Concepts and

Recommendations
For IMRT Planning : ICRU 83

Bijay Kumar Barik

Med.Physicist
1
 Contents

 ICRU
 3-DCRT Vs IMRT
 Point dose prescription and IMRT
 ICRU 83
 Levels of reporting
 Dose- volume reporting
 Problems associated with planning
 Summary

2
 International Commission on Radiation Units and
Measurements(ICRU)
Establishment (in 1925)
Objective :
It has been continously working for development of internationally
acceptable recommendations regarding:

 Radiation quantities, units and radioactivity.

 Suitable procedures for mesurement and application of quantities

in clinical radiology and radiobiology.

 Physical data needed in the application of these procedures which

tends to assure uniformity in reporting.

3
Difference between traditional and IMRT optimization

4
 3DCRT Vs IMRT

3-D CRT IMRT

 Simple.  Complex.
 Forward planning  Inverse/optimized planning
 Uniform fluence.  Non-uniform fluence.
 Uniform dose.  High dose gradient.
 Low MU.  High MU.
 Dose defined at isocentre.  Dose at isocentre is meaningless.

5
ICRU Dose/planning Guidelines for EBT

6
 ICRU-50 Reference Point and Reference Dose

The process for selection of reference point was specified as follows:

 Clinically relevant.

 Easy to define.

 Absorbed dose can be accurately determined.

 Region where there is no steep absorbed-dose gradient.

These recommendatations will be fulfilled if the ICRU reference point is located:

 Always at the center (or in a central part) of the PTV and

 When possible at the intersection of beam axes.

7
 Problems with point dose in IMRT

 Absorbed dose distribution in PTV –inhomogeneous.

 Larger dose gradient within a PTV.

 There is a sharp dose fall off at the boundary.

 Monte-carlo simulation - difficult to determine absorbed dose to a point

- statistical fluctuations.

8
 ICRU Report no.83 (2010)

 Updatation of these reports are required to take into account

the new opportunities offered by IMRT.

 Provides the standard techniques and procedures for

prescribing, recording and reporting IMRT.

 Recommendations are given for selection and delineation

of the target volumes and organs at risk.

 Concepts of dose prescription and dose-volume

reporting have also been refined.

9
 Definition of volumes

PRV- Planning organ at risk volume

RVR- Remaining volume at risk
10
 ICRU-83 Levels of reporting

 Three levels
Level 1:
• Minimum standard - all the centers below which radiotherapy should not be performed.

• Sufficient for treatment where the knowledge of absorbed doses on the central axis is known.

Level 2:
• It implies that treatments are performed using 3-D imaging and computational dosimetry. All
volumes of intrests are defined using CT and/or MR , dose distribution include heterogeneity
corrections.

• Dose volume histogram for all volume of interests are computed.

• Complete QA programme is placed to ensure the prescribed treatment is accurately

delivered.

11
 ICRU-83 Levels of reporting

Level 3:

• Development of new techniques for which reporting criteria are not established till
now.

• Tumor-controll-probability(TCP) ,normal tissue complication probability(NTCP) and

equivalent uniform dose(EUD).

 Level 1 is not adequate for 3-D CRT and IMRT.

12
 Dose – Volume Reporting

 Reporting of minimum dose should be replaced by the better-

determined near-minimum dose D98%, also designated as Dnear-min.

 Other dose-volume values, such as D95% , may also be reported but

should not replace the reporting of D98%.

 Analogously, it is recommended to report the near-maximum dose

D2% as a replacement for the “maximum dose”.

 If the “maximum dose” defined by ICRU 50 is clinically relevant this

value may be reported.

13
Dose – Volume Reporting

14
 OAR and PRV Specific Dose-Volume Reporting

 For “serial-like” OAR’s (e.g. spinal cord, intestines, optic nerve )

D2% is to be reported and the entire organ should be delineated.

 A high estimate of D2% will result if only those portions of the organ
that receive a high dose are delineated.

15
 OAR and PRV Specific Dose-Volume Reporting

 For parallel-like structures (e.g. parotid, lung, kidney, liver͙) , more than
one dose-volume specification be considered for reporting.

 The mean dose in parallel-like structures may be a useful measure

of dose in an organ at risk.

 Because most organs are not clearly a serial-like or parallel-like

structure (e.g. heart) at least 3 dose-volume specifications should
be reported.

 These would include Dmean, D2%, and a third specification VD

16
 Dose Homogeneity and Confirmity

 Homogeneity and dose conformity are independent specifications of the

quality of the dose distribution.
 Dose homogeneity:
 Characterizes the uniformity of dose distribution within the target volume.
Homogeneity index, HI = (D2 % - D98 %) / D50 %
 D50% is suggested as the normalization value because reporting of
D50% is strongly recommended in Level 2 reporting.
 Dose conformity:

 The degree to which the high dose region conforms to the target volume, usually
the PTV.

Conformity Index = TV prescr/ PTV volume

 Because of increasing of DVH format reporting, the applicability of these indices

for IMRT reporting is likely to be limited.

17
Dose Homogeneity and Confirmity

Homogeneity

18
 Over lapping of PTV and PRV

 PTV and PRV delineation often results in one or more

overlap regions.

 It is recommended that the margin should not be

compromised for PTV and PRV.

 For sufficient normal tissue sparing priority rules can be

used or PTV and PRV can be divided into regions of
different dose constraints.

 It is recommended that the dose be reported in the full

PRV and PTV.

 Different sub-volume PTV can be used for planning

purpose but the dose should be reported for the whole
PTV.

19
 PTV in Buildup Region or Outside Body

 Most dose-computation algorithms can not accurately

compute dose in buildup region.

 Attempt to increase the absorbed dose in this region leads

to inhomogenous dose to PTV.

 Subdivision of PTV into sub-volumes.

 Acceptable absorbed dose to PTV , planning aim is relaxed.

20
 Summary

 Prescribing and reporting with dose-volume specifications.

 No use of ICRU-Reference Point.

 Instead of Dmax and Dmin, D2%(near-max) and D98%(near-min) should be

reported.

 Need to report median dose D50%.

 Use model-based dose calculations.

 More emphasis on statistics.

21
THANK YOU

22