BASIC PRINCIPLES OF

PLAN EVALUATION
IN RADIOTHERAPY
 E valuating a radiation plan is an essential

task for the radiation oncologist that is becoming

more complex due to advances in radiation
techniques. Multiple components are required to
ascertain the quality and acceptability of a
radiation therapy plan, which can be difficult to
remember for the radiation oncologist in training.
Herein is proposed a systematic approach for plan
evaluation to ensure all aspects are properly
CB-CHOP: A simple acronym for
evaluating a radiation treatment
plan
Contours.

 B e a m a r r a n g e m e nt .

Coverage.

Heterogeneity/Hotspot.

Organs at Risk.

Prescription.
Identify the correct statement?
• It is a cumulative DVH
• It is an integral DVH
• It does not give idea about Minimum and
Maximum dose
• None of the above
Why Should You Listen?
• Essential task for radiation oncologist
• Complex: advancements in techniques
• Multiple components required
The CB-CHOP Approach
Gautam K Sharan I ICRO, Jaipur, 2018 I Basic Principles of Plan Evaluation in Radiotherapy
Contours
Beam
Arrangement
Heterogeneity/
Hotspot
Coverage
Organsat
Risk
Prescription
Mary Dean et al, Applied radiation Oncology, December 2017
 Be a m ar r a n g e m e n t Coverage
Contours

Prescription
He t e r o g e n e i t y /H o t s p o t Organs at Risk
Contours
• Review the delineated target volumes
• OARs: accounted for and contoured accurately
Delegated to others!
Forgot to contour
Isodose lines spill into OAR initially thought not at risk
• Accurate expansion: GTV modified without appropriate re-
expansion
 Contouring: Education & Standardization

Oncologists should receive and maintain adequate training:

Workshops, international courses;
E.g. ESTRO School of Radiotherapy and Oncology E-Learning FALCON

Training should include different imaging modalities:

CT, MRI, PET;
Relative strengths and weaknesses;
Spend time in Nuclear Medicine & Radiology depts

Protocols and atlases should be used to standardize contouring

 Contouring: Delineating Volumes

• Access to appropriate hardware and software is essential for

high
precision contouring:
3D contouring and volume view is essential;
Appropriate quality assurance should be performed on the
hardware and software:
Does the display on the treatment planning system match that on
the diagnostic systems in terms of orientation, distortion, voxel size
etc.
• Standard nomenclature for volumes should be used and standard
color-coding is encouraged.
Contouring: Volume Definitions (ICRU 50/62)

Gross Tumour Volume (GTV) – is the gross demonstrable extent of

the tumour

• Clinical Target Volume (CTV) – is an extension of the GTV and

includes any microscopic malignant disease

The delineation of GTV and CTV are based on purely anatomic topographic
and biological considerations without regard to
technical factors of treatment

• Internal Target Volume (ITV) – an expansion of the CTV to account

for organ motion

• Planning Target Volume (PTV) – is a geometrical concept that is an

expansion of the ITV to account for any uncertainties in patient
positioning, planning systems and treatment delivery
Organ at Risk (OAR) – normal tissue whose radiation sensitivity
may impact planning

Planning OAR Volume (PRV)– is a geometrical expansion of the

OAR to account for uncertainties in patient positioning, planning
systems and treatment delivery

Treated Volume
• It is a volume enclosed by an isodose surface, selected and specified
by the radiation oncologist as being appropriate to achieve the
purpose of treatment (tumor eradication or palliation)
• It may closely match to the PTV or may be larger than the PTV
• If, however, it is smaller than the PTV, or not wholly enclosing the
PTV, then the probability of tumor control is reduced and the
treatment plan has to be reevaluated or the aim of the therapy has to
be reconsidered
Reasons for Identification of Treated
Volume
1. The shape and size of the Treated Volume relative to the
PTV is an
important optimization parameter
2. Also, a recurrence within a Treated Volume but outside the
PTV
may be considered to be a “true”, “in-field” recurrence due
to
inadequate dose and not a “marginal” recurrence due to
inadequate volume
Window Levels
• Tissue contrast is
heavily dependent on
the windowing level
and width
• Presets have been optimized
Multimodality Imaging and Image Registration
• Multimodality imaging should be used where appropriate,
especially
for GTV delineation
• Links with Nuclear Medicine and Radiology departments are
recommended to aid with interpretation of multimodality
images
• Image fusions can be a source of error and so registration
needs to be
checked prior to contouring
• Any deformable registration should also be rigorously
checked prior
and during clinical use
• Flicking between image modalities is an effective way of
Contouring: PTV Margins
• In order to minimize variation between
clinicians:
Published or web-based atlases should be used for CTV
delineation
Defined protocols should be used for deriving the ITV
• Radiation therapists and medical physicists
should be involved in
determining appropriate protocols for PTV
margins
• This should involve measurement & analysis of
local errors
Contouring: OAR Delineation
• Good Planning CT
Good Immobilization setup
Contrast imaging
3mm slice thickness or smaller
• MRI fusion if required
• Optimal CT window settings [Centre (HU) and
width (HU) values] used to delineate the OARs
 Contouring: Reviewing Volumes

The contouring process may involve several clinicians and

so it is
important that all OARs and targets have been accounted
for and are
accurately outlined
• The reviewing process should ideally be performed by a
separate
oncologist
• Small departments are encouraged to form links with
other
departments for the purpose of peer review
• Documents such as the Peer Review Audit Tool (PRAT)1
can be useful
 Contouring: Graphics
These are used to delineate the different volumes and
the other
landmarks.
• These are in different colors for an easy and uniform
interpretation.
GTV - Dark Red
CTV – Light Red
ITV – Dark Blue
PTV – Light Blue
OAR – Dark Green
PRV – Light Green
Landmarks - Black
 Digitally Reconstructed Radiograph- DRR

A synthetic radiograph produced by tracing

ray-lines from a virtual source position
through the CT data to a virtual film plane
• It is analogous to conventional simulation
radiographs.
• DRR is used
For treatment portal design
For verification of treatment portal by comparison with
port films or
electronic portal images
Provides planar reference image for transferring 3D
treatment plan to
clinical setting
 Beam’s Eye View - BEV

Observer’s viewing point is at the source

of radiation looking out along axis of
radiation beam

• Demonstrates geometric coverage of

target
volume by the beam
• Shielding & MLCs are designed on BEV
• Useful in identifying best gantry,
collimator,
and couch angles to irradiate target &
avoid
adjacent normal structures by interactively
moving patient and treatment beam
 Room’s Eye View - REV

The REV display provides a viewing point

simulating any arbitrary
location within the treatment room.

The REV helps

§ To better appreciate overall
treatment technique
§ Geometry and placement of the isocenter
 Beam Arrangements/ Fields

Simple (single or opposed) to complex arc

• Delivery technique specified by physician
• Beam arrangements discretion of dosimetrist
 Beam Arrangements: 3D-CRT

Choice of beam entrance point is important – avoid critical OARs

and excessive normal tissue irradiation
• Beam’s Eye View (BEV) can indicate whether OARs
are appropriately shielded by MLCs and jaws
• Also based on 3D isodose lines overlaid on the CT images
 Coverage: Goals of Treatment Planning

• Prescription dose conforms to target volume

• Normal tissues are not excessively irradiated
• PTV receives uniform dose
• Doses to OARs do not exceed tolerance values
 Plan Evaluation

PTV dose coverage, OARs dose sparing, overall maximum dose

• Number of MUs
• Cumulative DVH for each PTV and OAR are compared
• Conformity of the prescription dose to the PTV
Conformity index (CI, ICRU-62,1999)
Homogeneity index (HI, ICRU-83, 2010)
• Values of CI and HI approaching 1 and 0 are regarded as favorable
indication of plan quality
 Plan Evaluation: 3D Planning

Normalization and normalized prescription dose

• Global dose maxima
• Dose volume parameters of PTV and OARs
• Plan sum of phase wise plan
• Hot/ Cold spots: their location and value
• CI and HI
• DVH shape and distribution
• Beam’s eye view and DRRs
Optimization
• Physical: based on physical dose coverage
• Biological: based on TCP and NTCP calculation
• A total objective function (SCORE) is then derived
from these
• Priorities are defined to tell the algorithm the
relative importance
of the different planning objectives (PENALTIES)
• The algorithm attempts to maximize the score based
on the
criteria and penalties
Plan Normalization
• After the dose calculation is over, the dose at some point has to be
normalized to 100%
• This point can be anywhere in the grid: User’s choice
Check Global Dose Maximum
• Not more than 107% for 3-D CRT, may be up to 115% for IMRT
• Should be within CTV, preferably within GTV
Coverage Evaluation
• Isodose curves
• Orthogonal planes and isodose
surfaces
• Dose distribution statistics
• Differential DVH
• Cumulative DVH
Isodose Curves
• Isodose curves are the lines joining the points of
equal
Percentage Depth Dose (PDD)
• Isodose covering the periphery of the target is
compared with the
isodose at the isocenter
• If the ratio is within a desired range (95-100%), then
the plan may
be acceptable provided that critical organ doses are
not exceeded
• Ideal approach if the number of transverse slices is
small
Orthogonal Planes and Isodose
Surfaces
• Larger number of transverse planes (CT scan): axial
slice isodose
distribution alone is impractical
• Isodose distributions can be generated on orthogonal
CT planes,
reconstructed from the original axial data.
• Sagittal and coronal plane distributions are available
on most TPS
Dose Statistics
• Minimum dose
Strong correlation between target minimum dose
and clinical outcome
High percentage of the dose maximum
• Maximum dose
Useful tool for critical structures
Typically tolerance dose
• Mean dose
Indicator of dose uniformity within the target volume
Should be very close to maximum dose
For Target Volumes
• Target volume maximal dose ideally should not be more than
5-7% of the prescribed dose and minimum dose to the target
volume should not be less than 5% of prescribed dose
• Inhomogeneity within target volume kept to ± 10% of the
prescribed dose. ICRU 83 report is used for describing IMRT has
described D98%, D50%, and D2%. (Dmax, Dmedian and Dmin)
• Dmax are checked in the dose color wash in each slice to note its
location; whether it is within the PTV
For OARs
• In case of serial OARs, Dmax is checked as to whether it is
limited
to within tolerance doses
• In parallel OARs, Dmean is seen for analysis. Dmax is also
noted to
check for any undue hot spots
• Check plan sum of all phases of the treatment plan to
ensure once
more that all dose parameters are within prescribed limits
DVH
• 3D treatment plan consists of dose distribution information over a
3D matrix of point over the patient’s anatomy
• DVH summarizes the information contained in the 3D dose
distribution (in a graphical 2D format)
• Extremely powerful tool for quantitative evaluation of plan
Direct (or differential) DVH
Cumulative (or integral) DVH
 Generating DVH

Each volume is divided into a

number of voxels (volume
elements)
• The dose delivered to each
voxel is determined; and
• The number of voxels
receiving each dose is tallied
Dose (D) /% No. voxels Percentage of
receiving a total no.
dose ≥ D voxels
100 0 0.0
90 2 3.8
80 2 3.8
70 4 7.5
60 7 13.2

50 13 24.5
40 23 43.4
30 31 58.5
20 39 73.6
10 44 83.0
0 53 100.0
Target DVH
OARs DVH
Cumulative DVH
• Illustrates the volume of a structure receiving a
given dose or
greater
• Useful for indicating whether dose-volume
constraints are met
Differential DVH
• Illustrates the volume of the a structure
receiving a given dose
• Useful for indicating maximum and
minimum doses
• Nice tool for assessing PTV dose
uniformity
How to Interpret a DVH?
• Whether PTV coverage is adequate?
• Whether OARs are being adequately
spared?
• Target volume maximal dose?
• Target volume minimal dose?
• Serial OAR: Dnearmax
• Parallel OAR: D50%
Limitations of DVH
• No spatial information
• Location of HOT/ COLD spot
Whether it occurred in one or several disconnected
regions
Cannot be the sole criterion for evaluation/ disclosing
best plan
• Interpretation of the plot can be subjective
 Coverage Factor

Tells you how much you miss on PTV

Volume of PTV covered by TV MISS

BODY

Volume of PTV PTV

PTVPPPTV
Volume of overlapping region

TV
Volume of PTV

Ideal value = 1
 Perfectly Conformal Plan…

Body
PTV

TV

How much of PTV is covered?

• How much is the spill?
• How is the uniformity within PTV?
 Conformity Index (CI)

Tells you how much

you spill outside
PTV

As defined in ICRU 50: CI = TV / PTV

• Here the Treated Volume (TV) is the volume
irradiated by a dose deemed
appropriate for the purpose of treatment (typically
95% isodose) or greater
• Ideally, CI = 1. A value greater than 1 implies the
TV is too large whilst a value
less than 1 implies inadequate coverage
Heterogeneity: Hot & Cold Spots
• Three questions to ask about all hot and cold
spots
Volume?
Magnitude?
Location?
• Is there a consensus to any of these questions
in any tumor site?
Hot Spots
• Volume: In accordance with ICRU 50
There should be no hotspots outside the PTV;
Hotspots within the PTV should be <107% of the Dprescription
• Location: Hotspots should be central within the
PTV, preferably
within the GTV
• Hotspots at the peripheral of the PTV, especially
near OARs, should
be avoided
• However, greater doses may be encouraged for
certain techniques
SABR – up to 140%, RCR (2016);
APBI – up to 120%, RTOG 0413 (2011);
 Cold Spots

Volume: In accordance with ICRU 50, there

should be complete
coverage of the PTV by the 95% isodose;
• However, this is not always achievable:
At the boundary of a lung tumor with air;
Due to a compromise with nearby OARs;
• Location:
§ There should be no cold spots at the center of
the PTV.
 Homogeneity Index (HI)
Measure of uniformity of absorbed dose
distribution within PTV
(ICRU 83)
• Expressed as the ratio (D2% - D98%) / D50%
D2% is the dose received by at least 2% of the
PTV
D98% is the dose received by at least 98% of the
PTV
D50% is the dose received by at least 50% of the
PTV
• An HI of zero indicates that the absorbed-dose
Organ(s) at Risk (OAR)
• These are normal tissues whose radiation
sensitivity may
significantly influence the treatment planning
and/or prescribed
dose
• They may be divided into 3 classes :
Class I : Radiation lesions are fatal or result in
severe morbidity
Class II : Radiation lesions result in mild to
moderate morbidity
Class III : Radiation lesions are mild, transient,
OARs: Biological Classification
• Tissues can be thought of as
containing functional subunits
(FSUs):
E.g. lung alveoli or kidney
nephrons
• The FSUs can be arranged in
serial or parallel architectures
• In practice, organs will display
a mix of serial and parallel
characteristics
• Serial architecture: tissue
function impaired even if a small
volume is irradiated above a
certain threshold:
§ Maximum dose constraints are
important
• Parallel architecture: function is
impaired if a certain proportion
of a tissue receives a dose above
a given threshold:
§ Mean or dose-volume
constraints are important
OARs: Reviewing Constraints
• DVH statistics should be reviewed against recommended
constraints:
DV = the dose received by at least V% of the volume
VD = the volume receiving a dose of at least D Gy/%
• The 3D dose distribution should also be reviewed:
The position of isodose contours relative to OARs should
be
checked, particularly for serial organs
OARs: Choice of Constraints
• The QUANTEC data is a useful resource for appropriate
constraints;
• AAPM TG-101 is also useful for hypofractionated
regimes;
• BED conversions can be used for alternative
fractionations;
• The relative priority of constraints is also relevant:
Critical thresholds for severe toxicities are likely to take
priority
Prescription
• Last step of plan evaluation
• Dosimetrist may have edited the prescription: Recheck
• Treatment details must also be specified
Type of radiation (Photon/ electron)
Energy
Delivery technique (3D-CRT/ IMRT/ VMAT)
Schedule
• Specify Image guidance and setup verification imaging
Prescription: Immobilization
• Patient immobilization is important for reproducible
patient setup
and for preventing patients moving during treatment;
• Appropriate immobilization is both site and technique
dependent:
Highly conformal treatments with nearby critical organs
will require
more precise immobilization;
• Patient immobilization will not prevent
internal
organ motion.
Prescription: Image Verification
• Image verification involves acquiring patient images
immediately
prior to treatment and comparing these to reference
images
(planning CT or DRRs)
• Online verification – the verification and reference
images are
compared immediately prior to treatment and are used to
correct
set-up if required
• Offline verification – the verification and reference
images are
Prescription: Image Verification
• Image verification can be performed with combinations kV or
MV
planar or CBCT images
• Planar imaging provides 2D verification which is quick and
delivers
less dose than CBCT
• CBCT is required for 3D verification
• MV images can be used for portal imaging (imaging with the
treatment beam)
• kV images provide better contrast but are more sensitive to
metal
artifacts
TO Recapitulate:
C
B
C
HO P
Contours: Review target volumes and OARs
Beam Arrangements/ Fields: Appropriate and reasonable
Coverage: Evaluate on graphic plan and DVH
Heterogeneity/Hotspots: value and location
OARs: Review specified constraints, isodose lines, and
DVH
Prescription: Total dose, dose per fraction, and image
guidance
Conclusions
• CB-CHOP: systematic, step-wise approach
• Develop a consistent approach
• Even a trusted and experienced dosimetrist
may commit mistake,
stay thorough and objective
• Plan revisions may be requested
However, remember there is a threshold beyond which
further
improvements in plan is minimal
• May be detrimental as it will delay initiating the
treatment
• Foresee maximum possible requests in the first
review
•FINAL RESPONSIBILITY FOR A
PLAN’S SUITABILITY LIES WITH
THE
RADIATION ONCOLOGIST
Contours: Review target volumes and OARS
• Beam Arrangements/Fields: Appropriate and
reasonable
• Coverage: Evaluate on graphic plan and DVH
• Heterogeneity/Hot Spots: Value and location
• Organs at Risk: Review specified constraints,
corresponding isodose lines on plan, and DVH
• Prescription: Total dose, dose per fraction,
and image guidance
Dose Indices
ICRU #62: Conformity Index (CI)
 Defined as the: Treated Volume
PTV Volume
 Implies the Treated Volume totally encompasses
the
PTV
 CI = 1 Ideal conformation
 CI > 1 Irradiated volume includes healthy tissue
 CI < 1 Target volume is only partially irradiated
ICRU #62: Conformity Index
Prostate Example
 Volume of Prostate PTV: 157 cc
 Volume of 95% Volume: 198 cc
 CI = 198cc/157cc = 1.26
 Treated volume includes healthy
tissue
ICRU #62: Conformity Index
PBI Example
 Volume of PTV_eval: 144 cc
 Volume of 95% Volume: 138
cc
 CI = 138cc/144cc = 0.958
 PTV only partially covered