Chapter 7: Clinical Treatment Planning in

External Photon Beam Radiotherapy

Set of 232 slides based on the chapter authored by
W. Parker, H. Patrocinio
of the IAEA publication (ISBN 92-0-107304-6):
Review of Radiation Oncology Physics:
A Handbook for Teachers and Students
Objective:
To familiarize the student with a variety of modern photon beam
radiotherapy techniques to achieve a uniform dose distribution
inside the target volume and a dose as low as possible in the
healthy tissues surrounding the target.
Slide set prepared in 2006
by G.H. Hartmann (Heidelberg, DKFZ)
Comments to S. Vatnitsky:
[email protected]

Version 2012
IAEA
International Atomic Energy Agency
CHAPTER 7. TABLE OF CONTENTS

7.1 Introduction
7.2 Volume Definition
7.3 Dose Specification
7.4 Patient Data Acquisition and Simulation
7.5 Clinical Considerations for Photon Beams
7.6 Treatment Plan Evaluation
7.7 Treatment Time and Monitor Unit Calculations

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.Slide 1
7.1 INTRODUCTION

General considerations for photon beams

 Almost a dogma in external beam radiotherapy:

Successful radiotherapy requires a uniform dose

distribution within the target (tumor).

External photon beam radiotherapy is usually

carried out with multiple radiation beams
in order to achieve a uniform dose distribution
inside the target volume and a dose as low as
possible in healthy tissues surrounding the
target.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 1
7.1 INTRODUCTION

Criteria of a uniform dose distribution within the target

 Recommendations regarding dose uniformity, prescribing,

recording, and reporting photon beam therapy are set forth
by the International Commission on Radiation Units and
Measurements (ICRU).

 The ICRU report 50 recommends a target dose uniformity

within +7 % and –5 % relative to the dose delivered to a
well defined prescription point within the target.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 2
7.1 INTRODUCTION

To achieve this goal, modern beam radiotherapy is

carried out with a variety of:

 Beam energies

and

 Field sizes

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 3
7.1 INTRODUCTION

Beam energies used:

• Superficial
(30 kV to 80 kV)
• Orthovoltage
(100 kV to 300 kV)
• Megavoltage or
supervoltage energies
(Co-60 to 25 MV)

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 4
 7.1 INTRODUCTION

 Field sizes range from:

.

Standard rectangular Very large fields used

and irregular fields for total body
irradiations
Small circular fields
used in radiosurgery
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 5
7.1 INTRODUCTION

Methods of Patient setup:

 Photon beam radiotherapy is carried out under two setup
conventions

constant isocentric setup

Source-Surface Distance with a constant
Source-Axis Distance

(SSD technique) (SAD technique).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 6
7.1 INTRODUCTION

SSD technique
 The distance from the source to the surface of the patient
is kept constant for all beams.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 7
7.1 INTRODUCTION

SAD technique
 The center of the target volume is placed at the machine
isocenter, i.e. the distance to the target point is kept
constant for all beams.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 8
7.1 INTRODUCTION

Note:
In contrast to SSD technique,
the SAD technique requires
no adjustment of the patient
setup when turning the gantry
to the next field.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.1 Slide 9
7.2 VOLUME DEFINITION

 The process of determining the volume for the treatment

of a malignant disease consists of several distinct steps.

 In this process, different volumes may be defined, e.g.

due to:
• Varying concentrations of malignant cells.
• Probable changes in the spatial relationship between volume and
beam during therapy.
• Movement of patient.
• Possible inaccuracies in the treatment setup.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2 Slide 1
7.2 VOLUME DEFINITION

The ICRU 50 and 62

Reports define and
describe several target
and critical structure
volumes that:
• Aid in the treatment
planning process
• Provide a basis for
comparison of treat-ment
outcomes.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2 Slide 2
7.2 VOLUME DEFINITION

The following slides describe these "ICRU volumes" that

have been defined as principal volumes related to three-
dimensional treatment planning.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2 Slide 3
7.2 VOLUME DEFINITION
7.2.1 Gross Tumor Volume (GTV)

GTV

 The Gross Tumor Volume (GTV) is the gross palpable or

visible/demonstrable extent and location of malignant
growth.
 The GTV is usually based on information obtained from a
combination of imaging modalities (CT, MRI, ultrasound,
etc.), diagnostic modalities (pathology and histological
reports, etc.) and clinical examination.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.1 Slide 1
7.2 VOLUME DEFINITION
7.2.2 Clinical Target Volume (CTV)

CTV

GTV

 The Clinical Target Volume (CTV) is the tissue volume

that contains a demonstrable GTV and/or sub-clinical
microscopic malignant disease, which has to be
eliminated.
 This volume thus has to be treated adequately in order to
achieve the aim of therapy, cure or palliation.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.2 Slide 1
7.2 VOLUME DEFINITION
7.2.2 Clinical Target Volume (CTV)

 The CTV often includes the area directly surrounding

the GTV that may contain microscopic disease and other
areas considered to be at risk and require treatment.
Example: positive lymph nodes.
 The CTV is an anatomical-clinical volume.
 It is usually determined by the radiation oncologist, often
after other relevant specialists such as pathologists or
radiologists have been consulted.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.2 Slide 2
7.2 VOLUME DEFINITION
7.2.2 Clinical Target Volume (CTV)

 The CTV is usually stated as a fixed or variable margin

around the GTV.
Example:
CTV = GTV + 1 cm margin

 In some cases the CTV is the same as the GTV.

Example:
prostate boost to the gland only

 There can be several non-contiguous CTVs that may

require different total doses to achieve treatment goals.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.2 Slide 3
7.2 VOLUME DEFINITION
7.2.3 Internal Target Volume (ITV)

General consideration on margins:

 Margins are most important for clinical radiotherapy.
They depend on:
• organ motion internal margins
• patient set-up and beam alignment
external margins
 Margins can be non-uniform but should be three
dimensional.
 A reasonable way of thinking would be: “Choose
margins so that the target is in the treated field at
least 95 % of the time.”

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.3 Slide 1
7.2 VOLUME DEFINITION
7.2.3 Internal Target Volume (ITV)

ITV
CTV

CTV

 The Internal Target Volume (ITV) consists of the CTV

plus an internal margin.
 The internal margin is designed to take into account the
variations in the size and position of the CTV relative to
the patient’s reference frame (usually defined by the bony
anatomy), i.e., variations due to organ motions such as
breathing, bladder or rectal contents, etc.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.3 Slide 2
7.2 VOLUME DEFINITION
7.2.4 Planning Target Volume (PTV)

PTV
ITV
CTV

 In contrast to the CTV, the Planning Target Volume

(PTV) is a geometrical concept.
 It is defined to select appropriate beam arrangements,
taking into consideration the net effect of all possible
geometrical variations, in order to ensure that the
prescribed dose is actually absorbed in the CTV.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.4 Slide 1
7.2 VOLUME DEFINITION
7.2.4 Planning Target Volume (PTV)

 The PTV includes the internal target margin and an

additional margin for:
• set-up uncertainties
• machine tolerances
• and intra-treatment
variations.
 The PTV is linked to the
reference frame of the
treatment machine
(IEC 1217: "Fixed System").

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.4 Slide 2
7.2 VOLUME DEFINITION
7.2.4 Planning Target Volume (PTV)

 The PTV is often described as the CTV plus a fixed or

variable margin.
Example:
PTV = CTV + 1 cm

 Usually a single PTV is used to encompass one or several

CTVs to be targeted by a group of fields.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.4 Slide 3
7.2 VOLUME DEFINITION
7.2.4 Planning Target Volume (PTV)

 The PTV depends on the precision of such tools such as:

• Immobilization devices
• Lasers

 The PTV does NOT include a margin for dosimetric

characteristics of the radiation beam as these will require
an additional margin during treatment planning and
shielding design.
Examples not included:
• Penumbral areas
• Build-up region

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.4 Slide 4
7.2 VOLUME DEFINITION
7.2.5 Organ at Risk (OAR)

PTV
ITV
CTV
OAR

 Organ At Risk is an organ whose sensitivity to radiation

is such that the dose received from a treatment plan may
be significant compared to its tolerance, possibly requiring
a change in the beam arrangement or a change in the
dose.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.5 Slide 1
7.2 VOLUME DEFINITION
7.2.5 Organ at Risk (OAR)

 Specific attention should be paid to organs that, although

not immediately adjacent to the CTV, have a very low
tolerance dose.
Example for such OARs:
• Eye lens during nasopharyngeal or brain tumor treatments

 Organs with a radiation tolerance that depends on the

fractionation scheme should be outlined completely to
prevent biasing during treatment plan evaluation.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.2.5 Slide 2
7.3 DOSE SPECIFICATION

 The complete prescription of radiation treatment must

include:
• Definition of the aim of therapy
• Volumes to be considered
• Prescription of dose and fractionation.
 Only detailed information regarding total dose, fractional
dose and total elapsed treatment days allows for proper
comparison of outcome results.
 Different concepts have been developed for this
requirement.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.3 Slide 1
7.3 DOSE SPECIFICATION

 When the dose to a given volume is prescribed, the

corresponding delivered dose should be as homogeneous
as possible.
 Due to technical reasons, some heterogeneity has to be
accepted. PTV =
Example: dotted area

frequency dose-area
histogram for the PTV
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.3 Slide 2
7.3 DOSE SPECIFICATION

 The ICRU report 50 recommends a target dose uniformity

within +7 % and –5 % relative to the dose delivered to a
well defined prescription point within the target.
 Since some dose heterogeneity is always present, a
method to describe this dose heterogeneity within the
defined volumes is required.
 ICRU Report 50 is suggesting several methods for the
representation of a spatial dose distribution.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.3 Slide 3
7.3 DOSE SPECIFICATION

 Parameters to characterize the dose distribution within a

volume and to specify the dose are:
• Minimum target dose
• Maximum target dose
• Mean target dose
• A reference dose at a representative point within the volume

 The ICRU has given recommendations for the selection of a

representative point (the so-called ICRU reference point).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.3 Slide 4
7.3 DOSE SPECIFICATION

 The ICRU reference dose point is located at a point

chosen to represent the delivered dose using the following
criteria:
• The point should be located in a region where the dose can be
calculated accurately (i.e., no build-up or steep gradients).
• The point should be in the central part of the PTV.
• For multiple fields, the isocenter (or beam intersection point) is
recommended as the ICRU reference point.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.3 Slide 5
 7.3 DOSE SPECIFICATION

ICRU reference Example for a 3 field prostate boost

point for multiple treatment with an isocentric technique
fields

The ICRU (reference)

point is located at
the isocenter
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.3 Slide 6
7.3 DOSE SPECIFICATION

 Specific recommendations are made with regard to the

position of the ICRU (reference) point for particular beam
combinations:
• For single beam:
the point on central axis at the center of the target volume.
• For parallel-opposed equally weighted beams:
the point on the central axis midway between the beam entrance
points.
• For parallel-opposed unequally weighted beams:
the point on the central axis at the centre of the target volume.
• For other combinations of intersecting beams:
the point at the intersection of the central axes (insofar as there
is no dose gradient at this point).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.3 Slide 7
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.1 Need for patient data

 Within the simulation process of the entire treatment using

the computerized treatment planning system, the patient
anatomy and tumor targets can be represented as three-
dimensional models.

Example:
 CTV: mediastinum (violet)
 OAR:
• Both lungs (yellow)
• Spinal cord (green)

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.1 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.1 Need for patient data

 Patient data acquisition to create the patient model is the

initial part of this simulation process.

 The type of gathered data varies greatly depending on the

type of treatment plan to be generated.
Examples:
• manual calculation of parallel-opposed beams
requires less effort
• complex 3D treatment plan with image fusion
requires large effort

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.1 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.1 Need for patient data

General considerations on patient data acquisition:

 Patient dimensions are always required for treatment
time or monitor unit calculations, whether read with a
caliper, from CT slices or by other means.
 Type of dose evaluation also dictates the amount of
patient data required (e.g., DVHs require more patient
information than point dose calculation of organ dose).
 Landmarks such as bony or fiducial marks are required to
match positions in the treatment plan with positions on the
patient.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.1 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.2 Nature of patient data

 The patient information required for treatment planning

varies from rudimentary to very complex data acquisition:

• Distances read on the skin.

• Manual determination of contours.

• Acquisition of CT information over a large volume.

• Image fusion using various imaging modalities.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.2 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.2 Nature of patient data

 The patient information required for treatment planning in

particular depends on which system is used:

Two-dimensional system Three-dimensional system

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.2 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.2 Nature of patient data

2D treatment planning
 A single patient contour, acquired using lead wire or
plaster strips, is transcribed onto a sheet of graph paper,
with reference points identified.
 Simulation radiographs are taken for comparison with port
films during treatment.
 For irregular field calculations, points of interest can be
identified on a simulation radiograph, and SSDs and
depths of interest can be determined at simulation.
 Organs at risk can be identified and their depths
determined on simulator radiographs.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.2 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.2 Nature of patient data

3D treatment planning
 CT dataset of the region to be treated is required with a
suitable slice spacing (typically 0.5 - 1 cm for thorax,
0.5 cm for pelvis, 0.3 cm for head and neck).
 An external contour (representative of the skin or
immobilization mask) must be drawn on every CT slice
used for treatment planning.
 Tumor and target volumes are usually drawn on CT
slices.
 Organs at risk and other structures should be drawn in
their entirety, if dose-volume histograms are to be
calculated.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.2 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.2 Nature of patient data

Contours for different

volumes have been
drawn on this CT slice
for a prostate
treatment plan:
• GTV
• CTV
• PTV
• Organs at risk (OAR)
(bladder and rectum).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.2 Slide 5
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.2 Nature of patient data

3D treatment planning (cont.)

 MRI or other studies (PET) are required for image fusion.
 With many treatment planning systems, the user can
choose:
• To ignore inhomogeneities (often referred to as
heterogeneities).

• To perform bulk corrections on outlined organs.

• To use the CT data itself (with an appropriate conversion to
electron density) for point-to-point correction.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.2 Slide 6
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.2 Nature of patient data

3D treatment planning (cont.)

 CT images can be used to produce digitally reconstructed
radiographs (DRRs)
 DRRs are used for comparison with portal films or beam’s
eye view to verify patient set up and beam arrangement

A digitally reconstructed
radiograph with super-imposed
beam’s eye view for an
irregular field

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.2 Slide 7
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.3 Treatment simulation

 Patient simulation was initially developed to ensure that

the beams used for treatment were correctly chosen and
properly aimed at the intended target.
Example: The double
exposure technique

Film is irradiated with

the treatment field first,
then the collimators are
opened to a wider
setting and a second
exposure is given to
film.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.3 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.3 Treatment simulation

 Presently, treatment simulation has a more expanded role

in the treatment of patients consisting of:
• Determination of patient treatment position
• Identification of the target volumes and OARs
• Determination and verification of treatment field geometry
• Generation of simulation radiographs for each treatment beam
for comparison with treatment port films
• Acquisition of patient data for treatment planning.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.3 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.3 Treatment simulation

Comparison of simple simulation with portal image (MV) and

conventional simulation with diagnostic radiography (kV) of the
same anatomical site (prostate) demonstrates the higher
quality of information on anatomical structures.
Check portal film (MV) Reference simulator film (kV)

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.3 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.3 Treatment simulation

 It is neither efficient nor practical to perform simulations

with portal imaging on treatment units.

• There is always heavy demand for the use of treatment units for
actual patient treatment.
• Using them for simulation is therefore considered an inefficient
use of resources.
• These machines operate in the megavoltage range of energies
and therefore do not provide adequate quality radiographs for a
proper treatment simulation.

poor image quality!

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.3 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.3 Treatment simulation

 Reasons for the poor quality of port films:

• Most photon interactions with biological material in the
megavoltage energy range are Compton interactions that
produce scattered photons that reduce contrast and blur the
image.
• The large size of the radiation source (either focal spot for a
linear accelerator or the diameter of radioactive source in an
isotope unit) increases the detrimental effects of beam penumbra
on the image quality.
• Patient motion during the relatively long exposures required and
the limitations on radiographic technique also contribute to poor
image quality.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.3 Slide 5
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.3 Treatment simulation

Therefore, dedicated
equipment – fluoroscopic
simulator - has been
developed and was widely
used for radiotherapy
simulation.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.3 Slide 6
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.3 Treatment simulation

Modern simulation
systems are based on
computed tomography
(CT) or magnetic
resonance (MR) imagers
and are referred to as CT-
simulators or MR-
simulators.

A dedicated radiotherapy CT simulator

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.3 Slide 7
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

Patients may require an external immobilization device for

their treatment, depending upon:
 Patient treatment position
or
 Precision required for beam delivery.

Example:
Precision
required in
radiosurgery

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

Immobilization devices have two fundamental roles:

 To immobilize the patient during treatment;
 To provide a reliable means of reproducing the patient
position from treatment planning and simulation to
treatment, and from one treatment to another.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

 The immobilization means include masking tape, velcro

belts, or elastic bands, or even a sharp fixation system
attached to the bone.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

 The simplest immobilization device used in radiotherapy is

the head rest, shaped to fit snugly under the patient’s head
and neck area, allowing the patient to lie comfortably on the
treatment couch.

Headrests used for patient positioning and immobilization

in external beam radiotherapy

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

Other immobilization accessories:

 Patients to be treated in the head and neck or brain areas
are usually immobilized with a plastic mask which, when
heated, can be moulded to the patient’s contour.

 The mask is affixed directly

onto the treatment couch
or to a plastic plate that lies
under the patient thereby
preventing movement.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 5
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

For extra-cranial treatments (such as to the thoracic or pelvic

area), a variety of immobilization devices are available.
Vacuum-based devices are popular because of their
re-usability.

A pillow filled with tiny styrofoam balls is placed around the

treatment area, a vacuum pump evacuates the pillow
leaving the patient’s form as an imprint in the pillow.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 6
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

Another system, similar in concept, uses a chemical

reaction between two reagents to form a rigid mould of the
patient.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 7
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

Another system uses the mask method adopted to the body.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 8
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.4 Patient treatment position and immobilization devices

 Special techniques, such as stereotactic radiosurgery,

require such high precision that conventional
immobilization techniques are inadequate.
 In radiosurgery, a stereotactic
frame is attached to the patient’s
skull by means of screws and
is used for target localization,
patient setup, and patient
immobilization during the entire
treatment procedure.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.4 Slide 9
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.5 Patient data requirements

 For simple hand calculations of the dose along the central

axis of the beam and the beam-on time or linac monitor
units, the source-surface distance along the central ray
only is required.

Examples:
• Treatment with a direct field.
• Parallel and opposed fields.

Requirement: a flat beam incidence.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.5 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.5 Patient data requirements

 If simple algorithms, such as Clarkson integration, are

used to determine the dosimetric effects of having blocks
in the fields or to calculate the dose to off-axis points, their
coordinates and source to surface distance must be
measured.

The Clarkson integration method

(for details see chapter 6)

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.5 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.5 Patient data requirements

 For simple computerized 2D treatment planning, the

patient’s shape is represented by a single transverse skin
contour through the central axis of the beams.

 This contour may be acquired using lead wire or plaster

cast at the time of simulation.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.5 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.5 Patient data requirements

 The patient data requirements for modern

3D treatment planning systems are more elaborate
than those for 2D treatment planning.

 The nature and complexity of data required limits the use

of manual contour acquisition.

 Transverse CT scans contain all information required

for complex treatment planning and form the basis of CT-
simulation in modern radiotherapy treatment.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.5 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.5 Patient data requirements

The patient data requirements for 3D treatment planning

include the following:
 The external shape of the patient must be outlined for all
areas where the beams enter and exit (for contour
corrections) and in the adjacent areas (to account for
scattered radiation).
 Targets and internal structures must be outlined in
order to determine their shape and volume for dose
calculation.
 Electron densities for each volume element in the dose
calculation matrix must be determined if a correction for
heterogeneities is to be applied.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.5 Slide 5
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

 A fluoroscopic simulator consists of a gantry and couch

arrangement similar to that on a isocentric megavoltage
treatment unit.

 The radiation source

is a diagnostic quality
x-ray tube rather than
a high-energy linac
or a cobalt source.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

 Modern simulators provide the ability to mimic most

treatment geometries attainable on megavoltage treatment
units, and to visualize the resulting treatment fields on
radiographs or under fluoroscopic examination of the
patient.

Adjustable bars made of

tungsten can mimic the
planned field size
superimposed to the
anatomical structures.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

 Photons produced by the x-ray tube are in the kilovoltage

range and are preferentially attenuated by higher Z
materials such as bone through photoelectric interactions.
 The result is a high quality diagnostic radiograph with
limited soft tissue contrast, but with excellent visualization
of bony landmarks and high Z contrast agents.
 A fluoroscopic imaging system may also be included and
would be used from a remote console to view patient
anatomy and to modify beam placement in real time.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

 For the vast majority of sites, the disease is not visible on

the simulator radiographs
 Therefore the block positions can be determined only with
respect to anatomical landmarks visible on the
radiographs (usually bony structures or lead wire clinically
placed on the surface of the patient).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

Determination of treatment beam geometry

 Typically, the patient is placed on the simulator couch,
and the final treatment position of the patient is verified
using the fluoroscopic capabilities of the simulator (e.g.,
patient is straight on the table, etc.).
 The position of the treatment isocenter, beam geometry
(i.e., gantry, couch angles, etc.) and field limits are
determined with respect to the anatomical landmarks
visible under fluoroscopic conditions.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 5
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

Determination of treatment beam geometry

 Once the final treatment
geometry has been established,
radiographs are taken as a
matter of record, and are also
used to determine shielding
requirements for the treatment.
 Shielding can be drawn
directly on the films, which
may then be used as the
blueprint for the construction
of the blocks.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 6
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

Acquisition of patient data

 After the proper determination of beam geometry, patient
contours may be taken at any plane of interest to be
used for treatment planning.
 Although more sophisticated devices exist, the simplest
and most widely available method for obtaining a patient
contour is through the use of lead wire.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 7
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

Acquisition of patient data (cont.)

The lead wire method:
 The wire is placed on a transverse plane parallel to the
isocenter plane.
 Next, the wire is shaped to the patient’s contour.
 The shape of the wire is then transferred to a sheet of
graph paper.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 8
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.6 Conventional treatment simulation

Acquisition of patient data (cont.)

 Use of a special drawing instrument.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.6 Slide 9
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.7 Computed tomography-based conventional simulation

Data acquisition with Computed Tomography

 With the growing popularity of computed tomography (CT)
in the 1990s, the use of CT scanners in radiotherapy
became widespread.
 Anatomical information on CT scans is presented in the
form of transverse slices, which contain anatomical
images of very high resolution and contrast.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.7 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.7 Computed tomography-based conventional simulation

 CT images provide excellent soft tissue contrast allowing

for greatly improved tumor localization and definition in
comparison to conventional simulation.
 Patient contours can be
obtained easily from the
CT data:
• Patient’s skin contour
• Target
• Any organs of interest

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.7 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.7 Computed tomography-based conventional simulation

 The position of each slice and therefore the target can be

related to bony anatomical landmarks through the use of
scout or pilot images obtained at the time of scanning.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.7 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.7 Computed tomography-based conventional simulation

Scout films
 Pilot or scout films are obtained by keeping the x-ray
source in a fixed position and moving the patient
(translational motion) through the stationary slit beam.
 The result is a high definition radiograph which is
divergent on the transverse axis, but non-divergent on the
longitudinal axis.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.7 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.7 Computed tomography-based conventional simulation

Scout films
 The target position can also be determined through
comparison between the CT scout and pilot films.
 Note: A different magnification between simulator film and
scout film must be taken into account.
 This procedure allows for a more accurate determination
of tumor extent and therefore more precise field definition
at the time of simulation.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.7 Slide 5
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.7 Computed tomography-based conventional simulation

Scout films
 If scanned in treatment position, field limits and
shielding parameters can be directly set with respect to
the target position, similar to conventional treatment
simulation.
 The result is that the treatment port more closely conforms
to the target volume, reducing treatment margins around
the target and increasing healthy tissue sparing.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.7 Slide 6
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

Virtual Simulation
 Virtual simulation is the treatment simulation of patients
based solely on CT information.
 The premise of virtual simulation is that the CT data can
be manipulated to render synthetic radiographs of the
patient for arbitrary geometries.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

CT-Simulator
 Dedicated CT scanners for use in radiotherapy treatment
simulation and planning have been developed.
 They are known as
CT-simulators.

Example of a modern
CT-simulator

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

Components of a CT-simulator include:

 CT scanner, including scanners with a

large bore (with an opening of up to 85
cm to allow for a larger variety of patient
positions and the placement of treatment
accessories during CT scanning);

 Movable lasers for patient positioning and

marking;

 Flat table top to more closely match

radiotherapy treatment positions;

 Powerful graphics workstation, allowing

for image manipulation and formation.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

Virtual Simulation
 Synthetic radiographs can be produced by tracing ray-
lines from a virtual source position through the CT data of
the patient to a virtual film plane and simulating the
attenuation of x-rays.
 Synthetic radiographs are called
Digitally Reconstructed Radiographs (DRRs).
 Advantage of DRRs is that anatomical information may be
used directly in the determination of treatment field
parameters.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

Example of a DRR

Note: gray levels, brightness, and contrast can be adjusted to

provide an optimal image.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 5
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

Beam’s eye view (BEV)

Beam’s eye views (BEV) are projections through the
patient onto a virtual film plane perpendicular to the
beam direction.
Projections include:
 Treatment beam axes
 Field limits
 Outlined structures

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 6
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

Beam’s eye view (BEV)

 BEVs are frequently superimposed onto the corresponding
DRRs resulting in a synthetic representation of a simulation
radiograph.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 7
 7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.8 Computed tomography-based virtual simulation

Multiplanar reconstructions (MPR)

 Multiplanar reconstructions (MPR) are images formed
from reformatted CT data.
 They are effectively CT images through arbitrary planes
of the patient.
 Although typically sagittal or coronal MPR cuts are used
for planning and simulation, MPR images through any
arbitrary plane may be obtained.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.8 Slide 8
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.9 Conventional simulator vs. CT simulator

Conventional simulator
Advantage Disadvantages
 Useful to perform a  Limited soft tissue contrast.
fluoroscopic simulation  Tumour mostly not visible.
in order to verify  Requires knowledge of
isocenter position and tumor position with respect
field limits as well as to to visible landmarks.
mark the patient for
treatment.  Restricted to setting field
limits with respect to bony
landmarks or anatomical
structures visible with the
aid of contrast.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.9 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.9 Conventional simulator vs. CT simulator

CT simulator
Advantages Disadvantages
 Increased soft tissue  Limitation in use for some
contrast. treatment setups where
 Axial anatomical patient motion effects are
information available. involved.
 Delineation of target and  Require additional training
OARs directly on and qualification in 3D
CT slices. planning.
 Allows DRRs.
 Allows BEV.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.9 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.9 Conventional simulator vs. CT simulator

 Another important advantage of the CT-simulation

process over the conventional simulation process is the
fact that the patient is not required to stay after the
scanning has taken place.
 Patient only stays the minimum time necessary to acquire
the CT data set and mark the position of reference
isocentre; this provides the obvious advantage as the
radiotherapy staff may take their time in planning the
patient as well as try different beam configurations without
the patient having to wait on the simulator couch.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.9 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.9 Conventional simulator vs. CT simulator

 Another important advantage : CT-simulator allows the

user to generate DRRs and BEVs even for beam
geometries which were previously impossible to simulate
conventionally.
 Example:
A DRR with superimposed beam’s
eye view for a vertex field of a
brain patient.
This treatment geometry would be
impossible to simulate on a
conventional simulator because
the film plane is in the patient.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.9 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.10 Magnetic resonance imaging for treatment planning

 MR imaging plays an increasing role in treatment

planning.
 Soft tissue contrast offered by magnetic resonance
imaging (MRI) in some areas, such as the brain, is
superior to that of CT, allowing small lesions to be seen
with greater ease.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.10 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.10 Magnetic resonance imaging for treatment planning

Disadvantage of MRI
It cannot be used for radiotherapy simulation and planning for
several reasons:
 The physical dimensions of the MRI and its accessories limit the use
of immobilization devices and compromise treatment positions.
 Bone signal is absent and therefore digitally reconstructed
radiographs cannot be generated for comparison to portal films.
 There is no electron density information available for heterogeneity
corrections on the dose calculations.
 MRI is prone to geometrical artifacts and distortions that may affect
the accuracy of the treatment.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.10 Slide 2
 7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.10 Magnetic resonance imaging for treatment planning

 To overcome this problem, many modern virtual simulation

and treatment planning systems have the ability to combine
the information from different imaging studies using the
process of image fusion or registration.
 CT-MR image registration or fusion combines the
• Accurate volume definition from MR
with
• Electron density information available from CT.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.10 Slide 3
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.10 Magnetic resonance imaging for treatment planning

MR CT

On the left is an MR image of a patient with a brain tumour. The target has
been outlined and the result was superimposed on the patient’s CT scan.
Note that the particular target is clearly seen on the MR image but only
portions of it are observed on the CT scan.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.10 Slide 4
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.11 Summary of simulation procedures

Goals and tools in conventional and CT simulation

Goals Conventional CT simulation

Treatment position: fluoroscopy pilot/scout views

Identification of target volume: bony landmarks from CT data

Determination of beam geometry: fluoroscopy BEV/DRR

Shielding design: bony landmarks conformal to target

Contour acquisition: manual from CT data

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.11 Slide 1
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.11 Summary of simulation procedures

The following six steps are typically involved in conventional

simulation procedures:
1. Determination of patient treatment position with
fluoroscopy.
2. Determination of beam geometry.
3. Determination field limits and isocentre.
4. Acquisition of contour.
5. Acquisition of beam’s eye view and set-up radiographs.
6. Marking of patient.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.11 Slide 2
7.4 PATIENT DATA ACQUISITION AND SIMULATION
7.4.11 Summary of simulation procedures

The following nine steps are typically involved in CT simulation:

1. Determination of patient treatment position with pilot/scout films.

2. Determination and marking of reference isocentre.
3. Acquisition of CT data and transfer to virtual simulation workstation.
4. Localization and contouring of targets and critical structures.
5. Determination treatment isocentre with respect to target and
reference isocentre.
6. Determination of beam geometry.
7. Determination of field limits and shielding.
8. Transfer of CT and beam data to treatment planning system.
9. Acquisition of beam’s eye view and setup DRRs.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.11 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS

Clinical considerations for photon beams include the

following items:
 Isodose curves
 Wedge filters
 Bolus
 Compensating filters
 Corrections for contour irregularities
 Corrections for tissue inhomogeneities
 Beam combinations and clinical application

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.1 Isodose curves

 Isodose curves are defined as lines that join points of

equal dose.
 They offer a planar representation of the dose
distribution.
 Isodose curves are useful to characterize the behavior of
• One beam
• Combination of beams
• Beams with different shielding
• Wedges
• Bolus, etc.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.1 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.1 Isodose curves

How are isodose curves obtained?

 They are measured directly using a beam scanning

device in a water phantom.

 They are calculated from percentage depth dose and

beam profile data.

 They are adopted from an atlas for isodose curves.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.1 Slide 2
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.1 Isodose curves

To which dose values do isodose curves refer?

 While isodose curves can be made to display the actual
dose in Gy (per fraction or total dose), it is more common
to present them normalized to 100 % at a fixed point.
 Possible point normalizations are:
• Normalization to 100 % at the depth of dose maximum on the
central axis.
• Normalization at the isocenter.
• Normalization at the point of dose prescription.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.1 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.1 Isodose curves

Different normalizations for a single 18 MV photon beam

incident on a patient contour

Isodose curves for a fixed SSD beam Isodose curves for an isocentric beam
normalized at depth of dose normalized at the isocenter
maximum

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.1 Slide 4
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

Three types of wedge filters are currently in use:

1. Physical (requiring manual intervention)
2. Motorized
3. Dynamic
 Physical wedge:
It is an angled piece of lead or steel that is placed in the beam to
produce a gradient in radiation intensity.

 Motorized wedge:
It is a similar physical device, integrated into the head of the unit and
controlled remotely.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

 Physical wedge:
A set of wedges (15°, 30°, 45°, and 60°) is usually provided with the
treatment machine.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 2
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

 Dynamic wedge:
Produces the same wedged intensity gradient by having one jaw
close gradually while the beam is on.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

Isodose curves obtained for a

wedged 6 MV photon beam.

Isodose curves have been normalized

to zmax with the wedge in place.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 4
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

 Wedge angle is defined

as the angle between
the 50 % isodose line
and the perpendicular to
the beam central axis.

 Wedge angles in the

range from 10° to 60°
are commonly available.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 5
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

There are two main uses of wedges

1. Wedges can be used to

compensate for a
sloping surface.

Example 1:

Two 15° wedges are used in a

nasopharyngeal treatments to
compensate for the decreased
thickness anteriorly.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 6
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

2. Wedges can be used to

compensate for a sloping
surface.

Example 2:

A wedged pair of beams is

used to compensate for the
hot spot that would be
produced with a pair of open
beams at 90° to each other.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 7
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

There are two main uses of wedges (cont.)

3. Wedges can also be used in the treatment of relatively low

lying lesions where two beams are placed at an angle
(less than 180°) called the hinge angle.

The optimal wedge angle (assuming a flat patient surface)

may be estimated from:

wedge angle  90  hinge angle

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 8
 7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

Example:
 A wedge pair of 6 MV beams
incident on a patient.

 The hinge angle is 90°

(orthogonal beams) for which
the optimal wedge angle
would be 45°.

 However, in this case the

additional obliquity of the
surface requires the use of a
higher wedge angle of 60°.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 9
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.2 Wedge filters

Wedge factor:
 Wedge factor is defined as the ratio of dose at a specified
depth (usually zmax) on the central axis with the wedge in
the beam to the dose under the same conditions without
the wedge.
 This factor is used in monitor unit calculations to
compensate for the reduction in beam transmission
produced by the wedge.
 Wedge factor depends on depth and field size.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.2 Slide 10
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.3 Bolus

Bolus is a tissue-equivalent material placed in contact with

the skin to achieve one or both of the following:

1. Increase of surface dose

Because of the dose buildup
in megavoltage beams
between the surface
and the dose maximum
(at a certain depth zmax),
the dose may not be sufficient for
superficial targets.
dose

depth

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.3 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.3 Bolus

 To increase the surface dose, a layer of uniform

thickness bolus is often used (0.5 cm – 1.5 cm), since it
does not significantly change the shape of the isodose
curves at depth.
 Several flab-like materials were developed commercially
for this purpose.
 Cellophane wrapped wet towels or gauze offer a low cost
substitute.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.3 Slide 2
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.3 Bolus

Bolus is also used to achieve:

2. Compensation for
missing tissue
Custom made bolus can be built
wax bolus
such that it conforms to the
patient skin on one side and
yields a flat perpendicular
incidence to the beam.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.3 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.3 Bolus

 The result is an isodose distribution that is identical to that

produced on a flat phantom.
 However, skin sparing is not maintained with a bolus,
in contrast to the use of a compensator.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.3 Slide 4
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.3 Bolus

Difference between a bolus and a compensating filter:

a) A wax bolus is used. Skin sparing is lost with bolus.
b) A compensator achieving the same dose distribution as in (a) is constructed
and attached to the treatment unit. Due to the large air gap skin sparing is
maintained.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.3 Slide 5
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.4 Compensating filters

 A compensating filter achieves the same effect on the

dose distribution as a shaped bolus but does not cause a
loss of skin sparing.
 Compensating filters can be made of almost any material,
but metals such as lead are the most practical and
compact.
 Compensating filters can produce a gradient in two
dimensions.
 They are usually placed in a shielding slot on the
treatment unit head.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.4 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.4 Compensating filters

 Thickness of the compensator is determined on a point-

by-point basis depending on the fraction I/I0 of the dose
without a compensator which is required at a certain
depth in the patient.
 Thickness of compensator x along the ray line above that
point can be solved from the attenuation law:
I
 ex
I0
where μ is the linear attenuation coefficient for the radiation beam and
material used to construct the compensator.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.4 Slide 2
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.4 Compensating filters

Use of Compensating Filters

Advantage: Disadvantages:
 Preservation of the skin  Generally more laborious
sparing effect and time consuming
 Difficult to calculate
resulting dose distribution
 Additional measurements
may be required

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.4.9 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.5 Corrections for contour irregularities

 Measured dose distributions apply to a flat radiation

beam incident on a flat homogeneous water phantom.
 To relate such measurements to the actual dose
distribution in a patient, corrections for irregular surface
and tissue inhomogeneities have to be applied.
 Three methods for contour correction are used:
1. Manual isodose shift method.
2. Effective attenuation coefficient method.
3. TAR method.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.5 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.5 Corrections for contour irregularities

 Grid lines are drawn parallel 1. Manual isodose shift method

to the central beam axis all
across the field.
 The tissue deficit (or excess) h is
the difference between the SSD
along a gridline and the SSD on the
central axis.
 k is an energy dependent
parameter given in the next slide.
 Isodose distribution for a flat
phantom is aligned with the SSD
central axis on the patient contour.
 For each gridline, the overlaid
isodose distribution is shifted up (or
down) such that the overlaid SSD is
at a point k×h above (or below) the
central axis SSD.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.5 Slide 2
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.5 Corrections for contour irregularities

Parameter k used in the isodose shift method

Photon energy (MV) k (approximate)

<1 0.8
60Co –5 0.7

5 – 15 0.6

15 – 30 0.5

> 30 0.4

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.5 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.5 Corrections for contour irregularities

2. Effective attenuation coefficient method

 Correction factor is determined from the attenuation factor
exp(μx), where x is the depth of missing tissue above the
calculation point, and μ is the linear attenuation coefficient
of tissue for a given energy.
 For simplicity the factors are usually pre-calculated and
supplied in graphical or tabular form.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.5 Slide 4
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.5 Corrections for contour irregularities

3. TAR method
 Tissue-air ratio (TAR) correction method is also based on
the attenuation law, but takes the depth of the calculation
point and the field size into account.
 Generally, the correction factor CF as a function of depth z,
thickness of missing tissue h, and field size f, is given by:

TAR( z  h, f )
CF 
TAR( z, f )

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.5 Slide 5
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

 In a simple approach to calculate the dose and its

distribution in a patient, one may assume that all tissues
are water-equivalent.
 However, in the actual patient the photon beam traverses
tissues with varying densities and atomic numbers such
as fat, muscle, lung, air, and bone.
 This will influence the attenuation and scatter of photons
beam such that the depth dose curve will deviate from
that in water.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

 Tissues with densities and atomic numbers different from

those of water are referred to as tissue inhomogeneities
or heterogeneities.
 Inhomogeneities in the patient result in:
• Changes in the absorption of the primary beam and associated
scattered photons
• Changes in electron fluence.

 The importance of each effect depends on the position of

the point of interest relative to the inhomogeneity.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 2
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

Difference in isodose curves

obtained using a single vertical
7×7cm2 field.
 Top:
Assuming that all tissues
(including the lung) have water-
equivalent density

 Bottom:
Taking into account the real
tissue density

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

 In the megavoltage range the Compton interaction

dominates and its cross-section depends on the electron
density (in electrons per cm3).
 The following four methods correct for the presence of
inhomogeneities within certain limitations:
• TAR method.
• Batho power law method.
• Equivalent TAR method.
• Isodose shift method.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 4
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

 The four methods are

presented using the
schematic diagram
which shows an
inhomogeneity with an
z1 1 = 1
electron density e
nested between two z2 2 = e
layers of water-
z3 3 = 1
equivalent tissue.
Point P

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 5
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

TAR method
Dose at each point is corrected by the factor CF:

TAR( z ', rd )
CF 
TAR( z, rd )
where z1 1 = 1

z’ = z1 + ρez2 + z3 z2 2 = e

and z3 3 = 1

z = z1 + z2 + z3 Point P

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 6
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

Batho Power-law method

Dose at each point is corrected by:
3 2
TAR( z ', rd )
CF  12
TAR( z, rd )
z1 1 = 1
where
z2 2 = e
z’ = z1 + ρ2z2 + z3
and z3 3 = 1

z = z1 + z2 + z3 Point P

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 7
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

Equivalent TAR method

Method is similar to the TAR method. The field size parameter
rd is now modified into rd as a function of density

TAR( z, rd )

CF 
TAR( z, rd )
where
1 = 1
z’ = z1 + ρ2z2 + z3 z1

and z2 2 = e

z = z1 + z2 + z3 z3 3 = 1
Point P

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 8
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.6 Corrections for tissue inhomogeneities

Isodose shift method

 The isodose shift method for the dose correction due to the
presence of inhomogeneities is essentially identical to the isodose
shift method outlined in the previous section for contour
irregularities.
 Isodose shift factors for several types of tissue have been
determined for isodose points beyond the inhomogeneity.
 The factors are energy dependent but do not vary significantly with
field size.
 The factors for the most common tissue types in a 4 MV photon
beam are: air cavity:  0.6; lung:  0.4; and hard bone: + 0.5. The
total isodose shift is the thickness of inhomogeneity multiplied by the
factor for a given tissue. Isodose curves are shifted away from the
surface when the factor is negative.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.6 Slide 9
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

 Single photon beams

are of limited use in the
treatment of deep-
seated tumors, since
they give a higher dose
near the entrance at the
depth of dose maximum
than at depth.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 1
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

 Single fields are often used for palliative treatments or

for relatively superficial lesions
(depth < 5 cm – 10 cm, depending on the beam energy).
 For deeper lesions, a combination of two or more photon
beams is usually required to
concentrate the dose in the
target volume and spare the
tissues surrounding the target
as much as possible.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 2
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Weighting and normalization

 Dose distributions for multiple beams can be normalized
to 100 % just as for single beams:
• at zmax for each beam,
• at isocenter for each beam.

 This implies that each beam is equally weighted.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 3
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Weighting and normalization

 Beam weighting may additionally applied at the
normalization point for the given beam.
 Example:
Wedged pair with zmax normalization weighted as 100 % : 50 %
will show one beam with the 100 % isodose at zmax and the other one
with 50 % at zmax.

 A similar isocentric weighted beam pair would show the

150 % isodose at the isocenter.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 4
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Fixed SSD vs. isocentric techniques

 Fixed SSD techniques require
adjusting the patient such that the
skin is at the correct distance
(nominal SSD) for each beam
orientation.
 Isocentric techniques require placing
the patient such that the target
(usually) is at the isocentre.
 Machine gantry is then rotated around
the patient for each treatment field.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 5
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Fixed SSD vs. isocentric techniques

 There is little difference between fixed SSD techniques
and isocentric techniques with respect to the dose:
• Fixed SSD arrangements are usually at a greater SSD than
isocentric beams because the machine isocenter is on the
patient skin.

• They have therefore a slightly higher PDD at depth.

• Additionally, beam divergence is smaller with SSD due to the
larger distance.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 6
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Fixed SSD vs. isocentric techniques

 Dosimetric advantages of SSD techniques are small.

 With the exception of very large fields exceeding
40×40 cm2, advantages of using a single set-up
point (i.e., isocentre) greatly outweigh the dosimetric
advantage of SSD beams.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 7
7.5 Clinical considerations for photon beams
7.5.7 Beam combinations and clinical application

Parallel opposed beams

 Example:
A parallel-opposed beam
pair is incident on a patient.
 Note the large rectangular
area of relatively uniform
dose (<15 % variation).
 Isodose curves have been
normalized to 100 % at the
isocentre.
 This beam combination is well suited to a large variety of
treatment sites (e.g., lung, brain, head and neck).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 8
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple coplanar beams:

 Allow for a higher dose in the beam intersection region.
Two examples:
4-field box 3-field technique using wedges

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 9
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple co-planar beams

4-field box

 A 4-field box allows

for a very high dose
to be delivered at the
intersection of the
beams.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 10
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple co-planar beams

3-field technique using wedges
 A 3-field technique
requires the use of
wedges to achieve
a similar result.
 Note that the latter can
produce significant hot
spots near the entrance
of the wedged beams
and well outside the
targeted area.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 11
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple coplanar beams: General characteristics

Type Characteristics Used for:

Wedge pairs Used to achieve a Low-lying lesions (e.g., maxillary

trapezoid shaped sinus and thyroid lesions).
high dose region

4-field box Produces a relatively Treatments in the pelvis, where

high dose box most lesions are central
shaped region (e.g., prostate, bladder, uterus).

Opposing pairs High dose area has Similar indications

at angles other a rhombic shape
than 90°

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 12
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple coplanar beams: General characteristics

 Wedge pair:
Two beams with wedges (often orthogonal) are used to achieve a
trapezoid shaped high dose region. This technique is useful in
relatively low-lying lesions (e.g., maxillary sinus and thyroid lesions).
 4-field box:
A technique of four beams (two opposing pairs at right angles)
producing a relatively high dose box shaped region. The region of
highest dose now occurs in the volume portion that is irradiated by all
four fields. This arrangement is used most often for treatments in the
pelvis, where most lesions are central (e.g., prostate, bladder, uterus).
 Opposing pairs at angles other than 90°:
also result in the highest dose around the intersection of the four
beams, however, the high dose area here has a rhombic shape.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 13
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple coplanar beams: General characteristics

 Occasionally, three sets of opposing pairs are used,
resulting in a more complicated dose distribution, but also
in a spread of the dose outside the target over a larger
volume, i.e., in more sparing of tissues surrounding the
target volume.
 The 3-field box technique is similar to a 4-field box
technique. It is used for lesions that are closer to the
surface (e.g., rectum). Wedges are used in the two
opposed beams to compensate for the dose gradient in
the third beam.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 14
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Rotational techniques
 Isodose curves for
two bilateral arcs
of 120° each.
 Note:
Isodose curves are
tighter along the
angles avoided by
the arcs (anterior
and posterior).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 15
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Rotational techniques: General characteristics

 Target is placed at the isocentre, and the machine gantry
is rotated about the patient in one or more arcs while the
beam is on.
 Rotational techniques produce a relatively concentrated
region of high dose near the isocentre.
 But they also irradiate a greater amount of normal tissue
to lower doses than fixed-field techniques.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 16
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Rotational techniques: General characteristics

 Useful technique used mainly for prostate, bladder, cervix
and pituitary lesions, particularly boost volumes.
 Dose gradient at the edge of the field is not as sharp as
for multiple fixed field treatments.
 Skipping an angular region during the rotation allows the
dose distribution to be pushed away from the region;
however, this often requires that the isocentre be moved
closer to this skipped area so that the resulting high-dose
region is centered on the target .

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 17
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple non-coplanar beams: General characteristics

 Non-coplanar beams
arise from non-standard
couch angles coupled
with gantry angulations.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 18
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple non-coplanar beams: General characteristics

 Non-coplanar beams may be useful to get more adequate
critical structure sparing compared to conventional co-
planar beam arrangement.
 Dose distributions from non-coplanar beam combinations
yield similar dose distributions to conventional multiple
field arrangements.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 19
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple non-coplanar beams: General characteristics

 Care must be taken when planning the use of non-
coplanar beams to ensure no collisions occur between the
gantry and patient or couch.
 Non-coplanar beams are most often used for treatments
of brain as well as head and neck disease where the
target volume is frequently surrounded by critical
structures.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 20
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Multiple non-coplanar beams: General characteristics

 Non-coplanar arcs are also used.
 The best-known example is
the multiple non-coplanar
converging arcs technique
used in radiosurgery.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 21
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Field matching
 Field matching at the skin is
the easiest field matching
technique.
 However, due to beam
divergence, this will lead to
significant overdosing of
tissues at depth and is only
used in regions where tissue
tolerance is not compromised.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 22
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Field matching
 For most clinical situations field matching is performed
at depth rather than at the skin.
 To produce a junction dose
similar to that in the center z
of the open fields, beams must
be matched such that their
diverging edges match at the
desired depth z.
50 % isodose lines

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 23
7.5 CLINICAL CONSIDERATIONS FOR PHOTON BEAMS
7.5.7 Beam combinations and clinical application

Field matching
 For two adjacent fixed SSD fields of different lengths L1
and L2, the surface gap g required to match the two fields
at a depth z is:  z   z 
g  0.5L1     0.5L2   SSD 
 SSD   

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.5.7 Slide 24
7.6 TREATMENT PLAN EVALUATION

 It is essential to assess the "quality" of a treatment plan

regardless whether the dose calculations are performed
• On computer.
• Or by hand.

 Good "quality" means that the calculated dose distribution

of the treatment plan complies with he clinical aim of the
treatment.
 A radiation oncologist must therefore evaluate the result
of the treatment plan.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6 Slide 1
7.6 TREATMENT PLAN EVALUATION

 Depending on the method of calculation, the dose

distribution may be obtained:
1. Only for a few significant points within the target volume.
2. For a two-dimensional grid of points over a contour or an image.
3. For a full three-dimensional array of points that cover the
patient’s anatomy.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6 Slide 2
7.6 TREATMENT PLAN EVALUATION

 Treatment plan evaluation generally consists of verifying:

• Treatment portals
They are verified to ensure that the desired PTV is covered
adequately.
• Isodose distribution
It is verified to ensure that target coverage is adequate and that
critical structures surrounding the PTV are spared as necessary.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6 Slide 3
7.6 TREATMENT PLAN EVALUATION

The following tools are used in the evaluation of the planned

dose distribution:
 Isodose curves.
 Orthogonal planes and isodose surfaces.
 Dose distribution statistics.
 Differential Dose Volume Histogram.
 Cumulative Dose Volume Histogram.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6 Slide 4
7.6 TREATMENT PLAN EVALUATION
7.6.1 Isodose curves

 Isodose curves are used to evaluate treatment plans

along a single plane or over several planes in the patient.

Example:

Isodose curve covering

the periphery of the
target is compared to
the isodose curve
through isocentre.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.1 Slide 1
7.6 TREATMENT PLAN EVALUATION
7.6.1 Isodose curves

Same example:
Isodose line through [%]
the ICRU reference -150
point is 152 %.
-140
Maximum dose 154 %.
-130
-120
The 150 % isodose
curve completely -100
covers the PTV. - 70
- 50

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.1 Slide 2
7.6 TREATMENT PLAN EVALUATION
7.6.1 Isodose curves

 If the ratio of isodoses covering the periphery of the

target to that at the isocentere is within a desired range
(e.g., 95 % - 100 %) then the plan may be acceptable
provided critical organ doses are not exceeded.
 This approach is ideal if the number of transverse
slices is small.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.1 Slide 3
7.6 TREATMENT PLAN EVALUATION
7.6.2 Orthogonal planes and isodose surfaces

 When a larger number of transverse planes are used for calculation it

may be impractical to evaluate the plan on the basis of axial slice
isodose distributions alone.
 In such cases, isodose distributions can also be generated on
orthogonal CT planes, reconstructed from the original axial data.
 For example, sagittal and coronal plane isodose distributions are
usually available on most 3D treatment planning systems.
 Displays on arbitrary oblique planes are also becoming increasingly
common.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.2 Slide 1
7.6 TREATMENT PLAN EVALUATION
7.6.2 Orthogonal planes and isodose surfaces

 An alternative way to display isodoses is to map them in

three dimensions and overlay the resulting isosurface on
a 3D display featuring surface renderings of the target and
or/other organs.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.2 Slide 2
7.6 TREATMENT PLAN EVALUATION
7.6.2 Orthogonal planes and isodose surfaces

Example: Prostate cancer

Target volume: blue

Prescription isodose:
white wireframe

Bladder and rectum

are also shown.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.2 Slide 3
7.6 TREATMENT PLAN EVALUATION
7.6.2 Orthogonal planes and isodose surfaces

Such displays are useful to assess target coverage in a

qualitative manner.
Disadvantages:
 They do not convey a sense of distance between the
isosurface and the anatomical volumes.
 They do not give a quantitative volume information.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.2 Slide 4
7.6 TREATMENT PLAN EVALUATION
7.6.3 Dose statistics

 In order to get more quantitative information, statistics

tools have been introduced.
 In contrast to the isodose tools, the dose statistics tools
cannot show the spatial distribution of dose superimposed
on CT slices or anatomy that has been outlined based on
CT slices.
 Instead, they can provide quantitative information on the
volume of the target or critical structure, and on the dose
received by that volume.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.3 Slide 1
7.6 TREATMENT PLAN EVALUATION
7.6.3 Dose statistics

From the location of matrix points within an organ and the

calculated doses at these points, a series of statistical
characteristics can be obtained.
These include:
 Minimum dose to the volume.
 Maximum dose to the volume.
 Mean dose to the volume.
 Dose received by at least 95% of the volume.
 Volume irradiated to at least 95% of the prescribed dose.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.3 Slide 2
7.6 TREATMENT PLAN EVALUATION
7.6.3 Dose statistics

 Target dose statistics as well as organ dose statistics can

be performed.
 "Dose received by at least 95 % of the volume" and the
"Volume irradiated to at least 95 % of the prescribed
dose" are only relevant for the target volume.
 Organ dose statistics are especially useful in dose
reporting, since they are simpler to include in a patient
chart than dose-volume histograms that are described in
the next slides.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.3 Slide 3
 7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

 Dose volume histograms (DVHs) summarize the information

contained in a three-dimensional treatment plan.
 This information consists of dose distribution data over a
three-dimensional matrix of points over the patient’s
anatomy.
 DVHs are extremely powerful tools for quantitative
evaluation of treatment plans.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 1
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

 In its simplest form a DVH represents a frequency

distribution of dose values within a defined volumes
such as:

• PTV itself

Frequency
• Specific organ
in the vicinity
of the PTV.

Dose value

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 2
 7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

 Rather than displaying

Per cent volume of

the frequency, DVHs
are usually displayed
in the form of “per

total volume
cent volume of total
volume” on the
ordinate against the
dose on the abscissa.

Dose value in Gy

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 3
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

Two types of DVHs are in use:

 Direct (or differential) DVH

 Cumulative (or integral) DVH

Definition: Volume that receives
at least the given dose and plotted versus
versus dose.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 4
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

Direct Dose Volume Histogram

 To create a direct DVH, the computer sums the number of
voxels which have a specified dose range and plots the
resulting volume (or the percentage of the total organ
volume) as a function of dose.
 Ideal DVH for a target volume would be a single column
indicating that 100% of the volume receives the
prescribed dose.
 For a critical structure, the DVH may contain several
peaks indicating that different parts of the organ receive
different doses.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 5
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

Differential DVHs
Example: Prostate cancer

Target

Rectum

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 6
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

Cumulative Dose Volume Histogram

 Traditionally, physicians have sought to answer questions

such as: “How much of the target is covered by the 95 %
isodose line?”

 In 3-D treatment planning this question is equally relevant

and the answer cannot be extracted directly from the
direct DVH, since it would be necessary to determine the
area under the curve for all dose levels above 95 % of the
prescription dose.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 7
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

Integral DVHs
Example: Prostate cancer

Target

Critical structure:
rectum

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 8
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

For this reason, cumulative DVH displays are more popular.

 Computer calculates the volume of the target (or critical
structure) that receives at least the given dose and plots
this volume (or percentage volume) versus dose.
 All cumulative DVH plots start at 100 % of the volume for
zero dose, since all of the volume receives at least no
dose.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 9
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

 While displaying the percent volume versus dose is more

popular, it is also useful in some circumstances to plot the
absolute volume versus dose.
 For example, if a CT scan does not cover the entire
volume of an organ such as the lung and the un-scanned
volume receives very little dose, then a DVH showing
percentage volume versus dose for that organ will be
biased, indicating that a larger percentage of the volume
receives dose.
 Furthermore, in the case of some critical structures,
tolerances are known for irradiation of fixed volumes
specified in cm3.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 10
7.6 TREATMENT PLAN EVALUATION
7.6.4 Dose-volume histograms

 The main drawback of the DVHs is the loss of spatial

information that results from the condensation of data
when DVHs are calculated.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.4 Slide 11
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

Port films
 A port film is usually an
emulsion-type film, often
still in its light-tight paper
envelope, that is placed
in the radiation beam
beyond the patient.

Since there is no conversion of x rays to light photons as in diagnostic

films, the films need not be removed from its envelope.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 1
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

Port films
 Two port films are available.
 Depending on their sensitivity (or speed) port films can be
used for:
• Localization:
A fast film is placed in each beam at the beginning or end of the
treatment to verify that the patient installation is correct for the
given beam.
• Verification:
A slow film is placed in each beam and left there for the duration
of the treatment.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 2
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

Localization (fast) vs. verification (slow) films

Advantages: Disadvantage:
 Fast films generally  Not recommended for larger
produce a better image. fields for example where as
 Recommended for many as 4 films may be
verifying small or required to verify the
complex beam treatment delivery.
arrangements.
 Patient or organ
movement during
treatment will not affect
the quality of the film.
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 3
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

 Localization films used in radiotherapy do not require

intensifying screens such as those used in diagnostic
radiology.
 Instead, a single thin layer of a suitable metal (such as
copper or aluminum) is used in front of the film (beam
entry side) to provide for electronic buildup that will
increase the efficiency of the film.
 A backing layer is sometimes used with double emulsion
films to provide backscatter electrons.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 4
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

Port films are taken either in single or double exposure

technique.
 Single exposure:
Film is irradiated with the treatment field alone. This technique is well
suited to areas where the anatomical features can clearly be seen
inside the treated field. Practically all verification films are single
exposure.

 Double exposure:
• Film is irradiated with the treatment field first.
• Then the collimators are opened to a wider setting, all shielding is
removed, and a second exposure is given to the film.
• The resulting image shows the treated field and the surrounding
anatomy that may be useful in verifying the beam position.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 5
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

Double exposure technique: Two examples

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 6
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

Online portal imaging

 Online portal imaging systems consist of:
• Suitable radiation detector, usually
attached through a manual or semi-robotic
arm to the linac.
• Data acquisition system capable of
transferring the detector information to
a computer.
• Software that will process it and convert
it to an image.

 These systems use a variety of detectors,

all producing computer based images of
varying degrees of quality.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 7
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

Online portal imaging systems currently include:

1. Fluoroscopic detectors.
2. Ionisation chamber detectors.
3. Amorphous silicon detectors.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 8
 7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

 Fluoroscopic portal imaging detectors:

• Work on the same principle as a simulator image intensifier system.
• Detector consists of a combination of a metal plate and fluorescent
phosphor screen, a 45° mirror and a television camera.
• Metal plate converts incident x-rays to electrons and the fluorescent
screen converts electrons to light photons.
• Mirror deflects light to the TV camera, reducing the length of the
imager, and the TV camera captures a small fraction (<0.1 %) of the
deflected light photons to produce an image.
• Good spatial resolution (depends on phosphor thickness).
• Only a few MU are required to produce an image.
• Uses technology that has been used in many other fields.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 9
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

 Matrix ionisation chamber detectors:

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 10
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

 Matrix ionisation chamber detectors:

• Are based on grid of ion chamber-type electrodes that measure
ionisation from point to point.
• Detector consists of two metal plates, 1 mm apart with the gap
filled with isobutene. Each plate is divided into 256 electrodes
and the plates are oriented such that the electrodes in one plate
are at 90° to the electrodes in the other.
• Voltage is applied between two electrodes across the gap and
the ionisation at the intersection is measured. By selecting each
electrode on each plate in turn, a 2D ionisation map is obtained
and converted to a gray-scale image of 256×256 pixels.
• Maximum image size is usually smaller than for fluoroscopic
systems.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 11
7.6 TREATMENT PLAN EVALUATION
7.6.5 Treatment evaluation

 Amorphous silicon detectors:

• Solid-state detector array consisting of amorphous silicon
photodiodes and field-effect transistors arranged in a large
rectangular matrix.
• Uses metal plate/fluorescent phosphor screen combination like
the fluoroscopic systems. Light photons produce electron-hole
pairs in the photodiodes whose quantity is proportional to the
intensity allowing an image to be obtained.
• Produces an image with a greater resolution and contrast than
the other systems.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.6.5 Slide 12
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Introductory remark:
The process of treatment planning and optimization may be
considered as completed if the calculated relative dose
distribution shows an acceptable agreement with the PTV.
By way of example, the 80 % isodose curve may well
encompasses the PTV.
It remains to determine the most important final parameter
which controls the absolute dose delivery, that is:
 Treatment time (for radiation sources).
or
 Monitor units (for linacs).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 1
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Data on treatment time and/or monitor units are usually

provided by modern TPS after having passed the "dose
prescription" procedure.
However, a manual calculation
method to obtain such data
independent from the TPS
is of highest importance.

 Accidents in radiotherapy
can and do happen.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 2
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Before going into the details of manual calculation methods

for an individual plan, a clear understanding of the following
associated issues is required:
 Techniques used for patient setup:
• Fixed SSD setup.
• Isocentric setup.

 Methods used for :

• Dose prescription
• Addition of dose from multiple fields.

 Formulas used for central axis dose calculations.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 3
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Methods used for patient setup: (already shown previously)

 Patient treatments are carried out either with a fixed SSD
or isocentric technique.
 Each of the two techniques is characterized with a specific
dose distribution and treatment time or monitor unit
calculation.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 4
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Fixed SSD technique Isocentric technique

Fixed SSD technique results in Isocentric technique results in an

an isodose distribution that is dose distribution that is typically
typically governed by governed by tissue-maximum
percentage depth dose data. ratios (or tissue-phantom ratios).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 5
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Methods used for dose prescription

Determination of treatment time or monitor units (whether by
the treatment planning system or manually)
is directly related to the two following actions:
 Selection of an appropriate point for dose prescription
(recommended by ICRU: the ICRU reference point).
 Prescription of an absolute dose at this point.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 6
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Isodose distributions of a three field treatment of

Example: the prostate using fixed SSD on a 6 MV linac
[%]
-150
 The ICRU point is -140
ICRU
located at the -130 point
intersection of -120
-100
three fields.
- 70
- 50
 A dose of 200 cGy
per fraction is
prescribed at the
ICRU point.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 7
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Methods used for dose prescription (continued)

 There are also other methods such as using a
dose volume histogram (DVH).
 This method is particular useful for IMRT when the
evaluation of a treatment plan is based on the DVH of the
target.
 Method consists of assigning the prescribe dose to the
median dose in the target volume.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 8
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Methods used for dose prescription (continued)

 Example is shown in the DVH:
Median dose is the dose at the
50 % volume level.
 Since this method is not
applicable in manual dose
calculations, it is not further
median dose
explained in the following
slides.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 9
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Methods used for adding the dose at the ICRU point from
multiple fields:
1. The simplest method (usually not used):
Each field contributes to the total prescribed dose at the ICRU point
using an equal number of MU (or equal treatment time).
2. Each field contributes to the total prescribed dose at the
ICRU point with different weights.
Prescribed weights for individual fields may refer to:
• ICRU point IP (used for the isocentric techniques).
• Point of maximum dose Dmax of each field
(used for fixed SSD techniques).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 10
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

 In the following slides two examples are shown to

calculate treatment time or monitor units when using
different weights at the ICRU point.
 The method used is divided into 5 steps and is based on
well known central axis formulas for the dose calculation
(at the ICRU point).

 Note: This method deviates slightly from that given in

the Handbook.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 11
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

The five steps are:

1. Get calibrated output of the machine at the calibration reference point.
2. Determine the dose at the ICRU point (IP) from each beam, initially
for an arbitrary value of 100 MU.
3. Rescale the MUs such that the dose contributions (at IP or Dmax) are
proportional to the pre-defined weights and sum up the total resultant
dose using the rescaled MUs.
4. Determine the ratio between the prescribed dose and the sum dose at
IP obtained in step 3.
5. Rescale again the MUs (from step 3) by the ratio
obtained in step 4 to get finally the required MU.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 12
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Step 1: Calibrated output of the machine

 For kilovoltage X ray generators and teletherapy units the
output is usually given in Gy/min.
 For clinical accelerators the output is given in Gy/MU.
 For superficial and orthovoltage beams and occasionally
for beams produced by teletherapy radionuclide
machines, the basic beam output may also be stated as
the air kerma rate in air (Gy/min) at a given distance from
the source and for a given nominal collimator or
applicator setting.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 13
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

Output for a radiotherapy

machine is usually stated:
• In water phantom.
• As the dose rate for a point P
at a reference depth zref
f = SSD
(often the depth of
maximum dose zmax).
• For a nominal source - surface P
distance (SSD) or source - axis
distance (SAD)
zref
• Reference field size Aref
(often 10×10 cm2) on the Aref
phantom surface or the
isocenter.
water phantom

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 14
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS

 Second step is performed differently depending on whether

the fixed SSD set-up or the isocentric set-up is used.

Fixed SSD Isocentric technique

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7 Slide 15
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Example of isodose distributions of a three field treatment of

the prostate using fixed SSD on a 6 MV linac
[%]
-150
-140
ICRU
-130 point
-120
-100
- 70
- 50

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 1
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Field parameters as obtained from the treatment planning:

Anterior field:
7.5×7.5 cm2 open field
weight W = 1.0

Right posterior field: Left posterior field:

6.5×7.5 cm2 wedge field 6.5×7.5 cm2 wedge field
weight W = 0.8 weight W = 0.8
wedge factor WF =0.53 wedge factor WF =0.53

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 2
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

[%]
-150
Note: -140
ICRU
Prescribed weights -130 point
refer to the point of -120
maximum dose in -100
- 70
each field: - 50
PA W = 1.0
PRPO W = 0.8
PRPO W = 0.8

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 3
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Normalization was Method of normalization:

first performed for
[%]
each field individually: ICRU point is at
-150
-140 isocenter: 152 %
Anterior field: -130
Dmax refers to 100 % -120
Right posterior field: -100
Dmax refers to 80 % - 70
Left posterior field: - 50
Dmax refers to 80 %

Isodose lines are then

obtained by summing
up the individual %-
values.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 4
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Step 2: For each field i, the dose at the ICRU point, Di(IP),
is calculated by (using 100 MU):

. PDD( z, A, f , E )
Di (IP)  D( zmax , Aref , f , E )   RDF( A, E )  WF  100
100

where
.
D(zmax , Aref ,f ,E ) is the calibrated output of the machine
PDD( z, A, f , E ) is the percentage depth dose value
WF is the wedge factor
RDF(A,E) is the relative dose factor (see next slide)

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 5
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Relative dose factor RDF describes the field size dependence:

 For a given beam energy E, the dose at the calibration
point P (at depth zref) depends on the field size A.
 The ratio of dose to that of reference field size Aref is called
the output factor, also known as total scatter factor.
 The IAEA Handbook is using the expression:
relative dose factor (RDF):

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 6
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

 RDF is defined as: Aref

DP ( zref , A,SSD, E )
RDF( A, E ) 
DP ( zref , Aref ,SSD, E )
IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 7
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Step 3: Rescale the MUs such that the dose contributions at

Dmax are proportional to the pre-defined weights and
sum up the total resultant dose using the rescaled MUs.

Starting Dose at Weighted dose Rescaled Dose at

Field
MU Dmax Weight at Dmax MU IP
Anterior 100 98.0 1.0 100 %=98.0 100 69.5
Left post. 100 51.4 0.8 80 % =78.4 152 39.7
Right post. 100 51.4 0.8 80 % =78.4 152 39.7

(dose) = 148.96

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 8
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Step 4: Determine the ratio between the prescribed dose

and the sum dose at IP obtained in step 3.

Prescribed dose = 200 cGy

Calculated dose = 148.96 cGy

Ratio  200  1.343

148.96

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 9
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.1 Calculations for fixed SSD set-up

Step 5: Rescale again the MUs (from step 3) by the ratio

obtained in step 4 to get finally the required MU.

 Anterior field: 100 MU × 1.343 = 134 MU

 Left posterior field: 152 MU × 1.343 = 205 MU

 Right posterior field: 152 MU × 1.343 = 205 MU

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.1 Slide 10
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.2 Calculations for isocentric set-ups

Example for an isodose distribution obtained for a 3 field

prostate boost treatment with an isocentric technique
In this example, the
normalization was
ICRU point
performed for each 240%
beam individually
such that Disocenter
is 100 % times the
beam weight.

Isodose lines are

then obtained by
summing up the
individual %-values.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.2 Slide 1
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.2 Calculations for isocentric set-ups

Field parameters as obtained from the treatment planning:

Anterior field:
8×8 cm2 open field
PDD = 70.9, W = 1.0

Right posterior field: Left posterior field:

7×8 cm2 wedge field 7×8 cm2 wedge field
PDD = 50.7, W = 0.7 PDD = 50.7, W = 0.7
wedge factor WF =0.53 wedge factor WF =0.53

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.2 Slide 2
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.2 Calculations for isocentric set-ups

Step 2: For each field i, the dose at the ICRU point, Di(IC), is
calculated by (using 100 MU):
.
Di (IC)  D( zmax , Aref , f , E )  TMR( A, z )  ISF  RDF( A, E )  W F  100

where:
.
D(zmax, Aref ,f ,E ) is the calibrated output of the machine.
TMR( A, z ) is the tissue-maximum-ratio at depth z.
WF is the wedge factor.
RDF(A,E) is the relative dose factor.
ISF is the inverse-square factor (see next slide).

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.2 Slide 3
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.2 Calculations for isocentric set-ups

.
When the calibrated output factor D(zmax , Aref , f , E ) is used in
isocentric calculations, it must be corrected by the inverse-
square factor ISF unless the machine is actually calibrated
at the isocentre:
2
 SSD  zmax 
ISF   SSD 
 

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.2 Slide 4
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.2 Calculations for isocentric set-ups

Step 3: Rescale the MUs such that the dose contributions at the
IP are proportional to the pre-defined weights and sum
up the total resultant dose using the rescaled MUs.
Field Starting Dose at Weight Weighted dose Rescaled
MU IP at IP MU
Anterior 100 73.1 1.0 100 %= 73.1 100
Left post. 100 28.7 0.7 70 % = 51.2 178
Right post. 100 28.7 0.7 70 % = 51.2 178

(dose) = 175.44

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.2 Slide 5
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.2 Calculations for isocentric set-ups

Step 4: Determine the ratio between the prescribed dose

and the sum dose at IP obtained in step 3.

 Prescribed dose = 200 cGy

 Calculated dose = 175.44 cGy

Ratio  200  1.140

175.44

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.2 Slide 6
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.2 Calculations for isocentric set-ups

Step 5: Rescale again the MUs (from step 3) by the ratio

obtained in step 4 to get finally the required MU.

 Anterior field: 100 MU x 1.14 = 114 MU

 Left posterior field: 178 MU x 1.14 = 203 MU

 Right posterior field: 178 MU x 1.14 = 203 MU

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.2 Slide 7
 7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.3 Normalization of dose distributions

Important: Dose distributions can be normalized in different ways:

Normalized to maximum dose Normalized such that 100 % = 100cGy

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.3 Slide 1
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.3 Normalization of dose distributions

 Frequently the dose distribution is normalized to the

maximum dose.
 The ICRU recommends normalization of the dose
distribution to 100 % at the prescription point.
 As a consequence, values of the dose distribution larger
than 100 % will be obtained if the prescription point is not
located at the point of maximum dose.
 If the isodose values generated by the TPS itself are used
for the monitor calculations, the method of normalization
used in the TPS must be taken into account.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.3 Slide 2
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.4 Inclusion of output parameters in dose distribution

 Modern treatment planning systems give the user the

ability to take into account several dosimetric parameters
in the dose distribution affecting the beam output.
 For example, the isodose values in a dose distribution
may already include:
• Inverse square law factors for extended distance treatments.
• Effects on dose outputs from blocks in the field.
• Tray and wedge factors.

 If the isodose values generated by the TPS are used for

the monitor calculations, it is of utmost importance to
know exactly what the isodose lines mean.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.4 Slide 1
7.7 TREATMENT TIME AND MONITOR UNIT CALCULATIONS
7.7.5 Orthovoltage and cobalt-60 units

 Treatment time calculations for orthovoltage units and

cobalt-60 teletherapy units are carried out similarly to the
above examples except that machine outputs are stated
in cGy/min and the treatment timer setting in minutes
replaces the monitor setting in MU.
 Shutter correction should be included in the time set.

IAEA Review of Radiation Oncology Physics: A Handbook for Teachers and Students - 7.7.5 Slide 1