Special report

Dose prescription, reporting and

recording in intensity-modulated radiation
therapy: a digest of the ICRU Report 83
Rapid development in imaging techniques, including functional imaging, have fueled the drive to
implement new methods of delivering 3D radiation therapy, such as intensity-modulated radiation therapy,
with unprecedented accuracy. The International Commission on Radiation Units and Measurements (ICRU)
Report 83 provides the information necessary to standardize techniques and procedures and to harmonize
the prescribing, recording and reporting of intensity-modulated radiation therapy. Applicable concepts
and recommendations in other International Commission on Radiation Units and Measurements reports
concerning radiation therapy were adopted, and new concepts and recommendations were elaborated.
In particular, additional recommendations were given on the selection and delineation of the target
volumes and the organs at risk; concepts of dose prescription and dose-volume reporting have also
been refined.

KEYWORDS: clinical target volume n dose constraint n dose metric n dose optimization Vincent Gregoire1
n gross tumor volume n intensity-modulated radiation therapy n organ at risk
& Thomas R Mackie†1,2
n planning target volume n radiation oncology
1
Center for Molecular Imaging and
Experimental Radiotherapy &
Radiation Oncology Department,
During the latter part of the last century, key imaging improvements and advances in treat- Université catholique de Louvain,
innovations in radiotherapy technology, diag- ment-planning techniques, it became practical St-Luc University Hospital, Avenue
Hippocrate 10, B-1200 Brussels,
nostic imaging and computer science greatly to design treatment fields that conformed more Belgium
modified the routine practice of radiotherapy, closely to the target volume. 2
University of Wisconsin – Madison,
Departments of Human Oncology,
leading to substantial improvements in treat- Conventional radiotherapy was tradition- Medical Physics, 600 Highland Avenue,
ment delivery and outcome [1] . Before 1950, ally administered using a number of coplanar Madison, WI 53792, USA
deeply seated tumors were treated with cross- beams, usually of relatively uniform or smoothly †
Author for correspondence:
[email protected]
fired beams or rotation techniques to ensure an varying intensity across the field. The use of low
acceptably low dose to the normal tissues, espe- melting-point heavy cast-metal alloys allowed
cially skin, soft tissues and bone [2] . The intro- the treatment fields to be more easily custom
duction of deeply penetrating external photon shaped than with lead blocks. Multileaf colli-
beams, initially 60Co in the 1950s, and even- mators, designed to replace molded heavy metal
tually, those from high-energy electron linear blocks, made it easier to use multiple complex-
accelerators (linacs) in the 1960s, allowed the shaped fields, even in the same treatment ses-
target dose to be increased without increasing sion. Many linacs became equipped with elec-
normal-tissue morbidity. tronic portal-imaging systems for verification of
During the 1970s and 1980s, treatment plan- patient positioning, thus improving conformity
ning based on the use of planar diagnostic x-rays between the planned and delivered doses. All of
was widely implemented. A ‘simulator’, a special- these technical innovations allowed more accu-
ized imaging system for radiotherapy employing rate treatment delivery to tumors, potentially
an x‑ray imaging system with the same geometry allowing higher tumor doses, and thus increased
and degrees of freedom as a linac or rotational local tumor control and/or reduced doses to the
60
Co unit, became a widely used tool for plan- surrounding normal tissues.
ning treatment delivery. The bony anatomy was When 3D planning techniques and special
visible with planar x-rays, but the location of soft delivery systems to shape the field are used to
tissues, including tumors, was difficult to ascer- reduce normal tissue damage close to the tar-
tain, and could often only be deduced from or get volume, the technique is usually referred to
correlated with bony landmarks, air cavities or as conformal radiotherapy or 3D-CRT. When
contrast-enhanced images. The increasing use of compared with conventional approaches,
x-ray CT in the 1980s, and MRI in the 1990s, 3D-CRT tends to use more treatment fields and
enabled much more reliable 3D assessment of the a reduced dose to normal tissues abutting the
location and extent of the disease. With these target volume.

10.2217/IIM.11.22 © 2011 Future Medicine Ltd Imaging Med. (2011) 3(3), 367–373 ISSN 1755-5191 367
Special report Gregoire & Mackie

The concept of intensity-modulated radia- of these volumes is an obligatory step in the

tion therapy (IMRT) arose because radiother- planning process, as dose cannot be prescribed,
apy treatment-planning optimization algorithms recorded and reported without the specification
predicted that the optimal radiation pattern of target volumes and volumes of normal tissue
from any single direction was typically nonu- at risk.
niform [3–5] . It was shown that a collective set The gross tumor volume (GTV) is the gross
of intensity‑modulated beams from multiple demonstrable extent and location of the malig-
directions could be designed to produce dose nant growth. It consists of the primary tumor,
homogeneity similar to conventional radiother- the regional lymph nodes or the distant metas-
apy within the tumor, but with superior confor- tases according to the clinical situation. The
mality, especially for concave or other complex- GTV can be delineated on anatomic (e.g., CT
shaped target volumes, thereby sparing nearby or MRI) or functional (e.g., PET with various
normal tissues [6] . In addition, IMRT makes tracers) imaging modalities; it can be delineated
it easier to produce nonuniform dose distribu- before the start of treatment and, eventually,
tions if required for treatment of a volume within during treatment to capture a change in target
another defined volume (also known as concom- volume. More than one GTV can be specified.
itant boost, or simultaneous integrated boost A nonambiguous annotation has been proposed
techniques) [7–9] . Rather than using uniform or to name such GTVs (e.g., GTV-tumor [MRI-
constantly varying intensity distributions across T2, 0 Gy]) for a primary-tumor GTV delineated
each incident field, IMRT attempts to achieve before treatment based on a T2-weighed MRI.
more optimal dose distributions by varying the It is known that tumors have the potential to
beam intensity (fluence) within each incident microscopically infiltrate into the surrounding
beam, usually by subdividing the beam into a normal tissues and/or disseminate through the
number of smaller segments and modulating lymphatic network to reach the regional lymph
each to achieve its selected fluence contribution. nodes. In this framework, the clinical target vol-
Modulation of the beam is greatly facilitated by ume (CTV) is a volume that contains a demon-
the use of multileaf collimators or binary col- strable GTV and/or subclinical malignant
limators combined with a moving couch. The disease that must be eliminated. Over the last
latter were specifically developed for IMRT. years, data on the incidence of regional tumor
In the context of radiotherapy delivery, the and lymph node infiltration have been compiled
International Commission on Radiation Units for various primary tumor sites, based on which
and Measurements (ICRU) has been develop- recommendations for the definition of CTVs
ing guidelines for prescribing, recording and have been proposed [16–18] . Similar to the GTV,
reporting dose for radiation therapy. The first clear annotation should be used for the CTV
set of guidelines was published in 1978, and (e.g., CTV-T [MRI-T2 ; 0 Gy]) for a primary-
was subsequently updated in 1993 and 1999 to tumor CTV associated to a GTV delineated
integrate the new development in radiotherapy, before treatment based on a T2-weighed MRI.
including electron and proton beams [10–15] . In addition, it should be emphasized that both
These documents recommended concepts and the GTV and the CTV are oncological concepts
procedures for the delineation of the tumor, and represent volumes that must be treated in
normal-tissue structures and margins to take order to achieve the aim of radical therapy.
into account potential tumor invasion, organ After these volumes have been selected, before
motion and set-up error. They also proposed applying a particular radiation technique, one
recommendations for dose reporting and, to a must consider different types of variations,
lesser extent, for dose prescription and record- uncertainties or even errors related to geometri-
ing. With the wider use of IMRT, there was cal factors. Indeed, physiological factors (e.g.,
a need to update these reports to take into change in organ filling or breathing) may intro-
account the new opportunities offered by such duce movements of the CTV, and the whole
a treatment modality [15] . patient could be slightly differently positioned
from one session to another. Thus, these geo-
Definition of target volume metric factors require the addition of a mar-
As introduced in the previous ICRU Reports 50, gin around the CTV, composed of an internal
62, 71 and 78, several volumes related to both margin (i.e., an internal target volume related
tumor and normal tissues have been defined to internal movement of the CTV) and a set-
for use in the treatment-planning and -report- up margin (i.e., related to variation in patient
ing processes [11–14] . Selection and delineation set-up). The internal target volume might be

368 Imaging Med. (2011) 3(3) future science group

 A digest of the ICRU Report 83 Special report

useful in clinical situations in which the inter- the definition and description of the ‘planning
nal movement of the target dominates the set- aims’ using image-based information from
up uncertainties. The planning target volume which all of the volumes of interest (e.g., GTVs,
(PTV) is defined as the volume including the CTVs, OARs, PTVs and PRVs) are deline-
CTV and the surrounding margin. It is a geo- ated and the desired absorbed-dose levels are
metrical concept used for treatment planning specified; a complex beam delivery optimiza-
and defined to ensure that the prescribed dose is tion process to achieve and, if needed, modify
actually delivered to the CTV with a clinically the initial planning aims; and a complete set
acceptable probability. Recommendations have of finally accepted values, which becomes the
been published on how to calculate margins to ‘treatment prescription’ and, together with the
delineate PTVs [19] . There may be more than one required ‘technical data’, represents the ‘accepted
GTV and corresponding CTV specified. Each treatment plan’.
CTV should have a corresponding PTV. IMRT The planning aims are dosimetric goals used
makes it relatively easy to specify different doses to develop the treatment plan. These goals can
to each of the PTVs. be defined for any specified volume, includ-
The organs at risk (OARs), or critical nor- ing the PTVs and PRVs, for which constraints
mal structures, are tissues, which, if irradiated, are needed. Typically, multiple constraints are
could suffer significant morbidity and, thus, defined, such as mean or median dose, dose to
might influence the treatment planning and/or ‘x%’ of a volume (e.g., D2% or Dnear-maximum dose)
the dose prescription. In principle, all nontarget or volume receiving at least an absorbed dose
tissues could be OARs. However, normal tis- (e.g., V20Gy). Also in the optimization process,
sues considered as OARs typically depend on priority of one constraint over another and/or
the location of the CTV and/or the prescribed priority of one volume over another are specified.
dose. Care will have to be given to the deline- All of these constraints are defined in the plan-
ation of OARs: for example, for ‘tubed’ organs ning protocol. To initiate the planning process,
(e.g., the rectum), the wall and not the full organ medical physicists or technologists sometimes
including the content will be delineated; also use so-called artificial dose-volume constraints,
for finite normal tissues (e.g., the parotids and which may be different from the desired ones
the lungs), the full organ will have to be deline- or from clinically relevant dose constraints. The
ated as the figures of merit to evaluate radiation dose-volume constraints will then be modified
toxicity in these organs (e.g., mean parotid dose, iteratively to achieve the best plan.
V20Gy for the lung) will have to be related to the When the optimized dose distribution is
full volume. Recent recommendations have been accepted by the physician, the prescription and
published regarding normal-tissue tolerance [20] . technical data are finalized. The treatment plan
As is the case with the PTV, uncertainties and includes the final prescription as well as all tech-
variations in the position of the OAR during nical data required for treatment delivery. The
treatment must be considered to avoid serious prescription is a description of the volumes of
complications. For this reason, margins have to interest, the dose and/or dose-volume require-
be added to the OARs to compensate for these ments for the PTV, the fractionation scheme,
uncertainties and variations using similar princi- the normal tissue constraints and the dose
ples as for the PTV. This leads, in analogy with distribution(s) that have been planned. This
the PTV, to the concept of planning OAR vol- final process is the responsibility of the treating
ume (PRV). The selection of the margin will, physician. The prescription is then referred to as
however, depend on the structure of the OAR the finally accepted set of values of the modified
being more critical for organs such as the spi- planning aims in the treatment plan after an
nal cord or nerves than for organs such as the optimization process.
parotid glands or the lungs. In practice, for these
latter organs, the OAR–PRV margin could be Dose-volume prescription, reporting
set to 0 mm. & recording
The main reason for the use of dose-volume
Planning aims reporting and recording in IMRT is that the
& treatment optimization coverage of the PTV by a specific absorbed dose
In IMRT, the distribution of dose to multiple can be explicitly determined from a dose–vol-
volumes is prioritized and tailored through an ume histogram and be better controlled through
iterative process, referred to as ‘optimization’. optimized planning. The use of dose-volume
The process consists of three major components: reporting and recording instead of reporting and

future science group www.futuremedicine.com 369

Special report Gregoire & Mackie

recording the more established absorbed dose slice-by-slice (or in 3D) to make sure that the
at the ICRU reference point is predicated on PTV is being adequately irradiated and normal
the use of an adequate dose-calculation system. sensitive tissues avoided as best as possible.
Recently, model-based dose‑calculation algo- The functional arrangement of normal-tissue
rithms, such as the convolution/superposition cells has been described as parallel or serial [21] .
method, or Monte Carlo simulation, have been For parallel-like structures it is recommended
adopted and provide accurate absorbed-dose cal- that more than one dose-volume specification
culations even in situations of tissue heterogene- be considered for reporting and recording. The
ity such as the lung. The report recommends mean absorbed dose in parallel-like structures
that the users of treatment-planning systems can be a useful measure of absorbed dose in an
ensure that treatment-planning systems have the OAR. Typically, because of highly non-uniform
ability to compute the absorbed dose accurately absorbed-dose distributions in OARs, the mean
for small fields, inhomogeneous tissues and in absorbed dose and the median absorbed dose are
regions in which there is electronic disequilib- not similar in value, and so the median absorbed
rium. The absorbed dose in Gy to a small mass dose cannot be used as an accurate substitute
of water within the heterogeneous tissue is the for the mean. For parallel-like normal tissues,
relevant dose to compute. This means that direct dose-volume reporting specifying V D, which is
computation of dose with Monte Carlo simula- a volume that receives at least the absorbed dose,
tion to the tissue (including the correct atomic D, specified in Gy, is a concept that has been
composition and density) must be converted commonly used and can also be easily obtained
to the dose of a small mass of water within the from a dose-volume histogram.
tissue type. The maximum absorbed dose as specified by a
Prescription values for IMRT should be based single calculation point (Dmax or D 0%) has often
on statistically meaningful dose-volume speci- been reported for serial-like structures; however,
fications, and not on specifying the dose only this is based on a single point and has great
at a single point. The older specification of an delineation uncertainty. This report instead
ICRU reference point dose is not recommended recommends that D 2% be reported. To obtain
for IMRT, and nor is the minimum dose to the a true value of D2% , the entire organ should be
PTV. This is because the minimum dose rep- delineated. When not possible (e.g., for the spi-
resents the dose to a single point likely at the nal cord), the anatomic description of the deline-
boundary of the PTV and is far too susceptible ated regions should be described when report-
to errors in delineation. A specific dose-volume ing the D2 % . Care should be taken in changing
prescription value to use is not prescribed but it from a maximum absorbed dose, D 0% , or other
should be clinically relevant, statistically mean- maximum-like dose-volume specification to the
ingful and clearly described. For example, D98% , near-maximum absorbed dose, D 2% , with the
also called the near-minimum dose, may be an dose constraints altered if necessary.
acceptable choice as it represents the dose that When organs are not clearly classified as
at least 98% of the PTV receives. Radiation serial-like or parallel-like structures, at least
oncologists should be aware that any change in three dose-volume specifications should be
the prescription protocol or dose-volume speci- reported and recorded. These would include
fication is likely to result in a change to the dose Dmean, D 2% and a third specification, V D , that
received by the patient. It is important when correlates well with an absorbed dose, D, which,
making changes to the prescription to evalu- if exceeded within some volume, has a known
ate the magnitude and extent of these changes high probability of causing a serious complica-
by comparing the dose received by patients for tion. Other specifications of risk, as deemed by
the old and new protocols so that dose values the radiation oncologist to be relevant, may also
specified can be adjusted if necessary. Whatever be reported and recorded.
dose-volume prescription value is chosen, the The reported and recorded dose prescriptions
median dose, represented by D50% , should also and technical data defining the accepted plan are
be reported and recorded as it represents a typi- only relevant if there is adequate quality control
cal dose within the PTV and is usually nearest on the whole process of IMRT to ensure that the
to the dose value of the more traditional ICRU doses are being delivered accurately. Machine-
reference point. The radiation oncologist should specific quality-assurance tests on the planning
not rely solely on the dose–volume histogram and delivery system are sometimes more complex
for treatment evaluation but should also care- than for other forms of radiation therapy because
fully inspect the absorbed-dose distributions the ability to plan and deliver the modulation of

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 A digest of the ICRU Report 83 Special report

intensity must be specially measured. In addition normalized to the absorbed-dose prescription

to machine-specific tests, patient-specific quality (e.g., D 50%), should be no more than 3.5%.
assurance is also recommended. One or more of This means that approximately 85% of points
the following methods producing a statistically should be within 5% of the desired value (nor-
relevant set of comparisons can be used to verify malized to the prescription absorbed dose).
that the intensity pattern will deliver the desired For high-gradient (>20% per cm) regions, the
absorbed dose: accuracy of distance to agreement of isodose
ƒƒ Measurement of the intensity pattern from lines should be within 3.5 mm, which means
individual beams for a specific patient; that 85% of the measurement or calculation
samples should be within a 5-mm distance to
ƒƒ Measurement of absorbed dose in a phantom agreement. Such a proposal is either based on
of the beam-intensity pattern planned for a comparison measured or on independently cal-
specific patient; culated absorbed dose. Investigative action is
ƒƒ Independent but equivalently accurate recommended if 85% of points of comparison
absorbed-dose ca lcu lations for the fail to meet either the distance to agreement or
patient-specific beam-intensity pattern. absorbed-dose accuracy.

Conclusion
„„ In vivo dosimetry Intensity-modulated radiation therapy is char-
It is recommended that, for a low-gradient acterized by nonuniform intensity distributions
(<20% per cm) region, the one standard that have been optimized to collectively deliver
deviation difference between the measured an adequately homogenous dose to the target
(or independently computed) absorbed dose volume and spare normal tissues as much as
and the treatment-planning absorbed dose, possible. Usually, these intensity patterns are

Executive summary
Generalities
ƒƒ Intensity-modulated radiation therapy (IMRT) requires new procedures for specifying treatment aims and prescriptions.
ƒƒ IMRT employs treatment optimization to obtain better dose distributions to trade off a uniform dose to the treatment volume and
protection of normal tissues.
Target volumes & organs at risk
ƒƒ Multiple gross tumor volumes (GTVs) may be necessary to specify the demonstrable tumor region.
ƒƒ Each GTV should have a corresponding clinical target volume that takes into account microscopic extension of the tumor or the regional
spread of the disease.
ƒƒ Each GTV or clinical target volume may be obtained from a different imaging modality or point in time.
ƒƒ Each GTV and its corresponding clinical target volume should have a planning target volume (PTV) that takes into account set-up
uncertainty and organ motion.
Dose prescription
ƒƒ Optimized planning is an iterative process that may require changing the planning aims as communicated to the treatment
planning system.
ƒƒ The prescription takes into account the PTV as well as the organs at risk and their corresponding planning organ at risk volumes, which
accommodates a margin for set-up and organ movement.
ƒƒ The treatment plan, accepted by the radiation oncologist, refers to the prescription and the technical data necessary for delivering
the treatment.
ƒƒ Adaptive radiotherapy takes into account the changing patient anatomy or tumor response throughout the course of therapy and, if
necessary, makes changes to the treatment plan.
Dose reporting
ƒƒ The dose prescription for the PTV should not use International Commission on Radiation Units and Measurements reference point dose
reporting and recording for IMRT but, instead, use dose-volume reporting.
ƒƒ Along with the dose prescription used to specify the clinically relevant dose to the PTV, the median dose to the PTV should also
be reported.
ƒƒ The reporting of the prescription values for normal tissues depends on whether the tissue can be classified as parallel-like or serial-like in
tissue architecture.
Quality assurance
ƒƒ New machine-specific quality-assurance procedures are necessary to ensure that intensity-modulated fields can be accurately delivered.
ƒƒ Patient-specific quality-assurance tests are recommended for intensity-modulated radiation therapy.
ƒƒ New statistically based quality guidelines that differentiate between high- and low-dose gradients are recommended.

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Special report Gregoire & Mackie

iteratively optimized by specifying dose and curative intentions. Among these patients,
dose-volume constraints to the target volume some will even require frequent re-imaging and
and normal tissues. The optimization leads to re-planning during IMRT treatment to adapt
an approved treatment plan, which is specified the dose distribution to the tumor evolution.
by the prescription (which also includes specifi- Such adaptive radiotherapy could possibly
cations for OARs as well as the target volume) lead to dose escalation on specific parts of the
and the technical data needed to deliver the tumor volume, aiming at further increasing the
plan. Treatment plans can be altered during treatment efficacy.
the course of radiation therapy to take into In this context, more so than ever, such
account patient anatomy changes due to tumor treatment evolutions will require accurate and
shrinkage or weight loss. This so-called adap- homogeneous dose prescription, reporting and
tive therapy can result in new target-volume recording, which will be greatly facilitated by
and OAR delineations. ICRU Report 83 docu- the use of a unique set of recommendations,
ments the specific differences between earlier such as the one proposed by ICRU. It is likely
ICRU reports for the specification of procedures that refinements of these recommendations
for the prescribing, reporting and recording of will have to be elaborated to better integrate
IMRT treatments. In particular, additional rec- the possible evolution of adaptive radiotherapy
ommendations were given on the selection and or other delivery techniques (e.g., stereotactic
delineation of the target volumes and the OARs; treatment). However, as it has been for the last
concepts of dose prescription and dose-volume 30 years, the ICRU recommendations should
reporting have also been refined. remain the backbone for radiotherapy practice,
as a unique common language aiming at facili-
Future perspective tating and improving communication between
Today, approximately one patient out of two radiation oncologists.
suffering from cancer benefits from radio-
therapy given in one or several stages of their Financial & competing interests disclosure
disease. This number is expected to rise owing The authors have no relevant affiliations or financial
to the aging of the population requiring can- involvement with any organization or entity with a finan-
cer treatment, the need for more organ- and cial interest in or financial conflict with the subject matter
function-preserving treatment approaches and or materials discussed in the manuscript. This includes
the fact that more and more patients cured employment, consultancies, honoraria, stock ownership or
from one cancer may experience another one options, expert testimony, grants or patents received or
(or other ones). Regarding radiotherapy deliv- pending, or royalties.
ery, it is anticipated that worldwide IMRT will No writing assistance was utilized in the production of
be used in a majority of patients treated with this manuscript.

6 Intensity Modulated Radiation Therapy 11 ICRU: Prescribing, Recording and Reporting

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