Principles of 3D- Planning

Raghavendra Hajare
Medical Physicist & Radiation Safety Officer,
Department Of Radiation Oncology and Medical Physics,
HBCH&RC, Visakhapatnam
Contents:
• Aim of Radiotheraphy
• 3DCRT and IMRT definition
• Work flow of 3DCRT and IMRT
• ICRU 50 and 62.
References and Acknowledgement
• The physics of Radiotherapy- F M Khan
• IAEA Tech Doc 1588
• Some Slides from TMH Mumbai.
Aim of radiotherapy:
• Maximum dose to the tumor
• Minimum dose to OARs.
• Goal of radiotherapy is to
increase the distance
NTCP
between the TCP and the
TCP
NTCP, so as to improve the
A
therapeutic index

%age lethal effect

B
• Evolution of Radiotherapy
from the era of 2D planning
to 4D planning → in pursuit
of achieving this goal
What is 2D planning?
• Planning on a single CT slice, (while the
patient is a 3D object)
• Planning on a physical simulator using
Fluro images, based on bony land
marks
• No Irregularity correction
• No in-homogenity correction
• Patients are treated as uniform
structured
What is 2D planning?

The dose in the central plane is assumed

to be the dose throughout the
treatment volume
Limitation of 2D planning
• No information about target and the OARs

• Unable to determine if adequate dose is delivered to the

target volume.

• A large volume of normal tissue is irradiated to high dose.

What is mean by 3DCRT?
• 3D CRT, or three-dimensional conformal radiation therapy, is
an advanced technique that incorporates the use of imaging
technologies to generate three-dimensional images of a
patient's tumor and nearby organs and tissues.

• It requires
• 3-D anatomic information
• Treatment planning system(3D dose calculation and
Optimization)
What is a 3DCRT?

• Multiple conformal beams are used to increase dose conformity to

the target volume MLC

Coplanar
Non-Coplanar

Blocks
IMRT (Intensity Modulated Radiation Therapy)
• Advanced RT technique which utilizes the
superimposition multiple beams of non-uniform
intensities to achieve a superior dose distribution as
compared to 3DCRT or conventional techniques.

• A better target dose conformality resulting in better

sparing of critical structures.
• Desired dose distribution – homogenous or
inhomogenous
IMRT different from 3DCRT?
• IMRT is an extension of 3DCRT that uses non uniform
radiation beam intensities that have been determined by
various computer based optimisation techniques
• The treatment planning steps for IMRT are similar to
3DCRT during the initial & final stages, but diverge in the
middle.
• IMRT performed using Inverse Planning & 3DCRT
performed using Forward Planning.
• Forward Planning : Physicist specify Beams weights, Wedge
angles, beam modifiers. They have direct control over these
parameters at any point in the treatment planning process.

• Inverse planning : Physicist does not specify these

parameters. The numbers, energy & direction of the beams
are still chosen by the physicist. But once beams have been
specified, the computer takes complete control over all
parameters e.g.MUs, weights, beam modifiers etc.
Methods of IMRT Step and
shoot
MLC based
Fixed Gantry Dynamic

I MIMiC
(Serial
M Tomo)
Fan beam
R Helical
Tomo
T Intensitu
Arc based modulated
Cone beam arc therapy
Aperture
modulated
single arc
Advantages
• Conformality
• Concave shaped dose distribution
• OAR sparing with sharp dose fall-off
• Reduced penumbra margins
• Dose escalation
• Lower rates of complications
• Reduced cost of patient care
 Target and
Patient
Simulation OARs
Selection
Segmnetation

Treatment
Quality Planning/Opti
Plan Evaluation
Assurance mization

Treatment
Followup
Delivery
Simulation: Patient positioning & immobilization
• A planning session that takes place before the first radiation
treatment
• Is a process to ensure the patient will be in exactly same
position everyday for treatment.
• Achieved using with help of immobilisation devices.
• A flat couch to simulate the treatment machine couch.
• Radio-opaque fiducial are placed to assist in any coordinate
transformation for TPS.
Patient positioning & immobilization

• reproducible
• Patient comfort
• Accuracy
Various devices of Immobilization

Plaster of Paris cast Thermoplastic shells Body fix

Alpha cradle Vac lock

Imaging Acquisition:
• Every radiotherapy department should develop protocols for image
acquisition for various body sites.

• Modern imaging modalities for treatment planning include

• Computed tomography (CT)-Mandatory for dose calculation
• magnetic resonance imaging (MRI),
• ultrasound (US),
• single photon emission tomography (SPECT), and
• positron emission tomography (PET).
Image acquisition
• Patient in treatment position
• Aligned with respect to lasers/adjust if needed
• Positioning of fiducial markers for coordinate transformation
• CT site protocol (eg, slice thickness- 3mm, IV contrast,
bladder protocol etc)
• Scan area
• Complete body contours( no shoulder cuts) reconstruct if
needed
• Transfer to TPS
Why RT planning is done on CT?
• High spatial integrity
• High spatial resolution
• Excellent bone structure depiction
• Electron density information
• Axial 3D data set used to define reference origin enabling
virtual simulation
Image Registration:
• is the process of transforming different sets of data into one
coordinate system
• Image registration facilitates comparison of images from one
study to another and fuses them into one data set that could
be used for treatment planning
• It automatically corealtes thousands of points from two
image sets,providing true volumetric fusion of anatomical
data sets.
• Eg: mapping of structures seen in MRI onto the CT images
• Registration can be Rigid or Deformable.
• Various registration techniques include:

• Point to point fitting

• Line or curve matching
• Surface or topography matching
• Volume matching
Image segmentation:
• image segmentation in treatment planning refers to slice-by-slice
delineation of anatomic regions of interest such as targets,OARs.
• The radiation oncologist draws the target volumes in each slice with
appropriate margins to visible to tumors as per guidelines
• Image segmentation is one of the most laborious but important processes
in treatment planning.
• Although the process can be aided for automatic delineation based on
image contrast near the boundaries of structures, target delineation
requires clinical judgment, which cannot be automated or completely
image based.
• it should not be delegated to personnel other than the physician in charge
of the case, the radiation oncologist
Volume concepts in EBRT
• ICRU Report No: 29(1978)
• ‘’ Dose Specification For Reporting External Beam Therapy With Photons and
Electrons’’

• ICRU Report No: 50 (1993):

‘’Prescribing, Recording, and Reporting Photon Beam Therapy’’
(Updates and Supercedes on Report no 29)

• ICRU Report 62 (1999):

‘’Prescribing, Recording and Reporting Photon Beam Therapy (Supplement to
ICRU 50)’’
ICRU report no 50 is still valid
Target volume delineation
• Volume definition is a prerequisite for meaningful 3-D
treatment planning and for accurate dose reporting.

• ICRU Reports No. 50 and 62 define and describe several

target and critical structure volumes that aid in the
treatment planning process and provide a basis for
comparison of treatment outcomes.
Gross tumour volume(GTV):
• is the gross palpable or visible/demonstrable extent of
location of malignant growth

• The GTV is usually based on information obtained from

• physical examination by the oncologist and
• the results from imaging modalities (such as CT, MR, PET
etc.) and other
• diagnostic modalities (such as pathologic and
histopathologic reports).
Clinical target volume(CTV):
• is the tissue volume that contains a demonstrable GTV
and/or sub-clinical microscopic malignant disease, which has
to be eliminated
• This volume thus has to be treated adequately in order to
achieve the aim of therapy, cure or palliation.
• In order to define the CTV, a margin has to be created for
sub-clinical microscopic spread and other areas considered
being at risk and requiring treatment (i.e. positive lymph
nodes).
Planning target volume(PTV):
• is a geometrical concept, and it is defined to select appropriate beam
arrangement, taking into consideration the net effect of all possible
geometrical variation
• Defined to ensure r to ensure that the prescribed dose is actually
absorbed in the CTV.
• Encompass daily setup errors (both random and systemic
uncertainties in patient set-up).
• Careful and accurate patient immobilization and verification studies
are needed in each department to quantify these geometric
uncertainties
Courtesy: Slideshare
Treated Volume (TV):
• Ideally, the dose should be delivered only to the PTV.
However, due to limitations in radiation treatment
technique.
• The volume enclosed by an isodose surface, selected and
specified by the radiation oncologist as being appropriate to
achieve the purpose of treatment (e.g., tumor eradication,
palliation).
• Usually taken as the volume enclosed by the 95% of isodose
curve.
Treated Volume (TV):
• There are several reasons for identifying the Treated Volume.
• One reason is that the shape and size of the Treated
Volume relative to the Planning Target Volume is an
important optimization parameter.
• Another reason is that a recurrence within the Treated
Volume but outside the Planning Target Volume may be
considered to be a " true," " in-field" recurrence due to
inadequate dose and not a "marginal" recurrence due to
inadequate volume.
Irradiated Volume(IV):
• tissue volume which receives a dose that is considered
significant in relation to normal tissue tolerance.
• The irradiated Volume depends on the treatment technique
used.
• Usually taken as the volume enclosed by the 50% of isodose
curve.
• The comparison of the Treated Volume and the Irradiated
Volume for different beam arrangements can be used as part
of the optimization procedure.
Organs At Risk(OAR):
• Organs at risk are normal tissues whose radiation sensitivity
may significantly influence treatment planning and/or
prescribed dose.

• As is the case when defining the Planning Target Volume, any

possible movement of the organ at risk during treatment, as
well as uncertainties in the set up during the whole
treatment course, must be considered
Hotspot:
• A Hot Spot represents a volume outside the PTV which
receives a dose larger than 100% of the specified PTV Dose.
• a hot spot is, in general, considered significant only if the
minimum diameter exceeds 15 mm. If it occurs in a small
organ (e.g., the eye, optic nerve, larynx), a dimension smaller
than 15 mm has to be considered.

• ICRU 29:Area outside 100% specified to target-at least 2cc in

a section.
ICRU 62:
Internal Target Volume(ITV):
• It is the internal margin given around the CTV to compensate
for all variations in the size, shape and position of organs and
tissues contained in or adjacent to CTV.
• These variation may be due to respiration, different organ
fillings(bladder & Rectum), swallowing, movement of bowels
etc

• ITV=CTV +IM
• PTV=ITV+ SM(setup margin)
Planning Organ at Risk Volume(PRV)
• PRV to OAR is analogues to the PTV for the CTV.
• Aim is account for all variations in the size, shape ,position
and setup uncertainties.

• PTV and PRV may Overlap-Priority depends case to

case(oncologist to decide).
PTV ITV

CTV

GTV
PRV SC
SC
• ICRU 50(1993) & 62(1999): Prescribing, Recording
and Reporting Photon Beam Therapy:
• GTV, CTV, PTV, ITV, TV, IV and
OAR
• Dmax, Dmin, Hot Spots
• DVH, 3D Dose distribution
• CI, PRV, Serial and Parallel OAR
Dose prescription
• Dose to target
• Dose to OAR
Site specific, department protocol

Tolerance doses of OARs:For eg in H& N

spinal cord = max 48 Gy
Brain stem = max 54 Gy
Parotids = mean 24 Gy
Treatment Planning
• Once Segmentation of Target and OARs and doses have been defined, treatment
plan will produced.
• Aim:
• Achieve dose objective to Targets and OARs
• Produce a optimal dose distribution.

Beam Arrangement:
coplanar static beams in a standard geometric configuration with MLCs or conformal blocks
Non Coplanar can be used---→Complexity, entry and exit doses through OARs (Useful in
Brain)

• Beam Angle:
• 1.Standard template like six field in prostate,4 field in Cx etc.
• 2.. Using Beams Eye view-Maximize PTV and minimize Critical structure irradiation.
• Margin:
• 7 to 8 mm additional
margin (All directions)-
• Superior inferior direction-
12-15mm –Beam
divergence effects

• Dose Calculation
Algorithm: latest available
Treatment planning – selection of isocenter
• at the center of PTV
• easily reproducible
• Preferably ODI should be readable
• Should not be blocked
Beam orientation

G=100, C=90 G=100, C=350

G=260 C=10 G=10, C=90

Normalization
• Very crucial for 3DCRT
• Various normalization options are available
• Target max,
• Target min
• Target mean
• Reference point
• isocenter
Beam Eye View (BEV):

• In BEV viewing point is at the source

of photons.
• Target and OARs can be viewed from
different directions in planes
perpendicular to the beams central
axis.
• . BEV allows the planner to easily view
the target with respect to OARs
Digitally Reconstructed Radiograph (DRR):

• is a simulation of a conventional 2D x-ray image, created from

computed tomography (CT) 3D data
• In other words synthetic radiograph produced by tracing ray lines
from a virtual source position through the CT data to a virtual film
plane.
• DRR used in
• selecting beam directions and shaping fields around the target.
• Image registration
• As reference image for treatment setup verification
Field Multiplicity and Collimation:

• Multiplicity of fields also removes the need for using ultrahigh-energy

beams (>10 MV), which are required when treating thoracic or pelvic
tumors with only two parallel opposed fields.

• In general, the greater the number of fields, the less stringent is the
requirement on beam energy because the dose outside the PTV is
distributed over a larger volume.
Plan evaluation
• Qualitative methods
• Quantitative methods
Isodose Curves and Surfaces
• Dose distributions of competing plans are evaluated by viewing
isodose curves in individual slices, orthogonal planes (e.g., transverse,
sagittal, and coronal), or 3-D isodose surfaces.

• surfaces of a designated dose value covering a volume. An isodose

surface can be rotated to assess volumetric dose coverage from
different angles.
Dose Color Wash:
Graphical displays are most practical effective way of plan
evaluation and comparison
Dose Volume Histograms:
• provides quantitative information with regard to how much
dose is absorbed in how much volume,
• summarizes the entire dose distribution into a single curve
for each anatomic structure of interest.
• It is a great tool for evaluating a given plan or comparing
competing plans.

• The DVH may be represented in two forms:

1. The cumulative integral DVH
2. The differential DVH
Cumulative DVH:
• The cumulative DVH is a plot of the volume of a given
structure receiving a certain dose or higher as a function of
dose.

• Any point on the cumulative DVH curve shows the volume

that receives the Indicated dose or higher
Differential DVH:
• is a plot of volume receiving a dose within a specified dose
interval (or dose bin) as a function of dose.
• the differential form of DVH shows the extent of dose
variation within a given structure.

• It is important to note that DVHs contain no geometric

information, i.e. they do not indicate which part of the organ
is receiving a high or low dose.
• Clinical plan comparison should therefore involve inspecting
DVHs and physical dose distributions.
Dose Statistics:
It give quantitative information on the dose received by the volume such as
Max, Min, Mean etc. for Target and OARs)
Data transfer for treatment delivery
• Once the treatment plan has been designed and approved
by the radiation oncologist the details need to be transferred
to the treatment unit.

• If possible, a R&V system should be used to control the

treatment unit and with data transfer carried out
electronically, preferably over a radiotherapy network
Plan implementation:
• Couch shifts between reference fiducial markers place during CT simulation
and treatment isocenter should be calculated.

• During first fraction, patient is positioned using the reference marking from
simulation and then shifted to treatment isocenter using calculated shifts.

• The treatment isocenter is the marked on the patient.

Position verification and treatment delivery:
• Patient position can be verified using EPID or CBCT.

• Bony or volume based matching can be done to get set

errors.

• Corrections can be either Offline or Online.

 [email protected]

Thank You!