1400 IMRT Impact of ICRU-83

ICRU:International Commission on
Radiation Units and Measurements

1978, ICRU-29; Dose specification for reporting
external beam therapy with photon and electron beams.
IMRT: Impact of ICRU-83

Indra J. Das, PhD, FACR Department of Radiation Oncology Indiana University School of Medicine Indianapolis, USA
1993, ICRU-50; Prescribing, recording and

reporting photon beam therapy.
1999, ICRU-62; Prescribing, recording and

reporting photon beam therapy (Supplement to ICRU 50).
Thailand/Indra/2011
Thailand/Indra/2011
Tumor
Nomenclature
Vessel
GTV CTV IM ITV SM PTV OR PRV TV IR
Thailand/Indra/2011
Lymph node Tumor Cell Density
Gross Tumor Volume Clinical Target Volume Internal Margin Internal Target Volume Set Up Margin Planning Target Volume Organ at Risk Planning organ at Risk Volume Treated Volume Irradiated volume
high
?
Low?, Zero?
? Distance
CTV II
GTV CTV I
Thailand/Indra/2011
PTV = ITV + SM
Treated Volume (TV) GTV CTV ITV PTV
Thailand/Indra/2011
SM = Setup margin is uncertainties in patients positioning, and alignment during treatment. It is physical parameter associated with geometry and technical factors. SM is easy to control by immobilization devices and maintenance of accuracy and stability of machine.
Irradiated Volume (IV) IR=TV + penumbra

Thailand/Indra/2011
Schema
Radical vs Palliation
GTV Subclinical disease CTV IM ITV= CTV+IM Internal margin
SM PTV= CTV+SM OR PRV, Planning organ at Risk Volume

Thailand/Indra/2011
Set up margin
ICRU defines that if adequate dose cannot be delivered to the GTV, the whole aim of therapy should be termed as palliative.
PTV & PRV
Thailand/Indra/2011
Conformity Index; ICRU-50

Conformity index (CI) =TV/PTV TV= treated volume is the tissue volume that receives at least the dose selected and specified by radiation oncologist.
Dose Reporting
Dose must be reported to the ICRU reference point
ICRU Reference point is usually isocenter It could be a point in the center of the PTV
CIiso=
TV covered by % Isodose Planning Target Volume
Maximum and minimum Dose must be reported in PTV Whenever possible Dose should be reported to PRV
CI = > optimized closed to 1.0

Thailand/Indra/2011 Thailand/Indra/2011
Digital Dose Era

IMRT is a digital dose distribution 3D is an analogue dose distribution
IMRT Plan
Traditional Treatment
3D-CRT Treatment
Thailand/Indra/2011
Thailand/Indra/2011
IMRT Plan of head and neck nodes
Difference between 3DCRT and IMRT
Thailand/Indra/2011
Thailand/Indra/2011
Paradigm Shift
In 3D conformal therapy, ICRU-50 recommended
Uniform dose to PTV (-5% to +7%) Report dose @ isocenter
3D-CRT vs IMRT
Simple No need of volume and OAR Forward calculation Give what you wish to target volume Uniform fluence Exact solution Uniform dose Low MU Analogue dose Dose defined to volume but specified at isocenter
Thailand/Indra/2011
IMRT represents 40% of the radiation treatment with a paradigm shift

Thailand/Indra/2011
Non uniform dose (dose painting) Large dosimetric variations Isocenter dose is meaningless Radiobiological consequence of large heterogeneous dose is uncertain (ie 180cGy/day versus 250cGy/day)
Complex Target and OAR must be present Inverse calculation Requires dose-volume constraints and cost function Non-uniform Approximate solution High gradient dose High MU Digital dose Isocenter dose undefined and meaningless
IMRT APPROACHES
Software
Inverse planning (simulated annealing) Optimization
Gradient search Global minimum Cost functions
Thailand/Indra/2011
IMRT Terminology
Number of Fields
Non opposing, odd/even numbers Coplanar/noncoplanar
Hardware
Mimic (binary MLC by NOMOS) MLC Tomotherapy Compensator Based
Beam divided into:

Beamlet (5, 10, 15, 30 etc) Segments (no longer rectangular field) Beamlet =segments
Bixels (resolution of the MLC)
Beamlet, single level
Level (dose painting in a Bixel)

Intensity level Integer number (5, 7, 10, 15, 20 etc)
Thailand/Indra/2011
4 5 2 3 7
Multi level, beamlet
IMRT Segments
Subfields (beamlets)
IMRT Field
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Thailand/Indra/2011
0 0 0 0 0
1 1 0 1 1
1 1 1 1 0
1 1 1 1 1
0 0 0 0 0
0 0 0 0 0
1 1 0 1 1
1 1 1 1 0
1 1 1 1 1
0 0 0 0 0
Digital Dose Matrix & Understanding
Segmentation
Beams Eye View , BEV Selection of grid size (mm) Split fields in small building block, beamlets, bixels PTV Segment = Collection of beamlets with same intensity level Map (Fluence) = Collection of segments with different intensity level
Level 1
0 0 0 0 0 1 1 0 1 1 1 1 1 1 0 1 1 1 1 1 0 0 0 0 0
0 0 0 0 0
1 1 0 1 1
1 1 1 1 0
1 1 1 1 1
0 0 0 0 0
Intensity Level= Layer of dose level
Level 4
0 0 0 0 0 4 4 0 4 4 4 4 4 4 0 4 4 4 4 4 0 0 0 0 0
Thailand/Indra/2011
Thailand/Indra/2011
Calculation of beamlet/ segmentation

Rx with 5 fields of 10x10 cm2 and 5 levels
Optimization & Cost Function
10x10 mm =>100x5 5x5 mm 4x4 mm 3x3 mm 2x2 mm
= 500
=>20x20x5 = 2000 =>25x25x5 = 3125 =>33x33x5 = 5445 =>50x50x5 = 12500
S S S wijk(Dopt-Dcal)2 = minimum
i,j,k
wijk= weight for constraint of an organ
Target volume Imaging
DVH Constraints
Inverse planning Beamlet sequencing
Record & Verification Treatment
IMRT
Transfer & sequencing Phantom Plan
Portal Imaging
Thailand/Indra/2011
Dose Measurements Film dosimetry
Inverse Planning Systems

Corvous; NOMOS Corp, Pennsylvania, USA Pinnacle, ADAC, Philips, California, USA Eclipse/Helios, Varian, California, USA Conrad, DKFZ, Germany Helax, TMS, Upsala, Sweden Oncentra (TPP+Helax), Nucletron Corp, Canada Plato, Nucletron, Netherlands Xio, CMS, St Loius, MO, USA Xplan, Radionics, Boston, USA Brainlab, California, USA PLUNC, Chapel Hill, NC Prowess, CA
Thailand/Indra/2011
Three Selected Clinical Cases

1 5 1 2 9
PTV - Prostate
100 90 80 70 60 50 40 30 20 10 0 60
Thailand/Indra/2011
Lung
5 Fields
2 8 3
3 7
1 7 2
Prostate
7 Fields
6 3 6 5
Brainlab CMS-XiO Corvus Eclipse Helax Konrad Oncentra Pinnacle Plato Prowess Radionics Constraints
Head and Neck

9 Fields
% Volume
65
70
75
80
85
90
95
100 105 110 115 120
Thailand/Indra/2011
% Dose
Volume (%)
0
100 90 80 70 60 50 40 30 20 10 0 0
10
20
30
40
50
60
70
80
90
100 110 120

100
10
20
30
40
50
60
70
80
90
100 110 120
Brainlab
% Volume
100 90 80 70 60 50 40 30 20 10 0
100
Rectum
90 80 70 60 50 40 30 20 10
Bladder
PTV- Lung
100 90 80 70 60 50 40 30 20 10 0
80
Rt Femoral Head
90 80 70 60 50 40 30 20 10 0 0 10 20
Lt Femoral Head
CMS-XiO Corvus Eclipse Helax Konrad Oncentra Pinnacle Plato Prow ess Radionics Constraints
10
20
30
40
50
60
70
80
30
40
50
60
70
70
Thailand/Indra/2011
75
80
85
90
95
100
105
110
115
120
Dose (%)
Thailand/Indra/2011
% Dose
100 90 80 70 60
100
Lt Lung
90 80 70 60 50
Heart
100 90 80 70
PTV - Head and Neck
50
40
40
30
30
20
20
10
10
0
60 50 40 30 20 10 0 60 65
0 0 10 20 30 40
100 90 80
10
20
30
40
50
60
70
80
90
100
110
120
50
60
70
80
Cord
70 60 50 40 30 20 10 0 0 10 20 30 40 50 60
% Volume
% Volume
70
75
80
85
90
95
100
105
110
115
120
125
130
70
80
Thailand/Indra/2011
% Dose
Thailand/Indra/2011
% Dose
100 90 80 70 60 50 40 30 20
100 90
Rt Optic Nerve
Optic Chiasm
80 70 60 50 40 30 20 10 0
Inter- and intra-planner variation

One TPS system (Eclipse/Helios) Identical Machine (6 MV, Varian) Five institutions
% Volume
10 0 0 10 20 30 40 50 60 70 80 90 100 110
0
100
10
20
30
40
50
60
70
80
90
100
110
100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 80 90
Lt Parotid
90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70
Brainstem
Sewel, NJ Orlando, Florida Buffalo, NY Worcester, Massachusetts Waterbury, CT
80
90
100
110
120
Identical constraints Independent planning of each site 3 times

Thailand/Indra/2011
Thailand/Indra/2011
% Dose
Inter-Planner Variation, Prostate

100 90 80 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 Dose (%) 70 80 90 100 110 120
Inter-Planner Variation, Prostate

100 90
PTV Rectum
80 70
PTV Rectum
Volume (%)
Volume (%)
60 50 40 30 20 10 0 0 10 20 30 40 50 60 Dose (%) 70 80 90 100 110 120
Rt Fem Head
Rt Fem Head
Das I. J, Cashon K.W., Chopra K.L., Khadivi K.O., Malhotra, H.K., Thailand/Indra/2011 Mayo, C.S.. Med. Phys., 32(6), 2147, 2005
Thailand/Indra/2011
Inter-Planner Variation, Lung

100 90 80 70
100 90
Inter-Planner Variation, H&N

Optic Chiasm Optic Nerve Lt Eye
PTV
Volume (%)
80 70 60 50 40 30
PTV
Volume (%)
60 50 40 30 20 10 0 0 10 20 30 40 50 60 Dose (%) 70 80 90 100 110 120
Heart Cord Lt Lung
20 10 0 0
Parotid
10
20
30
40
50
60 Dose (%)
70
80
90
100
110
120
Thailand/Indra/2011
Thailand/Indra/2011
Intra-planner variation, Prostate

30
25
Planner #1 Planner #2 Planner #3 Planner #4 Planner #5
% Variation in MU
20
15
10
0 1 2 3 4 5 6 7
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Beam Number
Thailand/Indra/2011
Variations in doses in 803 patients among institutions

1.5 1.4 1.3
Irrelevent Dose Recording @ Isocenter

Institution 5
Institution 1
Institution 2
Institution 3
Institution 4
Prescription Deviation: (Planned/Prescribed Dose)
46%
1.2 1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0
Isocenter position in low dose region near or in OAR
63%
Minimum Maximum Median Isocenter
0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 750 800
Patient Number
Das et al. J Natl Cancer Thailand/Indra/2011
Inst 100 (5), 300-3007, 2008
Thailand/Indra/2011
Thailand/Indra/2011
Thailand/Indra/2011
Thailand/Indra/2011
Thailand/Indra/2011
ICRU-83 views
Maximum dose is defined as D2% Median dose, D50% is closed to prescription dose and very close to reference dose Median and mean dose are very close D98%, considered minimum in PTV Use of PET imaging should be explored for CTV & PTV definition along with CT and MRI Definition of sub volume with overlaps
Waiting Time with Physicians

80 70
Prostate Head & Neck Lung
Total time/patient (hr)
60 50 40 30 20 10 0
Corvous
Eclipse
Pinnacle
BrainLab
Plato
Plunc
Radionics
Oncentra
Thailand/Indra/2011
Thailand/Indra/2011
Das et al, JACR, 6, 514-517, 2009
Contouring & Processing Time

40 36 32 Prostate Head & Neck Lung 28 24 20 16 12 8 4 0
10 9 8
Dose Calculation Time
Prostate Head & Neck Lung
7 6 5 4 3 2 1 0
Corvous
Eclipse
BrainLab
Pinnacle
Plato
Radionics
Oncentra
Plunc
XiO
Corvous
Eclipse
BrainLab
Pinnacle
Plato
Radionics
Oncentra
Plunc
Thailand/Indra/2011
Das et al, JACR, 6, 514-517, 2009
XiO
Thailand/Indra/2011
Das et al, JACR, 6, 514-517, 2009
XiO
Time for all operations excluding physician waiting time

50 45 40
Head & Neck Lung
35 30 25 20 15 10 5 0
Measurement Difference (%)
Prostate
8 7 6 5 4 3 2 1 0 -1 -2 -3 -4
Acceptable accuracy 5% and 3 mm
Corvous
GU CNS GI
Eclipse
Pinnacle
BrainLab
Plato
Plunc
Radionics
Oncentra
XiO
PED GYN H&N HEM SAR
THOR
Treatment Sites
Das et al, JACR, 6, 514-517, 2009
Dong et al, IJROBP, 56, 867-877, 2003
ICRU-83 Reporting
Dose homogeneity
HI = [D2-D98%]/D50%
Dose Confomality as ICRU-50 Clinical & Biological Evaluation

TCP: Tumor control probability NTCP: Normal tissue complication probability EUD: Equivalent uniform dose
Uncertainty & confidence interval Dose reporting of OAR and PRV

Verification & Evaluation
Verification & Evaluation

Monte Carlo simulation Clinical condition
Thailand/Indra/2011
Thailand/Indra/2011
Sanchez-Doblado et al, IJROBP, 68,301-310, 2007
Summary ICRU-83 Recommendation

Use of PET imaging should be explored for CTV & PTV definition along with CT and MRI Definition of sub volume with overlaps Optimazation should be fully explored Maximum dose is defined as D2% Median dose, D50% is closed to prescription dose and very close to reference dose D98%, considered minimum in PTV
Thailand/Indra/2011
-Summary ICRU-83 Recommendation

DVH is a measure of delivered dose, and be used in clinical practices Quality assurance for IMRT optimization and uniqueness of the IMRT solution should be thoroughly investigated Commissioning of accelerator should include thorough investigation of MLC leaf, gap and transmission Treatment planning system should incorporate advance algorithm for inhomogeneity correction & MUST be used for dose calculation
Thailand/Indra/2011
Thailand/Indra/2011
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1400 IMRT Impact of ICRU-83

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1400 IMRT Impact of ICRU-83

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ICRU:International Commission on

Radiation Units and Measurements

IMRT: Impact of ICRU-83

1993, ICRU-50; Prescribing, recording and

1999, ICRU-62; Prescribing, recording and

Lymph node Tumor Cell Density

Irradiated Volume (IV) IR=TV + penumbra

SM PTV= CTV+SM OR PRV, Planning organ at Risk Volume

PTV & PRV

Conformity Index; ICRU-50

TV covered by % Isodose Planning Target Volume

CI = > optimized closed to 1.0

Digital Dose Era

IMRT Plan of head and neck nodes

Difference between 3DCRT and IMRT

IMRT represents 40% of the radiation treatment with a paradigm shift

Beam divided into:

Level (dose painting in a Bixel)

Multi level, beamlet

Digital Dose Matrix & Understanding

Intensity Level= Layer of dose level

Calculation of beamlet/ segmentation

Optimization & Cost Function

10x10 mm =>100x5 5x5 mm 4x4 mm 3x3 mm 2x2 mm

=>20x20x5 = 2000 =>25x25x5 = 3125 =>33x33x5 = 5445 =>50x50x5 = 12500

wijk= weight for constraint of an organ

Target volume Imaging

Inverse planning Beamlet sequencing

Record & Verification Treatment

Transfer & sequencing Phantom Plan

Dose Measurements Film dosimetry

Inverse Planning Systems

Three Selected Clinical Cases

Head and Neck

100 105 110 115 120

100 110 120

100 110 120

PTV - Head and Neck

Inter- and intra-planner variation

Sewel, NJ Orlando, Florida Buffalo, NY Worcester, Massachusetts Waterbury, CT

Identical constraints Independent planning of each site 3 times

Inter-Planner Variation, Prostate

Inter-Planner Variation, Prostate

60 50 40 30 20 10 0 0 10 20 30 40 50 60 Dose (%) 70 80 90 100 110 120

Inter-Planner Variation, Lung

Inter-Planner Variation, H&N

60 50 40 30 20 10 0 0 10 20 30 40 50 60 Dose (%) 70 80 90 100 110 120

Heart Cord Lt Lung

Intra-planner variation, Prostate

Planner #1 Planner #2 Planner #3 Planner #4 Planner #5

Variations in doses in 803 patients among institutions

Irrelevent Dose Recording @ Isocenter

Prescription Deviation: (Planned/Prescribed Dose)

Isocenter position in low dose region near or in OAR

Das et al. J Natl Cancer Thailand/Indra/2011

Inst 100 (5), 300-3007, 2008

Waiting Time with Physicians

Total time/patient (hr)

Das et al, JACR, 6, 514-517, 2009

Contouring & Processing Time

Dose Calculation Time

Prostate Head & Neck Lung

Total time/patient (hr)