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Isocenter Shifts in Treatment Planning and Its Clinical Implications

Yasmin Ahmed, BS, R.T. (R)(MR), Stephanie Damiani, B.S., Yijian Cao, PhD, Abolghassem
Jamshidi, PhD.
ABSTRACT
In radiation oncology, the placement of isocenter for each patient is crucial during the
planning phase. It is important because it allows radiation beams to point at the center of the
tumor, maximizing dose to the target volume and minimizing dose to normal tissues. Often
times, during the planning phase, a shifted isocenter is created. Each time the patient comes for
treatment this process of shifting to the appropriate location is implemented. Therefore, isocenter
shifts yield longer patient set-up time, thus reducing productivity. In addition, errors may occur
because of the additional steps noted in the treatment plan. This study seeks to reduce future setup time and errors by determining if shifted isocenters are in fact always necessary.
The population size consists of 340 patients treated on 4 machines. Data was collected
retrospectively over eight weeks to determine how and why these shifts occur and was
categorized according to treatment site and treatment type. Results indicated that these shifts
occurred due to necessary and unnecessary means. The final analysis shows that an average of
53% of planned isocenter shifts can be avoided. Careful planning at the CT simulator and a
detailed review of CT images when the simulation is performed is important to reduce any
complications that can emerge in the next stages of treatment. The clinical impact of isocenter
shifts such as issues of patient safety, treatment efficiency, and quality of treatment planning will
be further discussed in detail. In addition, more studies must be conducted in order to conclude
theories regarding isoshifts in radiation oncology.
Key Words: Shifted isocenter, pelvis, lung, treatment planning.
Introduction
When the patient goes through the CT simulator, which is the first step in treatment
planning, external marks are made. These marks may or may not be at the same location as the
isocenter once the images are sent to treatment planning. If they are not, a shift from the
isocenter is necessary. Hence, patients with a shift must be repositioned before their treatment is
delivered. When this occurs, there are additional steps that need to be taken; shifts can be less

intuitive and straightforward based on where the treatment site is. Patients are set up based on the
external marks made during the CT simulation and will be moved on the treatment table in three
dimensions to where the desired location is, based on the instructions given in the plan.
In addition, isocenter shifts are strongly related to treatment sites, specifically breasts.
Multiple disease locations, limitations of each machine, and treatment plan quality aid in why
shifts occur. In addition, shape changes and size of tumor contribute to isoshifts.1 Furthermore, if
there is an isoshift, this means that treatment time will increase due to patient set-up. This
includes gantry rotations, couch shifts, and time spent on repositioning the patient if there are
multiple isocenters. It is also important to note that total treatment includes patient changing time
and time the patient enters and exits the treatment room. Less time during setup will lead to
higher efficiency, decreased amount of patient discomfort, and improved accuracy because there
is reduced risk for patient movement.2
If an isocenter shift is necessary, the direction of the shift should always be well thoughtout. In prostate cases, in regards to set-up errors, a left to right shift will have fewer
consequences as compared to a cranio-caudal or anterior/posterior shift.3 Set-up error refers to
any incongruity among the real treatment position of the patient and the intended planned
position. A gross error is a large mistake which may have detrimental effects, such as the tumor
volume receiving less than prescribed dose or organs at risk receiving greater than maximum
constraints outlined. One of the many causes of gross error includes setting up the patient at an
incorrect isocenter position.4 The risk for this type of error may heighten when a shifted isocenter
technique is applied. Conversely, other times shifts may not be necessary, and this is
demonstrated by re-evaluating the treatment plans without applying the isocenter shifts for lung
and pelvis.
Incidents related to isocenter shift of a treatment plan and workflow with practice of daily
isocenter shift is high comparing other contributing factors. Shifts are however sometimes
necessary. For instance, multiple sites, work around of machine limitations, and optimized
dosimetry may be valid reasons for having shifted isocenters. However, other times shifts are not
necessary and this is tested by re-evaluating the treatment plans without applying the isocenter
shifts for lung and pelvis cases. Unnecessary isocenter shifts on a daily basis will yield longer
times for therapists to set-up the patient and verify the shift every treatment. This would affect
the throughput of the patient flow.

In this study, there are 6 intensity modulated radiation therapy (IMRT) lung cases and 9
IMRT pelvis cases. IMRT has many benefits compared to 3D conformal radiotherapy (3D-CRT).
Intensity modulated radiation therapy allows maximum dose to be delivered directly to the tumor
while minimizing dose to organs at risk (OR) surrounding the tumor. However, since IMRT
employs a modulated method to regulate beam intensity, stricter quality assurance (QA)
procedures are required as compared to 3D-CRT.5
Methods and Materials
Within the context of radiation oncology workflow, isocenter shifts are employed for
different reasons. When the patient arrives for the simulation CT, the radiation oncologist usually
is not present with the radiation therapist. For this reason, the simulation therapist chooses the
placement of external marks. The simulation radiation therapist picks the location based on the
particular treatment site, as well as their knowledge and experience. Many times, the placement
of this marked isocenter is not feasible for planning purposes. Therefore, another location is
created and is referred to as the shifted isocenter. The radiation therapist will shift to this new
location from the marked isocenter on a daily basis for many patients.
Patients
Combined data collected over 8 weeks consisted of 340 patients from 4 different linear
accelerators. Of these 340 patients, an average of 51% had isocenter shifts. The patient data was
then categorized according to site category and plan type (Figures 1 and 2). To examine the data
even further, each site category consists of a subset of different tumor sites. For the purpose of
this study, 2 site categories are investigated further: chest and pelvis. The tumor sites under
investigation within these categories are: lung and pelvis. These specific sites were chosen due to
the large amount of patients being treated for these sites. There were a total of 17 lung cases and
27 pelvis cases. Of the lung cases, 6 patients did not have a shifted isocenter; of the pelvis cases,
17 patients did not have a shifted isocenter. Taking this into consideration, 11 lung patients and
10 pelvis patients were examined in detail to determine whether or not the shifted isocenter was
necessary. Figures 3 and 4 demonstrate the total size of the shift for each patient. The data shows
the absolute value of the sum of the shifts per patient in all directions. For the lung patients, the

size of the shifts range between 0 cm and 12 cm. For the pelvis patients the shifts range from 0
cm to 11 cm.
Plan Comparisons
The final treatment plan for each case was re-opened in the respective planning system
and was re-calculated using the original marked isocenter for all beams. The generated plan data
was then analyzed to outline the statistics of the original plan with the shifted isocenter and the
new plan with the marked isocenter. A side-by-side comparison was done for each case
comparing the maximum dose received by the planning target volume (PTV), which is referred
to as the Dmax, the minimum dose received by the PTV, which is Dmin, and what dose 90
percent of the PTV volume received (D90). Up to 3 ORs were also chosen for each case to
compare Dmax and mean dose received by these organs. This was done because it is not only
important to evaluate PTV coverage for the comparison, as the ORs are also of concern. The
dose that the ORs receive is also important when evaluating treatment plans.
Results
Based on the dose comparison between isocenters, the percent change was calculated for
each case. Out of 11 lung cases, 6 were IMRT and 5 were 3D-CRT. Of the IMRT plans, only 1
was deemed necessary regarding the creation of a shifted isocenter; of the 3D-CRT plans, 4
shifted isocenters were deemed necessary. In total, 45% of cases with shifted isocenter were
deemed necessary. The pelvis studies consisted of 9 IMRT and 1 3D-CRT case. Five IMRT cases
were deemed necessary based on the percent change between plans and 1 3D-CRT was deemed
necessary. In total, 60% of the pelvis cases with shifted isocenters were necessary. These results
suggested that about 53% of the lung and pelvis patients combined did not need a shifted
isocenter.
In addition, a qualitative survey that consisted of 5 questions was distributed to
11radiation therapists regarding isoshifts (see Table). The printed survey was distributed
randomly to the radiation therapists and answers were anonymous. The questions included time
spent on patients that had isocenter shifts, daily errors, simulation procedures, etc. The results
indicated variation in responses between therapists. Since the survey was anonymous however,

factors affecting response such as therapist experience, training, and other influencing factors
could not be determined.
Discussion
The reason a shifted isocenter is created may have several explanations. These may
include subjective and objective reasons. For example, each individual planner with ranging
experience levels will have a different view on whether or not a shift is needed and how to plan
in general. These factors require more in-depth research and several more studies need to be
conducted in order to investigate this topic further. During the isoshift process however, it is
important to verify each step during the delivery of radiation. The purpose of this is to ensure
that the radiotherapy is delivered within treatment plan guidelines and geometric accuracy is
maintained. In order to reduce gross errors, personnel should abide by certain guidelines put in
place by each department that should include:

Management team that includes physicians, dosimetrists, physicists, etc. to verify and

construct department rules regarding process and responsibilities.

Providing staff with refresher courses for training/competency.
Follow department protocol at all times. If deviation is requested/required, consult with

supervisor.
Have independent checks put in place during each phase of the radiation therapy

department workflow as deemed necessary.4

Physics verification should be implemented post first treatment to avoid/correct errors.

In addition to personnel responsibilities, another recommended procedure to reduce errors is to

have the radiation oncologist present during the patients simulation CT for more accurate
isocenter placement. The most important thing to note is that it is imperative that all oncology
staff be reminded to always follow department policy regarding procedures for all their decisionmaking processes. When in doubt in regards to patient care, the radiation therapist should be
encouraged to always consult another therapist, dosimetrist, physicist, etc. as deemed
appropriate, in order to reduce errors in treatment delivery.

References

1. Wang L, Hayes S, Paskalev K, Jin L, et al. Dosimetric comparison of stereotactic body

radiotherapy using 4D CT and multiphase CT images for treatment planning of lung cancer:
Evaluation of the impact on daily dose coverage. Radiother Oncol. 2009;91(3):314-324.
http://dx.doi.org/10.1016/j.radonc.2008.11.018
2. Meyers P, Stathakis S, Gutierrez AN, et al. Dosimetric comparison of craniospinal axis
irradiation (CSI) treatments using helical tomotherapy, smartarc, and 3D conventional
radiation therapy. Int J Med Phys, Clin En Rad Oncol. 2013;2:30-38.
http://dx.doi.org/10.4236/ijmpcero.2013.21005
3. Stemminger S, Kunz G, Brown D, et al. Influence of isocenter shift on dose distribution in
prostate cancer patients. Strahlentherapie und Onkologie. 2006;182(suppl 1):179.
4. Radiologists TRCo: On target: ensuring geometric accuracy in radiotherapy. London: The
Royal College of Radiologists, Society and College of Radiographers, Institute of Physics
and Engineering in Medicine; 2008.
5. Shin D, Yoon M, Park SY, et al. Isocenter optimal matching shift algorithm to verify the dose
distribution in intensity-modulated radiation therapy through the stochastic property. J
Korean Phys Soc. 2007;51(5):1792-1797. http://dx.doi.org/10.3938/jkps.51.1792

Figure 1. Shifts by Site Category from Marked Isocenter

160
3

140

100

92.31

80

% OF SHIFTS

60
40
20
0

120

64.29
# WITH SHIFTS

2
1

37.50
3

36
48

8
14

7 SHIFTS17
# NO

61.11

23.08
20

18.28

49.30

35

36.36

3
10

76
36

11
7

This figure demonstrates according to site category how many cases had shifted isocenters and
how many did not. It also shows the percentage of patients with shifts from each category total.

Figure 2. Plan Type based on Site Category

120
8

100

22

80
6

60

VMAT
3
1

40

10

27

IMRT

16
2
1
11

20
0

3D
4

27

1
2
1

10

56

51
26
0

41

1
11
1

1
15
2

This figure shows the different plan types of each case based on the specific site. The plan types
include volumetric modulated arc therapy (VMAT), 3D-CRT, and IMRT.

Figure 3. Size of Lung Shifts

14 15 16 17 18 19 20 21 22 23 24 25 26 27
13

12

12
11
1010
9

8 8

7.5

7 7

6.5

5
4

2
1

1 2 03 04 5 6 07 8 9 10
0 11 12 13 14
0 15
0 16 17 18
0 19
0 20 21 22 23
0 24 25
0 26 27

This figure shows the total size of lung shifts in each direction in centimeters for every patient.

Figure 4. Size of Pelvis Shifts

10

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
11
10

9
8

11
10

8.5
8
7
6
5

4
3

2.55

1 2 03 4 05 6 07 8 9 10
0 11
0 12
0 13
0 14
0 15 16 17
0 18
0 19
0 20
0 21 22
0 23
0 24
0 25
0 26
0 27
0

This figure shows the total size of pelvis shifts in each direction in centimeters for every patient.

Table. Survey of radiation therapists regarding isocenter shifts.

11

Question

Yes

No

Same

When a patient has a shift, is it more

difficult to reproduce setup?

Would it be helpful for the radiation

<5 min.

Within 10 min.

>10 min.

oncologist to be present at the time of

CT simulation?
Would it be helpful to reduce daily
setup error if the shifted isocenter is
remarked/tattooed during virtual
simulation?
Are there always at least 2 therapists
present to verify correct positioning?
How much extra time does it take to
position a patient with a shifted
isocenter?