Counsellor University Hospital
H. O. WYCKOFF Lund, Sweden
J. PURDY
Assistant Secretary
Washington University School of Medicine
W. R. NEY St. Louis, Missouri, US.A.
Executive for Development Consultants to the Report Committee
H. G. EBERT AAKANUMA
University of Tokyo
Commission Sponsor Tokyo, Japan
A W AMBERSIE J.-P. GERARD
Universite Catholique de Louvain Centre Hospitalier Lyon Sud
Bruxelles, Belgium Pierre-Benite, France
J.-C. HORIOT
Centre G.-F. Leclerc
Dijon, France
N . SUNTHARALINGAM
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania, US.A.
The Commission wishes to express its appreciation to the individuals involved in the preparation of this report for
the time and effort they devoted to this task and to express its appreciation to the organizations with which they are
affiliated. In addition, The Commission wishes to express its appreciation to Dr. T. Landberg, of the Malmo General
Hospital and Dr. A Wambersie, of the Universite Catholique de Louvain for providing funding, making it possible to
include color illustrations in this report.
Copyright © International Commission on Radiation Units and Measurements 1993

(For detailed information on the availability of this and other ICRU Reports, see page 67.)
Preface
Scope of ICRU Activities The ICRU invites and welcomes constructive com-
ments and suggestions regarding its recommenda-
The International Commission on Radiation Units
tions and reports. These may be transmitted to
and Measurements (ICRU) , since its inception in
the Chairman.
1925, has had as its principal objective the develop-

ment of internationally acceptable recommendations
regarding: Current Program
(1) Quantities and units of radiation and radioac- The Commission has divided its field of interest
tivity, into twelve technical areas and has assigned one or
(2) Procedures suitable for the measurement and more members of the Commission the responsibility
application of these quantities in clinical radiology for identification of potential topics for new ICRU
and radiobiology, activities in each area. Each area is reviewed periodi-
(3) Physical data needed in the application of these cally by its spopsors. Recommendations for new
procedures, the use of which tends to assure unifor- reports are then reviewed by the Commission and a
mity in reporting. priority assigned. The technical areas are:
The Commission also considers and makes similar Radiation Therapy
types of recommendations for the radiation protec- Diagnostic Radiology
tion field. In this connection, its work is carried out Nuclear Medicine
Radiobiology
in close cooperation with the International Commis- Radioactivity
sion on Radiological Protection (ICRP). Radiation Physics-X Rays, Gamma Rays and Electrons
Radiation Physics-Neutrons and Heavy Particles
Radiation Protection
Radiation Chemistry
Policy Critical Data
Theoretical Aspects
The ICRU endeavors to collect and evaluate the Quantities and Units
latest data and information pertinent to the problems The actual preparation of ICRU reports is carried
of radiation measurement and dosimetry and to out by ICRU report committees. One or more Commis-
recommend the most acceptable values and tech- sion member serves as sponsor to each committee and
niques for current use. provides close liaison with the Commission. The
The Commission's recommendations are kept un- currently active report committees are:
der continual review in order to keep abreast of the Absorbed Dose Standards for Photon Irradiation and Their
rapidly expanding uses of radiation. Dissemination
Beta-ray Dosimetry for Radiation Protection
The ICRU feels that it is the responsibility of Clinical Dosimetry for Neutrons (Specification of Beam Quality)
national organizations to introduce their own de- Determination of Body Burdens for Radionuclides
tailed technical procedures for the development and Dose Specification for Reporting Interstitial Therapy
Fundamental Quantities and Units
maintenance of standards. However, it urges that Fundamentals of Particle Counting Applied to Radioactivity
all countries adhere as closely as possible to the Hyperthermia
In situ Gamma Spectrometry in the Environment
internationally recommended basic concepts of radia- Medical Application of Beta Rays
tion quantities and units. Performance Assessment in the Digital Representation of Im-
The Commission feels that its responsibility lies in ages
Prescribing. Recording and Reporting Electron Beam Therapy
developing a system of quantities and units having Proton Therapy
the widest possible range of applicability. Situa- Relationships Between Quantities for Radiological Protection
tions may arise from time to time when an expedient Against External Radiation (Joint with ICRP)
ROC Analysis
solution of a current problem may seem advisable. Secondary Electron Spectra Resulting from Charged Particle
Generally speaking, however, the Commission feels Interactions
that action based on expediency is inadvisable from a Statistical Aspects of Environmental Sampling
Stopping Power for Heavy Ions
long-term viewpoint; it endeavors to base its decisions Tissue Substitutes, Characteristics of Biological Tissue and
on the long-range advantages to be expected. Phantoms for Ultrasound
iii
iv ... Preface
ICRU's Relationships With Other During the last ten years, financial support has
Organizations been received from the following organizations:
In addition to its close relationship with the Inter- ADAC Laboratories
Agfa-Gavaert, N.V.
national Commission on Radiological Protection, the American Society for Therapeutic Radiology and Oncology
ICRU has developed relationships with other organi- Atomic Energy Control Board
BayerAG
zations interested in the problems of radiation quan- Central Electricity Genera ting Board
tities, units and measurements. Since 1955, the ICRU CGR Medical Corporation
has had an official relationship with the World Health Commissariat it L'Energie Atomique
Organization (WHO) whereby the ICRU is looked to Commission of the European Communities
Dutch Society for Radiodiagnostics
for primary guidance in matters of radiation units Eastman Kodak Company
and measurements and, in turn , the WHO assists in Ebara Corporation

~ . I. duPont de Nemours a nd Company
the world-wide dissemination of the Commission's Electricite de France
recommendations. In 1960, the ICRU entered into Elscint
consultative status with the International Atomic Fuji Medical Systems
Fuji Photo
Energy Agency. The Commission has a formal rela- General Electric Company
tionship with the United Nations Scientific Commit- Gilbert X- Ray Company
tee on the Effects of Atomic Radiation (UNSCEAR), Hitachi, Ltd.
International Atomic Energy Agency
whereby ICRU observers are invited to attend International Radiation Protection Association
UNSCEAR meetings. The Commission and the Inter- International Society of Radiology
national Organization for Standardization (ISO) infor- Italian Radiological Associa tion
J apan Industries Association of Radiation Apparatus
mally exchange notifications of meetings, and the Konica Corporation
ICRU is formally designated for liaison with two of Na tional Cancer Institute of the U.S. Department of Health and
the ISO Technical Committees. The ICRU also corre- Human Services
National Electrical Manufacturers Association
sponds and exchanges final reports with the following National Institute of Radiological Sciences of Japan
organizations: N .V. Phillips Gloielampenfabrieken
Burea u International de Metrologie Legale Philips Medical Systems, In corporated
Bureau International des P oits et Mesures Pyne Corporation
Commission ofthe European Communities Radiation Research Society
Council for International Organizations of Medical Sciences Scanditronix AB
Food and Agriculture Organization of the United Nations Shimadzu Corporation
International Council of Scientific Unions Siemens Aktiengesellschaft
International Electrotechnical Commission Society of Nuclear Medicine
International Labor Office Sumitomo Heavy Industries, Ltd.
International Organization for Medical Physics Theratronics
International Radiation Protection Association Toshiba Corporation
International Union of Pure and Applied l(hysics University Hospital, Lund, Sweden
United Nations Educational, Scientific and Cultural Organiza- World Health Organization
tion Xerox Corporation
The Commission has found its relationship with all In addition to the direct monetary support provided
of these organizations fruitful and of substantial by these organizations, many organizations provide
benefit to the ICRU program. Relations with these indirect support for the Commission's program. This
other international bodies do not affect the basic support is provided in many forms, including, among
affiliation of the ICRU with the International Society others, subsidies for (1 ) the time of individuals partic-
of Radiology. ipating in ICRU activities, (2) travel costs involved in
ICRU meetings, and (3) meeting facilities and ser-
vices.
Operating Funds In recognition of the fact that its work is made
possible by the generous support provided by all of
In the early days of its existence, the ICRU oper- the organizations supporting its program, the Com-
ated essentially on a voluntary basis, with the travel mission expresses its deep appreciation.
and operating costs being borne by the parent organi-
zation of the participants. (Only token assistance was ANDRE ALLISY
originally available from the International Society of Chairman, fCR U
Radiology.) Recognizing the impracticability of con-
tinuing this mode of operation on an indefinite basis, Sevres, France
operating funds were sought from various sources. 1 September 1993
Executive SUlDlDary
When delivering a radiotherapy treatment, param- Planning Target Volume
eters such as the volume and dose have to be specified
The Planning Target Volume (PTV) is a geometri-
for different purposes: prescription, recording, and
cal concept, and it is defined to select appropriate
reporting. It is important that clear, well defined and
beam sizes and beam arrangements, taking into con-

unambiguous concepts and parameters are used for
sideration the net effect of all the possible geometrical
reporting purposes to ensure a common language
variations and inaccuracies in order to ensure that
between different centers. Furthermore, it is an
the prescribed dose is actually absorbed in the CTV.
advantage if the same terminology is used also for
The Planning Target Volume is thus a static,
prescribing and recording.
geometrical concept, used for treatment planning and
for specification of dose. Its size and shape depend
primarily on the CTV, but also on the treatment
Aim of Therapy technique used.
It is important to define the aim of therapy (radical, Depending on treatment technique, two further
or palliative), since this influences the choice of the volumes can be identified: Treated Volume and Irradi-
volume to be treated, the radiation dose, and the ated Volume.
treatment technique.
Treated Volume
Volumes The Treated Volume is the volume enclosed by an
It is imperative to define in a clear and concise way isodose surface, selected and specified by the radia-
the volume(s) to be treated to the prescribed dose(s), tion oncologist as being appropriate to achieve the
irrespective of the technique that will be used. This purpose of treatment (e.g., tumor eradication, pallia-
leads to the concepts of: GTV (Gross Tumor Volume), tion).
and CTV (Clinical Target Volume).
Irradiated Volume
Gross Tumor Volume The Irradiated Volume is that tissue volume which
receives a dose that is considered significant in rela-
The Gross Tumor Volume (GTV) is the gross pal- tion to normal tissue tolerance.
pable or visible /demonstrable extent and location of
the malignant growth.
Organs at Risk
Furthermore, consideration has to be given to
Clinical Target Volume normal tissues.
The Clinical Target Volume (CTV) is a tissue Organs at risk are normal tissues whose radiation
volume that contains a GTV and/or subclinical micro- sensitivity may significantly influence treatment plan-
scopic malignant disease, which has to be eliminated. ning and /or prescribed dose.
This volume thus has to be treated adequately in
order to achieve the aim of therapy: cure or palliation.
The CTV is thus an anatomical-clinical concept,
General Recommendations for
that has to be defined before a choice of treatment
Reporting Dose
modality and technique is made. The dose at or near the center of the Planning
For external beam therapy, margins will have to be Target Volume, as well as the maximum and the
added around the CTV to compensate for the effects minimum dose to the PTV, shall always be reported.
of organ and patient movements and inaccuracies in Additional information (such as average dose and its
beam and patient set up. This leads to the concept of standard deviation, dose/volume histograms), when
Planning Target Volume (PTV). available, may be useful.
v
vi ... Executive Summary
The ICRU Reference Point erations, different levels of ambition for dose evalua-
tion can be identified:
The present system of recommendations for report-
ing is based on the selection of a point within the
PTV, which is referred to as the JCRU Reference Level 1: Basic Techniques
Point. The minimum requirements for reporting can be
The JCR U Reference Point shall be selected accord- followed in all centers including those with restricted
ing to the following general criteria: therapy equipment, dosimetric, computer, and staff
-the dose at the point should be clinically relevant facilities. This basic level may sometimes be sufficient
and representative of the dose throughout the in any center when simple treatments are performed
Planning Target Volume (PTV), (e.g., some palliative treatments).
-the point should be easy to define in a clear and At this level, it is assumed that the dose at the

unambiguous way, ICRU Reference Point and an estimation of the
-the point should be selected where the dose can be maximum and the minimum doses to the PTV can be
accurately determined (physical accuracy), determined.
-the point should be selected in a region where there
is no steep dose gradient.
These recommendations will be fulfilled if the Level 2: Advanced Techniques
ICRU Reference Point is located firstly, at the center, The standards of dose planning at this level allow
or in the central parts, of the Planning Target the exchange between different centers of more com-
Volume, and secondly, on or near the central axis of plete and relevant information. At this level, it is
the beam(s). assumed that the GTV, CTV, and PTV can be defined
In some situations, it is not possible to define the in one or more planes (sections) using reliable patient
ICRU Reference Point at the center of the Planning data acquisition tools, and/or modern imaging tech-
Target Volume. In these conditions, one has to select niques under reliable conditions (e.g., a series of CT
the ICRU Reference Point inside the tissues repre- and/or MRI scans). It is also assumed that complete
sented by the PTV, and in a place where dose dose distributions are computed in the central plane
specification is considered to be meaningful. Such a and in other planes (sections) using only central axis
place could be the region where the tumor cell density dose data, and with inhomogeneity corrections, when
is considered to be at its maximum. appropriate.
The dose at the ICRU Reference Point is the JCRU
Reference Dose.
Level 3: Developmental Techniques
The Dose Variation Throughout the Planning The performance of dose planning at level 3 pro-
Target Volume vides for the development of new techniques and
clinical research in radiotherapy. At this level, 3-D
As a minimum requirement, the maximum and the dose computation of any beam arrangement (such as
minimum dose to the PTV shall be reported together non-coplanar beams) and dose/volume histograms
with the dose at the ICRU Reference Point. The three are available.
dose values then represent the dose to the Clinical
NB: In summary, the 3 levels could be described as
Target Volume and the dose variation.
follows:
Other dose values considered to be relevant (e.g.,
average dose and its standard deviation, dose/volume Level 1: Only the dose at the Reference Point
histograms, biologically weighted doses), when avail- and its variation along a central beam
able, should also be reported. axis is available.
Level 2: The dose distribution can be computed
for plane(s).
Three Levels of Dose Evaluation for Reporting Level 3: The dose distribution can be computed
The level of completeness and accuracy of reporting for volumes.
therapeutic irradiation depends to a large extent on At any level, the dose at the ICRU Reference Point
the situation in the department and on the aim of the and the best estimation of the maximum and the
treatment. For different clinical and practical consid- minimum dose to the PTV should be reported.
Contents
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. HI
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
1. Introduction ............................ ... ............... 1
2. Definitions of Terms and Concepts. . . . . . . . . . . . . . . . . . . . . . . . . 3

2.1 The Different Steps in the Radiotherapy Procedure. . . . . . . . . . 3
2.2 Aim of Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.3 Volumes................................................ 3
2.3.1 Gross Tumor Volume (GTV) . . . . . . . . . . . . . . . . . . . . . . . . 6
2.3.2 Clinical Target Volume (CTV). . ........ . ...... ..... . 6
2.3.3 Planning Target Volume (PTV) . . . . . . . . . . . . . . . . . . . . . 7
2.3.4 Treated Volume. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16
2.3.5 Irradiated Volume. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16
2.3.6 Organs at Risk ........................ : . . . . . . . . . .. 18
2.4 Absorbed Dose Distribution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 18
2.4.1 Dose Variation in the Planning Target Volume. . . . . . .. 18
2.4.2 Representation of a Spatial Dose Distribution ........ 20
2.4.3 Maximum Dose (DmaJ. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 20
2.4.4 Minimum Dose (Dmin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
2.4.5 Average Dose (Daverage)' . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
2.4.6 Median Dose (Dmedian) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
2.4.7 Modal Dose (Dmodal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
2.4.8 Hot Spots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
3. Recommendations for Reporting. . . . . . . . . . . . . . . . . . . . . . . . .. 27
3.1 Introduction............................................ 27
3.2 General Recommendations for Reporting Volumes .. ..... ... 27
3.2.1 Gross Tumor Volume. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27
3.2.2 Clinical Target Volume. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27
3.2.3 Planning Target Volume. . . . . . . . . . . . . . . . . . . . . . . . . .. 27
3.2.4 Treated Volume. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27
3.2.5 Irradiated Volume. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 28
3.3 General Recommendations for Reporting Doses. . . . . . . . . . . .. 29
3.3.1 The ICRU Reference Point. . . . . . . . . . . . . . . . . . . . . . . .. 29
3.3.2 The ICRU Reference Dose. . . . . . . . . . . . . . . . . . . . . . . . .. 33
3.3.3 The Dose Variation Throughout the Planning Target
Volume......................................... 33
3.3.4 The Three Levels of Dose Evaluation for Reporting. . .. 33
3.3.4.1 Level 1: Basic Techniques .................. 33
3.3.4.2 Level 2: Advanced Techniques. . . . . . . . . . . . . .. 33
3.3.4.3 Level 3: Developmental Techniques. . . . . . . . .. 33
3.4 A Single Planning Target Volume . . . . . . . . . . . . . . . . . . . . . . . .. 34
3.4.1 Simple Beam Arrangements. . . . . . . . . . . . . . . . . . . . . . .. 34
3.4.2 Complex Beam Arrangements. . . . . . . . . . . . . . . . . . . . . .. 34
3.5 Complex Treatments With More Than One Planning Target
Volume. .. ........... ....... . . ........ . . ...... . ....... 36
3.5.1 Introduction...................................... 36
3.5.2 Adjacent Planning Target Volumes. . . . . . . . . . . . . . . . .. 36
3.5.3 Overlapping Planning Target Volumes. . . . . . . . . . . . . .. 36
vii
viii ... Contents
3.5.3.1 At levell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 36
3.5.3.2 At levels 2 and 3 . . . . . . . . . . . . . . . . . . . . . . . . . .. 38
3.6 Organs at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 38
3.7 Hot Spots. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 38
Appendix I. Minimum Requirements for Documentation and
Recommendations for Description of
Technique for Reporting. . . . . . . . . . . . . . . . . . . . .. 39
1.1 Minimum Requirements for Documentation . . . . . . . . . . . . . . .. 39
1.2 Description of Treatment Techniques, Including Methods for
Planning, Dose Calculation and Control, for the Purpose of
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

1.2.1 Treatment Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
1.2.2 Technique... . ....... . ...... . ...... . .. .. ....... . . . . 44
1.2.3 Absorbed Dose Calculation. . . . . . . . . . . . . . . . . . . . . . . . .. 47
1.2.4 Quality Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 47
1.2.5 Special Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Appendix II. Examples of the Use of the Recommendations
in Some Different Beam Arrangements . . . . . .. 49
Appendix III. Relative Merits of Central Dose, Minimum
Dose, and Average Dose for Reporting. . . . .... 64
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 66
ICRU Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 67
Index .. .. . . . . .. ... .. . . .. .... . . .. . .. .. . .... .... . .. .... .. . . . . ... 71
Prescribing, Recording, and
Reporting Photon BealD.
Therapy

1. Introduction
When treating a patient with radiotherapy, the d. to enable the results of the department's treat-
radiation oncologist normally prescribes doses 1 to ments to be meaningfully compared with those
both the malignant disease and to relevant normal of other centers without having access to the
tissues. The therapist also records doses delivered complete, original data. This is particUlarly im-
during treatment within various volumes or at vari- portant in m'ulti-center studies, in order to keep
ous points in the tissues for the purpose of documen- treatment parameters well-defined, constant,
tation. Doses will also have to be specified for the and reproducible.
purpose of reporting. The recommendations in this It will be noted that all of these functions, except
report are intended to be applicable to most clinical the first are intended to facilitate communication. In
situations, past or present, and to most radiotherapy fact, there is little purpose in reporting the treatment
centers. if the data cannot be interpreted by other workers in
Specification of volume(s) and dose(s) has to be the field. It is, therefore, considered essential to adopt
done for different purposes: a common method for recording and reporting. The
(a) for prescription, recommendations given here, however, will give some
(b) for recording (to be included in the treatment freedom to the radiation oncologist to use different
chart), methods to prescribe the dose, but the prescription,
(c) for reporting. recording, and reporting should be unambiguous.
In principle, prescriptions, records and reports of The outcome of treatment can only be interpreted
radiotherapeutic procedures should be as complete meaningfully if the parameters of the irradiation, in
and accurate as possible and should contain adequate particular the distribution of dose in space and time,
and explicit information on the patient's disease, the can be accurately correlated with the clinical and
volumes irradiated, the physical parameters and tech- pathological extent of the disease.
nique of irradiation, the overall treatment time and However, this obvious statement is still far from
the fractionation scheme. In some situations, factors being realized in practice. Many radiation oncologists
additional to those listed may be considered to have and physicists are so used to the style and conven-
clinical implications and should, therefore, be re- tions in their own departments that they would be
corded and possibly reported as well. shocked to learn that their treatment reports were
Such specifications serve a number of purposes: ambiguous, uncertain, or even incomprehensible, to
a. to enable the radiation oncologist to maintain a others. Unfortunately, there is substantial evidence
consistent treatment policy and improve it in
that this is often the case. It is not uncommon for the
the light of experience;
reporting of a treatment to be insufficiently explicit
b. to enable the radiation oncologist to compare
and without adequate details to enable the treatment
the results of treatment with those of departmen-
to be repeated or evaluated without having recourse
tal colleagues;
to the center of origin for further information.
c. to enable other radiation oncologists to benefit
While a complete description of the data relating to
from the department's experience;
each patient is clearly desirable, in practice, the
amount of information that can be reported in many
1 If not otherwise stated, in this report dose is taken to imply situations, e.g., in a published paper, is limited.
absorbed dose. Furthermore, complete information for each patient,
1
2 ... 1. Introduction
including extent of the disease and a full individual ated by beams of x or gamma rays in radiotherapy
dose distribution, is not always available. One is, procedures, and defined a number of terms of impor-
therefore, faced with the problem of selecting a tance in these procedures. Definitions of certain
minimum set of data for recording and for reporting, terms and concepts used in radiotherapy as well as
that will be the most relevant for assessing the results recommendations for dose specification in reporting
of treatment. external beam therapy with photons and electrons
It is expected that the rapid development of new were given in a third ICRU report (Report 29 [ICRU,
techniques for the acquisition of patient data (e.g., 1978]), and in a fourth report (Report 38 [ICRU,
computed tomography, magnetic resonance imaging, 1985]), recommendations were given on dose and
nuclear medicine imaging, and ultrasonography), and volume specifications for reporting intracavitary ther-
the use of image handling systems will increase the apy in gynecology. The radiation dosimetry of elec-

complexity of radiotherapy, and this will emphasize tron beams with energies between 1 and 50 MeV was
the need for general, strict guidelines. It is equally described in Report 35 [ICRU, 1984]. The use of
important that recommended criteria are maintained computers in external beam radiotherapy with high-
whether the treatment is a basic or complex one. So energy photons and electrons was analyzed in Report
the methods of reporting dose should be almost 42 [ICRU, 1987].
independent of the aim of therapy, of the treatment It is now over a decade since Report 29 [ICRU,
technique, of the anatomical information, and of the 1978] was published and it has become clear that
computation facilities and methods employed. further interpretation of the concepts and more
The need for selecting a subset of data is high- guidelines for the application of the recommenda-
lighted by the growing use of computerized systems tions have become necessary in order for it to be used
for acquisition and recording of patient data and more widely. Furthermore, the expanding use of
planning of treatment procedures. The information computers in radiotherapy, allowing for inter alia a
recorded in these systems is becoming more exten- more proper evaluation of three-dimensional dose
sive. We are thus getting more and more information distributions, has changed the clinical practice. There-
about the treatments, and this should improve our fore, it was felt appropriate to update the recommen-
understanding of the results of treatment, providing dations given in 1978, and this is the purpose of the
the input and output data are valid and unambiguous. present report. It largely repeats the previous recom-
The ICRU has found it important to issue a series mendations, but some definitions and recommenda-
of reports on delivery and specification of doses. Thus, tions have been clarified or modified (e.g., definitions
an earlier ICRU Report (Report 23 [ICRU, 1973]) on volumes, Section 2.3., and general principles for
described the measurement of dose in a phantom target dose specification, Section 3). The recommenda-
irradiated by a single beam of x or gamma rays. A tions apply to reporting but they are useful in all steps
second ICRU report (Report 24 [ICRU, 1976]) de- of the radiotherapy procedure. It is hoped that they
scribed the determination of dose i'n a patient irradi- will be adopted in day-to-day practice.
2. Definitions of Terms and Concepts
2.1 The Different Steps in the Radiotherapy Recording of parameters related to the treatment
Procedure (see Appendix I, Table 1.1.) should be possible during
the whole treatment procedure, as indicated in Fig.
The decision to use radiotherapy as a treatment
2.1., and a summary should be made in an unambigu-
modality must be based on adequate clinical work-up
ous way.
including confirmation of the histological diagnosis, Reporting of the treatment should be unambiguous
staging, etc. In the radiotherapy process, different and sufficiently detailed to fulfil the statements al-
steps then have to be taken successively, as illus- ready given in the introduction (Section 1). The
trated in Fig. 2.1. radiation oncologist and physicist have, in contrast to
The specification of volumes and doses serves three

when prescribing, no freedom when reporting basal
different purposes, namely: data on volumes and doses. Recommendations for
for prescribing therapy, reporting the different parameters are given in Sec-
- for recording therapy (documentation), tion 3, and different aspects of these are dealt with in
- for reporting therapy. Appendix I.
Prescription of the radiation treatment includes a
statement of the aim of therapy (Section 2.2), the
definition of volumes (Section 2.3) and the specifica- 2.2 Aim of Therapy
tion of doses (Section 2.4) that are prescribed as well A. Radical Treatment of Malignant Disease. The
as other treatment parameters, e.g. , fractionation. aim of radical radiotherapy ("curative radio-
Prescription of the treatment is a clinical decision, therapy" ) is to decrease the number of tumor
based on the judgement and experience of the radia- cells to a level that achieves permanent local
tion oncologist for the given type of disease and tumor control. The volumes to be irradiated
clinical situation. The prescribed dose depends on the have to include any demonstrated tumor, and
aim of therapy (tumor eradication or palliation). also volumes in which subclinical spread is
However, the tolerance of surrounding normal tis- expected at a given level of probability. These
sues will also have to be taken into account and this different volumes will often have to be irradi-
could modify the prescribed dose. The prescribed ated to different dose levels. In the radical
dose, with acceptable dose variation, should be deliv- treatment of malignant disease, anatomical tu-
ered to each defined tissue volume of interest. A mor limits thus mayor may not be demonstra-
provisional prescription of treatment should be per- ble. When the tumor has been previously re-
formed at the time of the decision to use radiother- moved (e.g. , by mastectomy or hysterectomy),
apy. When a standardized treatment technique is to the remaining tissue may contain subclinical
be used (e.g., according to the department's policy, or disease, the limits of which cannot be demon-
according to a protocol), it is often possible to have a strated clinically.
sufficient knowledge of the probable final dose distri- B. Palliative Treatment of Malignant Disease. The
bution for this provisional prescription to remain aim of palliative radiotherapy is to decrease
unchanged during the planning process. However, symptoms (e.g., pain) of the malignant disease.
this is not always the case, and then the prescription The palliative treatment of malignant disease
has to be modified during treatment planning (feed- may include all or only part ofthe demonstrated
back procedure). tumor (e.g. , irradiation of the spine for a painful
If the intent of therapy is changed, e.g. , from radical deposit in a case of wide-spread metastases).
to palliative (Section 2.2), then it may well turn out C. Non-malignant Diseases. The radiotherapy of
that it is not meaningful to stay with the provisional non-malignant conditions mayor may not in-
prescription, and the final prescription may well have clude all of the affected tissues (e.g., irradiation
to be modified from the provisional one. of dermatoses) .
The radiation oncologist should have the freedom The recommendations in this report are based on
to prescribe the parameters in his / her own way, situation A, but are, in principle, also applicable to
mainly using what is current practice to produce an situations Band C.
expected clinical outcome of the treatment. The pre-
scription should, however, always be unambiguous
2.3 Volumes
and comprehensible to all of the staff in the depart-
ment, and it should allow for a later specification for The process of determining the volumes for the
recording and for reporting. treatment of a malignant disease consists of several
3
4 ... 2. Definitions of Terms and Concepts
,--
Complete clinical work-up
(site and extent of tumor, stage,
Record ~
morphologic type etc.)
D
Decision on external beam ::

therapy and prescription of treatment It---- Record ~ 0
Localization-simulation
C
Acquisition of additional anatomical 1+--- Record ~
data for dose planning

Delineation of volumes Record ~
M
Provisional selection of beam
arrangements and computation of
corresponding dose distribution
E
Comparison of dose distributions and

selection of optimal treatment plan N
Full cofTllutation and display of the

selected treatment plan 1+---
Record ... T
A
Verification-simulation Record ~
Set-up at the therapy machine ~

T
Record
Treatment
Verification Record .. I
Follow-up Record .. 0
'==
Fig.2.1. Steps in the radiotherapy procedure. NB: There should be a continu ou s feed-back between all the different steps. A difficulty at a
given point may question all the decisions made at previous steps.
distinct steps. Different volumes may be defined, During the treatment planning process, other vol-
often with varying concentrations of demonstrated or umes have to be defined:
suspected malignant cells. Furthermore, consider- - Planning Target Volume (PTV).
ations have to be given to probable changes in the - Organs at Risk.
spatial relationship between the volume(s) and ther- As a result of treatment planning, further volumes
apy beam(s) during treatment, viz., movements of the can be described. These volumes are:
tissues/ patient, and to possible inaccuracies in the - Treated Volume.
treatment set-up. - Irradiated Volume.
Two volumes should be defined prior to treatment Further details are given below.2 A schematic pre-
planning. These volumes are:
Gross Tumor Volume (GTV). 2 Throughout, in the following, the singular (e.g., CTV) will also
- Clinical Target Volume (CTV). include the plural (e.g., CTVs).
2.3 Volumes ... 5
sentation of the different volumes is shown in Fig. tumor with decreasing density towards the periphery.
2.2. The GTV and its local margin for subclinical disease
Acquisition of additional anatomical data besides constitute a Clinical Target Volume (CTV) (e.g., CTV
the diagnostic information may be needed, and should I).
be obtained with the patient under treatment condi- If the tumor has been removed prior to radiother-
tions. Such further information could be CT -scans or apy, no Gross Tumor Volume can be defined.
orthogonal x-ray films in the treatment position. Additional volumes which do not contain demon-
The palpable or visible extent of the malignant strable tumor but with suspected malignant cells,
tumor (evaluated also by different imaging tech- may also be considered for therapy (e.g., regional
niques) constitutes the Gross Tumor Volume (GTV). lymph nodes and their volumes for subclinical spread).
Usually, depending on tumor site and diagnostic These volumes with only subclinical disease also
methods, this volume corresponds to the part of the constitute Clinical Target Volumes (e.g., CTV II,

disease where the malignant tumor cell concentration etc.).
is at its maximum. The delineation of the Gross Tumor Volume and
Next, a margin has to be added around the Gross the Clinical Target Volume are based on purely
Tumor Volume to include direct, local subclinical anatomic-topographic and biological considerations
spread. This volume surrounding the GTV often has without regard to technical factors of treatment.
a high tumor cell density close to the demonstrated For radiation treatment planning and for adequate
==4---4---1-- Gross tumor volume
<I---I-.J..---I-- Clinical target volume
~.J..---I-- Planning target volume
1---1-- Treated volume
Irradiated volume
Fig. 2.2. Schematic illustration of the different volumes.

Gross Tumor Volume (GTV) denotes the demonstrated tumor.
Clinical Target Volume (CTV) denotes the demonstrated tumor (when present) and also volumes with suspected (subclinical) tumor (e.g.,
margin around the GTV, and e.g., regional lymph nodes, NO (according to the TNM-classification [VICC, 1987]), considered to need
treatment). The CTV is thus a pure anatomic· clinical concept.
Planning Target Volume (PTV) consists of the CTV(s) and a margin to account for variations in size, shape, and position relative to the
treatment beam(s). The PTV is thus a geometrical concept, used to ensure that the CTV receives the prescribed dose, and it is (like the
patient/tissues concerned) defined in relation to a fixed coordinate system. Note that in the example shown the magnitude of foreseen
movements of the CTV is different in different directions.
Treated Volume is the volume that receives a dose that is considered important for local cure or palliation.
Irradiated Volume is the volume that receives a dose that is considered important for normal tissue tolerance (other than those specifically
defined for organs at risk).
treatment set-up, margins have to be added around include not only the GTV but also volumes with
the Clinical Target Volume to account for variation in suspected, subclinical disease, and, furthermore, it
size and position of tissues relative to the treatment was previously also defined to include margins for
beams, due to, e.g., patient movement, respiration, expected variations in shape, size, and position of the
changes in size and internal position of the Clinical demonstrated tumor and/or subclinical disease, as
Target Volume and to variation in the daily set up due well as variations in patient set-up and beam sizes
to technical and other factors. This volume, which and orientation. There are reasons to differentiate
takes into account both anatomical/biological factors between, on the one hand, considerations taking into
and treatment reproducibility factors, is the Planning account purely oncologic/biological factors (Clinical
Target Volume (PTV). Target Volume [CTV]) , and, on the other hand,
margins taking into account the reproducibility of

different anatomical/technical factors in treatment
2.3.1 Gross Tumor Volume (GTV) set up (Planning Target Volume [PTV]) (see 2.3.3). A
From the origin of medical terminology the word detailed analysis of the problem was given by Goitein
tumor (latin tumor) was used to designate a swelling, (1985).
which could be of different natures. Clinical experience indicates that around the GTV
The Gross Tumor Volume (GTV) is the gross pal- there is generally subclinical involvement, i.e., individ-
pable or visible / demonstrable extent and location of ual malignant cells, small cell clusters, or microexten-
malignant growth. sions, which cannot be detected by the staging proce-
The GTV may consist of primary tumor, metastatic dures. The volume surrounding the macroscopic
lymphadenopathy, or other metastases. The GTV tumor has usually a high tumor cell density close to
corresponds usually to those parts of the malignant the edge of the GTV with decreasing density towards
growth where the tumor cell density is largest. No the periphery of this volume (often a margin of about
GTV can be defined if the tumor has been removed, 1 cm). The GTV together with this surrounding
e.g., by previous surgery. volume of local subclinical involvement is now de-
The shape, size, and location of the GTV may be fined as a Clinical Target Volume (CTV). This CTV
determined by means of different diagnostic methods will usually be denoted CTV I.
such as clinical examination (e.g., inspection, palpa- The delineation of a CTV is thus based on purely
tion, endoscopy), and various imaging techniques anatomic-topographic and biological considerations
(e.g., x-ray, CT, DI, US, MRI, and radioisotope meth- without regard to movement of the tissues/patient or
ods). The methods used to determine the GTV should technical factors, and it should be described in ana-
meet the requirements for staging the tumor accord- tomic-topographic terms.
ing to the clinical TNM (UICC, 1987), and (AJCCS, Additional volumes with presumed subclinical
1988), and the definition of the G"I:V is then in full spread (e.g., regionallymphnodes) may also be consid-
agreement with the criteria used for the TNM- ered for therapy. They are also defined as Clinical
classification. Target Volumes, and may be designated CTV II, CTV
The GTV (primary tumor, metastatic lymphadenop- III, etc.
athy, other metastases) may seemingly be different in The Clinical Target Volume (CTV) is a tissue
size and shape, sometimes significantly, depending on volume that contains a demonstrable GTVand/or
what examination technique is used for evaluation subclinical microscopic malignant disease, which has
(e.g., palpation versus mammography). The therapist to be eliminated. This volume thus has to be treated
should, in each case, therefore, indicate which meth- adequately in order to achieve the aim of therapy, cure
ods have been used for evaluation and for definition of or palliation.
the GTV. In external beam radiotherapy, the Clinical Target
There are at least two reasons to identify the GTV. Volume (CTV) is a tissue volume that has to be
Firstly, an adequate dose must be delivered to the irradiated to a specified dose according to a specified
whole GTV in order to obtain local tumor control in dose-time pattern.
radical treatments. Secondly, identification is neces- If different doses are prescribed, this implies the
sary to allow for recording of tumor response in definition of different CTVs for different dose levels.
relation to the dose and its variation, and to other Thus, for any given situation, there is often more
relevant factors. than one CTV. One situation can be illustrated by
considering a primary tumor and its regionallymphat-
ics separately (e.g., in breast saving procedures where
2.3.2 Clinical Target Volume (CTV)
the breast and regional lymphatics are separated
In the previous recommendations (Report 29, anatomically). In other situations, the aim is to treat
[ICRU 1978]), the "Target Volume" was defined to two CTVs to different dose levels ("boost" therapy),
2.3 Volumes ... 7
where the "high-dose" volume (often containing the CTV (e.g., with respiration), as well as move-
GTV) is located inside the "low-dose" volume. ments of the patient,
In some cases, a dose gradient over a volume may variations in size and shape of the tissues that
be wanted and this gradient may be either continuous contain the CTV (e.g., different fillings of the
or step-wise. The decision to prescribe different dose- bladder),
levels or dose-gradients is based on an estimate of variations in beam geometry characteristics
variations in tumor cell densities in different volumes (e.g., beam sizes, beam directions).
or along different lines. This leads to the concept of the Planning Target
In practice, the delineation of a CTV will require Volume (PTV).
consideration of factors such as the local invasive The Planning Target Volume is a geometrical
capacity of the tumor and its potential to spread to, concept, and it is defined to select appropriate beam
e.g., regional lymph nodes. Consideration may also sizes and beam arrangements, taking into consider-

need to be given to the presence of any specially ation the net effect of all the possible geometrical
radiosensitive normal tissue (Organs at Risk, Section variations, in order to ensure that the prescribed dose
2.3.6) as well as to other factors such as the general is actually absorbed in the CTV.
condition of the patient. The PTV is related to the beam(s) through a fixed
If there is a change in the size, shape, and location coordinate system (e.g., couch top or laser planes
of a CTV during treatment (e.g., shrinkage of a tumor through a tatoo or a bony landmark).
during therapy, or the addition of further diagnostic The PTV is used for dose planning and for specifica-
data), there may be a need for re-planning. tion of dose. Therefore, the PTV has to be clearly
It must be clearly recognized that volumes are indicated on the s.ections used for dose planning. The
treated, even if representations of volumes usually dose distribution to the PTV has to be considered to
are given only in two dimensions, or linearly. For be representative of the dose to the CTV.3
documentation and retrieval, it is an advantage if the Note that the definition of Planning Target
different parts of the CTVs are codified according to Volume is identical to the previous (Report 29,
an internationally recognized system (e.g., lCD, or [ICRU 1978]) definition of "Target Volume."
SNOMED, see Section 3.2.2 and Appendix I). The two concepts are thus synonymous.
Depending on the clinical situation (e.g., patient
The definitions of the GTV and CTV are thus
condition and site of the CTV) and the chosen tech-
entirely based on general oncologic principles, and are
nique, the PTV could be very similar to the CTV (e.g.,
not limited to external beam therapy. Thus, in sur-
in the case small skin tumors, pituitary tumor), or by
gery, a safety margin is taken around the gross tumor
contrast, much larger (e.g., lung tumors). The PTV
according to clinical judgement, and this implies the
may surpass normal anatomical borders (e.g., it may
same use of the Clinical Target Volume concept as in
include parts of clinically unaffected bony struc-
external beam therapy. Also, in brachytherapy, vol-
tures), or even extend into the air (e.g., in a case of
umes to be irradiated are defined, and thus the
tangential irradiation of a breast).
concept of CTV is valid. Furthermore, the concept can
The Planning Target Volume is thus a static,
be applied to other modalities, e.g., regional chemo-
geometrical concept, used for treatment planning.
therapy, hyperthermia, and photocoagulation.
The PTV does not, in fact, exactly represent defined
For external beam radiotherapy, additional vol-
tissues or tissue borders. Actually, the tissues con-
umes have to be defined, as given below.
tained geometrically within the PTV may not truly
receive the planned dose distribution, at least not in
some parts close to its border. This is due to the
2.3.3 Planning Target Volume (PTV) variation in position of the CTV within the bound-
To ensure that all tissues included in the Clinical aries of the PTV during a course of treatment.
Target Volume receive the prescribed dose, one has, However, the PTV is the volume that is used for dose
in principle, to plan to irradiate a geometrically larger calculation and for specification of target dose (see
volume than the CTV. Ideally, the position, shape, Section 3).
and size of the CTV and of the treatment beams An example of Gross Tumor Volume, Clinical Tar-
should be related to a common fixed coordinate get Volume and Planning Target Volume for a patient
system in a reproducible way. However, in practice, with a carcinoma ofthe bronchus is shown in Fig. 2.3.
this will not be possible to achieve, and intrafrac- When defining the PTV for a given CTV, one has to
tional as well as interfractional variations in this
respect may be foreseen due to a number of factors 3 Note that the penumbra is not included in the PTV. The
such as: ' penumbra has to be taken into account separately when selecting
- movements of the tissues which contain the beam sizes.
8 .. . 2. Definitions of Terms and Concepts
Fig. 2.3. Example of Gross Tumor Volume (GTV), Clinical Target Volumes (CTVs), and Planning Target Volume (PTV) for a patient
with a bronchial carcinoma, T3 NO MO (according to the TNM-classification [VICC, 1987]) of the right lung .
•
Fig.2.3.a. One frontal chest radiograph and one transverse CT-section at the level of the centre of the demonstrated tumor are shown,
and considered here to represent the true three-dimensional situation. Structures above and below the transverse section are projected into
the section.
make an estimation of the overall importance of the etc. Also, consideration has to be given to the fact that
possible variations in relation to the selected beam most imaging techniques used for dose-planning
arrangement, considering, furthermore, anatomical (mainly x-ray diagnostic procedures) actually show
location, the use of patient immobilization devices, the situation in seconds or fractions of a second, and
2.3 Volumes •.. 9
I,

,
Fig.2.:I.b. The demon5trnted tumor in the right hilar region extending into the lung tissue. but not involving the chest wall is the CT\'.
and is shown by the strioted area.
not the whole integrated situation during the actual margins, resulting in unnecessary side·effects. Some
treatment (= exposure time for a s ingle treatment of the movements and variations previously listed
fraction). could systematically deviate at the time of the irradia-
It is not recommended that all uncertainties due to tion compared to the planning process. Other u ncer-
the movements and spatial variations be added lin- tainties may vary at random. It is desirable to have
early because this would probably lead to too large detailed estimation of all these spatial uncertainties.
10 .. . 2. Definitions of Terms and Concepts
II
Fig.2.3.c. A margin is added around the GTV to include presumed local subclinical involvement around the demonstrable tumor, due to
individual malignant cells, small cell clusters, or microextensions, which can not be detected clinically. This constitutes the CTV I, and is
shown by the broken line.
However, the information that can be obtained is standard deviations, the combined effect can be esti-
usually limited, and they can only be estimated. If the mated. The total standard deviation is then the root
random uncertainties are normally distributed and of the square sum of random and systematic uncer-
the systematic uncertainties are estimated by their tainties.
2.3 Volumes ... 11

,
Fig. 2.3.d. There wer(l no mediustinal lymph node metastases that could be demonstrated by clinical investigations. However, the
medinstinallymph nodes us well liS the medial parts of the contralateral hilar region Ur<J considered to be at high risk. and to be trcuted for
subclinical disease liS CTV I I. shown by the broken line.
Treatment planning consists of the delineation of with respect to the technical factors ofthe irradiation ,
the Clinical Target Volume and the prescription of including select ion of beam arrangements, etc. Note
lhe Target Dose. Th is constitutes the pure medical that for a given CTV, t he PTV may vary sign ificantly
prescri ption, which must precede the integrated pro· with diffe rent beam arrangements.
cess of defining a proper Plann ing Target Volume A Clinical Target Volume may occasionally have to
If
Fig.2.3.e. The patient's condition did not allow for radical therapy, and the prescribed dose is the same (and relatively low) for both CTV
I and CTV II. The two CTVs will be treated with the same beams, and a re here shown joined.
be represented by 2 or more Planning Target Vol- sections is presented, the PTV should be clearly
umes. Such special situations are illustrated in Figs. indicated on the diagram (represented by an area in a
2.4. and 3.4. particular section). It is an advantage if the CTV is
When a dose distribution in one or more anatomical also shown (Figs. 2.3.f. and II.4.).
2.3 Volumes ... 13
Fig. 2.3.f. The geometrical relationship between the CTV and other relevant parts of the patient on one hand and the treatment beam(s)
on the other hand should be stable and not change during or between fractions. This relation should be correlated to a fixed coordinate system
related to a point in/at the patient (e.g., the sternal notch). However, in relation to the fixed coordinate system, the CTV will move, e.g., with
respiration, and the patient as a whole will not be perfectly immobilized during each fraction. Furthermore, there may be minor random
variations in the set up (positioning of the beams in relation to the fixed coordinate system, small variations in beam size and blockings, etc.).
Therefore, treatment has to be planned for a larger volume than the CTV, and a suitable PTV (indicated by the thick solid line) is defined for
treatment planning purpose and for dose recording and reporting. Note that in this example the PTV extends into healthy tissues (the chest
wall).

Fig.2.4.a. A case of recurrent carcinoma of the uterine cervix. The local tumor and the iliac nodes have to be irradiated and the rectum to
be spared. Two Planning Target Volumes are identified (hatched areas). The bony structures of the pelvis (dotted areas) , the bladder (8) and
the rectum (R) are represented. The treatment consists of a double arc therapy (180°) with a 10 MV linear accelerator (@ = the 2 axes of
rotation).
\
I
/
(
I
I
/ /
--// _}~....-_1.0
Fig. 2.4.h. The dose distribution correspond ing to the treatment described in Fig. 2.4.a. is shown. The following isodose curves are
drawn: 2.0, l.8, l.6, l.4, l.2, and l.0 Gy.
2.3 Volumes ... 15

Fig. 2.4.c. A case of advanced carcinoma of the prostate. The local tumour and the iliac nodes have to be irradiated and the rectum to be
spared. Four Planning Target Volumes are identified (thick full lines and hatched areas). The bony structures of the pelvis and femora
(dotted areas), the bladder (B), and the rectum (R) are represented (thin full lines). The treatment consists of a triple arc therapy with a 10
MV linear accelerator (@ = the 3 axes of rotation).
Fig.2.4.d. The dose distribution corresponding to the treatment described in Fig. 2.4.c. The following isodose curves are drawn: 2.0, 1.8,
1.6, 1.4, 1.2, and 1.0 Gy.
2.3.4 Treated Volume reduced, and the treatment plan has to be reevaluated
and, if necessary, even the aim of therapy may have to
Ideally, the dose should be delivered only to the
be reconsidered.
PTV. However, due to limitations in radiation treat-
There are several reasons for identifying the Treated
ment technique, this goal cannot be achieved, and
Volume. One reason is that the shape and size of the
this leads to the definition ofthe Treated Volume.
Treated Volume relative to the Planning Target
The Treated Volume is the volume enclosed by an
Volume is an important optimization parameter.
isodose surface, selected and specified by the radiation
Another reason is that a recurrence within the Treated
oncologist as being appropriate to achieve the purpose
Volume but outside the Planning Target Volume may
of treatment (e.g., tumor eradication, palliation).
be considered to be a " true," " in-field" recurrence
When the minimum target dose envelope is se-
due to inadequate dose and not a "marginal" recur-
lected as appropriate, the Treated Volume may, in

rence due to inadequate volume.
some cases, closely match the Planning Target Vol-
ume, but in other cases, the Treated Volume may be
considerably larger than the Planning Target Vol-
2.3.5 Irradiated Volume
ume. Examples of different Treated Volumes with
different techniques for the same Planning Target The Irradiated Volume is that tissue volume which
Volume are given in Fig. 2.5. receives a dose that is considered significant in rela-
If, however, the Treated Volume turns out to be tion to normal tissue tolerance.
smaller, or not wholly enclosing the Planning Target The Irradiated Volume depends on the treatment
Volume, then the probability of tumor control is technique used.
Fig. 2.5. Examples of four different Treated Volumes resulting from irradiating the same Planning Target Volume (indicated by the
dotted area) with four different treatment techniques. In all cases, the Treated Volume is defined by the 95% isodose curve (..... ), and, in
addition, the 20% isodose (- -) is given as representing the Irradiated Volume. The geometrical limits of the beams are indicated by
(- ' - ' - ).
The following ratios can be observed between the respective areas of the Planning Target Volume (1.0), the Treated Volume, and the
Irradiated Volume:
a. 1.0 : 2.4 : 4.6
b. 1.0 : 1.9 9.0
c. l.0 1.4 9.0
d . l.0 l.1 : 1l.0
(-
.....-- - -----
Il I \
\I \. : : « <» <::: : i \I
~ ~:::::::::::::::::: :::::::::: :::::::::1 1/
1\J(18:~ I
/1 : ,\
I \ :I
.
1\
1\ \ I
\.
-------- J
Fig. 2.5.a. Two opposed equally weighted beams.

2.3 Volumes •.. 17

\
/'
/ '" "'. \
/
/
Fig. 2.5.h. Three beams.
~=-:-==-:-=~-LI _~ _-=~._I . ==-.. =._.

1,1 :(\1 1 1IJ.;. ;.~.;. .:.I}'-t-J +-;_-\--_ _ _....::...----_ _ _ _\ _~
. \95
.....
· .............-:-:.:-:..
........ . . -J ..
.-
.. 20
----l,--+--=-===-= J
--------
~- .-= . . = - . - ,=:
.-._.
. _._ .
\
I
Fig. 2.5.c. Four beam box technique.
---
--- --- -

\
\
t
/
Fig. 2.S.d. Moving beam therapy; large arc.
The comparison of the Treated Volume and the 2.4 Absorbed Dose Distribution
Irradiated Volume for different beam arrangements
The prescription of radiation treatment includes a
can be used as part of the optimization procedure as
definition of the aim of therapy and volumes to be
illustrated in Fig. 2.5.
considered, as described in Sections 2.2. and 2.3., and
If the Irradiated Volume is reported, the significant
also a prescription of dose and fractionation.
dose level must be expressed either in absolute values
A provisional dose prescription is usually made at
or relative to the specified dose to the PTV.
the same time as the decision to use radiotherapy is
made and the volumes to be considered are specified.
When a standardized treatment technique is used
2.3.6 Organs At Risk (e.g., in a protocol), it is often possible, at the time of
prescription, to have sufficient knowledge of the final
Organs at risk are normal tissues whose radiation
dose distribution that there is no need to change the
sensitivity may significantly influence treatment plan-
prescription due to factors that may emerge during
ning and/or prescribed dose.
dose planning. However, in non-standard individual-
As is the case when defining the Planning Target
ized treatments, it may not be possible to achieve the
Volume, any possible movement of the organ at risk
prescribed doses in the selected volumes. This may be
during treatment, as well as uncertainties in the set
due, for instance, to high dose to organs at risk. The
up during the whole treatment course, must be
final dose prescription will then have to be modified
considered.
from the provisional one.
Estimations of dose limits for normal tissues under
Different concepts needed for reporting are defined
different conditions have been tabulated by, e.g.,
below. Recommendations for reporting are given in
Rubin (1975), and further elaborated by Brahme et
Section 3.
al. (1988). Organs at risk may be divided into three
different classes:
Class I organs: Radiation lesions are fatal or re-
2.4.1 Dose Variation in the Planning Target
sult in severe morbidity.
Volume
Class II organs: Radiation lesions result in moder-
ate to mild morbidity. When the dose to a given volume has been pre-
Class III organs: Radiation lesions are mild, tran- scribed, then the corresponding delivered dose should
sient, and reversible, or result in be as homogeneous as possible. Indeed, due to the
no significant morbidity. steep slopes of the dose-effect-relationships for tumor
2.4 Absorbed Dose Distribution ... 19

Fig. 2.6.a. Section at the level of Th V in a case of mammary carcinoma. The Planning Target Volume is indicated by the dotted area.
Note that it extends slightly outside the surface of the skin over the breast in order to safeguard against variations in the position of the
breast due to breathing and beam positioning variations.
Tangential irradiation using two opposed equally weighted 6 MV photon beams. The isodose distribution has been normalized to the dose
midway between the beam entrances and on the central axes of the beams.
Area, cm 2 Area, cm 2
800
600
400
200
20 40 60 80 100
Dose, % Dose, %
Fig. 2.6.h. Dose-area histograms for the same patient as in Fig. 2.6.a.
i. frequency dose-area histogram (left) for the PTV.
ii. cumulative dose-area histogram (right) for the whole section.
(Modified from Report 42 LICRU, 1987]).
control, the outcome of treatment cannot be related structures of importance (e.g., bony landmarks). For
to dose if there is too large a dose heterogeneity. this purpose, a series of parallel transverse planes or
Furthermore, any comparison between different pa- orthogonal planes or other presentations may be
tient series becomes difficult, or even impossible. used. Usually, at least a plane through the centre of
However, even if a perfectly homogeneous dose distri- the Clinical Target Volume or Planning Target Vol-
bution is, in principle, desirable, some heterogeneity ume is used, but often, several sections are necessary
has to be accepted due to obvious technical reasons. in order to display the full topography and dose
Thus, when prescribing the treatment, one has to distribution.
forsee a certain degree of heterogeneity, which today In some situations, only one section may be used
in the best technical and clinical conditions should be for dose planning (Fig. 2.6.a.). In doing so, one is
kept within +7% and -5% of prescribed dose (Witt- forced to assume that all structures through which

kamper et al., 1987, Brahme et al., 1988, Mijnheer et the section passes have a cylindrical shape. This
al., 1987). assumption is, in most cases, an over-simplification
If such a degree of homogeneity cannot be achieved, and should be used with great care (Fig. 2.7.).
it is the responsibility of the radiation oncologist to Regardless of what type of section is used, the
decide whether this can be accepted or not. In fact, in extreme outlines of the CTV, organs at risk, the
some cases, a higher dose may be found in a part of tissue heterogeneities and anatomical reference points
the PTV where the highest malignant cell concentra- in the corresponding three-dimensional slice should
tion may be expected, especially within the GTV, and be projected onto the section. The section then con-
such a situation may even be of advantage. In such tains all the relevant information for the whole slice.
cases, the different dose levels in different volumes The isodose lines should be drawn according to
should also be reported. given recommendations (Report 42 [ICRU, 1987]).
For palliative treatments, and for subclinical dis- In many situations, the practice is to evaluate the
ease, a more heterogeneous dose distribution can dose-distribution only unidimensionally, e.g., along
more often be accepted than for radical treatments. the coinciding central axes of two opposing beams
(Fig. 2.8.), or at points on a single central axis at given
depths (Fig. 2.9.). Such procedures require, however,
that a full treatment plan be worked out for reference
2.4.2 Representation of a Spatial Dose purposes, and that the actual estimations only aim at
Distribution verifying if any substantial deviations from the refer-
It must always be borne in mind that radiotherapy ence plan exist in the actual patient.
is concerned with volumes. Patients have a three- The proliferation of computers for treatment plan-
dimensional shape, and so do Gross Tumor Volumes, ning purposes also allows for alternative ways of pre-
Clinical Target Volumes, Planning Target Volumes, senting dose variations as histograms. This usually
Organs at Risk, and tissue heterogeneities. means displaying the dose as a distribution-function
Thus, when evaluating a dose distribution, the or frequency-function over a specified volume (area)
variation within a defined volume must be taken into (dose-volume/area histogram) (Fig. 2.6.b.). In addi-
account. Modern dose-planning systems are based on tion, different single values of dose are easily obtained.
CT cross-sectional images of the patient and should The following definitions of dose (Sections 2.4.3.-
have the capacity of handling fully three-dimensional 2.4.8) apply to dose calculations in a volume. When
topographic patient data as well as performing a fully calculated in a section, they are clinically relevant
three-dimensional dose calculation. Methods of pre- only if they can be assumed to represent the entire
senting results of calculation have been reviewed in three-dimensional situation.
Report 42 (ICRU 1987), and further developments in
the field are expected.
A full three-dimensional dose distribution can only 2.4.3 Maximum Dose (Dmax)
be inspected and visually evaluated on the screen of One can identify the maximum dose within the
the graphic's display unit. For the hard-copy documen- PTV, and the maximum dose at tissues outside the
tation of an isodose distribution, only two-dimen- PTV (e.g., at Organs at Risk [2.3.6]), or Hot Spots
sional sections are meaningful in daily routine. For (2.4.8).
practical reasons, only a limited number of sections The maximum dose to normal tissues is of impor-
are used. These sections should be chosen in such a tance for limiting and for evaluating side-effects of
way that they illustrate as closely as possible the treatment. However, a significant tissue volume must
GTV, CTV, PTV, and organs at risk, and other be irradiated for the dose level to be reported as
2.4 Absorbed Dose Distribution . .. 21
Fig. 2.7. Figures to illustrate the elfe<:t of treatment planning based on one se<:tion only (left figure in each set) and a complcte set of
sections (n - 24, right row) in a patient with a central bronchogenic ca rcinoma. The Clinical Target Volume includes the mediastinal and
supraclavicular nodes. (By courtesy, I.·L. !.amm, Ph. D., Dept. of Radiation Physics, Lund!.

Fig. 2.7.s. & b. Sections used for defining volumes; in the 2 0 case a se<:tion th rough the central part of the GTV. and in the 3 0 case all
24 sect.ions, but here only the central. the most cranial and the most caudal sections are fully displayed in a gray-scale.
Fig. 2.7.c. & d. T he Gro!l/l Tumor Volume


. ' ig. 2.7.e. & r. Clinical Targt!l Volume. defined to include the nodes in both hilar regio ns. in the upper medili/ltinum and in both
supraclaviC1Jlar regions.
Fig. 2.7.g. & h . Clinical Target Volume and the len lung.
2.4 Absorbed Dose Distribution . .. 23

Fig. 2. 7.i. & j. Clinical Target Volume and both lungs.
Fig. 2.7.k. & I. Clinical Target Volume, both lungs, and spinal cord. as seen from behind.
Dose distribution
along central axis
% Absorbed dose /Gy
58
100 54
50

80
Beam # 1 Beam # 2
Weight, % Absorbed dose/Gy Weight, % Absorb ed dose/Gy
60 45
tOO ,--------,-------,------~ ~ 24
4 MV
99 22
. .~ ! 40
6~V_
53 ICRUI Midline ICRU 2
4MV Dl cm 20
-
8MV _
- - ., - - ---. 35
18
6 MV o = Distance betwee n entrance point s
52
96
95
8MV 30 - 16
51 14
25
94+----1----- 1-------+ 14 15 16 17
14 15 16 17
Di em Di em
-:::::--. --=-;--
Beam # 1 Beam # 2
Fig. 2.8. Example of a standard treatment technique with two opposed unequally weighted beams for irradiation of malignant glioma,
The prescribed dose in the center of the tumor-bearing hemisphere (lCRU Point 1) is 58 Gy, and in the center of the other hemisphere (ICRU
Point 2) 50 Gy, in order to irradiate presumed malignant growth across the midline.
The beam weight and corresponding total peak absorbed dose for each beam can be read from the two nomograms for different distances
between the beam entrances (D) and for different beam energies.
The resulting dose distribution along the central axis is also shown.
The case illustrates a quite complex situation (more than one prescribed dose, and unequally weighted beams ), where, with a detailed
analysis of the procedure as a basis, the routine work can be done in a greatly simplified but nevertheless standardized way.
2.4 Absorbed Dose Distribution ... 25
% 1.
100 5. 3.
4.
80 2.
60
40
20

eM.
10
--l
I I
I I
I I
I I
I
I
I
I
L EFT R IGH T
I
I
I
I
Fig. 2.9. Example of dose evaluation only along the central beam axis ("one-dimensional" dose evaluation). Treatment with a single 60CO
gamma beam at SSD 80 cm of a patient with painful vertebral metastases (patient prone, level L III). The beam size was selected to allow for
patient movement during treatment due to pain. Normalization at peak absorbed dose in the central beam ( = 100%).
For specification, the doses at the following points along the central beam axis were considered:
1. The dose at the most dorsal part of the spinal process of the vertebral body (= 98%).
2. The dose at the ventral surface of the vertebral body (= 65%).
3. The dose in the geometrical center of the whole vertebra (= midway between points 1 and 2) (= 81%).
4. The dose centrally in the vertebral body proper (= 73%).
5. The dose at the dorsal surface of the spinal cord (= 85%).
For reporting purposes, the dose at point 3 was not considered adequate, since this point is not within the proper bony structures. Instead,
the dose at point 4 was selected as ICRU Reference Dose. This dose was in a position where the bone destruction was most obvious. This dose,
together with the dose at point 1 and point 2, represent the Target Dose specified for reporting (= 73%, variation 98%-65% of peak absorbed
dose). The dose to the organ at risk (spinal cord) is 85%.
The figure illustrates a common clinical situation. Even when no isodose distribution is available, it is possible to state within certain
restrictions the PTV dose at an ICRU Reference Point and the dose variation as well as the dose to organs at risk.
maximum. For three-dimensional computation, a vol- equation:

ume is considered clinically meaningful if its mini-
mum diameter exceeds 15 mm. A smaller volume is, 1
in most cases, not relevant to normal tissue tolerance Daverage = N ~ Dij,k
for large organs such as lung, liver, kidney, skin, etc.
However, when other smaller organs are at risk, a
dimension smaller than 15 mm has to be considered where N is the number of lattice points, i is the
(e.g., eye, optical nerve, larynx, etc.). column index in this lattice, j is the row index, k is the
The Maximum Dose to the PTV, with the areal level index, and Di j ,k is the dose at the lattice point
volume restriction described above, has to be taken ij,k located inside the volume V.
into account for evaluating the homogeneity of the
dose distribution (part of the optimization criteria). 2.4.6 Median Dose (Dmedian)
When the maximum dose outside the PTV exceeds

the prescribed dose, then a "hot spot" can be identi- The Median Dose is the central value of the doses at
fied (see 2.4.8). all lattice points, when arranged according to magni-
tude.
2.4.4 Minimum Dose (Dmin ) 2.4.7 Modal Dose (D moda1 )
The minimum dose is the smallest dose in a defined The Modal Dose is the dose that occurs most
volume. frequently at lattice points in the volume concerned.
In contrast to the situation with the maximum There may be more than one modal dose value, which
absorbed dose (see 2.4.3), no volume limit is recom- then makes this concept useless for reporting pur-
mended when reporting minimum dose. pose.
The Minimum Planning Target Dose is the lowest NB: In order to determine the values of D average,
Dmedian, and D modaJ , a complete computer-based dose
dose in the Planning Target Volume.
distribution is required. This limits the universal use
of these concepts.
2.4.5 Average Dose (Daverage)4
2.4.8 Hot Spots
The determination of the average, the median and
modal doses is based on the calculation of the dose at In many situations, tissues outside the Planning
each one of a large number of discrete points (lattice Target Volume will receive a relatively large absorbed
points), uniformly distributed in the volume in ques- dose.
tion. A Hot Spot represents a volume outside the PTV
The Average Dose is the average of the dose values which receives a dose larger than 100% of the speci-
in these lattice points and can be' expressed by the fied PTV Dose.
As for the general rule about maximum dose (2.4.3.),
a hot spot is, in general, considered significant only if
4 In this report, the term average refers to the mathematical
the minimum diameter exceeds 15 mm. Ifit occurs in
mean. The reason for using the term average instead of mean is to a small organ (e.g., the eye, optic nerve, larynx), a
avoid confusion with " min." used as an abbreviation for minimum. dimension smaller than 15 mm has to be considered.
3. Recommendations for Reporting
3.1 Introduction Another coding system is the SNOMED (System-

atized Nomenclature of Medicine) (CAP, 1979) in
The aim of these recommendations is to promote
which the section on topography (T-SNOMED) con-
uniformity between radiotherapy centres, when re-
tains a suitable but rather complex code.
porting their treatments. It is, indeed, essential,
A comprehensive code for anatomical sites based on
when exchanging information, that the same type of
ICD-O(10) (WHO, 1990) is suggested in Appendix I,
treatment be reported in the same way from different
Table 1.2. A simple code for description of sections is
centers, using the same terminology and definitions.
suggested in Appendix I, Table 1.3.
These recommendations deal with volumes and
Schematic examples of how to utilize these coding
doses. They are valid for photon beams.

systems to describe volumes, viz., the Gross Tumor
Volume and Clinical Target Volume, for recording
and documentation purposes are given for four typi-
3.2 General Recommendations for Reporting cal clinical situations in Appendix I, Fig. 1.1.
Volumes For reporting purposes, however, a description in
plain language is recommended.
3.2.1 Gross Tumor Volume
The primary aim of the clinical work-up of a patient
with a malignant disease is to define the site of the 3.2.2 Clinical .Target Volume
primary tumor, its size and possible invasion of
The Clinical Target Volume is also a purely anatom-
adjacent structures, and to detect regional lymph
ical concept and can, in addition to any existing
node involvement and distant metastases. This stag-
tumor, be described as including structures with
ing procedure should result in an accurate assess-
clinically suspected but not proven involvement. Thus,
ment of the extent of disease. As this is a purely
the Clinical Target Volume cannot be defined a priori
anatomical concept, it can be accurately described in
in terms of a TNM or pTNM classification, but must
standard topographic terms, e.g., "tumor in the roof
be defined in plain topographic terms or according to
of nasopharynx with metastatic nodes in the sterno-
a corresponding code in conformity with the recom-
mastoid chain bilaterally in the neck." This consti-
mendations for GTV. Examples are to be found in
tutes the description of the Gross Tumor Volume.
Appendix I.
In many situations, a verbal description might be
too cumbersome, and, also, for the purpose of data
recording and analysis, a classification is needed. For
the purpose of recording and documentation, it might 3.2.3 Planning Target Volume
thus be necessary to codify this anatomical descrip- Since the Planning Target Volume is defined to
tion. take variations in size and position of the Clinical
There are several systems for coding anatomy. The Target Volume into account, it is a purely geometric
system probably most widely used at present for concept, and thus cannot be described in anatomic
describing the site of the primary tumor is Chapter 2 terms. The recommendations are that the PTV is
(Neoplasia) of the 9th edition of the ICD (Interna- described by giving the size of the margins around the
tional Classification of Diseases) (WHO, 1977). This CTV in all relevant directions. A desirable develop-
code can be supplemented by a TNM- or pTNM- ment could be the possibility of defining the PTV in
classification, indicating the extent of the malignant terms of coordinates in a patient related coordinate
disease (UICC, 1987, 1990). However, since the ICD system (Report 42 [ICRU, 1987]).
code was designed for the purpose of epidemiology
and health care statistics, it is not a pure topographic
descriptor, and has been modified for oncological
3.2.4 Treated Volume '
purposes in the ICD-O (WHO, 1976a, 1990) code. By
means of this code, it might be possible to describe the The definition of the Treated Volume is that vol-
Gross Tumor Volume and Clinical Target Volume in ume enclosed within a specified isodose envelope, and
most situations, but it does not allow for a sufficiently thus the description ofthis volume for reporting must
detailed description of a number of different struc- indicate which isodose level was selected or, prefera-
tures (e.g., lymph nodes) . Furthermore, laterality for bly, the corresponding absorbed dose value (Gy) and,
paired organs and structures must be indicated by a if possible, an estimation of the size of that volume
supplementary code. (cm 3 ).
27
28 ... 3. Recommendations for Reporting
TABLE 3. I-Summary of the recommendations for choosing ICRU Reference Point for dose specification for reporting treatments with
emphasis on simple beam arrangements. Note that for each situation the variation of dose (maximum and minimum dose) to the Planning
Target Volume will also have to be specified for reporting.
Location of ICRU Reference Point

Centrally in At specially
Type of Photon Beam Arrangement Planning Target Volume On beam axis selected points Illustrated by Figures
A single beam Recommended Recommended May be necessary" 3.l.a, 2.9

Two opposed equally weighted beams Recommended 3.l.b, 2.5.a, 2.6.a, ILl
Two opposed unequally weighted beams Recommended Recommended 3.l.c, 2.8
Two or more noncoaxial beams which all
intersect at a point Recommended 3.l.d, 3.l.e, 3.l.f, 2.5.b, 2.5.c
Moving beam therapy, large arc Recommended Recommended 3.l.g

Moving beam therapy, small arc Recommended 3.l.h
Several beams whose central axes do not
intersect at a point within the PTV, or
no central axis exists in the PTV Recommended Recommended 3.2, 3.3, 3.4
a For example, see Fig. 2.9 and Section 3.3.l.
3.2.5 Irradiated Volume absorbed dose value (Gy) should be given. Also, an
In conformity with the Treated Volume, the Irradi- estimation of the size of the volume (cm 3 ) should be
ated Volume is also defined by a specified isodose reported.
envelope and, for reporting purposes, the value of the An illustration of the variation in size of the
isodose chosen, or, preferably, the corresponding Treated Volume and Irradiated Volume with differ-
Fig.3.1. Examples ofICRU Reference Points (e) for dose specification, and the dose variation in the PTV from maximum (*) to minimum
in typical simple beam arrangements. The Planning Target Volume is represented by the striated areas.
8MV Xrays
ANT
~
BEAM =#= 1 10cm x10cm
RIGHT LEFT
50
10 10
POST
I I I
o 5 10cm
Fig. 3.1.a. One 8 MV photon beam. The ICRU Reference Point (100%) is in the center of the PTV and on the beam axis. The dose
variation in the PTV is from 114% to 86%.
3.3 General Recommendations for Reporting Doses • •• 29
ent techniques for the same PTV is to be found in Fig. the point should be selected where the dose can
2.5.a to d. be accurately determined (physical accuracy) ;
the point should be selected in a region where
there is no steep dose gradient.
3.3 General Recommendations for Reporting
These recommendations will be fulfilled if the
Doses
ICRU Reference Point is located firstly at the center,
The dose at or near the center of the Planning or in the central part, of the Planning Target Volume,
Target Volume as well as the maximum and the and secondly on or near the central axis of the
minimum dose to the PTV shall be reported. Addi- beam(s).
tional information (such as average dose, dose / The method of selection of the ICRU Reference
volume histograms) , when available, may be useful. Point is best illustrated by practical examples. Some
recommended ICRU Reference Points for simple

beam arrangements are listed in Table 3.1. and
3.3.1 The ICRU Reference Point
demonstrated in Fig. 3.1. They are located on the
The present system of recommendations for report- beam axes, or at the intersection of the beam axes (if
ing is based on the selection of a point within the such an intersection point exists inside the Planning
PTV, which is referred to as the ICRU Reference Target Volume, and provided it is located in the
Point. central part of the Planning Target Volume, i.e., at
The ICRU Reference Point shall be selected accord- least about 2 em inside the border of the PTV), or only
ing to the following general criteria: in the central part of the PTV.
the dose at the point should be clinically rele- In some situat~ons, the conditions do not allow for
vant and representative of the dose throughout the ICRU Reference Point to be localized both at or
the Planning Target Volume (PTV); near the center of the PTV, and also on the beam axis
the point should be easy to define in a clear and in an area where the dose distribution is homoge-
unambiguous way; neous. In these cases, the first criterion, i.e., localiza-
ANT
8 MV Xrays
~ BEAM #1 16cmx 20cm
I
95 .-/95
\.....!02 , 11cm
8o~i~
~~~ i
0
RIGHT ----- - LEFT
50
~! ~ 50
~
I
11cm
10 10
t BEAM #2 16cmx20cm
POST I Ii. i i •
o 5
Fig. 3.1.b. Two opposed equally weighted 8 MV photon beams. The ICRU Reference Point (1007< ) is midway between the beam
entrances and is also in the center of the PTV. The dose variat ion in the P TV is from 1027< to 957< .
BMV X rays
10cm x 10cm ANT
W= 2/3 ~ BEAM #1

80 80
50
20 \
o
i
5 10cm
i
10cm x 10cm t BEAM #2
W =1/3
POST
Fig. 3. I.e. Two opposed unequally weighted (1:3 at peak absorbed dose) 8 MV photon beams. Th e ICRU Reference Point (100%) is in the
center of the PTV and on the beam axes (but not midways between the beam entrances). The dose variation in the PTV is from 105% to 95%.
8MV X rays BEAM #1

gem x 10em
W:1
BEAM # 2
W:1 50
~ --
\]
Bern x 10em
r I
o 5 10em
Fig.3.I.d. Two orthogonal 8 MV photon beams. The ICRU Reference Point (100%) is in the center of the PTV and on the beam axes. The
dose variation in the PTV is from 102% to 95%.
3.3 General Recommendations for Reporting Doses . •. 31
8MV X rays ANT
BEAM #2 BEAM #3
~ ~
10cmx20cm
10cmx 20cm

RIGHT LEFT
20 20
j i I ,
t BEAM#1 10cm x 20cm
o 5 10cm
POST
Fig.3.1.e. Three equally weighted 8 MV photon beams that converge towards one point. The ICRU Reference Point (100%) is in the
center of the PTV and on the beam axes. The dose variation in the PTV is from 108% to 90%.
8MV Xrays
ANT
16cm x 20cm
~ BEAM #1 37%
RIGHT LEFT
10cm X 20cm 10cm X 20cm
j i 1 ,
o 5 10cm 16cm X 20cm BEAM # 2 37%
POST
Fig.3.1.f. Box technique with four 8 MV photon beams that converge towards one point. The ICRU Reference Point (100%) is in the
center of the PTV and on the beam axes. The dose variation in the PTV ranges from 103% to 95%.
0
8 MV X rays 7cm x 16cm Rotation 300

20 20
,..,
I
o 5 10cm
Fig.3.l.g. Moving beam therapy with 8 MV photons; large arc. The ICRU Reference Point (100%) is in the center of the PTV and also on
the central axis of the moving beam. The dose variation in the PTV is from 102% to 80%.
0
8MV Xrays 6cm X 10cm Rotation 100
I
o 5 10cm
Fig. 3.1.h. Moving beam therapy with 8 MV photons; small arc (100°) . The dose distribution has been normalized to the dose at the
intersection of the central axis of the moving beam (open circle, = 100%). The ICRU Reference Point (solid circle = 108%) is in the center of
the PTV. The dose variation in the PTV is from 114% to 85% (relative to the normalized dose), or from 106% to 79% (relative to the ICRU
Reference dose).
3.3 General Recommendations for Reporting Doses .•. 33
tion at or close to the center of the PTV should be volume histograms, biologically weighted doses), when
given preference. Some examples are given in Figs. available, should also be reported.
3.2, 3.3, and 3.4, and Appendix II, Fig. II.5.e. An analysis of the relative merits of using different
In other situations, it will be found that the "center types of doses for reporting is given in Appendix III.
of the PTV" will not be a meaningful concept, if it is
taken to imply the purely geometrical center or the
center of gravity. Such a definition could result in the 3.3.4 The Three Levels of Dose Evaluation for
"center" being outside the tissues represented by the Reporting
PTV (e.g., when treating the chest wall, where the
center of gravity of the PTV may be in healthy lung The level of completeness and accuracy of reporting
tissue, or, in the case of treatment of the regional therapeutic irradiation depends to a large extent on
lymph nodes of a pelvic tumor, where the PTV may be the situation in the department and on the aim of the

ring-shaped, and its center of gravity is not in the treatment. For different clinical and practical consid-
tissue concerned). In these cases, one has to select the erations, different levels of ambition for dose evalua-
ICRU Reference Point inside the tissues represented tion can be identified. Three levels have been selected
by the PTV, and in a place where dose specification is for reasons given below, but it is recognized that
considered to be meaningful. Such a place could be intermediate levels could also be identified.
the region where the tumor cell density is considered 3.3.4.1 Levell: Basic Techniques. The mini-
to be at its maximum. An example is given in Appen- mum requirements for reporting can be followed in
dix II, Fig. II.3.c. Wherever the ICRU Reference Point all centers, including those with restricted therapy
is localized, it must be clearly specified. equipment, dosimetric, computer, and staff facilities.
This minimum level may sometimes be sufficient, in
any center, when simple treatments are performed
3.3.2 The ICRU Reference Dose (e.g., some palliative treatments). At this level, it is
assumed that the dose at the ICRU Reference Point
The dose at the ICRU Reference Point is the ICRU
and an estimate ofthe maximum and minimum doses
Reference Dose, and should always be reported. to the PTV can be determined using, e.g., central axis
depth dose tables. Some information about the dose
outside the beam axis could also be obtained by means
3.3.3 The Dose Variation Throughout the of standard isodose charts.
Planning Target Volume 3.3.4.2 Level 2: Advanced Techniques. The
As previously indicated (Section 2.4.1.), a certain standards of dose planning at this level allow the
degree of inhomogeneity of the absorbed dose through- exchange between different centers of more complete
out the Planning Target Volume (PTV) cannot be and relevant information. At this level, it is assumed
avoided (i.e., the dose varies from the maximum dose that the GTV, CTV, and PTV can be defined in one or
value to the minimum dose level). more planes (sections), using reliable patient data
As a minimum requirement, the maximum dose acquisition tools, and/ or modern imaging techniques
and the minimum dose to the PTV shall be reported, under reliable conditions (e.g., a series of CT and/or
together with the dose at the ICRU Reference Point. MRI sections). It is also assumed that complete dose
The three dose values then indicate the dose to the distributions are computed in the central plane and in
Clinical Target Volume and the dose variation. other planes (sections) using only central plane dose
The maximum dose is also relevant in relation to data, and with inhomogeneity corrections, when ap-
possible side effects. propriate.
The minimum dose is considered to be relevant in 3.3.4.3 Level 3: Developmental Techniques.
relation to tumor control. The isodose corresponding The performance of dose planning at level 3 provides
to the same value is sometimes called the "minimum for the development of new techniques and clinical
isodose envelope." However, it cannot be used as the research in radiotherapy. At this level, 3-D dose
sole predictor of tumor control due to possible ambiguity computation of any beam arrangement (such as
in the definition of the border of the Clinical Target non-coplanar beams) and dose-volume histograms
Volume (where, by definition, the tumor cell concen- are available.
tration should be zero). Tumor control may be more NB: In summary, the 3 levels could be described as
likely determined by the dose level in the GTV where follows:
tumor cell density is large. Furthermore, there are Levell: only the dose at the ICRU Reference Point
large dose compilation uncertainties near or in the and its variation along a central beam axis
penumbra region, where the dose gradient is steep. is available.
Other dose values considered to be relevant (e.g., Level 2: the dose distribution can be computed for
average dose and its standard deviation, dose areal plane(s).
Fig. 3.2. Example of a technique for radiotherapy after breast conserving surgery in node positive patients. There are two
topographically separate PTVs, namely, the breast (dotted line in section II, Fig. 3.2.c) and regional lymph nodes in axilla and supraclavicular
fossa (dotted line in section I, Fig. 3.2.b). An overview of the beam arrangements is given in Fig. 3.2.a. The treatment machine is equipped
with asymmetric jaws, which are used to shield to the midline in each beam, producing the four 5·MV·photon beams (two tangential [Nos. 1
and 2] to the breast, and two AP·PA [Nos. 3 and 4] towards the lymph nodes in the axilla and supraclavicular fossa). All four beams have the
same isocenter (circle with cross), and all beams thus have a common border through the isocenter. Thus, there is no central axis within any
of the beams. Additional parts of the beams are shielded and shown as hatched areas. The 100%, 95%, and 105% isodose lines are given,
normalized to the ICRU Reference Points for the two PTVs (as indicated by the triangle [breast] and the square [regional lymph nodesD. A
dose of 50 Gy is given to each of these PTVs according to the ICRU Reference Points (100% isodose lines).
-~}-.

SECTION
::::...
. _. _. _.- SECTION II
# 1 #2
Fig. 3.2.a. Schematic overview.
Level 3: the dose distribution can be computed for The dose to the ICRU Reference Point as well as
volumes. the maximum and the minimum dose to the PTV
At any level, the dose at the ICRU Reference Point should be reported.
and the best estimation of the maximum and the Several of the simple beam arrangements, consid-
minimum dose to the PTV should be reported. In ered in Fig. 3.1., are used in a large proportion of
addition, this information could be supplemented by, treatments, especially for palliation.
e.g., isodose plans, dose-area/volume histograms, and
other information, when available, at levels 2 or 3.
3.4. A Single Planning Target Volume 3.4.2 Complex Beam Arrangements

In some situations, the ICRU Reference Point
3.4.1 Simple Beam Arrangements cannot be selected according to the basic criteria
The way to select the ICRU Reference Point is given in section 3.3.1, for instance:
illustrated in Fig. 3.1 for a series of typical simple non-coaxial parallel opposing or non-opposing
beam arrangements. The ICRU Reference Point is beams (e.g., different beam sizes or parallel
located centrally in the PTV on the beam axes at their beams),
intersection (provided that such an intersection point non-coplanar beams,
exists and that it is located in the central part of the beam intersection outside (or at the outer part
PTV, or at least well inside the border of the PTV). oD the PTV.
3.4. A Single Planning Target Volume ... 35
RIGHT LEFT ,
#3 I
SECTI ON I
J
o
00

\
\
\
o
\
Fig.3.2.h. Transverse section at the level of the regional lymph nodes.
SECTI ON II
Fig. 3.2.c. Transverse section at the level of the breast.
In such situations, the ICRU Reference Point will the maximum and the minimum dose to the PTV,
have to be selected according to the additional criteria should be reported.
given in section 3.3.1. Examples are given in Figs. 3.2., 3.3., and 3.4., and
The dose to the ICRU Reference Point, as well as in Appendix II, Figs. 11.4. b to d.
Field Radiation SSD Field size Weight (ICRU

em em x em Reference Point)
25 MV X-rays 100 18 x 14 0 . 22
2 60 Co gamma rays 80 27 x 14 1. 20
3 9 MeV electrons 100 8 x

2
....
5 em
Fig. 3.3. Treatment of a thyroid carcinoma with mediastinal involvement using coplanar beams whose central rays do not intersect at
one point. The purpose of treatment was to deliver 60 Gy to the thyroid and anterior mediastinum and to keep the dose to the cord below 42
Gy. Only anterior beams were used: their weight is expressed by their dose contribution to the ICRU Reference Point (triangle) and, for the
electron beam, to the 60 Gy isodose in the sagital median plane. The PTV is indicated by the dotted line. The isodose lines indicate absolute
values (Gy). The ICRU Reference Point is indicated by the triangle. The dose specified for reporting is 60 Gy, with the variation from 69 Gy to
47 Gy. Modified from Report 29 [lCRU, 1978l.
3.5. Complex Treatments with More Than other PTV, reporting at level 1 may give information
One Planning Target Volume that does not take this into consideration. Informa-
tion obtained at levels 2 and 3 (e.g., isodoses, dose-
3.5.1 Introduction area/ volume histograms) will increase the usefulness
of the information.
With the increasing complexity of radiotherapy
treatments, more than one Planning Target Volume
is frequently identified. In practice, the two most
3.5.3 Overlapping Planning Target Volumes
common situations are adjacent PTVs and overlap-
ping PTVs (Fig. 3.5.) . In this situation, one PTV is totally contained
within the confines of the other. A typical example is
the "boost" technique. In this case, again, two situa-
3.5.2 Adjacent Planning Target Volumes
tions may occur:
In this situation, the PTVs are adjacent to each the beam axes of the two PTVs are identical and
other; they do not overlap. A typical example may be the centers coincide (see Appendix II, Figs.
the postoperative treatment of breast cancer includ- II.3.a. and b.).
ing the breast and chest wall, and the regional the centers of the two PTVs and the beam axes
lymphatics (see Fig. 3.2., and Appendix I, Fig. l.l.b.). differ (see Appendix II, Fig. 11.2.).
When the PTVs are adjacent to each other, as a NB: The "shrinking field technique" can be consid-
minimum requirement, the dose to each PTV (at its ered as consisting of a series of smaller PTVs inserted
ICRU Reference Point, as well as the maximum and into each other.
the minimum dose to each PTV) should be reported When the PTVs are overlapping the following
as indicated in section 3.4.1. Note that since treat- procedures are recommended:
ment of one PTV may give a dose contribution to the 3.5.3.1 At Levell. The dose to the ICRU Refer-
3.5. Complex Treatments with More Than One Planning Target Volume . .. 37
60 Co
Field SSD Size Wedge Beam weight
em em x em %
1 70 22 x 22 - 100
2 70 22 x 22 100
3 70 5 x 5 15° 40
4 70 5 x 5 15° 40
2 5 70 12 x 5 - 180
6 70 12 x 5 - 180

30 30
5
, 6
II
100
._IM
5 em
Fig. 3.4. Dose plan in 3 sections for the treatment of medulloblastoma with two PTVs (a. the demonstrated cerebellar tumor [GTV1 and
its local subclinical extensions [CTV I/PTV IJ, and b. the whole subdural space and the ventricular system [CTV II/PTV II]) with coplanar
beams whose central rays do not intersect at one point, non-coplanar beams, and opposed noncoaxial beams. The weighting of the beams was
chosen to give the prescribed total absorbed dose in the two PTVs with the same number offractions. The distribution of the absorbed dose is
calculated firstly for PTV I and the cranial part of the PTV II in a frontal section (I) and then a dose plan is produced for the spinal part of the
PTV II in a median sagittal section (II). Furthermore, in order to evaluate the kidney dose, a transverse section (Ill) was also used. For
reporting, three different ICRU Reference Points are defined, namely, one for the PTV I (e = ICRU 1), two (. = ICRU 2, and.a, = ICRU 3,
respectively) for the cranial and spinal parts of the PTV II, respectively. From Report 29 [ICRU, 19781.
Fig. 3.5. Two different Planning Target Volumes which may be:
a. Adjacent to each other.
b. One totally contained within the confines of the other with coinciding centers and identical beam axes.
c. One totally contained within the confines of the other but different centers of the PTVs and the beam axes.
@ = PTVI@ = PTVII
ence Point and the maximum and minimum dose to 3.6 Organs at Risk
each PTV for each part of the treatment are calcu- For each organ at risk, the maximum dose, to-
lated along the central beam axes and should be gether with the volume of the organ receiving that
reported accordingly. At levell, the report is confined dose, should, when possible, be reported, (e.g., maxi-
to a simple description of technique. mum spinal cord dose 42 Gy, 10 cm C1-C4, or left
3.5.3.2 At Levels 2 and 3. The dose distribu- kidney dose 21 Gy, whole kidney).
tions for each PTV are calculated and added and the In some situations, part of the organ or even the
dose to each ICRU Reference Point, as well as the whole organ is irradiated to doses above the accepted
maximum and minimum dose for each PTV, are tolerance level. In that case, the volume that receives
reported, taking into account the cumulative contribu- at least the tolerance dose should be estimated.
tion to each PTV. For the smaller PTV, the criteria of When reporting at Level 3 is possible, dose-volume

central position of the ICRU Reference Point in the histograms for organs at risk, average doses, biologi-
PTV can usually be met. For the larger PTV (see cally weighted quantities, etc. could also be reported.
Appendix II, Fig. 11.3.), an ICRU Reference Point has
to be selected according to criteria given in section 3.7 Hot Spots
3.3.1. (i.e., at a specially selected position considered If a hot spot (see section 2.4.8.) occurs, its size and
to be significant for tumor control in this PTV). position should be reported.
Appendix I
Minimum Requirements for Documentation and
Recommendations for Description of Technique for
Reporting

1.1 Minimum Requirements for the diagnosis, aim of therapy, the GTV(s), the
Documentation CTV(s), prescribed dose, and fractionation.
In section 2.1 and Fig. 2.1, the different steps in the It must be easy to include information neces-
radiotherapy procedure are indicated as well as the sary for treatment planning as well as relevant
need for recording at all different stages of the whole treatment parameters resulting from planning.
radiotherapy procedure. The form must provide the technician with all
The recording of certain parameters at each step details concerning the actual patient setup, and
constitutes the necessary documentation of the treat- it must also be possible to use it as a log-book to
ment. Currently, this documentation is usually car- enter notes on every given fraction.
ried out in the form of notations on a specially For control purposes, it must be possible to
designed treatment record form. In the future, this prescribe and record all dose measurements
process may be replaced by various computer based and other types of patient supervision and
systems, such as clinical registers, but the basic control of treatment together with the corre-
rationale and requirements for documentation should sponding measures taken.
still apply. This topic has also been addressed in The form must provide the supervising physi-
Report 42 [ICRU, 1987]. cian with adequate information to correctly
The requirements placed specifically upon a record evaluate the reactions of the patient during the
form (and any equivalent computerized record form) entire course of treatment.
for external beam therapy may be summarized as After conclusion of treatment, all values of
follows (modified from Moller et al. 1976): doses and time must be summarized to give the
The radiation oncologist should be able to use final dose/time values for the different volumes
the form as a prescription sheet, which states (PTVs and organs at risk).
TABLE I. I-List of parameters that should be recorded at different steps in the radiotherapy procedure (compare Section 2.1 and Fig. 2.1)
Note: * indicates recommended, (*) indicates optional
Treatment
Radiation Record Form!
Oncologist's Dose Check and Clinical
Information Prescription Plan Confirm Register Reporting
PATIENT DATA
Patient ID # *
Diagnosis
site
histologic type (*)
extent! stage (*)
Intention of treatment
DOSE PLAN
Plan ID #
Date of planning
Patient position *
Anatomical description of:
GTV(s)
CTV(s)
organs at risk
39
40 ... Appendix I
TABLE I.l---continued
Treatment
Radiation Record Form/
Oncologist's Dose Check and Clinical
Information Prescription Plan Confirm Register Reporting
Image information on:

GTV(s)
CTV(s)
PTV(s)
tissue heterogeneities
anatomical landmarks
Orientation and position of

reference plane
other planes
Normalization method
ICRU Reference Point *
Target absorbed dose per fraction
Total target absorbed dose
at ICRU Reference Point
maximum
minimum
average (*) (*) (*)
median (*) (*) (*)
modal (*) (*) (*)
others (* ) (* ) (* )
Dose to organs at risk
Dose calculation method
Full dose distribution (*)
BEAM PARAMETERS
Beam #
Radiation quality
SSD /SAD *
Field sizes
Beam position (*)
Beam direction (*)
Gantry angle
Collimator angle
Other machine settings
Wedges, compensators, etc.
Beam weight (*)
Monitor units
Peak absorbed dose
Dose contribution to target dose
Exit dose (*)
Technician's signature
CONTROL MEASURES
Port films (*)
Verification imaging
In-vivo dosimetry * (*)
Overall accuracy of treatment set-up *
TIME SCHEDULE
Date of start (*)
Date of conclusion (*)
Number of fractions per day
Time interval between fractions
Time relation of other treatments (* )
Total number of fractions (*)
Total number of days (* )
1.1 Minimum Requirements for Documentation . .. 41
TABLE I.2-Anatomical code
The code given here is a suggestion of how an internationally C16.2 Body of stomach
accepted classification can be used to describe the Gross Tumor C16.9 Stomach
Volume and Clinical Target Volume. It is an adaptation from the C17.0 Duodenum
C17.1 Jejunum
International Classification of Diseases for Oncology, ICD-O, 2nd
C17.2 Ileum
Edition (WHO, 1990), which, in turn, is based on the proposed 10th
C17.3 Meckel's diverticulum
Revision of the International Statistical Classification of Diseases
C17.9 Small intestine
and Related Health Problems (lCD-lO).
C1S.0 Cecum
Since the ICD-O is not specific enough to describe anatomical C1S.1 Appendix
structures in sufficient detail, a letter has been added to accomo- C1S.2 Ascending colon
date the necessary subsites for skin, soft tissue, bone, and lymph C1S.3 Hepatic flexure of colon
nodes. Laterality is also added by using the code for laterality from C1S,4 Transverse colon
WHO Handbook for Standardized Cancer Registries (WHO, 1976b) C1S.5 Splenic flexure of colon
as follows: C18.6 Descending colon

1 = right, C1S.7 Sigmoid colon
2 = left, C1S.9 Colon
3 = central C19.9 Rectosigmoid junction
4 = bilateral, C20.9 Rectum
9 = unknown. C21.0 Anus
The full code thus has this format: C22.0 Liver
C22.0A Right lobe of liver
C22.0B Left lobe of liver
C22.1 Intrahepatic bile ducts
C23.9 Gallbladder
C ! - I - I 1- : I - I I _ I C24.0 Extrahepatic bile ducts
organ sub- sub- late- C24.1 Ampulla ofVateri
site site rality C25.0 Head of pancreas
1 2 C25.1 Body of pancreas
C25.2 Tail of pancreas
Examples are given in Fig. 1.1., and in Appendix II. C25,4 Islets of Langerhans
C25.9 Pancreas
COO-C14 ORAL CAVITY AND PHARYNX C30-C39 RESPIRATORY SYSTEM AND INTRATHO-
COO.O External upper lip RACIC ORGANS
COO.1 External lower lip C30.0 Nasal cavity
C01.9 Base of tongue C30.1 Middle ear
C02.9 Mobile tongue C31.0 Maxillary sinus
C03.0 Maxillary gingiva C31.1 Ethmoid sinus
C03.1 Mandibular gingiva C31.2 Frontal sinus
C04.9 Floor of mouth C31.3 Sphenoid sinus
C05.0 Hard palate C32.0 Vocal cord
C05.1 Soft palate C32.1 Supraglottis
C06.0 Cheek mucosa C32.2 Subglottis
C06.2 Retromolar area C32,4 Sinus Morgagni
C06.9 Oral cavity C32.9 Larynx
C07.9 Parotid gland C33.9 Trachea
C08.0 Submandibular gland C34.0 Main bronchus
COS.1 Sublingual gland C34.1 Upper lobe, lung
C09.9 Tonsil C34.2 Middle lobe, lung
ClO.1 Anterior surface of epiglottis C34.3 Lober lobe, lung
C10.2 Lateral wall of oropharynx C34.9 Lung
C10.3 Posterior wall of oropharynx C37.9 Thymus
C10.9 Oropharynx C3S.0 Heart
C11.9 Nasopharynx C3S.0A Pericardium
C12.9 Pyriform sinus C3S.3 Mediastinum
C13.0 Postcricoid region C3S.4 Pleura
C13.2 Posterior wall of hypopharynx C3S,4A Visceral pleura
C13.9 Hypopharynx C3S,4B Parietal pleura
C14.0 Pharynx C40-C41 BONES, JOINTS AND ARTICULAR CARTI-
C14.2 Waldeyer's ring LAGE
C15-C26 DIGESTIVE ORGANS C40.0 Long bones of upper limb, scapula and associ-
C15.3 Upper third of esophagus atedjoints
C15,4 Middle third of esophagus C40.0A Scapula
C15.5 Lower third of esophagus C40.0B Acromioclavicular joint
C15.9 Esophagus C40.0C Shoulder joint
C16.0 Cardia C40.0D Humerus
C16.1 Fundus of stomach C40.0E Elbow joint
42 ... Appendix I
TABLE I.2-Continued
C41.4E Sacrum
C40.0F Radius C41.4F Coccyx
C40.0G Ulna C41.4G Hip joint
C40.1 Short bones of upper limb and associated joints C42 HEMATOPOIETIC AND
C40.1A Wrist joint RETICULOENDOTHELIAL SYSTEMS
C40.1B Hand C42.1 Bone marrow
C40.2 Long bones of lower limb and associated joints C42.2 Spleen
C40.2A Hipjoint C44 SKIN
C40.2B Femur C44.0 Skin oflip
C40.2C Knee joint C44.1 Eyelid
C40.2D Tibia C44.1A Upper eyelid
C40.2E Fibula C44.1B Lower eyelid

C40.3 Short bones of lower limb and associated joints C44.2 External ear
C40.3A Ankle joint C44.2A Auricle
C40.3B Foot C44.2B External auditory canal
C41.0 Bones of skull and associated joints C44.3 Skin of face
C41.0A Skull C44.3A Forehead
C41.0B Maxilla C44.3B Temple
C41.1 Mandible C44.3C Cheek
C41.1A Temporomandibular joint C44.3D Nose
C41.2 Vertebral column C44.3E Nasal wing
C41.2A Atlas C44.3F Jaw
C41.2B Vertebra C II C44.4 Skin of scalp and neck
C41.2C Vertebra C III C44.5 Skin of trunk
C41.2D Vertebra C IV C44.5A Axilla
C41.2E Vertebra CV C44.5B Breast
C41.2F Vertebra C VI C44.5C Chest wall
C41.2G Vertebra C VII C44.5D Scapular region
C41.2H Vertebra Th I C44.5E Abdominal region
C41.21 Vertebra Th II C44.5F Flank
C41.2J Vertebra Th III C44.5G Groin
C41.2K Vertebra Th IV C44.5H Perineum
C41.2L Vertebra Th V C44.51 Anus
C41.2M Vertebra Th VI C44.6 Skin of upper limb and shoulder
C41.2N Vertebra Th VII C44.6A Shoulder
C41.20 Vertebra Th VIII C44.6B Arm
C41.2P Vertebra Th IX C44.6C Hand
C41.2Q Vertebra Th X C44.6D Palm
C41.2R Vertebra Th XI C44.6E Finger
C41.2S Vertebra Th XII C44.7 Skin oflower limb and hip
C41.2T Vertebra L I C44.7A Hip
C41.2U Vertebra L II C44.7B Leg
C41.2V Vertebra L III C44.7C Ankle
C41.2X Vertebra L IV C44.7D Foot
C41.2Y Vertebra L V C44.7E Plantar region
C41.3 Rib , Sternum, Clavicle and associated joints C44.7F Toe
C41.3A Clavicle
C48 RETROPERITONEUM AND PERITONEUM
C41.3B Sternum
Costa I C48.0 Retroperitoneal tissue
C41.3C
C41.3D Costa II C48.2 Peritoneum
C41.3E Costa III C49 CONNECTIVE, SUBCUTANEOUS AND
C41.3F Costa IV OTHER SOFT TISSUES
C41.3G Costa V C49.0 Soft tissue of head and neck
C41.3H Costa VI C49.0A Head
C41.3I Costa VII C49.0B Face
C41.3J Costa VIII C49.0C Neck
C41.3K Costa IX C49.0D Supraclavicular region
C41.3L Costa X C49.1 Soft tissues of upper limb and shoulder
C41.3M Costa XI C49.1A Shoulder
C41.3N Costa XII C49.1B Arm
C41.4 Pelvic bones, Sacrum, Coccyx and associated C49.1C Hand
joints C49.2 Soft tissues of lower limb and leg
C41.4A Pelvic bones C49.2A Hip
C41.4B Ilium C49.2B Thigh
C41.4C Ischium C49.2C Calf
C41.4D Pubic bone C49.2D Ankle
t.1 Minimum Requirements for Documentation ... 43
TABLE I.2-Continued
C69.6 Orbit (excl. eyeball)
C49.2E Foot C69.9 Eye
C49.3 Soft tissues of thorax C70.0 Cerebral meninges
C49.3A Axilla C70.l Spinal meninges
C49.3B Infraclavicular region C71.0 Cerebrum
C49.3C Chest wall C71.l Frontal lobe
C49.3D Scapular region C71.2 Temporal lobe
C49.4 Soft tissues of abdomen C71.3 Parietal lobe
C49.4A Abdominal wall C71.4 Occipital lobe
C49.4B Umbilicus C7l.5 Ventricle
C49.5 Soft tissues of pelvis C71.6 Cerebellum
C49.5A Inguinal region C71.7 Brain stem
C49.5B Perineum C72.0 Spinal cord
C49.5C Gluteal region C72.0A Cervical cord

BREAST C72.0B Thoracic cord
C50
C72.0C Lumbar cord
C50.0 Nipple
C50.l Central portion of breast C72.0D Sacral cord
Upper-inner quadrant of breast C72.l Cauda equina
C50.2
C50.3 Lower-inner quadrant of breast C72.2 Olfactory nerve
C50.4 Upper-outer quadrant of breast C72.3 Optic nerve
Lower-outer quadrant of breast C72.4 Acoustic nerve
C50.5
C50.7 Accessory mammary gla nd C72.5 Cranial nerve
C50.9 Breast C73-C75 THYROID AND OTHER ENDOCRINE
C5l-C58 FEMALE GENITAL ORGANS GLANDS
C73.9 Thyroid gland
C51.0 Labium maju s
C51.1 Labium minu s C74.0 Cortex of adrenal gland
C74.l Medulla of adrenal gland
C51.9 Vulva
C52.9 Vagina C74.9 Adrenal gland
C75.0 Parathyroid gland
C53.9 Cervix uteri
C54.l C75.l Pituitary gland
Endometrium
C54.2 Myometrium C75.2 Craniopharyngeal duct
C54.9 Corpus uteri C75.3 Pineal body
C75.4 Carotid body
C55.9 Uterus
C75.5 Aortic body and other paraganglia
C56.9 Ovary
C57.0 Fallopian tube C77 LYMPH NODES
C57.3 Parametrium C77.0 Lymph nodes of head and neck
C57.4 Uterine adnexa C77.0A Occipital lymph nodes
C60-C63 MALE GENITAL ORGANS C77.0B Preauricular lymph nodes
Prepuce C77.0C Submandibular lymph nodes
C60.0
Glans peni s C77.0D Retropharyngeallymph nodes
C60.l
C60.2 Body of penis C77.0E Cervical lymph nodes
C77.0F Supraclavicular lymph nodes
C60.9 Penis
C61.9 C77.l Intrathoracic lymph nodes
Prostate
C77.lA Lymph nodes of upper mediastinum
C62.0 Undescended testis
C77.lB Lymph nodes of lower mediastinum
C62.l Descended testis
C62.9 Testis C77.lC Hilar lymph nodes
C63.0 Epididymis C77.1D Parasternal lymph nodes
C63 .l Spermatic cord C77.lE Intercostal lymph nodes
C63.2 Scrotum C77.2 Intraabdominallymph nodes
C77.2A Celiac lymph nodes
C64-C68 URINARY TRACT C77.2B Hepatic lymph nodes
C64.9 Kidney C77.2C Splenic hilar lymph nodes
C65.9 Renal pelvis C77.2D Mesenteric lymph nodes
C66.9 Ureter C77.2E Para-aortic lymph nodes
C67.7 Urachus C77.3 Lymph nodes of axilla or arm
C67.9 Bladder C77.3A Infraclavicular lymph nodes
C68.0 Urethra C77.3B Axillary lymph nodes
C69-C72 EYE, BRAIN AND OTHER PARTS OF C77.3C Cubital lymph node
CENTRAL NERVOUS SYSTEM C77.4 Lymph nodes of inguinal region or leg
C69.0 Conjunctiva C77.4A Inguina l lymph nodes
C69.1 Cornea C77.4B Popliteal lymph nodes
C69.2 Retina C77.5 Pelvic lymph nodes
C69.3 Choroid C77.5A Iliac lymph nodes
C69.4 Ciliary body C77.5B Obturator lymph nodes
C69.5 Lacrimal gland C77.5C Sacral lymph nodes
44 ... Appendix I
TABLE I.3-Code for sections The data should be unambiguous, and should
The transverse planes are parallel planes perpendicular to the also follow accepted concepts and definitions, in
longitudinal axis of the body and (for the head and trunk) at 3-4 cm order to allow for pooling of information from a
intervals.
group of patients for evaluation.
TRANSVERSAL PLANES The record form must contain sufficient infor-
05 vertex of skull mation for legal purposes, should such need
06 9 cm above external auditory canal arise.
07 6 cm above external auditory canal
In order to meet these requirements, certain man-
08 glabella-external occipital protuberance
09 external audititory canal datory data will have to be recorded. Furthermore,
10 CI-hard palate for the interpretation of treatment results, it may be
11 CII useful also to record other data, which, from the point

12 CIII of view of the individual patient, may be considered to
13 CIV-larynx
be optional.
14 CV
15 CVI A list of the different parameters that may be
16 CVII considered useful to be recorded is given in Table 1.1.
20 Thl-acromio-clavicular joint It conforms with the recommendations given in Re-
21 ThIl port 42 [ICRU, 1987].
22 ThIll-sternal notch
It may, for retrieval purposes, be useful to digitize
23 ThlV
24 ThV the anatomical locations ofthe GTV and CTV as well
25 ThVI as the location of sections for dose planning. Codes for
26 ThVII these purposes are presented in Tables 1.2. and 1.3.
27 ThVIII-xiphoid process
28 ThlX
1.2 Description of Treatment Technique,
29 ThX
30 ThXI Including Methods for Planning, Dose
31 ThXII Calculation and Control, for the Purpose of
40 11 Reporting
41 LII-umbilicus
42 LIII--crista iliaca For reporting, it is recommended that the plan-
43 LIV ning, technique, calculation, and control methods are
44 LV described on the basis of the guidelines given below.
50 promontorium-anterior iliac spine
51 upper border of acetabulum
symphysis
1.2.1 Treatment Planning
52
53 tuber ischii (i) Patient positioning (e.g., prone/supine, head/
60 femur, upper half
feet towards stand, sitting, etc.).
61 femur, lower half
62 knee joint (ii) Immobilization devices (e.g., plaster of Paris
63 tibia, upper half cast, vacuum cast, bite blocks, etc.).
64 tibia, lower half (iii) Localization and simulation performed at simu-
65 ankle joint lator or at treatment machine.
66 foot
humerus, upper half
(iv) Treatment planning based on computed tomog-
70
71 humerus, lower half raphy or other relevant information.
72 elbow joint (v) Optimization of dose distribution at the com-
73 radius-ulna, upper half puter or at the simulator.
74 radius-ulna, lower half
75 wrist
1.2.2 Technique
76 hand
PLANES PARALLEL TO THE LONGITUDINAL AXIS (i) Number and arrangement, location, and direc-
80 cranium, frontal section tion of the beams in relation to the patient.
81 pelvis, frontal section (ii) Stationary beams with SAD or SSD technique
85 cranium, sagittal section
86 spine and trunk, sagittal section and distance, or moving beam technique and
87 pelvis, sagittal section arc.
SPECIAL PLANES (iii) Field sizes: geometrical field size usually corre-
90 sponds to the 50 per cent isodose curve. For
fixed SSD, the field size is usually given at the
skin, for fixed SAD the field size is usually
given at the isocenter. When field borders are
parallel to the planning section, the field size
in the section should be given first.
1.2 Description of Treatment Technique ... 45
Fig.l.1. Gross Tumor Volume and corresponding Clinical Target Volume for four different clinical situations described in anatomical
terms and codified according to some current coding systems (the ICD-OI9], lCD-OnOl, WHO Handbook for Standardized Cancer Registries
(for lateralityl, and T-SNOMED). See Section 3.2. Gross Tumor Volume = black area; Clinical Target Volume = dotted area .
...J'
?
\
\
\
\\

T21arynx
Anatomical structure ICD-O(9) T-SNOMED

Gross tumor volume
Left vocal cord 161.0 (i) C32.0 2 T-24410
Left ventricular cavity 161.1 (vi) C32 .1 2 T-24340
Left ventricular band 161.1 (v) C32 .1 2 T-24322
Clinical target volume

Larynx 161 .1 C32.9 3 T-24700
Cervical lymph nodes, bilat. 196.0 C77.0 4 T-08200
a. Glottic carcinoma (the figures illustrating GTV are taken from the TNM Atlas ([UlCe, 1982)).
Postoperative breast after left MRM
Anatomical structure ICD-O(9) ICD-O(10) Lateralit T-SNOMED

Gross tumor volume

Axillary lymph nodes, left 196.3 C77.3 2 T-08710
Supraclav. 196.0 C77.0 2 T-08220
Parasternal 196.1 C77 .1 2 T-08350
Thoracic wall 171.4 C49.3 2 T-Y2150
~
: .•.::.i::::: :":""" .:........ :. . .
·:·:·:·:·:::::::::::::····.•..••.•••.i...................
D·: · . ·: :·.·. . . .
. ....:....::::.::
b. Breast cancer after modified radical mastectomy.

46 ... Appendix I
5t.gell cS: II
p S: U S - H-N+M _

Hodgkins disease stage /I
Anatomical structure ICD-O 9) ICD-O(10) Lateralit T-SNOMED

Gross tumor volume
Paraaortic lymph nodes 196.2 C77.2 3 T-08480
Celiac lymph nodes 196.2 C77.2 3 T-08410

Splenic pedicle 196.2 C77.2 T-08472
Celiac lymph nodes 196.2 C77.2 3 T-08410
Paraaortic lymph nodes 196.2 C77.2 3 T-08480
Iliac lymph nodes 196.6 C77.5 4 T-08610
Inguinal lymph nodes 196.5 C77.4 4 T-08810
1 :.·•• • •· • ·• • ·• ·1
c. Abdominal Hodgkin's disease, stage II (the figure illustrating GTV is taken and modified from TNM Atlas [UICC, 1982]).
Medulloblastoma of 4th ventricle
Anatomical structure ICD-O(9) ICD-O(10) Laterality T-SNOMED

Gross tumor volume
Roof of the 4th ventricle 191.5 C71.7 3 T-X1820

Cerebellum 191.6 C71.6 3 T-X6000
Intracranial meninges 192.1 C70.0 T-X1410
Spinal meninges 192.3 C70.1 T-X1115
d. Medulloblastoma (the figure illustrating GTV is taken from Clinical Oncology, A Multidisciplinary Approach [ACS, 19831.
1.2 Description of Treatment Technique . .. 47
(iv) Radiation quality for each beam. All transverse sections of the patient should be
* Orthovoltage or low-energy x-ray beams as viewed from the foot end of the patient
( < 300 kV): the generating potential (kV) irrespective of the patient position. The right
and HVL (mm Al or Cu). and the left side of the section should be
* Gamma ray beams: the radionuclide (ele- indicated (e.g., Dxt/Sin, or Right/Left). For
ment and mass number). other sections, the orientation should also be
* X-ray beams> 2 MV: the nominal accelerat- clearly indicated in the figure.
ing potential, and the type of accelerator. For comparison purposes, 60CO gamma rays
(v) Beam modification devices (wedge filters, com- should be taken as the reference radiation. The
pensators, shielding blocks, individually cut
same RBE applies for photon radiations with a
blocks, etc.) should be indicated.
nominal energy of at least 2 MV, and for
electron radiation in the range 1-50 MeV. For

1.2.3 Absorbed Dose Calculation orthovoltage x-ray therapy, the RBE is larger
(i) Dose calculation method (computerized, or than unity value, and a conversion factor of
manual), 1-D, or 2-D, or 3-D. The reporting 1.18 may be considered adequate for the normal
should be in agreement with definitions of the radiotherapy procedures. If RBE-corrected val-
different levels for reporting (Section 3.3.4). ues are reported, this should be stated.
(ii) Correction for tissue inhomogeneity (state When isodose curves are shown (relative or
whether performed or not). The type of correc- absolute values), care should be taken so that
tion used should be indicated, e.g., 3-D or 2-D the correct !;lumber is unambiguously related to
correction for air cavities, lung, bone, etc., or the correct isodose line. It is an advantage if,
full correction for the electron density. e.g., the "hotter" side of an isodose can be
(iii) Beam weighting (at peak dose point, specifica- indicated, since this will, in some instances,
tion point, isocenter, or other point). indicate if a small volume/ area is a hotter area
or cooler area than the surroundings.
1.2.4 Quality Control When isodose plots are shown with relative
(i) Check and confirm systems. dose values, it is an advantage if the isodose
(ii) Verification imaging (when during treatment, through the ICRU Reference Point is given the
frequency, and acceptability). relative value 100%.
(iii) In-vivo dosimetry (type of measurements, fre- A report on radiation therapy must always give
quency, and acceptability). the absorbed dose(s) in Gy or cGy. Further-
more, biologically weighted doses, calculated
1.2.5 Special Comments according to specified biological models may be
of interest.
The reporting of absorbed dose for external
beam therapy should be accompanied by infor- Recording of target absorbed dose rate may be
mation on the time dose pattern including, at useful, and is recommended for values below
least, the number of fractions and the overall 0.1 Gy per minute for any part of the Planning
time (in days). The first and the last day of Target Volume.
treatment are then included. Unless otherwise It should always be clearly stated if correction
stated, it is understood that the fractionation is for tissue inhomogeneity has been carried out
regular (5 times per week) with equal fractions, or not when calculating the absorbed doses.
all fields being irradiated at each fraction. The The method used for calculation should also be
position and length of any gap or interruption reported. If corrected values are reported, then,
must be given as well as any change in dose per for intercomparison purposes, the uncorrected
fraction. values should also be given (see section 3.3.3).
Appendix II
Examples of the Use of the Recommendations in Some
Different Beam Arrangements

The patients #1 through #5 show situations of ing to the code list in Appendix I, Tables I.2
more and more complex character through levels 2 and I.3.
and 3 (see sections 3.4 and 3.5).
Note: The designations in [ ] denote anatomical site GTV = Gross Tumor Volume
ofGTV, CTV, and organs at risk, and anatomi- CTV = Clinical Target Volume
cal level of section(s) for dose planning, accord- PTV = Planning Target Volume
Case number 1. Lung Cancer.
CLINICAL SITUATION 65-year-old male, smoker, presented with a persistent cough. Clinical
examination normal. Chest radiography showed a right hilar mass. Bron-
choscopy showed endobronchial tumor in the right main bronchus. Biopsy
revealed squamous cell carcinoma. CT scan confirmed lesion in the right
bronchus with a 3 cm x 3 cm mass oflymphadenopathy at the right hilum,
no evidence of mediastinal lymphadenopathy. Clinical stage T2 Nl MO.
AIM OF THERAPY Patient inoperable. Palliative radiotherapy for the purpose of relieving
cough is planned.
GTV Primary endobronchial tumor and hilar lymphadenopathy [C34.0-1,
C77.1C-I].
CTV CTV I: GTV + local subclinical extensions [C34.0-1 , C77.1C-I].
CTV II: Mediastinal regional lymph nodes [C77 .IAJ.
PTV Ajoint PTV is defined for the two CTVs.
ORGANS AT RISK A: Spinal cord [C72.0BJ.
B: Left lung [C34.9-2J.
PRESCRIBED DOSES PTV: 30 Gy in 10 fractions over 2 weeks.
ACCEPTED DOSES TO A: Less than 35 Gy in 10 fractions .
ORGANS AT RISK B: As low as possible.
TENTATIVE TECHNIQUE AP-PA beams.
PATIENT POSITIONING AND Supine with head on standard head rest and arms by side. No special
IMMOBILIZATION patient fixation.
49
50 ... Appendix 1/
SECTION FOR DOSE One CT-scan through the centre of the GTV [26],
PLANNING
DOSE CALCULATION Central beam isodose data without inhomogeneity correction.
TECHNIQUE 60CO.
Two opposed equally weighted beams with direction 0° and 180°, respec-
tively.
Isocentric technique.
Field width 10 cm (both).

Field length 12 cm (both).
Two corners blocked in each beam.
No wedges.
CONTROL MEASURES Simulator port films.

Treatment verification films x 2.
Measurement of entrance dose x 2.
Fig.II.1. The PTV I for the primary tumor is indicated by the densely dotted area. The PTV II for mediastinal lymph nodes is indicated
by the sparsely dotted area.
DOSE SPECIFICATION FOR Dose distribution, see Fig. ILL

REPORTING 1. ICRU. Reference Point = midway between beam entrances, in the
center of the PTV (100%).
2. Maximum and minimum dose to the PTV according to the dose plan
(102%-95%).
3. Hot Spot (outside the PTV) = 108%.
Appendix II ... 51
Case number 2. Breast Cancer.
CLINICAL SITUATION 56-year old female presented with a 2 cm x 1.5 cm hard, mobile lump in the
upper outer quadrant of the left breast. There was no fixation to skin or
underlying muscle, and no regional lymphadenopathy palpable. Mammog-
raphy showed a mass suspicious of malignancy. Clinical diagnosis T1a NO
MO carcinoma. Excision biopsy showed infiltrating ductal carcinoma. Wide
local excision and axillary dissection was then performed. Histology showed
complete excision of primary tumour and 12 axillary lymph nodes excised,
all 12 free of metastases. Surgical clips were placed in the tumour bed at
time ofre-excision.

AIM OF THERAPY Radical radiotherapy after radical surgery. No systemic therapy.
GTV No GTV to be defined.
CTV CTV I : The local tumour bed with or without the use of surgical clips
[C50.4-2].
CTV II : The entire breast (outside CTV I, see above) , the extent to be
defined anatomically by palpation and CT scan [C50.9-2].
PTV For CTV I : A 1 cm margin is added to allow for movements of the chest
wall due to respiration, and variation in repositioning of the
beams. .
For CTV II: A 1 cm margin is added to allow for movements of the chest
wall due to respiration, and variation in repositioning of the
beams.
(See Fig. 11.2.)
ORGANS AT RISK A: Lung tissue [C34.9-2J .
B: Myocardium [C38.0J .
C: Remaining breast [C50.9-1J.
PRESCRIBED DOSES PTV I: 64 Gy in 32 fractions over 6.5 weeks.
PTV II: 50 Gy in 25 fractions over 5 weeks.
ACCEPTED DOSES TO A: 30 Gy in at most 200 cm 3 .
ORGANS AT RISK B: 30 Gy in at most 30 cm 3 .
C: Less than 5 Gy.
TENTATIVE TECHNIQUE PTV I: Two opposed tangential photon beams plus electron beam.
PTV II: Two opposed tangential photon beams.
PATIENT POSITIONING PTV I and II: Supine with arms raised above and immobilization of the
head and on a wedge to make the sternum horizontal.
Immobilized using plastic cast or arm poles and foot board.
SECTION FOR DOSE PTV I AND II: Transverse section through the site of the excised tumor
PLANNING [24J.
DOSE CALCULATION Single plane dose calculation using photon beam generating functions with
correction for oblique incidence and tissue inhomogeneity, but no correc-
tion for loss of sidescatter in 3-D. Electron beam calculation based on
uncorrected isodose data.
TECHNIQUE PTV I: (a) Tangential photon beams as described for PTV II.
(b) 9 MeV electrons.
Beam perpendicular to skin.
Beam direction 60°.
SSD 100cm.
Field width 5 cm.
Field length 4 cm.
100% in dose maximum.
52 ... Appendix 1/

Fig. II.2.a. Isodose values (relative values) for the dose distribution with two tangential 6 MV photons beams. The PTV I is indicated by
the densely dotted area and PTV II by the sparsely dotted area. The dose specified for prescription and for recording of this part of the whole
treatment is 50 Gy on the beam axes midway between the beam entrances, which also corresponds to the center of the PTV II.
Fig.II.2.h. Isodose values (relative values) for the dose distribution with one 9 MeV electron beam for PTV I (indicated by densely dotted
area). The dose specified for prescription and for recording of this part of the whole treatment is 100% (the beam energy chosen so that this
value is found near the center of the PTV). The absolute dose value is 14 Gy.
Appendix II ... 53

Fig. I1.2.c. Isodose values (absolute values in Gy) for the total dose distribution. For reporting purposes, the following specification of
dose and fractionation was adopted:
For PTV I the dose for reporting was specified at the center of PTV I = 64 Gy, with the variation 66-60 Gy, given in 32 fractions over 6.5
weeks.
For PTV II the dose only from the two photon beams, midway between the beam entrances was taken to be representative of the dose to the
breast tissue outside the " boosted" volume (thus disregarding the electron treatment of PTV I). Total dose to PTV II is 50 Gy, with the
variation 64-50 Gy, given in 25-32 fractions over 5-6.5 weeks.
PTVII: 6 MV photons.
Two opposed beams.
Beam direction 305° and 125°.
Field width 8 cm.
Field length 19 cm.
Wedge 15° and 15°.
Beams equally weighted at isocenter.
Start treatment of both PTVs with the tangential photon beams, then add
with electrons to PTV I.
CONTROL MEASURES Simulator port films.
Verification films of photon beams once a week.
Diode measurements of entrance dose x 2.
DOSE SPECIFICATION FOR PTV I: 1. Centrally in PTV I. (= at the ICRU Reference Point 1).
REPORTING 2. Maximum and minimum.
PTV II: 1. At isocenter of photon beam treatment (ICRU Reference Point
2) only, supposing this to be representative of the central dose
in the whole breast (PTV II) outside the volume corresponding
to the tumor bed (PTV I).
2. Maximum and minimum.
54 ... Appendix II
I Case number 3. Cancer of the Prostate.
CLINICAL SITUATION 57-year-old male developed acute urinary retention. Rectal examination
revealed a hard prostate gland with an enlarged left lateral lobe. No
palpable extensions outside the prostate. Clinical diagnosis T2 carcinoma
of the prostate. No other abnormality on physical examination. Cystoscopy
revealed prominent left lateral lobe of prostate gland. Biopsy showed
adenocarcinoma of the prostate gland, poorly differentiated tumour (G 3).
I.V. pyelography, isotopic bone scan, chest radiograph and acid phosphata-
ses were all normal. CT scan of the pelvis confirmed T2 staging. No involve-

ment of seminal vesicles or lymph nodes.
AIM OF THERAPY Radical radiotherapy to prostate gland and pelvic lymph nodes.
GTV Tumour within the prostate gland.
CTV CTV I: The entire prostate gland with good left lateral margin. Define by
CT scan and palpation [C61.9) .
CTV II: The regional lymph nodes in the obturator, internal and external
iliac and pre-sacral lymph nodes and also common iliac lymph
nodes [C77.5B-4, C77.5A-4, C77.5C) .
PTV For CTV I and II to allow for variation in repositioning in the beams. There
is little organ movement. (See Fig. 11.3.)
3
Fig.II.3.a. Isodose (absolute values) distribution for the first treatmen t of both PTV I and II (the latter indicated by the sparsely dotted
area, and the former indicated by the densely dotted area). The dose specified for prescription and for recording (44 Gy) is at the intersection
ofthe beams.
5

---.---.
Fig.II.3.b. Isodose (absolute values) distribution for the second treatment intended to be only ofPTV I (indicated by the densely dotted
area). The dose specified for prescription and for recording (22 Gy) is at the intersection of the beams.
3
Fig.II.3.c. Isodose (absolute values) distribution of the total treatment. For reporting purposes, the following specification of dose and
fractionation was adopted:
For PTV I (the primary tumor and prostate) the dose at the intersection (see below) of the 7 beams and the variation of dose in PTV 1= 66
Gy (69-66) given in 32 fractions over 45 days.
For PTV II (the regional lymph nodes) the dose at a point considered significant for the regional lymph nodes (indicated by the circle) = 65
Gy) , and the variation in dose in PTV II = 68 - 52 Gy, given in 22-32 fractions over 31-45 days.
Note: The example illustrates the problems encountered in "boost" therapy. It is usually only possible to achieve a homogeneous dose to
PTV L It is recommended that a display of the total dose distribution from the combined treatments to both PTVs is made at the
outset. Also, for this case, note that for the dose planning of the two different parts of the whole treatment, different sections were
used, but for reporting purposes in this case, only one section was considered, disregarding the possible importance of 3-D evaluation.
The true minimum dose ofPTV II will then be lower than the one stated above, and of the order 42 Gy at the most cranial section.
56 ... Appendix II
ORGANS AT RISK A: Small bowel [C17.9].
B: Rectum-posterior wall [C20.9].
C: Femoral heads [C41.4G-4].
PRESCRIBED DOSES PTV I: 66 Gy in 32 fractions.

PTV II: 44 Gy in 22 fractions.
ACCEPTED DOSES TO A: Small bowel below 44 Gy.

ORGANS AT RISK B: As low as possible.
C: Below 35 Gy.

TENTATIVE TECHNIQUE PTV I and II: Four beams (anterior, posterior, right and left lateral).
PTV I: Anterior and two posterior oblique beams .
.
PATIENT POSITIONING AND PTV I and II: Supine with head on standard head rest and arms on chest.
IMMOBILIZATION No cast immobilization. Laser alignment and skin tattos.
SECTIONS FOR DOSE PTV II: Principal section through center ofPTV II.
PLANNING Other sections used for localization of target volume [51].
PTV I: Principal section through center of PTV I [52].
DOSE CALCULATION Dual plane but not off-axis dose calculation based on generating function,
corrected for oblique incidence and tissue inhomogeneity.
TECHNIQUE PTV I and II: 8 MV photons. Anterior, posterior, right and left lateral
beams.
Beam directions 0° and 180° (ant & post) and 90° and 270°
(laterals).
Field width 16 cm (ant & post).
Field width 12 cm (laterals).
Field length 16 cm (all beams) .
Weight at specification point 28%,28%, 22%, and 22%.
PTV I: 8MV photons.
Anterior and right and left posterior oblique beams.
Beam directions 0°, 250°, 110°.
Field width 8 cm (anterior) and 7 cm (posterior oblique beams).
Field length 9 cm.
Wedge 15° for posterior oblique beams.
Weight 46%,27%, and 27%.
Start treating both PTVs together, then treat only PTV I.
CONTROL MEASURES Simulator port films .

Verifications films of photon beams once a week.
DOSE SPECIFICATION FOR PTV I: 1. At isocenter nCRU Reference Point 1).

REPORTING 2. Maximum and minimum.
PTV II: 1. A point is selected that is considered to be representative for
the regional lymph nodes (ICRU Reference Point 2)
2. Maximum and minimum.
Appendix /I ..• 57
Case number 4. Cancer of the Floor of the Mouth.
CLINICAL SITUATION 58-year old male presented with a 4.5 cm x 3.5 cm x 4.0 cm ulcerated tumor
in the left floor of the mouth. The tumour extended into the tongue but did
not reach the midline. It did not involve the submandibular salivary gland.
There was no fixation to the mandible. There were no palpable regional
lymph nodes. Physical examination otherwise unremarkable. Clinical
stage = T4 NO MO. Biopsy showed moderately differentiated squamous cell
carcinoma. The patient was considered unfit for radical surgery.
AIM OF THERAPY Radical radiotherapy. No surgery, no systemic therapy.

GTV Demonstrated tumor in the floor of the mouth.
CTV CTV I: GTV + local subclinical extension [C04.9-2].

CTV II: The ipsilateral regional lymph nodes in the submandibular region,
the neck, and the supraclavicular fossa [C77.0C-2, C77.0E-2,
C77.0F-2] .
PTV 1 cm margin is added to allow for movements and variation in beam set up.
Note I: CTV I is well located inside CTV II and thus needs no special
margin for planning purpose, since no external beam boost
therapy was intended.
Note II: Since the dose to the cord would have been unacceptable with the
same margin around the CTVs in all direction, the compromise
was made to retain the prescribed dose (see below) but accept a
smaller positional margin close to the cord. Extra careful checking
of the beam positioning close to the cord then becomes necessary.
(See Fig. 11.4.)
ORGANS AT RISK A: Right parotid gland [C07.9-1]

B: Spinal cord [C72.0A]
PRESCRIBED DOSES 66 Gy in 33 fractions over 6.5 weeks.
ACCEPTED DOSES TO A: At most 20 Gy.

ORGANS AT RISK B: At most 46 Gy.
TENTATIVE TECHNIQUE Two photon beams.
PATIENT POSITIONING AND Supine in individualized plastic casts. Arms along side. Use mouth bites to
IMMOBILIZATION spare upper oral cavity.
SECTION FOR DOSE See Fig. II.4.a.

PLANNING 1. One section (#1) at the level of the GTV (principal plane) [11].
2. One section (#11) at the level of the larynx [13].
3. One section (#111) at the level of the supraclavicular fossae [20].
DOSE CALCULATION True 3-D dose planning based on the 3 sections and interpolated volume,
using pencil beam photon algorithms.
(f
Right Left
. - . _ . _ . _ . - Section _.1r.-
4.0 cm
Section II -·l·- 12.0 cm

I
-·-~A~:;...'= ..
·...:-g·~·~-.---.-_ _Se_c_t_i_on_I_I_I
4.0 cm
_-_._.x..=---J
Section I I
-- .......... P.i<;hl
Section III
Fig. II.4.a. Schematic presentation of the GTV and CTVs and the 3 different sections used for dose planning. The height of the PTV = 12 cm.
GTV = Striated area. CTV I = Dotted line (1). CTV II = Dotted line (II). PTV = Dashed line.
Appendix /I ... 59

Fig. II.4.h. Dose distribution (relative values normalized to the specification dose, the 85%, 95%, 100%, and 105% being shown in the
graphs) in section #I, at the level of the GTV. This level was considered to be the most relevant for dose specification rather than level #II
(which is the level of the intersection of the central rays, but where there is no GTV). Thus, an ICRU Specification Point 2 was defined in
section #I centrally in the GTV (indicated by the filled squa re). The dose prescribed at this Reference Point 2 is 100% = 66 Gy.
RIG HT LEFT
I
SECTI ON # II
I
I
I
I
\
I
" :p
"" \ BEAM # 2
I
I
Fig.II.4.c. Dose distribution in section #II ( =central plane). The cross indicates the position of the single largest dose value in the whole
volume.
60 ... Appendix II
SECTION # III

Fig.II.4.d. Dose distribution in section #III.
TECHNIQUE
6 MV photons.
Two beams.
Beam angles 0 and 140
0 0
•
Isocentric technique. The central beams intersect at the body surface (at
the level of section # I1).
Field width 7.4 cm.
Field length 14 cm.
Beams blocked using "beam's eye view."
Wedge +30 and -30
0 0
•
Beams equally weighted.

0
Collimator rotation: beam #1 = 17 beam #2 = 0
0
, •
CONTROL MEASURES Simulator port films. Verification films of photon beams three times a week
(with special attention to the medial borders, see above).
Diode measurements of entrance dose x 2.
DOSE SPECIFICATION FOR 1. Centrally in PTV in section # I (ICRU Reference Point 2) (since the
REPORTING beams intersect at the level of section # II where there is only
subclinical disease, and furthermore, they do not intersect well within
the tissues of the patient) = 66 Gy.
2. Maximum and minimum doses in PTV (to be found in sections #11 and
III, respectively) = 108% (71 Gy) and 84% (=55 Gy), respectively. Note
that the minimum dose can be raised by using beam compensating
filters, bolus to diminish the effect of build· up, or additional treatment
to section #111.
3. Furthermore, the following dose parameters to the PTV are available:
- average value = 102% (standard deviation = 6.6).
- median value = 101%,
4. Organs at risk:
Spinal cord dose = maximum 50% = 33 Gy.
Dose to the right parotid gland = < 15% = < 10 Gy.
Appendix" •.. 61
Case number 5. Liposarcoma of the Thigh.
CLINICAL SITUATION A 38-year old male presented with a painless mass in the right posterior
thigh. Clinical and radiological examination indicated a liposarcoma in the
long head of the biceps femoris muscle, which was verified by means of fine
needle aspiration biopsy. At subsequent operation, the lateral part of the
tumor was found to protrude out of the muscle. Microscopically, a grade IV
liposarcoma was diagnosed, and the surgical margin was classified as
probably not radical. Thus postoperative radiotherapy was indicated.
AIM OF THERAPY Radical radiotherapy to avoid local recurrence.

GTV Not to be defined, since there was no demonstrable tumor left after
surgery.
CTV Posterior compartment of the right thigh [C49.2B-1J.
PTV To allow for variations in set-up; organ movement is negligible.

(See Fig. 11.5)
ORGANS AT RISK The testes were carefully pushed well outside the beams [C62.9-4J.
PRESCRIBED DOSE 51 Gy in 17 fractions over 24 days.
ACCEPTED DOSE TO ORGANS Testes: as low as possible.

AT RISK
TENTATIVE TECHNIQUE Two lateral opposing beams. Care should be taken to avoid irradiation of
the entire cross-section of the leg.
PATIENT POSITIONING Recumbent position on right side and immobilization individual cast, with
right leg straight and left leg flexed 90 degrees.
SECTIONS FOR DOSE 55 transversal CT-slices from pelvis cranially to the knee joint caudally.
PLANNING Reconstructed sagittal section through entire length of femoral bone
[50 > > > 62].
DOSE CALCULATION True 3-D dose planning.

TECHNIQUE PTV: 6 MV photons.
Two opposed beams with directions 90° and 270°, respectively. Beam
sizes 14 em x 35 em (both).
CONTROL MEASURES Port films on simulator.

Verification films weekly.
In vivo dose measurements of entrance dose and dose to testes at each
fraction.
DOSE SPECIFICATION FOR PTV: 1. Centrally in PTV (= the ICRU Reference Point) .
REPORTING 2. Maximum and minimum .
62 ... Appendix II
Sciatic nerve

Excision border
Muscle fascia
Fig. 1I.5.a. Based on clinical. radiologic, and cytologic findings. Fig. 1I.5.b. At OIX'ration. the medial part of the tumor was
a high·grade lipoaaN;(lma in the long head of the bieeps femoris was found embedded in the long head of the bieeps muscle. The lateral
diagnosed. part of the tumor protruded out of the muscle and was oovered by a
thin membrane. Whether this was muscle fascia or a tumor
pseudocapsule was uncertain. The tumor and the long muscle head
were removed en bloc. Microscopic examination showed a grad", IV
liposarcoma. There Wall no fascialoontainment of the tumor in the
lateral part. The margin was thus c1llSfiified as marginal, and
radiotherapy was indicated.
Fig. I1.5.c. Multiple·plane display of 4 of the 8 CT sections Fig.II.5.d. Volum,~tric image ~'Onstructed from the outlinea in
taken before surgery. In each section, the external oontour and the 8 CT sections deSCI"ibed in Fig. 11.5.c. The most proximal and
outlines of bone, muscle oompartments. and gross tumor are distal sections are shown with a groy scale. The femur is displayed
visualised. as a solid structure (white) as well as the grOl!S tumor (pink), while
the biceps muscle is displayed as a semitransparent structure
(magenta). The spatial relationship of these structures can ellllily
be oonceived. The orientation of the image is given by the patient
related coordinate sysl<)m (L '" Left. R '" I{igh!, S .. Superior, I ~
Inferior, A .. Anterior. P '" Posterior).
Appendix II . . . 63
C~~~···· :0
.... ~
· \

R L
'.:: .::::::::::::::::::::::::::5~.::::::.:
_ .-. -- '-
'- ''-- '-
Fig. 11.5.e. Transverse section through theoontral part of the PTV. The entire cross· section of the posterior compartment was defined as
the CTV. Radiation is given by two oppoaing beams. beam directions 90' and 270' . respectively. Irradiation of the entire cross·section of the
thigh is l\Voided. The numbers indicate absolute dose levels (Gy l for the individual isodose curves. The specified target dose (P'rV-doscl is 51
Gy at a point centrally in the PTV 1_). This point was chosen as being more representative than the point midway on the beam axes (. ). The
maximum dose to the P1'V is 53 Gy, and the minimum dose is 45Gy.
Fig. 11 .5.g. Position of patient during radiotherapy.
Fig. II.5.f. Thegeomelric limitsofthe two beams aredisplayed

in green (beam III I and rod (beam 112). Sagittal section through the
femur constructed from 55 trunsverse CT·sections, of which three
are IIhown here
Appendix III
Relative Merits of Central Dose, Minimum Dose, and Average
Dose for Reporting

It is recommended (Section 3) that a point in the situation with mInImUm and average dose to the
center or in the central part of the Planning Target PTV, where, if the dose calculation is to be signifi-
Volume (PTV) be selected as the ICRU Reference cantly meaningful, it can only be done at level 3 and,
Point (Section 3.3.1), and that the dose at that point to some extent, at level 2 (Section 3.3.4).
be defined as the ICRU Reference Dose (Section A second requirement for reporting the dose is that
3.3.2). It is mandatory to report the ICRU Reference the dose value should be physically accurate. In an
Dose and to describe the dose variation by reporting irradiated medium without any heterogeneity, it is
also the maximum dose and the minimum dose in the obvious that the dose along the central axis can be
PTV. In Section 3.3.1, general criteria are given for calculated with good accuracy, since the beams are
the selection of the ICRU Reference Point. calibrated and also regularly checked at points along
Among radiation oncologists and radiophysicists this axis. In points located off-axis or at the periphery,
around the world, there is unanimous agreement the uncertainty in the dose value will be much larger.
regarding the need for uniformity in prescribing and This is caused by instability and heterogeneity of the
reporting treatments. However, currently, many dif- dose distribution as well as the steep dose gradient
ferent methods are used (Hendricson, 1988). Only close to the border of the beam. The dose at the
one dose value is usually reported in the scientific periphery of the PTV thus cannot be determined in
literature, and such a single value is often used an accurate way and hence is unsatisfactory for
without further explanation as to its meaning. Dose
comparison between different centers. The average
variations are seldom reported, and reports based on,
dose can, however, be computed with good accuracy,
e.g., dose-volume histograms, can not be easily inter-
since the off-axis variation is often averaged out
preted.
inside the beam.
For prescribing and reporting ex;ternal beam ther-
From a radiobiological point of view, the average
apy, many types of dose values are available (see
dose to the cancer cell population is the parameter
Sections 2.4.3-2.4.7). Three commonly used methods
which is best correlated with tumor response, pro-
for prescribing and reporting dose in external beam
therapy will be analyzed. These three methods of vided that the dose heterogeneity is not too large.
reporting by stating one single dose value are: However, in the CTV, the tumor cell density varies to
* dose in or at the central parts of the Planning a large extent and reaches, in principle, zero at its
Target Volume (PTV) and on or close to the border. Therefore, the average dose to the correspond-
central axis of the beam(s), ing PTV does not necessarily correspond to the
* dose at the periphery of the PTV, e.g., isodose average dose in the cancer cell population, and may
line or isodose surface (envelope) encompassing thus lose part of its biological significance.
thePTV, Isodose lines or isodose surfaces at the periphery of
* average dose in the PTV. the PTV are used in some centres for dose specifica-
The relative merits of the three different methods tion (for prescription and for reporting). The objec-
are given in Table 111.1. Other methods for reporting, tive with this approach is to ensure that all tissues
e.g. , median dose, maximum dose, and modal dose are containing tumor cells will receive at least the pre-
not dealt with here. scribed dose. In this situation, the dose value of the
One of the first requirements for specification of isodose line or isodose surface is identical to the
doses for reporting is that the specification should be minimum dose to the PTV. The dose at the periphery
applicable to all clinical situations and all different of the PTV thus can not be considered to be the most
levels of ambition for dose computation. The only relevant single value to describe a treatment (even
dose parameter that meets this criterion is the dose in though it has to be estimated and reported in addition
the central part of the PTV. This contrasts with the to the dose to the ICRU Reference Point). The
64
Appendix 11/ ••• 65
TABLE IILl-Advantages and disadvantages of using central dose in the PTV, minimum dose to the PTV, average dose to the PTV
Parameter Comments
COMPUTATION OF DOSE
Central dose in the PTV Easy to determine.
(=ICRU Reference Dose) Good physical accuracy.
Almost independent of type of dose computation (1-, 2-, or 3-D).
Minimum dose to the PTV Computer is needed.
Limited physical accuracy.
Dependent on dose computation method 0-, 2-, or 3-D).
Average dose to the PTV Computer is needed.
Good physical accuracy.
Dependent on dose computation method (1- , 2-, or 3-D).
SELECTION OF SPECIFICATION POINT

Central dose in the PTV No freedom for selection.
(=ICRU Reference Dose)
Minimum dose to the PTV Some freedom for selection.
Furthermore, the selection can be influenced by the presentation of the values
of the isodoses.
Average dose to the PTV No freedom for selection.
SPATIAL UNCERTAINTIES AND MOVEMENTS
Central dose in the PTV (= ICRU Reference Dose) Almost independent.
Minimum dose to the PTV Dependent.
Average dose to the PTV Somewhat dependent.
PLANNING TARGET VOLUME DEFINITION
Central dose in the PTV Independent of the delineation ofthe PTV.
(=ICRU Reference Dose) Independent of method of patient data acquisition (1-, 2-, or 3-D).
Can be used for all types of volumes.
Minimum dose to the PTV Delineation of the PTV may vary with different therapists, and the minimum
dose then depends on the PTV.
Dependent on type of patient data acquisition (1-, 2-, 3-D).
Can be used for all types of volumes.
Average dose to the PTV Dependent on the delineation of the PTV.
Dependent on method of patient data acquisition 0-, 2-, 3-D).
Little significance if large dose variation in PTV.
CLINICAL AND BIOLOGICAL RELEVANCE
Central dose in the PTV Defined in a region where the tumor cell density usually is high.
(=ICRU Reference Dose)
Minimum dose to the PTV Defined in a region with low or variable tumor cell density.
Average dose to the PTV Variation of tumor cell density from its maximum value down to zero.
decision of the clinical safety margin is one of the The dose at the central part of the PTV, along the
most critical steps in radiotherapy. Consequently, the central axes of the beams, must then be reported in
size and border of the CTV may vary considerably all cases. It is the most representative single dose
from one radiation oncologist to another for the same value for the PTV. However, in order to evaluate the
clinical situation, due to different opinions. Also, the total dose distribution in the PTV, the dose variation
selection of proper margins when defining the PTV (maximum and minimum dose to the PTV) (Section
may vary from therapist to therapist. 3.3.3) also have to be reported.
References
ACS (1983). American Cancer Society, Clinical Oncol- Energy Photons and Electrons, ICRU Report 42.
ogy for Medical Students and Physicians. A Multi- (International Commission on Radiation Units and
disciplinary Approach, 6th Edition, Rubin, P., Ed., Measurements, Washington).
page 269. (American Cancer Society, Atlanta). MIJNHEER, B. J., BATTERMANN, J. J., and WAMBERSIE,
AJCC (1988). American Joint Committee on Cancer, A (1987). "What degree of accuracy is required and
Manual for Staging of Cancer, 3rd edition, Beahrs, can be achieved in photon and neutron therapy?,"
O. H., Henson, D., Hutter, R V. P. and Myers, Radiotherapy and Oncology, 8,237-252.
M. H., Eds. (J. P. Lippincott, Philadelphia). MOLLER, T. R, NORDBERG, U. B., GUSTAFSSON, T.,

BRAHME, A., CHAVAUDRA, J., MCCULLOUGH, E., JOHNSSON, J.-E., LANDBERG, T. G., and SVAHN-
NUSSLIN, F., RAWLINSON, A, SVENSSON, G., LAND- TAPPER, G. (1976). "Planning, control, and docu-
BERG, T., ROSSI, H. and WAMBERSIE, A (1988). mentation of external beam therapy," Acta Radiol.
"Accuracy Requirements and Quality Assurance of Supp!. 353.
External Beam Therapy with Photons and RUBIN, P. (Ed.), (1975). Committee on Self-evaluation
Electrons," Acta Oncologica, Supp!. #1. and Testing: SET R .T .l: Radiation Oncology
GOITEIN, M. (1985). "Calculation of the uncertainty (American College of Radiology, Reston, VA).
in the dose delivered during radiation therapy." CAP (1979). College of American Pathologists, Sys-
Med. Phys. 12,608-612. tematized Nomenclature of Medicine, (SNOMED),
HENDRICKSON, F. R (1988). "Dose Prescription 2nd edition (College of American Pathologists,
Dilemma." International Journal of Radiation On- Northfield,IL).
cology, Biology, Physics, 14, 595-596. UICC (1982). International Union against Cancer,
ICRU (1973). International Commission on Radia- TNM Classification ofMalignant Tumours, Spiessi,
tion Units and Measurements, Measurement of B., Scheibe, O. and Wagner, G., Eds. (Springer
Absorbed Dose in a Phantom Irradiated by a Single Verlag, Berlin).
Beam of X or Gamma Rays, ICRU Report 23 UICC (1987). International Union against Cancer,
(International Commission on Radiation Units and TNM Classification of Malignant Tumours. 4th
Measurements, Washington) . edition, Hermanek, P. and Sobin, L. H., Eds.
ICRU (1976). International Commission on Radia- (Springer Verlag, Berlin).
tion Units and Measurements, Determination of UICC (1990). International Union against Cancer,
Absorbed Dose in a Patient Irradiated by Beams of TNM Atlas, Illustrated Guide to the TNM /pTNM
X or Gamma Rays, ICRU Report 24 (International Classification of Malignant Tumours, 3rd edition.
Commission on Radiation Units and Measure- Spiessl et al., Eds. (Springer Verlag, Berlin).
ments, Washington). WHO (1976a). World Health Organization, Interna-
ICRU (1978). International Commission on Radia- tional Classification of Diseases for Oncology,
tion Units and Measurements, Dose Specification (ICD-O [9» (1st edition, based on 9th revision)
for Reporting External Beam Therapy with Pho- (World Health Organization, Geneva).
tons and Electrons, ICRU Report 29 (International WHO (1976b). World Health Organization, Hand-
Commission on Radiation Units and Measure- book for Standardized Cancer Registries. WHO
ments, Washington). Offset Pub!. No. 25 (World Health Organization,
ICRU (1984). International Commission on Radia- Geneva).
tion Units and Measurements, Radiation Dosime- WHO (1977). World Health Organization, Interna-
try of Electron Beams with Energies between 1 and tional Classification of Diseases, Injuries and
50 MeV, ICRU Report 35. (International Commis- Causes of Death, 9th revision. (World Health Orga-
sion on Radiation Units and Measurements, Wash- nization, Geneva).
ington). WHO (1990). World Health Organization, Interna-
ICRU (1985). International Commission on Radia- tional Classification of Diseases for Oncology,
tion Units and Measurements, Dose and Volume (ICD-O [10» (2nd edition, based on 10th revision)
Specification for Reporting Intracavitary Therapy (World Health Organization, Geneva).
in Gynecology, ICRU Report 38 (International Com- WITTKAMPER, F. W., MIJNHEER, B. J. and VAN KLEF-
mission on Radiation Units and Measurements, FENS, H. J . (1987). "Dose intercomparison at the
Washington). radiotherapy centres in The Netherlands. 1. Pho-
ICRU (1987). International Commission on Radia- ton beams under reference conditions and for
tion Units and Measurements, Use of Computers in prostatic cancer treatment." Radiotherapy and
External Beam Radiotherapy Procedures with High- Oncology, 9,30.
66
ICRU Reports
ICRU Reports are distributed by the ICRU Publications' office. Information on prices and how to order
may be obtained from :
ICRU Publications
7910 Woodmont Avenue, Suite 800

Bethesda, Maryland 20814
U.s.A.
Copies of the reports may also be purchased from the following:
Prof. G.E. Adams Kazuya Yamashita, Ph.D.

Medical Research Council The Japanese Soc·iety of Radiological Technology
Radiobiology Unit Nijyo Plaza, 88 Nishinokyo,
Chilton, Didcot Kitatsuboi-cho,
Oxon OXll ORD, England Nakagyo-ku, Kyoto 604
Phone (0) 235-834-393 JAPAN
Mrs. Brigitte Harder Dr. Minoru Takada
Konrad-Adenauer-Stral3e 26 Japan Radioisotope Association
D-3400 Gottingen 28-45, Honkomagome 2-chome
Federal Republic of Germany Bunkyoku, Tokyo 113
Phone (0551) 22612 JAPAN
Prof. Andre Wambersie Prof. Torgil Moller
Unite de Radiobiologie et Radioprotection Regional Tumor Registry
UCL-Cliniques St. Luc University Hospital
Avenue Hippocrate, 54.69 S-22185 Lund
B-1200 Brussels, Belgium SWEDEN
Phone (02) 764.54.68
The currently available ICRU Reports are listed below.
ICRU
Report No. Title
lOb Physical Aspects of Irradiation (1964)
10c Radioactivity (1963)
10f Methods of Evaluating Radiological Equipment and Ma-
terials (1963)
12 Certification of Standardized Radioactive Sources (1968)
13 Neutron Fluence, Neutron Spectra and Kerma (1969)
14 Radiation Dosimetry: X Rays and Gamma Rays with
Maximum Photon Energies Between 0.6 and 50 MeV
(1969)
15 Cameras for Image Intensifier Fluorography (1969)
16 Linear Energy Transfer (1970)
67
68 ... ICRU Reports
17 Radiation Dosimetry: X Rays Generated at Potentials of 5

to 150kV(1970)
18 Specification of High Activity Gamma-Ray Sources (1970)
20 Radiation Protection Instrumentation and Its Application
(1970)
22 Measurement of Low-Level Radioactivity (1972)
23 Measurement of Absorbed Dose in a Phantom Irradiated
by a Single Beam of X or Gamma Rays (1973)
24 Determination of Absorbed Dose in a Patient Irradiated by
Beams of X or Gamma Rays in Radiotherapy Proce-
dures (1976)

25 Conceptual Basis for the Determination of Dose Equiva-
lent (1976)
26 Neutron Dosimetry for Biology and Medicine (1977)
27 An International Neutron Dosimetry Intercomparison
(1978)
28 Basic Aspects of High Energy Particle Interactions and
Radiation Dosimetry (1978)
30 Quantitative Concepts and Dosimetry in Radiobiology
(1979)
31 Average Energy Required to Produce an Ion Pair (1979)
32 Methods ofAssessment ofAbsorbed Dose in Clinical Use of
Radionuclides (1979)
33 Radiation Quantities and Units (1980)
34 The Dosimetry of Pulsed Radiation (1982)
35 Radiation Dosimetry: Electron Beams with Energies Be-
tween 1 and 50 MeV (1984)
36 Microdosimetry (1983)
37 Stopping Powers for Electrons and Positrons (1984)
38 Dose and Volume Specification for Reporting Intracavi-
tary Therapy in Gynecology (1985)
39 Determination of Dose Equivalents Resulting from Exter-
nal Radiation Sources (1985)
40 The Quality Factor in Radiation Protection (1986)
41 Modulation Transfer Function of Screen-Film Systems
(1986)
42 Use of Computers in External Beam Radiotherapy Proce-
dures with High-Energy Photons and Electrons (1988)
43 Determination of Dose Equivalents from External Radia-
tion Sources-Part 2 (1988)
44 Tissue Substitutes in Radiation Dosimetry and Measure-
ment (1989)
45 Clinical Neutron Dosimetry-Part I: Determination of
Absorbed Dose in a Patient Treated by External Beams
of Fast Neutrons (1989)
46 Photon, Electron, Proton and Neutron Interaction Data for
Body Tissues (1992)
46D Photon, Electron, Proton and Neutron Interaction Data for
Body Tissues, with Data Disk (1992)
47 Measurement of Dose Equivalents from External Photon
and Electron Radiations (1992)
48 Phantoms and Computational Models in Therapy, Diag-
nosis and Protection (1992)
49 Stopping Powers and Ranges for Protons and Alpha
Particles (1992)
ICRU Reports ... 69
49D Stopping Power and Ranges for Protons and Alpha Parti-
cles, with Data Disk (1993)
50 Prescribing, R ecording and Reporting Photon Beam
Therapy (1992)
Binders for ICRU Reports are available. Each binder will accommodate from six to eight reports. The binders
carry the identification, "ICRU Reports, " and come with label holders which permit the user to attach labels
showing the Reports contained in each binder.
The following bound sets of ICRU Reports are also available:
Volume I. ICRU Reports lOb, 10c, 10f
Volume II. ICRU Reports 12, 13, 14, 15, 16, 17, 18,20

Volume III. ICRU Reports 22, 23, 24,25, 26
Volume IV. ICRU Reports 27,28,30,31 , 32
Volume V. ICRU Reports 33, 34,35,36
Volume VI. ICRU Reports 37,38,39,40,41
Volume VII. ICRU Reports 42, 43, 44
Volume VIII. ICRU Reports 45, 46, 47
(Titles of the individual Reports contained in each volume are given in the list of Reports set out above. )
The following ICRU Reports were superseded by subsequent Reports and are now out of print:
ICRU
Report No. Title and Reference*
1 Discussion on International Units and Standards for
X-ray work, Br. J. Radiol. 23,64 (1927).
2 International X-Ray Unit oflntensity, Br. J. Radiol. (new
series) 1,363 (1928).
3 Report of Committee on Standardization ofX-ray Mea-
surements, Radiology 22,289 (1934).
4 Recommendations of the International Committee for Ra-
diological Units, Radiology 23,580 (1934).
5 R ecommendations of the International Committee for Ra-
diological Units, Radiology 29,634 (1937).
6 Recommendations of the International Commission on
Radiological Protection and of the International Com-
mission on Radiological Units, National Bureau of
Standards Handbook 47 (U .S. Government Printing
Office, Washington, D.C., 1951 ).
7 Recommendations of the International Commission on
Radiological Units, Radiology 62,106 (1954).
8 Report of the International Commission on Radiological
Units and Measurements (lCRU) 1956, National Bu-
reau of Standards Handbook 62 (U.S. Government
Printing Office, Washington, D.C., 1957).
9 Report of the International Commission on Radiological
Units and Measurements (lCRU) 1959, National Bu-
reau of Standards Handbook 78 (U.S. Government
Printing Office, Washington D.C., 1961).
lOa Radiation Quantities and Units, National Bureau of Stan-
dards Handbook 84 (U.S. Government Printing Office,
Washington, D.C., 1962).
10d Clinical Dosimetry, National Bureau of Standards Hand-
book 87 (U.s. Government Printing Office, Washington,
D.C., 1968).
70 ... ICRU Reports
10e Radiobiological Dosimetry, National Bureau of Standards

Handbook 88 (U.S. Government Printing Office, Wash-
ington, D.C., 1963).
11 Radiation Quantities and Units (International Commis-
sion on Radiation Units and Measurements, Washing-
ton, D.C., 1968).
19 Radiation Quantities and Units (International Commis-
sion on Radiation Units and Measurements, Washing-
ton, D.C., 1971).
19S Dose Equivalent [Supplement to ICRU Report 19] (Inter-
national Commission on Radiation Units and Measure-

ments, Washington, D.C. 1973).
21 Radiation Dosimetry: Electrons with Initial Energies Be-
tween 1 and 50 MeV (International Commission on Ra-
diation Units and Measurements, Washington, D.C.,
1972).
29 Dose Specification for Reporting External Beam Therapy
with Photons and Electrons (International Commission
on Radiation Units and Measurements, Washington,
D.C., 1978)
'References given are in English. Some of the Reports were also published in other languages.
Index
Absorbed dose calculation, 47 Evaluation, 5
Reporting, 47 Example, 5, 8-9, 21
Absorbed dose distribution, 18 Reporting, 27
Absorbed dose pattern, 20, 26, 47
Isodose plan, 47 Hot spots, 26, 38, 50

Three dimensional dose distribution, 20 Area/volume restrictions, 26
Acceptability of dose variation, 18, 20, 33 Definition, 26
Aim of therapy, 3 Example, 50
Non-malignant disease, 3 Reporting, 38
Palliative treatment of malignant disease, 3
Radical treatment of malignant disease, 3 ICRU Reference Dose, 33
Transverse sections, 44, 47 ICRU Reference Point, 24, 25, 28-38, 50, 52-53, 55, 59-60, 63
Reporting, 47 Example, 24, 25, 28-32, 34-37, 50, 52-53, 55, 59-60,63
Viewing, 47 Introduction, 1-2
Anatomical code, 41, 42, 43 Irradiated volume, 5, 16-18, 28-29
Anatomy, 27, 39, 41-46 Definition, 16-18 .
Codification, 27, 39, 41-44 Example, 5
Example, 45-46 Reporting, 28-29
Average dose (Daveeage), 26, 33, 60, 64-65
Labelling isodose curves, 47
"Boost" therapy, 6, 36, 51-56 Levels for reporting, 33-34
Central dose, 29, 33, 64-65 Maximum dose (Dmax), 20-22

Clinical Target Volume (CTV), 5, 7, 8-13, 21-23, 27, 45-46 Area/volume restrictions, 20-22
Change in the size, shape, and location during treatment, 7 Median dose (Dmedian), 26, 60
Codification, 7, 27, 45-46 Minimum dose (D min ), 22, 26
Example, 5, 8-13, 21-23 Minimum requirements for documentation and recommendations
Reporting, 27 for description of technique, 39, 44, 47
Coding anatomy, 27, 41-44 Modal dose (Dmodal), 26
Example, 41-44
Complex treatments with more than one Planning Target Vol- Non-malignant disease, 3
ume,36-38
Adjacent Planning Target Volumes, 36-37 Organs at risk, 18, 38
Overlapping Planning Target Volumes, 36-38 Definition, 18
Reporting, 36-38 Reporting, 38
Definitions of terms and concepts, 3-26 Palliative treatment of malignant disease, 3

Description oftechnique for reporting, 44, 47 Penumbra, 7, 64
Documentation, 39, 40, 44 Planning Target Volume (PTV), 5, 7-12, 13, 19,27,58
Dose, 18,20,29,33,34,38 Definition, 7-12
Heterogeneity, 18, 20 Example, 5, 13, 19, 58
Reporting, 29, 33, 34, 38 Penumbra, 7
Dose-area histograms, 19 Reporting, 27
Dose variation in the Planning Target Volume, 18, 20, 33 Target Volume, 7
Dose-volume histograms, 19 Uncertainties, 7-12
Prescribing therapy, 1, 3
Examples of the use of the recommendations, 49-63 Purpose for specification of dose, 1-2
Factors important to prescription, recording, and reporting, 1 Quality control, 39-40, 47

Fractions, 47 Reporting, 47
Reporting, 47
Radical treatment of malignant disease, 3
General recommendations for reporting doses, 29 Recommendations for reporting, 27-38
General recommendations for reporting volumes, 27, 28, 29 Recording therapy, 39-47
Gross Tumor Volume (GTV), 3, 4, 5, 6, 8, 9, 21, 27, 41-43 Parameters to be recorded, 39-40
Codification, 6, 27, 41-43 Reference radiation, 47
Definition, 3, 4, 5, 6 References, 66
71
72 ... Index
Reporting, 20, 26-29, 33-36, 38, 44, 47 Organs at risk, 38
Absorbed dose calculations, 47 Three levels of dose evaluation , 33-34
Absorbed dose rate, 47 Reporting therapy, 27
Complex treatments with more than one Planning Target Vol- Reporting volumes , 27-29
ume, 36, 38 Representation of a spatial dose distribution , 20-23
Description of technique, 44, 47
Doses, 47 Single Planning Ta rget Volume, 34-35
Fractions, 47 Complex beam arrangements, 34-35
Hot spots, 26 Simple beam arrangements, 34
Isodose curves, 20, 47 Steps in the radiotherapy procedure, 3-4
Isodose plots, 47
Organs at risk, 38 Target volume, 7
Quality control, 47 Three levels of dose evaluation for reporting, 33-34

Reference radiation , 47 Time dose pattern, 47
Single Planning Target Volume, 34-35 Reporting, 47
Technique, 44, 47 Tissue inhomogeneity correction, 47
Time dose patterns, 47 Reporting, 47
Tissue inhomogeneity correction, 33-34, 47 Treated volume, 5, 16- 18
Treatment planning, 33-34, 44 Definition, 16
Transverse sections, 20, 47 Example, 5
Volumes, 27-29 Reporting, 16-18
Reporting doses, 19, 29, 33-34, 36, 38, 60 Treatment planning, 44, 47
Average dose, 33, 60 Reporting, 44
Biologically weighted doses, 33 Use of sections, 47
Dose area /volume histograms, 19, 33 Treatment record form, 27, 39-40
ICRU Reference Dose, 33-38, 49-65 Reporting, 27, 39-40
Levell : basic techniques, 33, 36
Level 2: advanced techniques, 33-34, 38 Uncertainties, 20
Level 3: developmental techniques, 33-34, 38
Maximum, 33 Volumes, 3-18, 27-29
Minimum, 33 Reporting, 27-29

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Decision on external beam ::

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Comparison of dose distributions and

Full cofTllutation and display of the

Set-up at the therapy machine ~

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==4---4---1-- Gross tumor volume

<I---I-.J..---I-- Clinical target volume

~.J..---I-- Planning target volume

1---1-- Treated volume

Fig. 2.2. Schematic illustration of the different volumes.

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Fig. 2.5.a. Two opposed equally weighted beams.

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~=-:-==-:-=~-LI _~ _-=~._I . ==-.. =._.

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Fig. 2.S.d. Moving beam therapy; large arc.

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Fig. 2.7.c. & d. T he Gro!l/l Tumor Volume

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maximum. For three-dimensional computation, a vol- equation:

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2.4.4 Minimum Dose (Dmin ) 2.4.7 Modal Dose (D moda1 )

3.1 Introduction Another coding system is the SNOMED (System-

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Location of ICRU Reference Point

A single beam Recommended Recommended May be necessary" 3.l.a, 2.9