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1 s2.0 S0167814002000154 Main PDF
1 s2.0 S0167814002000154 Main PDF
www.elsevier.com/locate/radonline
Medical Physics Department, Bristol Oncology Centre, Horfield Road, Bristol BS2 8ED, UK
Radiotherapy Department, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
Received 5 September 2001; received in revised form 24 December 2001; accepted 5 February 2002
Abstract
Background and purpose: ICRU Report 62 suggests drawing margins around organs at risk (ORs) to produce planning organ at risk
volumes (PRVs) to account for geometric uncertainty in the radiotherapy treatment process. This paper proposes an algorithm for drawing
such margins, and compares the recommended margin widths with examples from clinical practice and discusses the limitations of the
approach.
Method: The use of the PRV defined in this way is that, despite the geometric uncertainties, the dose calculated within the PRV by the
treatment planning system can be used to represent the dose in the OR with a certain confidence level. A suitable level is where, in the
majority of cases (90%), the dose-volume histogram of the PRV will not under-represent the high-dose components in the OR. In order to
provide guidelines on how to do this in clinical practice, this paper distinguishes types of OR in terms of the tolerance doses relative to the
prescription dose and suggests appropriate margins for serial-structure and parallel-structure ORs.
Results: In some instances of large and parallel ORs, the clinician may judge that the complication risk in omitting a margin is acceptable.
Otherwise, for all types of OR, systematic, treatment preparation uncertainties may be accommodated by an OR ! PRV margin width of
1.3S. Here, S is the standard deviation of the combined systematic (treatment preparation) uncertainties. In the case of serial ORs or small,
parallel ORs, the effects of blurring caused by daily treatment execution errors (set-up and organ motion) should be taken into account. Near a
region of high dose, blurring tends to shift the isodoses away from the unblurred edge as shown on the treatment planning system by an
amount that may be represented by 0.5s. This margin may be used either to increase or to decrease the margin already calculated for
systematic uncertainties, depending upon the size of the tolerance dose relative to the detailed planned dose distribution. Where the detailed
distribution is unknown before the OR is delineated, then the overall margin for serial or small parallel ORs should be 1.3S 1 0.5s.
Examples are given where the application of this algorithm leads to margin widths around ORs similar to those in use clinically.
Conclusions: Using PRVs is appropriate both for forward and inverse planning. Dose-volume histograms of PRVs for serial- and parallelstructure ORs require careful interpretation. Nevertheless, use of the proposed algorithms for drawing margins around both serial and parallel
ORs can alert the dosimetrist/radiation oncologist to the possibility of high-dose complications in individual treatment plans, which might be
missed if no such margins were drawn. q 2002 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Radiotherapy; Organs at risk; Geometric uncertainty; Margins; Treatment planning
1. Introduction
Many workers have addressed the problem of geometric
uncertainty in radiotherapy by determining the widths of
margins to draw around clinical target volumes (CTVs)
[13,6,7,9,11,1315]. The converse problem is how to
deal with organs at risk (ORs). ICRU Report 62 [5] suggests
drawing margins around organs at risk (ORs) to produce
planning organ at risk volumes (PRVs) to account for
geometric uncertainty in the radiotherapy treatment process.
In that report it is recommended that an integrated margin be
added to the OR to compensate for any movements of the
OR during the treatment, as well as uncertainties in the set-
up during the whole treatment course. Some clinical examples (treatment of breast cancer, cancer of the prostate and
lung cancer) are given in which PRVs of various organs are
shown.
While a few workers have considered the effect of
geometric uncertainty on the dose to ORs (for example,
refs [4,14]), there is still a scarcity of advice in the literature
dealing with the question of how to draw the margins
recommended by the ICRU. Even in the clinical examples
given in ICRU Report 62, no details are given about the
origin of the margins drawn around the ORs. This paper
suggests an approach to that problem which effectively
mirrors that used in constructing margins around the CTV.
The need to draw margins around a CTV arises because
* Corresponding author.
0167-8140/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 0167-814 0(02)00015-4
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margins around the OR. The need for a margin around the
OR depends on the types of uncertainties and the dose
constraints for the OR. One should differentiate between
random and systematic geometric errors. Random errors
blur the dose distribution: high isodose lines move towards
the target, whilst low isodose lines move away from the
target. Systematic errors (i.e. errors that are fixed for a single
patient over all fractions but that are stochastic over a group
of patients) shift the dose distribution either closer to or
further away from an OR.
If the organ is parallel and large and if the risk is acceptable, the clinician may decide that the effect of geometric
errors can be ignored. The organ can be considered large
for these purposes if its dimensions considerably exceed the
scale of the geometric uncertainties. For dose levels that
cause unacceptable complications, in particular for serial
organs, the situation is different and geometric errors must
be taken into account. In these patients unacceptable
complications will occur if the tolerance isodose is close
to the OR. We suggest using a margin for the OR in the
latter situation, i.e. when dose levels are used close to an OR
that would cause unacceptable complications. This margin
is then used to draw the PRV. We suggest a definition of the
PRV such that, in 90% of cases, the DVH of the PRV will
not underestimate the contribution of the high-dose components to the OR.
The approach we shall take is.
1. Establish a margin which extends the OR (as defined at
the time of localisation) to encompass completely (at
least, in 90% of cases) the mean position of the OR.
This accounts for the systematic, treatment preparation
uncertainties introduced at localisation.
2. Examine the effect of random, treatment execution
uncertainties on the DVH of the OR.
3. Decide whether, in order to account for random uncertainties, a further margin in addition to the systematic
margin is necessary, or whether the systematic margin
itself can define the PRV, or even whether a margin
reduction may be applied.
4. Highlight the case of critical, serial ORs such as spinal
cord, optic nerve and brain stem, and calculate an appropriate margin to draw around the systematic margin in
order to produce the PRV.
2. Purpose
The aim of this paper is to propose an expression for
drawing an OR ! PRV margin, to compare the proposed
margin widths with examples from clinical practice and to
discuss the limitations of such an approach.
3. Theory
As in the case of the CTV, geometric uncertainties in the
position of the OR may be accommodated by drawing
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distribution represented by the blurred DVH than one represented by the unblurred DVH. In other words, where the OR
penetrates the high-dose region, the TPS slightly exaggerates the hazard to the OR because it uses the unblurred dose
distribution to calculate the DVH. Hence, in this circumstance, there is no need to add a further margin to the 1.3S
systematic margin. On the other hand, diminishing the
margin around the OR would also be wrong, because blurring will not reduce the maximum dose in the OR if it has
penetrated sufficiently into the high-dose region.
Fig. 2(a) shows an OR which does not quite extend to the
edge of the high dose region and Fig. 2(b) shows the corresponding DVH. In this case, blurring (dotted line) adds a
small high-dose component to the DVH. However, in the
case of large, parallel ORs, the comparatively small extra
high-dose component will be clinically acceptable, and so,
again, the 1.3S systematic margin is sufficient.
On the other hand, in the case of serial ORs, or where the
broadening of the penumbra due to blurring is a significant
fraction of the size of small, parallel ORs, the effect of the
blurring may be clinically significant (see Fig. 3). An
Fig. 3. (a) As in Fig. 2(a) but with a small OR. (b) Dose profile and DVH of
3(a). The dose profile is shown extended beyond the boundary of the OR
into the high-dose region. The effect of blurring caused by random, treatment execution errors is illustrated by the dotted line. Note that the blurred
high-dose component within the DVH contributes significantly to the DVH
because the extent of the OR is comparable with that of the blurring.
Fig. 2. (a) OR does not quite penetrate the high-dose region. (b) Dose profile
and DVH corresponding to 2(a). Again, the DVH may be understood in
terms of the dose profile along the OR. The dose profile is shown extended
beyond the boundary of the OR into the high-dose region. The effect of
blurring caused by random, treatment execution errors is illustrated by the
dotted line.
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tice to base clinical decisions on analysis of DVHs for delineated ORs, any such differences should be kept in mind.
This was discussed in detail in Section 3.4 in the context of
parallel-structure organs.
4.1. Spinal cord
Fig. 4. The effect of random, treatment execution errors is to blur the total
dose distribution, which is equivalent to blurring the dose of each beam. In
this figure, the edge of a single beam is considered. Due to beams from
other directions there will in general be a plateau dose, which is 50% in this
example. The 50% intensity of each particular beam will remain in its place
(at X 0), even when the dose is blurred. In the left of this figure (X , 0)
the dose increases with increased blurring, while in the right (X . 0) it
decreases. The shift of the isodose lines depends both on the location in
the dose profile and on the magnitude of the random errors. Typically, the
shift is zero at the block edge of the beam (75% of the total dose in this
example). The shift is around 0.5s with an increase in dose in the left hand
of the figure. The shift is around 0.5s with a decrease in dose at the right
hand of the figure. The arrows showing the extent of blurring are drawn
0.5s long, illustrating that the practical approximation of using a single
value, 0.5s, is a reasonable representation of the blurring over a useful
proportion of the profile.
4. Clinical examples
Before applying the proposed algorithm in the clinic, it is
necessary to have knowledge about the current practice. The
delineation of the OR should be done in a uniform way for
example, is the spinal canal drawn or is the spinal cord
considered to be the dose limiting organ? One has to be
sure that the clinician or dosimetrist has not already
included organ motion or set-up error in the delineation of
the OR. Quantitative information on the various factors
influencing the systematic and random uncertainties may
be derived locally and from the literature. In this section
we will compare margins for some ORs predicted by the
algorithm outlined in this paper with margin widths used in
clinical practice.
It should be recognised that, despite the efforts to allow
for geometric uncertainty by using the algorithm in the
previous section, the DVH for the PRV will, in general,
differ from that of the OR due to the blurring and shifting
effect of geometric errors. Therefore, if it is common prac-
For the spinal cord, systematic uncertainties in delineation, organ motion and change of organ size and shape are
negligible. The standard deviations of the set-up uncertainty
and that in transferring the image from the CT scanner to the
TPS (systematic errors) are each typically in the order of 2
mm so that S 2.8 mm, and so the margin for systematic
error is 1.3 2.8 3.6 mm. Only set-up error will contribute to the random, treatment execution uncertainty, and so
the corresponding margin for blurring is 0.5 2.0 1.0 mm
(where a value similar to that for the systematic set-up
uncertainty has been used for the treatment execution standard deviation).
Let us consider in more detail the effect of the blurring
(Fig. 4). Suppose that a centre considers the tolerance dose
of the spinal cord to be 45 Gy. Assume also that the
prescribed dose is 80 Gy, and that the cord receives a
plateau dose of 50% of this dose, i.e. 40 Gy. The bending
point of the edge of the high-dose region lies at 60 Gy.
The dose indicated by the TPS is the unblurred dose. If
the dose at the edge of the cord indicated by the TPS is less
than 45 Gy, this would mean that the cord is on the low-dose
side of the bending point, so that blurring will increase the
dose to the cord. Hence, a margin of 0.5s has to be added in
order for the TPS to indicate the increased dose due to
blurring. This may be seen by inspection of Fig. 4 where
the difference between the unblurred penumbra of the highdose region (i.e. as indicated by the TPS) and the blurred
dose may be represented by 0.5s approximately.
If, on the other hand, the prescribed dose is 50 Gy, the
bending point will be at 37.5 Gy. In that case, if the edge of
the cord moves past the bending point, close enough to the
high-dose region to receive the tolerance dose of 45 Gy
according to the TPS, then blurring will decrease the dose
to below 45 Gy. In that case, the margin may be reduced by
0.5s in order for the TPS to indicate the reduction in dose
due to blurring.
More generally, if the plateau dose and the prescribed
dose are known at the time of planning, and if the tolerance
dose for a serial OR is about halfway between the plateau
dose and prescribed dose, then no margin for random errors
is required. If the tolerance dose is lower, the overall margin
should be 1.3S 1 0.5s, while it may be 1.3S 2 0.5s if the
tolerance dose is higher. This margin defines the PRV.
If it is inconvenient to estimate the plateau dose before
delineating the PRV, or if the final prescribed dose is not
known at the time of planning, then it is prudent to assume
the worst case, and to add the margin for blurring. In this
example, the overall margin for systematic and blurring
uncertainties would be 3.6 1 1.0 4.6 mm. This is of the
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Table 1
Summary of suggested OR margins a
Situation
Dose constraint
Suggested OR margin
Any
When a simple margin that accounts for the bulk of the uncertainties is required
(as in the case of some large, parallel structures)
Any
1.3S
When the benefit of a simple margin is outweighed by the need for greater accuracy
(as, for example, in the case of serial ORs or small, parallel ORs)
1.3S 1 0.5s
1.3S
1.3S0.5s
1.3S
Any
1.3S 1 0.5s
For serial ORs or small, parallel ORs, when the value of the plateau dose or the final
prescription dose is unknown at the time of delineation of the OR
a
b
Note that when multiple dose constraints are set on an OR it may be necessary to define multiple PRVs, one for each dose constraint.
When one cannot count on the dose blurring effect, one should not reduce the margin for it.
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ment planning system will not under-represent the highdose components. The choice of 90% is pragmatic. To
achieve 100% certainty that the margin would encompass
the mean position of the edge of the OR, the margin width
would need to be indefinitely wide. Settling on the figure of
90% does not automatically condemn the remaining 10% of
ORs to radiation morbidity. The fraction of the volume of
the OR which breaches the margin limit will be relatively
small in most cases. An alternative to the 90% level may be
suggested for particular organs, but, as we have seen in the
case of the spinal cord, choosing the 90% level leads to
margins similar to those currently in clinical use.
The above derivation of an OR ! PRV margin is one
dimensional because, generally, positional uncertainty of
an OR is unimportant in all directions except for one, in
the direction of the nearest high-dose region. Rarely,
where a high-dose region bends around an OR to a significant extent, the problem can, in theory, become two-, or
even three-dimensional. We noted in Section 3.2 that the
systematic margin would change from 1.3 S in the onedimensional case to 2.2 S and 2.5 S in the two- and threedimensional cases respectively.
It is appropriate to emphasise that the margins suggested
by the model in this paper are of the same order as those
already used in clinical practice. The model, then, may be
viewed as a tool for achieving consistency in defining
margins, which is necessary for the widespread adoption
of the principles of ICRU Report 62 [5].
6. Conclusion
As conformal therapy and IMRT become standard techniques in radiotherapy centres, it is increasingly urgent to
consider an issue highlighted by ICRU Report 62 that of
drawing margins around Organs at Risk. The uncertainty in
the position of the OR at the time of localisation can be
accounted for by drawing a margin 1.3S wide to account
for systematic uncertainties. The daily treatment execution
uncertainties of set-up and organ motion are best visualised
by considering the penumbras of adjacent high-dose regions
to be blurred by the uncertainties. For large, parallel ORs
this blurring is either of no significance (if the OR already
penetrates the high-dose region) or it may be ignored
because the blurring adds a relatively small high-dose
component to the DVH. Hence, for large, parallel ORs,
the PRV is produced by drawing a margin of 1.3S around
the OR. In some instances, the clinician may decide that the
risk of complications in omitting margins for uncertainties is
acceptable.
However, in the case of serial or small, parallel ORs the
blurring may contribute a relatively large component to the
DVH and cannot be ignored. This is particularly important
with ORs such as spinal cord, optic nerve and brain stem,
where overdosing may have a critical effect. The margin for
blurring is 0.5s where s is the standard deviation of the
Acknowledgements
The authors would like to express their gratitude to Drs
Harry Bartelink and Peter Remeijer for having useful
discussions about this topic.
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