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ICRU REPORT 29

ON RADIATION UNITS
INTERNATIONAL COMMISSION

AND MEASUREMENTS
 ICRU REPORT 29

Dose Specification for

Reporting External Beam
Therapy with Photons

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and Electrons

Issued April 1 , 1978

INTERNATIONAL COMMISSION ON RADIATION

UNITS AND MEASUREMENTS
7910 WOODMONT AVENUE
WASHINGTON, D.C. 20014
U.S.A.
 THE INTERNATIONAL COMMISSION
ON RADIATION UNITS AND MEASUREMENTS
INDIVIDUALS PARTICIPATING IN THE PREPARATION OF THIS REPORT
Commission Membership During Preparation of Commission Sponsor
This Report A. W AMBERSIE
H. 0. WYCKOFF, Chairman UCL, Cliniques Universitaires St. Luc
A. ALLISY, Vice Chairman Brussels, Belgium
K. LIDEN, Secretary
R. S. CASWELL
H. J. DUNSTER Report Committee
P. EDHOLM
T. LANDBERG, Chairman
J. R. GREENING University Hospital
D.HARDER Lund, Sweden
P. HARPER P.ALMOND

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A. KELLERER M. D. Anderson Hospital
H. H. Rossi Houston, U.S.A.
J.M. V. BURGERS
W. K. SINCLAIR
Antoni van Leeuwenhoek Ziekenhuis
A. TSUYA Amsterdam, Netherlands
A. W AMBERSIE M. BUSCH
L. S. TAYLOR, Honorary Chairman and Member Strahlenklinik der Gesamthochschule
Emeritus Essen, Germany
C. A. JOSLIN
Current Commission Membership Cookridge Hospital
H. 0. WYCKOFF, Chairman Leeds, United Kingdom
.; A. ALLISY, Vice Chairman J.P. PAUNIER
,; G. E. D. ADAMS Hopital Cantonal
-,, R. CASWELL Geneva, Switzerland
.I G. COWPER

./ P. EDHOLM
.I J. R. GREENING
D.HARDER
Consultants Report Committee
/ A. KELLERER
1 H. H. Rossi M. COHEN
J W. K. SINCLAIR McGill University
J. VAN DER SCHOOT Montreal, Canada
A. W AMBERSIE A. DUTREIX
L. S. TAYLOR, Honorary Chairman and Member Institut Gustave-Roussy
Emeritus Villejuif, France
T. R. MOLLER
Technical Secretary University Hospital
W.ROGERNEY Lund, Sweden
The Commission wishes to express its appreciation to the individuals, and their organizations, involved in the
preparation of this report for the time and effort they devoted to this task and to the organizations with which
they are affiliated.

Copyright © International Commission on

Radiation Units and Measurements 1978

Library of Congress Catalog Card Number 78-59476

International Standard Book Number 0-913394-23-8

(For detailed information on the availability of this and other ICRU Reports see page 19
 Preface
Scope oflCRU Activities
The International Commission on Radiation Units
and Measurements (ICRU), since its inception in 1925,
has had as its principal objective the development of
internationally acceptable recommendations regard-
ing:
(1) Quantities and units ofradiation and radioactiv-
ity,
(2) Procedures suitable for the measurement and
application of these quantities in clinical radiology and
radio biology,
(3) Physical data needed in the application of these
procedures, the use of which tends to assure uniform-
ity in reporting.
The Commission also considers and makes similar
types of recommendations for the radiation protection
field. In this connection, its work is carried out in close
cooperation with the International Commission on
Radiological Protection (ICRP).
Policy
The ICRU endeavors to collect and evaluate the
latest data and information pertine.nt to the problems
of radiation measurement and dosimetry and to rec-
ommend the most acceptable values and techniques
for current use. · Radiation Physics-X Rays, Gamma Rays and Electrons
The Commission's recommendations are kept under
continual review in order to keep abreast of the rapidly
expanding uses of radiation.
The ICRU feels it is the responsibility of national
organizations to introduce their own detailed technical
procedures for the development and maintenance of
standards. However, it urges that all countries adhere
as closely as possible to the internationally recom-
mended basic concepts of radiation quantities and
units.
The Commission feels that its responsibility lies in
developing a system of quantities and units having the
widest possible range of applicability. Situations may
arise from time to time when an expedient solution of
a current problem may seem advisable. Generally
speaking, however, the Commission feels that action
based on expediency is inadvisable from a long-term
viewpoint; it endeavors to base its decisions on the
long-range advantages to be expected.
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The ICRU invites and welcomes constructive com-
ments and suggestions regarding its recommendations
and reports. These may be transmitted to the Chair-
man.
Current Program
The Commission has divided its field of interest into
twelve technical areas and has assigned one or more
members of the Commission the responsibility for
identification of potential topics for new ICRU activ-
ities in each area. A body of consultants has been
constituted for each technical area to advise the Com-
mission on the need for ICRU recommendations re-
lating to the technical area and on the means for
meeting an identified need. Each area is reviewed
periodically by its sponsors and consultants. Recom-
mendations of such groups for new reports are then
reviewed by the Commission and a priority assijroed.
The Technical areas are:
Radiation Therapy
Radiation Diagnosis
Nuclear Medicine
Radiobiology
Radioactivity
Radiation Physics-Neutrons and Heavy Particles
Radiation Protection·
Radiation Chemistry
Values of Factors- W, S, etc.
Theoretical Aspects
Quantities and Units
The actual preparation of ICRU reports is carried
out by ICRU report committees. One or more Com-
mission members serve as sponsors to each committee
and provide close liaison with the Commission. The
currently active report committees are:
Average Energy Reqmred to Produce an Ion Pair
C;.. and CE
Computer Uses in Radiotherapy
iv Preface
Definitions and Terminology for Computed Tomography
Dose Specification for Reporting Intracavitary and Inter-
stitial Tht:rapy
Dosimetry of Pulsed Radiation
Fundamental Quantities and Units
High-Energy Electron Beam Dosimetry
Measurement of Low-Level Radioactivity in Humans
Methods of Assessment of Dose in Tracer Investigations
Microdosimetry
Photographic Dosimetry in External Beam Therapy
Radiobiological Dosimetry
Scanning
Stopping Power
ICRU Reports
In 1962 the ICRU, in recognition of the fact that its
triennial reports were becoming too extensive and in
some cases too specialized to justify single-volume
publication, initiated the publication of a series of
reports, each dealing with a limited range of topics.
This series was initiated with the publication of six
reports:
ICRU Report lOa, Radiation Quantities anrl. Units
ICRU Report lOb, Physical Aspects of Irradiation
ICRU Report lOc, Radioactivity
ICRU Report lOd, Clinical Dosimetry
ICRU Report lOe, Radiobiological Dosimetry
ICRU Report !Of, Methods of Evaluating Radiological
Equipment and Materials
These reports were published, as had been many of
the previous reports of the Commission, by the United
States Government Printing Office as Handbooks of
th.e _National Bureau of Standards.
In 1967 the Commission determined that in the
future the recommendations formulated by the ICRU
would be published by the Commission itself. This
report is published by the ICRU pursuant to this
policy. With the exception of ICRU Report lOa, the
other reports of the "10" series have continuing valid-
ity and, since, except in the case of ICRU Report lOe,
none of the reports now in preparation is designed
specifically to supersede them, they will remain avail-
able until the material is essentially obsolete. All fu-
ture reports of the Commission, however, will be pub-
lished under the ICRU's own auspices. Information
about the availability of ICRU Reports is given on
page 18.
ICRU's Relationships With Other Organizations
In addition to its close relationship with the Inter-
national Commission on Radiological Protection, the
ICRU has developed relationships with other organi-
zations interested in the problems of radiation quan-
tities, units and measurements. Since 1955, the ICRU
has had an official relationship with the World Health
Organization (WHO) whereby the ICRU is looked to
for primary guidance in matters of radiation units and
measurements and, in turn, the WHO assists in the
world-wide dissemination of the Commission's rec-
ommendations. In 1960 the ICRU entered into con-
sultative status with the International Atomic Energy
Agency. The Commission has a formal relationship
with the United Nations Scientific Committee on the
Effects of Atomic Radiation (UNSCEAR), whereby
ICRU observers are invited to attend UNSCEAR
meetings. The Commission and the International Or-
ganization for Standardization (ISO) informally ex-
change notifications of meetings and the ICRU is
formally designated for liaison with two of the ISO
Technical Committees. The ICRU also corresponds
and exchanges final reports with the following orga-
nizations:
Bureau International des Poids et Mesures
Commission of the European Communities
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Council for International Organizations of Medical Sci-
ences
Food and Agriculture Organization
International Council of Scientific Unions
International Electrotechnical Commission
International Labor Office
International Radiation Protection Association
International Union of Pure and Applied Physics
United Nations Educational, Scientific and Cultural Or-
ganization
The Commission has found its relationship with all
of these organizations fruitful and of substantial bene-
fit to the ICRU program. Relations with these other
international bodies do not affect the basic affiliation
qf the ICRU with the International Society of Radiol-
ogy.
Operating Funds
In the early days of its existence, the ICRU operated
essentially on a voluntary basis, with the travel and
o!)erating costs being borne by the parent organiza-
tions of the participants. (Only token assistance was
originally available from the International Society of
Radiology.) Recogruzing the impracticability of con-
tinuing this mode of operation on an indefinite basis,
operating funds were sought from various sources.
Financial support has been received from the follow-
ing organizations:
B.A.T. Cigaretten-Fabriken GMBH
Commission of the European Communities
Council for International Organizations of Medical
Sciences
Eastman Kodak Company
E. I. duPont de Nemours and Company
Ford Foundation
General Electric Company
International Atomic Energy Agency
International Radiation Protection Association
 Preface • v

International Society of Radiology In recognition of the fact that its work is made
Japan Industries Association of Radiation Apparatus possible by the generous support provided by these
John och Augusta Perssons stiftelse organizations, the Commission expresses its deep ap-
National Cancer Institute of the U.S. Department of
Health, Education and Welfare preciation.
N.V. Philips Gloeilampenfabrieken HAROLD 0. WYCKOFF,
Picker Corporation Chairman, ICRU
Radiological Society of North America Washington, D.C.
Rockefeller Foundation 1March1978
Siemens Corporation
Society of Nuclear Medicine
Statens laegevidenskabelige Forskningsrad
U.S. Bureau of Radiological Health of the Food and
Drug Administration

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 Contents
Preface ................................................... . iii
1. Introduction ........ . 1
2. Definitions of Terms and Concepts Currently Used in Ra-
diotherapy . . . . . . ....... . 3
2.1 Volumes . 3

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2.1.1 Aim of Therapy .. 3
2.1.2 Target Volume .. 3
2.1.3 Treatment Volume .. . 4
2.1.4 Irradiated Volume ............ . 4
2.1.5 Organs at Risk . 4
2.2 Absorbed Dose Pattern ................ . 4
2.2.1 Representation of a Spatial Dose Distribution by a Set
of Planar Dose Distributions ................... . 4
2.2.2 Maximum Target Absorbed Dose .. . 5
2.2.3 Minimum Target Absorbed Dose . . ........... . 5
2.2.4 Mean Target Absorbed Dose ...... . 5
2.2.5 Median Target Absorbed Dose . . . ...... . 5
2.2.6 Modal Target Absorbed Dose . . . ....... . 5
2.2. 7 Hot Spots . . . . . . . . . . . . . . . . . ...... . 5
3. Recommendations for Reporting Absorbed Dose in Exter-
nal Beam Therapy 10
3.1 Introduction ........... . 10
3.2 Description of Technique .. 10
3.3 Specification of Target Absorbed Dose ................. . 11
3.3.1 Stationary Beams of Photons . . . . . . ........ . 11
3.3.2 Moving Beam Therapy . . . ...... . 13
3.3.3 Electron Therapy . . . . . . . . . . . . . . . . ..... . 14
3.3.4 Complex Treatments: General Recommendations 14
3.3.5 Additional Recommendations ....... . 14
4. Factors Influencing the Biological Effect ....... . 17
4.1 Radiation Quality . . . . . . . . ........ . 17
4.2 Time-Dose Pattern . . . . . . . . . . ....... . 17
References. . . . . ........ . 18
ICRU Reports . . ........ . ................ . 19
Index ............ . 21

vi
Dose Specification for Reporting External
Beam Therapy with Photons and Electrons
1. Introduction
When a patient undergoes a course of radiotherapy,
the radiotherapist normally records the radiation
doses delivered at various points in the irradiated
tissues, including both diseased and healthy tissues.
This record serves a number of purposes:
a. to enable the radiotherapist to maintain his treat-
ment policy and improve it in the light of experi-
ence;
b. to enable the radiotherapist to combine the results
of his treatments with those of his departmental
colleagues;
c. to enable other radiotherapists to benefit from the
department's experience;
d. to enable the results of the department's treatments
to be meaningfully compared with those of other
centers.
It will be noted that all of these functions, except
the first, are intended to facilitate communication with
others. In fact, there is little purpose in recording
absorbed doses if the data cannot be interpreted by
other workers in the field. However, this obvious state-
ment is far from being realized in practice. Most ra-
diotherapists and physicists are so used to the style
and conventions used in their own departments that
they would be shocked to learn that their treatment
reports were ambiguous, or even incomprehensible, to
other people. Unfortunately, there is substantial evi-
dence that more often than not this is, indeed, the
case. It is rare for a description of a treatment to be
sufficiently explicit and detailed to enable the treat-
ment to be repeated elsewhere without having re-
course to the center of origin for further information.
An earlier ICRU report (ICRU, 1973) described the
measurement of absorbed dose in a phantom irradi-
ated by a single beam of X or gamma rays. A second
ICRU report (ICRU, 1976) described the determina-
tion of absorbed dose in a patient irradiated by beams
of X or gamma rays in radiotherapy procedures, and
defined a number of terms of importance in these
procedures. The present report is the third in a series
dealing with dosimetric problems in radiotherapy. Its
1
purpose is to define important volumes, areas and
absorbed dose patterns and to recommend methods
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for specifying the absorbed dose in reports of treat-
ments with external radiation beams. It is hoped,
therefore, that this report will be regarded as a
step-albeit a very important step-towards the
achievement of adequate reports of radiation treat-
ment.
In principle, reports of radiotherapeutic procedures
should be as complete as possible and should contain
adequate and explicit information on the patient and
his disease, the physical parameters and irradiation
technique, the overall treatment time and the frac-
tionation scheme. The results of treatment can be
meaningfully interpreted only if all these factors can
be correlated; in particular only if the parameters of
the irradiation, including the distribution of absorbed
dose in space and time, can be significantly correlated
with the clinical and pathological extent of the disease.
Up to now such correlation has been very difficult to
establish, because data relating to both the extent of
the disease and to the absorbed dose distribution
(corrected for the individual patient anatomy) have
been inadequate. It is expected that the rapid devel-
opment of new techniques for the acquisition of pa-
tient data, such as computed tomography and ultra-
sonography, will greatly improve this situation.
While a complete description of the data relating to
each patient, as just indicated, is clearly desirable, in
practice the amount of information that can be re-
ported in many situations, e.g. in a published paper, is
limited. Furthermore, complete information for each
patient, including evaluation of the extent of the dis-
ease and a full individual dose distribution, is not
always available. One is therefore faced with the prob-
lem of selecting a minimum of information for report-
ing; such information will be the most relevant for
assessing the results of treatment.
The need for selecting is highlighted by the growing
use of computers for recording patient data and treat-
ment procedures. The information recorded in these
2 1. Introduction
systems is usually restricted, but the data should be
valid and unequivocal. A subsidiary purpose of the
present report, in addition to the specification of treat-
ment volumes and absorbed doses, is therefore to
make recommendations on the minimum require-
ments for reporting external beam therapy. These
recommendations are intended to be applicable to
most clinical situations, past or present, and to most
radiotherapy centers. In some situations factors addi-
tional to those listed may be considered to have clinical
implications and should therefore be reported as well.
The preliminary drafts of this report were widely
circulated among radiotherapists and radiation phys-
icists in several countries, but it will be no surprise
that it has not been possible to reach a complete
consensus of opinion. Any individual radiotherapist
may well find that the recommendations in this report
do not conform exactly with his present system of
recording. Nevertheless, there are substantial advan-
tages in adopting a common method of reporting. A
statement in any individual report that the system
used conforms to the recommendations of this report
will remove the need for a definition of terms and a
detailed explanation of the meaning of statements
relating to the absorbed dose and other factors. At the
very least, a comparison of any existing system of
reporting with that recommended here may help to
reveal inadequacies in the local procedures. It is hoped
that this report will encourage radiotherapy centers to
review their treatment reporting systems and that, in
doing so, they will give careful consideration to adopt-
ing the present recommendations.
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 2. Definitions of Terms and Concepts Currently Used in Radiotherapy
Note: Terms and concepts defined in this report are
in addition to those defined in previous ICRU reports
(e.g., ICRU Report No. 23 (1973), Measurement of
Absorbed Dose in a Phantom Irradiated by a Single
Beam of X or Gamma Rays, and ICRU Report No. 24
(1976), Determination of Absorbed Dose in a Patient
Irradiated by Beams of X or Gamma Rays in Radio-
therapy Procedures).
2.1 Volumes
2.1.1 Aim of Therapy
A. Curative Treatment of Malignant Disease. In
the curative treatment of malignant disease anatomic
tumor limits may or may not be demonstrated. When
demonstrated, the location and extent of the tumor
volume may be determined by means of clinical ex-
amination, roentgenologic, radioisotopic, ultrasonic,
and microscopic techniques. When the tumor has been
previously removed (e.g., by mastectomy or hysterec-
tomy) the remaining tissues may contain occult dis-
ease, the limits of which can not be demonstrated.
When planning treatment the volume to be treated
to a curative absorbed dose level has to include not
only the demonstrated tumor but also its presumed
occult spread.
B. Palliative Treatment of Malignant Disease. The
palliative treatment of malignant disease may include
all or only part of the demonstrated tumor(s) (e.g.,
irradiation of the spine for a painful deposit in a case
of widespread metastases).
C. Non-malignant Diseases. The radiotherapy of
non-malignant conditions may or may not include all
of the affected tissues (e.g., irradiation of a painful
joint in ankylosing spondylitis).
2.1.2 Target Volume
The target volume contains those tissues that are
to be irradiated to a specified absorbed dose according
to a specified time-dose pattern. For curative treat-
ment the target volume consists of the demonstrated
tumor(s), if present, and any other tissue with pre-
sumed tumor.
3
The delineation of the target volume will require
such considerations as the local invasive capacity of
the tumor and its potential to spread to regional lymph
nodes. Consideration needs to be given to the presence
of any specially radiosensitive normal tissue (organs
at risk) as well as to other factors such as the general
condition of the patient.
For any given situation there may be more than one
target volume.
Physical treatment planning is dependent on the
delineation of the target volume(s) and the prescrip-
tion of the target absorbed dose. These two factors
constitute the medical decision which must precede
the determination of the dose distribution in the pa-
tient. (In the past this sequence has often been re-
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versed and the target volume defined in terms of the
dose distribution, for example, the volume enclosed by
a particular isodose surface. This procedure is not
recommended).
The target volume(s) must always be described,
independently of the dose distribution, in terms of the
patient's anatomy and topography, and the physical
dimensions given. When a dose distribution in one or
more anatomical sections is presented, the target vol-
ume (or area in a particular section) should be clearly
indicated on the diagram. If the whole body section
constitutes the target volume, this fact should be
indicated on the isodose chart and stated in any ac-
companying description.
The size and shape of a target volume may change
during a course of treatment (e.g., shrinkage of a
mediastinal lymphoma), necessitating replanning.
Note: For external beam therapy the following pa-
rameters should be taken into account when describ-
ing the target volume:
a. expected movements (e.g., caused by breathing) of
those tissues which contain the target volume rel-
ative to anatomic reference points (e.g., skin mark-
ings, suprasternal notch),
b. expected variation in shape and size of the target
volume during a course of treatment (e.g., urinary
bladder, stomach),
c. inaccuracies or variation in treatment set-up during
the course of treatment.
An example of target volumes in a patient with a
carcinoma of the breast is given in Figure 2.1.
4 2. Definitions of Terms and Co11cepts
Ox
TRANSVERSE
SECTION
a Organs at risk are specially radiosensitive organs in
Ox
b considering the dose distribution in a set of parallel
Fig. 2.1. Radiotherapy for cancer of the breast as a sole method
of treatment, or combined with surgery. Example of a target volume
which includes not only the breast (in unoperated patients) and the
chest wall but also the internal mammary, the supraclavicular, and
the· axillary lymph nodes. The target volume appears as a target
area (8ihaded area) in the transverse section (b). In practice, as
shown in (a) several target volumes have to be identified, which are
irradiated with different beams, which partly overlap (From Abba-
tucci et al., 1972.)
2.1.3 Treatment Volume
Because of limitations in treatment techniques it is
impossible to administer. the prescribed absorbed dose
exclusively to the target volume. In general the volume
receiving at least the same absorbed dose as any part
of the target volume can not be made to coincide with
the target volume but will be larger and often of a
simpler shape.
The treatment volume is the volume enclosed by an
isodose surface, the value of which is the minimum
target absorbed dose (see Section 2.2.3). In some cases
the treatment volume may be considerably larger than
the target volume, as shown in Figure 3.2.
2.1.4 Irradiated Volume
The irradiated volume is that volume, larger than
the treatment volume, which receives an absorbed
dose which is considered significant in relation to
tissue tolerance. The significant absorbed dose level
can be expressed as absorbed dose in percentage (e.g.
50%) of the specified target absorbed dose (see below)
(e.g., Figure 3.5).
The irradiated volume, as well as the treatment
volume, will depend on the treatment technique used.
2.1.5 Organs at Risk
or near the target volume whose presence influence
treatment planning and/ or prescribed dose.
2.2 Absorbed Dose Pattern
2.2.1 Representation of a Spatial Dose Distri-
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bution by a Set of Planar Dose Distributions
A uniform dose distribution can rarely be achieved
in a target volume, and it is necessary to evaluate the
spatial absorbed dose distribution.
Such an evaluation could be made, in principle, by
planar sections sufficiently close to each other (the
distance between two sections being equal to the dis-
tance between the "lattice points", see Section 2.2.4).
However, for practical reasons only a limited num-
ber of sections can be evaluated. These sections may
be selected in the following way (Figure 2.2). The part
of the patient containing the target volume and rele-
vant anatomic structures is considered as a stack of
several parallel slices, the thickness of the slices being
chosen so that in each slice the following conditions
are fulfilled:
a. no important variations occur in the external con-
tour,
b. no important variations occur in the topography of
the relevant internal structures: size, shape and
location of the target volume, organs at risk, heter-
ogeneities, etc.,
c. no important variations are expected in the dose
distribution that are relevant to the treatment plan.
For each slice a section is chosen on which the extreme
borders of the target volume, the organs at risk, the
tissue heterogeneities and the reference points in that
slice are projected perpendicularly. The section then
displays all the relevant structures and the part of the
target volume which is located within this slice now
appears as a target area.
In many simple situations consideration is given
only to one section, as illustrated in Figure 2.3 for a
patient with a carcinoma of the urinary bladder.
The following definitions (Sections 2.2.2-2.2. 7) ap-
ply to dose calculations in a section. They are clinically
relevant only if they can be assumed to represent the
corresponding spatial situation.

2.2.2 Maximum Target Absorbed Dose (Dr.max)
The maximum target absorbed dose is the highest
absorbed dose in the target area that can be regarded
as "clinically meaningful". The latter term implies
that at least a minimum area is irradiated to the dose
level designated as "maximum". The minimum area
recommended for this purpose is 2 cm2 , unless the
whole target area is less than 4 cm2 , in which case a
minimum area of 1 cm2 should be taken to define the
maximum target absorbed dose.
The value 2 cm2 is based on two considerations.
First, 2 cm2 represents approximately the smallest
area for which the absorbed dose can be calculated
with confidence, either manually or with a computer;
second, the maximum target absorbed dose is often
related to the limiting effects of treatment such as
tissue tolerance and the smallest volume of tissue to
which these effects apply is considered to be that
volume whose section is at least 2 cm2 •
Within an isodose curve enclosing an area of 2 cm 2
the dose at a point may be even higher, but it is
recommended that such hot points be ignored in des-
ignating the value of the maximum target absorbed
dose.
2.2.3 Minimum Target Absorbed Dose (Dr.min)
The minimum target absorbed dose is the lowest
absorbed dose in the target area. No area limit is
recommended when reporting minimum target ab-
sorbed dose.
2.2.4 Mean Target Absorbed Dose (Dr.mean)
For the determination of the mean, as well as of the
median and modal target absorbed dose, it is necessary
to calculate the dose at each of a large number of
discrete points (lattice points), uniformly distributed
in the target area.
2.2 Absorbed Dose Pattern • • • 5
The mean target absorbed dose is then calculated
as the mean of the absorbed dose values in these
lattice points and can be expressed by the equation:
where N is the number oflattice points, i is the column
index in this lattice, j is the row index, and Di,i is the
absorbed dose at the lattice point i,j located inside the
target area AT.
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2.2.5 Median Target Absorbed Dose (Dr.median)
The median target absorbed dose is the central
value among the set of values of the absorbed dose at
all lattice points in the target area, when arranged
according to magnitude.
2.2.6 Modal Target Absorbed Dose (Dr,moda1)
The modal target absorbed dose is the absorbed
dose that occurs most frequently at lattice points in
the target area. Its value may be influenced by the
choice of method for its calculation (e.g., spacing of
lattice points). Exceptionally, in a particular patient,
more than one modal target absorbed dose may be
found.
An example of a computerized calculation of the
different above-mentioned target absorbed doses in
one section of a patient is given in Figure 2.4.
2.2. 7 Hot Spots
In many situations tissues outside the target area
will receive a relatively high absorbed dose. A hot spot
is an area which receives an absorbed dose higher than
100% of the specified target absorbed dose (see Sec-
tion 3.3). However, as in the case of the maximum
target absorbed dose (see Section 2.2.2), a hot spot is
considered clinically meaningful only if the corres-
ponding isodose curve encloses an area of at least 2
cm2 in a section.
6 2. Definitions of Terms and Concepts

a
--·-·---~ ---
-·-· -·-· -·-·-4-<M:· . . ·;/J-· -·- -- ·-·--
)---·---·--
II
© I

-·-· ---·-· -·-g · -·-·-·-·-·-·-·-III

~ II

~
- - -·- - - )' , .. ··-\-·-·---·-·-·-·-IV

-·-·cL . L. ~----- v

®
.. III
( I \?<'/ .

(''-----..____,__ "

@
(' \

Downloaded from http://jicru.oxfordjournals.org/ at Universite Laval on July 9, 2016

L" . . l
..
IV
---·-·-·-·--1 7 .A)) }---·-·--·--·-·- I

II
.•....
-·- -~ ~vr·-·-·-· -·-·-·-·-· III

CJ . .
f~o··
.. ..
v

·. ...: n··.... ·:·

-·-·-· - · - -,_!~/-!_-'g"-'"'--<t_,\·
Ii_ ..,: .-1
-·- ·- --·-·-·-·-· IV
..... ~O~ ..... .

"
ti /"x'
)~·.... ·\ r·-----·-- -·- -·- v

I \
Fig. 2.2(a). Example of a multi-section dose plan for the curative treatment of a carcinoma of the nasopharynx (demonstrated tumor=
target A, indicated by black) and its presumed spread to the regional lymph nodes in the neck and supraclavicular fossae (subclinical disease
= target B, indicated by the dotted line (Figure 2.2(a)) or honeycombed area (Figure 2.2(b), page 7). The prescribed absorbed dose for target
A is higher than that for target B. The organs at risk are the spinal cord, brafu stem, and to some extent the eyes. When calculating the
absorbed dose distribution, correction for tissue heterogeneity (lung tissue and bone) may be applied. The preliminary suggestion for treatment
technique is a multifield arrangement with lateral fields towards target A and one anterior and two oblique posterior fields towards target B,
in order to keep the dose to organs at risk as low as possible. After having defined optimal patient positioning with respect to suggested
treatment technique, representative sections will be produced. In this case, 5 sections (I- V) were needed for the calculation of the absorbed
dose pattern because of variation in shape and size of the two target volumes, outline of the patient and treatment technique. Each section
represents one slice of the patient. The extreme borders of the target volume, organs at risk, tissue heterogeneities and reference points in that
slice have been projected perpendicularly on to the section, thus defining the target area and other relevant structures ut;.the section.

Fig. 2.2(b). (Opposite page) The accepted dose plan appears in b. The schematic figure (top left) indicates (Arabic numerals) arrangement
of the fields. (Note: beams 2, 4, and 6 are actually directed towards the right side of the patient.) The weighting of the beams and the absorbed
dose distribution in each of the five sections have been normalized to peak absorbed dose in beam I (Modified from: Landberg and Svahn-
Tapper, 1976.)
b

5•7

II

Downloaded from http://jicru.oxfordjournals.org/ at Universite Laval on July 9, 2016

''
3

>

,I
I

I
I

:~ 2

Field Radiation SSD Field size Weight Wedge Compensator

cm x cm 5cm
60Co gamma rays 70 20 x 15 100 60 cm lead centrolly
2,3 60Co gamma rays 70 8 x 18 50 45°
4,5 8 MV X-rays 100 5 x 6 50 15°
6,7 8 MV X-rays 100 5 x 3 30

Absorbed dose (per cent of

peak absorbed dose in beam 1)

Target A Target B Brain stem, spinal

cord
Max.-Min. Max.-Min. Max.
Section I 135-125 55
II 140-120 140- 40 40
III 140-110 55
IV 145-130 40
v 130-100 45

7
8 2. Definitions of Terms and Concepts

Frontal projection (A.P. radiograph)

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Sagittal (or lateral) projec- lransverse (or cross) section
tion (lateral ~adiograph)
Fig. 2.3. Example of a target in a patient with localized cancer of the urinary bladder and presumed occult spread. The transverse section
is considered to be representative of the whole target volume and the relevant normal tissues. For the graphical construction of the transverse
section two radiographs are used that represent two perpendicular projections of the anatomy of interest. The border of the target is indicated
by the dotted line. The target appears in the two radiographs and is indicated as an area in the section. It includes the demonstrated tumor
(indicated in black). the whole bladder and the regional lymph nodes (the iliac and the obturator groups) as well as connecting lymphatics.

Fig. 2.4(a). (Opposite page) Computerized calculation of the

absorbed dose distribution (8 MV x rays) for a patient with carci-
noma of the esophagus, treated only in the prone position. (a)
Transverse section of the patient. The calculation of the absorbed
dose includes correction for tissue heterogeneity, the "effective
density" of the lung tissue being considered to be 500 kg m - 3 and
that of bone to be 1300 kg m- 3 • The border of the target area is
indicated by the thick line.
The display gives the distribution of the absorbed dose and also the
position of the maximum (4) and the minimum<•> target absorbed
dose. In this special case, the weighting of the beams (peak absorbed
dose 50%, 45%, and 45%, respectively), was chosen to give an
absorbed dose of 100% at the point of intersection of the central
axes of the three beams.
Fig. 2.4(b). (Opposite page) For the same patient a histogram
is given to demonstrate the distribution of absorbed dose in the
target area. The computation of the histogram gives sizes of areas
(one lattice point representing an area of 3 mm X 3 mm= 0.09 cm2)
for 21 equally large intervals of absorbed dose percentage values,
ranging from 102% to 93%. The maximum target absorbed dose
considered to be meaningful and to be used for reporting (see
Section 2.2.2) is 100%. The modal target absorbed dose is 99%, and
the median 98%. The computation also gives the mean target
absorbed dose (98%) (Modified from: Moller et al., 1976.)
 2.2 Absorbed Dose Pattern 9
a

SIN DX

Downloaded from http://jicru.oxfordjournals.org/ at Universite Laval on July 9, 2016

Field SSD Size
cm cm x cm

123~·76911
76111122
9928·76
2-1-llJGI
H.S.
u u
5 cm
... /
VENTR
2
3
100
100
100
9 x 14
8 x 14
8 x 14

Area
7 (=Nx TARGET ABSORBED DOSE
b 0.09)
MINIMUM MODAL MAXIMUM
4.0
'
3.2

2.4 -

1.6

0.8

O.O -t----,.---,.-----r-..u.L........,...._LU-L.U.1~..u....---. Relative absorbed

76 81 86 91 96 101 106 dose ( % )
 3. Recommendations for Reporting Absorbed Doses in External Beam Therapy
3.1 Introduction
The absorbed dose distribution is usually not uni-
form in the target volume (see Section 2.2.1). However,
for the purpose of treatment reporting a nominal
absorbed dose, which will be called target absorbed
dose, has to be selected. The use of the expression
"tumor dose" is no longer recommended.
The maximum and minimum target absorbed doses
alone or together can not as a rule be used for reporting
since they are not always representative of the dose
distribution. Although local tumor control depends on
the minimum dose to the malignant cell population,
the use of the minimum target absorbed dose alone
can not be recommended, since difficulties in deter-
mining the extent of the malignancy may reduce its
clinical significance and further may lead to ambiguity
in its definition.
The mean, median and modal target absorbed doses
can not be generally recommended since they usually
require a complete computerized dose plan, which may
be available only for a limited number of patients
and/ or hospitals.
The absorbed dose selected for reporting should be
chosen to be representative of the dose distribution in
the target volume, and its calculation should, if possi-
ble, not necessitate special computation facilities.
It should be stressed that target absorbed dose, as
specified in the tollowing paragraphs, represents a
minimum requirement for reporting, often carrying
limited radiobiological and clinical information.
Finally, the specification of target absorbed dose for
reporting depends on the treatment technique, and its
significance can only be interpreted when information
on the irradiation technique has been given.
10
3.2 Description of Technique
Necessary information:
a. Radiation quality
I. for conventional (100-300 kV) or low energy
(< 100 kV) x rays, the accelerating potential
(kV) and HVL,
2. for gamma rays, the radionuclide (element and
mass number),
3. for high energy x rays, the equivalent accel-
erating potential (MV) and the type of ma-
chine,
4. for electron beams, the energy (Me V) and type
of machine.
b. The number and arrangement of the beams. In-
Downloaded from http://jicru.oxfordjournals.org/ at Universite Laval on July 9, 2016
dication of SSD or SAD. The description of the
beam arrangement of external beam therapy
should always be done in relation to the patient.
c. Field sizes: geometrical field sizes which usually
correspond to the 50% isodose curve. For fixed
SSD, the field sizes are usually given at the skin;
for fixed SAD (isocentric arrangement) the field
sizes are given at the isocenter. For any field, its
size in the planned section should be given first.
d. Beam modification devices (wedges,. shielding
blocks, etc.).
e. Beam weighting. State whether this is defined in
terms of the ratio of peak (applied) absorbed
doses for the single beams, or in terms of the
ratio of doses delivered at a defined point in the
target, such as the isocenter or the "specification
point" (see Section 3.3.4). To avoid ambiguity,
the meaning of beam weighting should always be
made clear.
f. Corrections for tissue heterogeneity (state
whether performed or not).
g. Patient positioning.
Optional information:
h. Absorbed dose distribution (isodose pattern).
i. "In vivo" absorbed dose measurements.
 3.3 Specification of Target Absorbed Dose 11

Fields 1 and 2
soco
3.3 Specification of Target Absorbed Dose 70cm SSD

3.3.1 Stationary Beams of Photons

a. For a single beam the point at which the target

absorbed dose should be stated should be on the Ox
central axis at the center of the target area
(Figure 3.1).
b. For two opposed coaxial equally weighted beams
the point at which the target absorbed dose
should be stated should be on the central axis
midway between the beam entrances (Figure
!..I !ewl w
3.2). 2 5cm
c. For two opposed coaxial unequally weighted
beams the point at which the target absorbed Fig. 3.2. Treatment of a bronchogenic carcinoma including

Downloaded from http://jicru.oxfordjournals.org/ at Universite Laval on July 9, 2016

dose should be stated should be on the central
axis at the center of the target area (Figure 3.3).
d. For any other arrangement of two or more inter-
secting beams the point at which the target ab-
sorbed dose should be stated should be at the
intersection of the central axes of the beams
(Figures 2.4, 3.4, and 3.5).
treatment of the mediastinum with coaxial opposed equally
weighted 60 Co beams. No correction for tissue heterogeneity. The
point at which the target absorbed dose should be stated (e) is
located on the central axis, midway between the beam entrances.
• = demonstrated tumor; !Bl =· target area. In this patient the
treatment volume is delineated by the 100% isodose curve.

Weight = 1 .O

Fields 1 and 2
so co
70 cm SSD

so co
70 cm SSD
100 %
Ox

Ox

!wwl - lwwl
2 5cm
Weight = 0.5

Fig. 3.3. Treatment of a malignant thymoma with two coaxial

5cm
Fig. 3.1. Single beam therapy with 60 Co of the internal mam-
mary lymph nodes. No correction for tissue heterogeneity. The
point at which the target absorbed dose should be stated (e) is
located on the central axis at the center of the target area. ~ =
target area.
opposed unequally weighted beams. The weighting factors are 1.00
and 0.50 for the anterior and the posterior beams, respectively. No
correction for tissue heterogeneity.
The point at which the target absorbed dose should be stated
(e) is located at the central axis at the center of the target volume.
In this particular case, the relative target absorbed dose to be stated
is 103%. • = demonstrated tumor; ~ = target area.
 --'7'-1----------t=SECTION 3

Percentage value
60Co
SAD = 80 cm 60 10
Field No. Size Weighting ------ 70 20 1.
(cm x cm factors BO 30
17 x 20 0.37 .... ·············- 90 40
2 17 x 20 0.37 -------·- 95 50
3 10 x 20 0.13 100
4 10 x 20 0.13

10an
SECTION 2 ............. .......
.__,.~ ~ ~· _,,

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Ox

3-·--

2.
SECTION 1
I SECTION 3

60
Fig. 3.4. Irradiation of the pelvis with Co "box technique". Variation in patient outline at different levels necessitated multisection dose
calculations. The figure shows computerized calculation of the absorbed dose distribution in the principal plane (section 2) and in 2 parallel
planes 7 cm above (section 1) and below (section 3). In each section the border of the target area is indicated by the thick dotted line. The
point at which the target absorbed dose should be stated is located at the intersection of the central axes of the 4 beams. The absorbed doses
in the different sections are expressed in percentage of that dose level in the principal plane. The weighting factors indicated in the table
correspond to the contribution of each beam to the target absorbed dose. The target absorbed dose to be reported for section 2 is 100%. For
sections 1 and 3, the absorbed doses at the intersections of the beam axes are 87% and 94%, respectively.

SAD Size
cm cm x cm

100 10 x 10
Fig. 3.5. Treatment of a lesion of the tongue and the floor of
100 8xl0 the mouth (the border of the target area being indicated by the
thick dotted line) with two wedged 8 MV x-ray beams. The point at
which the target absorbed dose should be stated is located at the
intersection of the central axes. The absorbed dose level at this
point is defined as 100%, and is also indicated by the symbol B.
Almost the whole target area is confined within the 95% isodose
curve. The 50% isodose curve is also shown.
The left parotid and sub-maxillary glands were considered to be
organs at risk, and their positions are indicated in the section by the
broken line. The spinal cord receives less than 10%. Note that the
two beams have different wedge filters and also different weighting
factors (Modified from: Van der Laarse, 1976.)

o-------z-------.. -------f,.------it-------o-------z-------i.-------f.-------11-------
 3.3 Specification of Target Absorbed Dose 13
3.3.2 Moving Beam Therapy
Ox
For complete rotation the point at which the target
absorbed dose should be stated should be in the prin-
cipal plane at the center of rotation. The same rec-
ommendation applies when the arc of rotation is less Percentage value

than 360° but at least 270° (Figure 3.6). 100 60 10

COBALT 60
ARC THERAPY
For smaller arcs (Figure 3. 7) the target absorbed 105 70 20
SAD = 75 cm
110 80 30 2
dose should be stated in the principal plane, first, at 115 90 40
6.0 x 14.0 cm

ARC = 100
the center of rotation and second, at the center of the 95 50

target area. The irradiation parameters are usually

chosen in such a way that the absorbed dose in the 0 5cm

center of the target area is close to the maximum

target absorbed dose. Fig. 3.7. Moving beam therapy with a relatively small arc
(100°): treatment of a rectal tumour. For the chosen arc, the
maximum absorbed dose is not obtained at the axis of rotation, and
for reporting purposes it is recommended that the absorbed dose be
indicated at the center of rotation and at the cenier of the target

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area. In this particular patient the absorbed dose at the center
of the target area is 117% of the absorbed dose at the center of
rotation. The border of the target area is indicated by the thick
dotted line.

o-----z------•------•----•-----u-------l-------•------b------M-------u-------2------•-------b-------8
I
I
I
SAD Field size
I
2
I
Ox cm cm x cm
!
7 x 16
2'l,,b'
~ 100
l!
i.2 22
l 2
2 'l 2<r'22
2
z
2
,• 'l
l l
ll
2 ,,

2
ll I
2 I
>222 I
2 I
2
2
2
2
2
2
I 2 2222222<
222222 <2 2
< 2
l< 2
2 U22 2
2 PZZZZ~ 22'/t' 2 2?22222 2

0----2------•-------•----a-----u---- -t-------•-------b-------11-------v--- -i-----•-------b-------e-------u------2----

I

Fig. 3.6. Treatment of an esophageal lesion by moving beam technique (300°) with 8 MV x-rays. The point at which the target absorbed
dose should be stated is located at the isocenter. The relative absorbed dose at that point is 100%. The target area is located within the 95%
isodose curve. When correcting for tissue heterogeneity the lung was assumed to have a bulk density of 350 kg m- 3 • The spinal cord receives
an absorbed dose ranging from 40% to 20% of that at the isocenter. The border of the target area is indicated by the thick dotted line.
 14 3. Recommendations for Reporting Absorbed Doses

3.3.3 Electron Therapy 3.3.4 Complex Treatments: General Recom-

The energy of the electron herun is generally chosen
so that an isodose curve of at least 80% of the peak
absorbed dose encloses the target area. The stated
target absorbed dose should be the maximum target
absorbed dose; the absorbed dose in the center of the
target area is usually close to this value (Figure 3.8).
a
Electrons 15 MeV
110 cm SSD
100 %
6cmx14cm
mendations
There are some situations where the above-men-
tioned recommendations may not apply. Such are for
example
a. coplanar beruns whose central rays do not inter-
sect at one point (Figures 3.9, 3.10, and 3.11),
or intersect at a point outside the patient
(Figure 2. 2 (b) .IV).
b. non-coplanar berun treatments (Figure 3.9),
c. opposed non-coaxial beams (Figures 3.9 and
3.11),
d. different target volumes (Figure 3.9),
e. modification in the treatment technique.
It is recommended that one or more "specification
points" be defined for the above-mentioned situations,

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each having a meaningful relation to the target volume
and/ or the irradiation beams. The proper choice of
one or more points is facilitated by an isodose presen-
Ox tation. When reporting, information should be given
on the position of the specification point(s). The stated
target absorbed dose should be expressed as a per-
centage of the absorbed dose at one or more of these
points (Figure 3.12). Where more than one target
lwol lwol .....
volume is involved, more than one specification point
Scm is usually necessary (Figure 3.9). When treatment has
Fig. 3.8(a). Electron treatment (15 MeV) of the internal mam- to he modified, new specification point(s) may have to
mary lymph nodes. No correction for tissue heterogeneity. The he chosen with corresponding absorbed dose calcula-
target absorbed dose to be reported is the maximum absorbed dose tions being carried out.
in the central beam (100%). Because of the flatness of the electron
depth dose curve in the region of its maximum, 100% may be found
Note: The situations mentioned in Sections 3.3.1, 3.3.2,
at many points which can not be displayed by an isodose curve. and 3.3.3 can, if preferred, he dealt with ·as complex
Therefore, 100% is not indicated in the figure. In the example chosen treatments using specification points.
here, an absorbed dose close to 100% is found at the center of the For these treatment plans, even if complete ab-
target area.
sorbed dose distributions are not computed for each
particular patient, it is assumed that a basic or model
dose distribution is available, either from the srune
b
radiotherapy center or from a collection (such as an
Electrons 15 MeV atlas; IAEA, 1978) produced elsewhere.
110 cm SSD
100 % 3.3.5 Additional Recommendations
If the absorbed dose in the target volume varies by
more than ± 10% of the stated target absorbed dose,
Ox then the maximum (Section 2.2.2) and the minimum
(Section 2.2.3) target absorbed dose should also be
given. Multiplane calculations may he necessary.
Any hot spot should be reported (see Section 2.2.7).
The value of the absorbed dose of the hot spot to be
reported should be that of the isodose curve that
encloses an area of 2 cm2, not the absolute maximum
- J.+wl lww!
Scm
value.
Fig. 3.8(b). Same as Figure 3.8(a), but corrected for tissue
heterogeneity, the "effective lung density" considered to be 500 kg
For organs at risk the maximum absorbed dose
m.-3
should be given and the runount of the organ involved
stated (e.g., IO cm of the spinal cord, the upper half of
the left kidney).
Any other additional information considered to
carry relevant radiohiological and/or clinical infor-
mation should be reported.
 3.3
Note I: In an isodose plan the value of each isodose
curve should, if possible, be written at the higher
absorbed dose side of the curve.
Note II: The isodose plans shown in this report were
generated in clinical routine work in several different
centers and were only slightly edited for simplicity in
layJout. They show different ways of presenting dose-
distributions. It is not felt that recommendations
should be given at this time for presentation of isodose
distributions, but the reading of such a presentation is
facilitated if the isodose curve through the specifica-
tion point (see Section 3.3.4) is given the value 100%.
Specification of Target Absorbed Dose 15
Note III: The transverse sections in this report are
shown as viewed from the foot end of the patient. The
right and/or left sides of the sections are indicated by
Dx and Sin, respectively.
Note IV: The figures used in this report were selected
to illustrate and clarify the definitions and recommen-
dations given in the text. It is not the intention of the
authors of the report to recommend particular irradia-
tion techniques. Of course, the examples were chosen
to be as close as possible to the clinical situations to
be illustrated.

60Co
Field SSD Size Wedge Beam weight
I cm cm x cm %
70 22 x 22 - 100

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1
2 70 22 x 22 100
3 70 5 x 5 15° 40
4 70 5 x 5 15° 40
5 70 12 x 5 - 180
6 70 12 x 5 - 180

20
III
30 30

•
II

_. I.I IM
5 cm
Fig. 3.9. Dose plan in 3 sections for the treatment of medulloblastoma with two target volumes (a/the demonstrated cerebellar tumor,
and b/the whole subdural space and the ventricular .system) with coplanar beams whose central rays do not intersect at one point, non-
coplanar beams, and opposed noncoaxial beams. The weighting of the beams was chosen to give the total absorbed dose in the two target
volumes with the same number of fractions. The distribution of the absorbed dose is calculated for first, the demonstrated tumor and the
cranial subdural space down to the second cervical vertebra in a frontal section (I), second, for the spinal subdural space in a median sagittal
section (II) from the second cervical vertebra to the second sacral vertebra, and thirdly in a transverse section (III) through the kidneys. The
cranial subdural space is treated with two opposed and the spinal subdural space with two adjacent 6()Co beams to a target absorbed dose of
30 Gy. The cerebellar tumor is further treated with two smaller opposed 6()Co beams to a total of 40 Gy. For reporting, three different
specification points are chosen for the two target volumes, namely one (e) for the demonstrated cerebellar tumor and two C• and•) for the
whole subdural space and the ventricular system. (Modified from: Moller et al., 1976.)
16 3. Recommendations for Reporting Absorbed Doses

Field Radiation SSD Field size Weight (reference= Field Radiation SSD Field size Weight (reference =
cm cm x cm = speci ficotion point) cm cm x cm = specification point)
25 MV X-rays 100 60co gamma
18 x 14 0.22 rays 80 28 x 8 l.2
2 60Co gamma rays 80 27 x 14 l.20 2 25 MV X-rays 100 17 x 8 0.22
3 9 MeV electrons 100 8 x 14 0.12

5 o•

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Fig. 3.10. Treatment of a thyroid carcinoma with mediastinal
involvement with coplanar beams whose central rays do not inter-
sect at one point. The purpose of treatment was to deliver 50 Gy to
the upper mediastinum at mid-diameter (specification point, indi-
cated by the symbol ®. The 25 MV x-ray beam was necessary tr
boost the absorbed dose to the caudal part of the target area and
the 9 MeV electron beam to boost the absorbed dose to the cranial
part of the target area. It was decided to keep the spinal cord
absorbed dose below 42 Gy. The border of the target area is
indicated by the dotted line. The figures at the isodose curves
indicate absolute absorbed dose.
Fig. 3.11. Treatment of the upper one-third of the esophagus
with opposed non-coaxial beams. A dorsal 25 MV x-ray beam was
added to the ventral 60Co beam in order to avoid overdosage to the
spinal cord. Sufficiently high absorbed dose is delivered by the
dorsal 25 MV x-ray beam to provide 50 Gy to the upper mediastinum
at mid-diameter (specification point, indicated by the symbol ®).
The border of the target area is indicated by the dotted line. The
figures at the isodose lines indicate absolute absorbed dose values.

Fields 1 and 2
BO co
130 cm SSD Beam flattening•
contour comp. filter

0
ro

lww! lawaal !awl

5 cm

Fig. 3.12. Dose plan for the sagittal section in mantle treatment, showing isodose distribution and absorbed dose pattern along the
hypopharynx and the esophagus. The relatively short diameter in the neck region is compensated for by an individual copper filter which has
been constructed to correspond to the lined area. This contour compensating filter is placed at the collimator in addition to the general beam
flattening filter used for this technique. The specification point (e) is located on the central axis midway between the beams. The absorbed
dose at this point is 150% of peak absorbed dose at the central axis of either beam. In this particular patient the minimum target absorbed dose
was considered to be of particular importance, being located at the most cranial and most caudal part of the target area <•>
and being 90% of
the absorbed dose at the specification point. IW = target area.
 4. Factors Influencing the Biological Effect

4.1 Radiation Quality 4.2 Time-Dose Pattern

Radiation quality(ies) and the respective absorbed
dose(s) should be clearly stated (see Section 3.2.a).
For comparison purposes, 60Co gamma rays should
be taken as the reference radiation. Conversion factors
recommended in radiation therapy to take into ac-
count RBE differences are given in Table 4-1. They
agree with most of the published data relevant to
radiation therapy, which indicate a higher RBE value
The reporting of absorbed dose for external beam
therapy should be accompanied by information on the
time-dose pattern including at least the number of
fractions and the overall time (in days). The first and
the last day of treatment are included in the reported
overall time.
Unless otherwise stated, it is understood that the
fractionation is regular (5 fractions week- 1 ) with equal

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of conventional x rays. Absorbed dose values of con-
ventional x rays should then be multiplied by 1.18
when their effects are compared with those of high
energy radiation.
Unless otherwise stated, it is assumed that the ab-
sorbed doses are given by either 60Co gamma rays,
high energy x rays or high energy electrons.
fractions, all fields being irradiated at each session.
The position and length of any gap or interruption
must be given as well as any change in dose per
fraction.
Recording of target absorbed dose rate is useful and
is recommended for values below 0.1 Gy min- 1 at any
part of the target volume.

TABLE 4-l-Conversion factors recommended in radiation therapy to take into account differences in RBE
Radiation Quality Conversion Factors References
Conventionala (100-300 kV) x rays 1.18 ICRP (1963);
Krohmer (1965);
Wambersie and Dutreix (1971)
1.00 ICRP '(1963); Sinclair (1962);
Wambersie and Dutreix (1971);
Wambersie et al. (1973)
~2 MVxrays 1.00 ICRP (1963); Sinclair (1962);
Sinclair and Kohn (1964);
Wambersie and Dutreix (1971)
Electron beams 1.00 ICRP (1963); Hettinger et al. (1965);
(energy 1-50 Me V) Kim et al. (1968); Sinclair and Kohn (1964);
Wambersie et al. (1966);
Wambersie and Dutreix (1971)
a Note: For low energy (<100 kV) x rays the same conversion factor (1.18) can be recommended for most

practical situations, although some experimental data suggest increase of RBE with decreasing energy (ICRP,
1963; Krohmer, 1965; Wambersie and Dutreix, 1971).

17
 References
ABBATUCCI, J. s., QUINT, R., BLOQUEL, J., ROUSSEL,
A. and URBAJTEL, M. (1972). Techniques de Tele-
cobaltherapie radicale (L'Expansion Scientifique
Fran~aise, Paris).
HETTINGER, G., BERGMAN, S., and 0STERBERG, S.
(1965). "The relative biological efficiency (RBE) of
30 MeV electrons on haploid yeast," Biophysik 2,
276.
IAEA (1978). International Atomic Energy Agency,
Atlas of Radiation Dose Distributions, Vol. VI,
Treatment Plans for Cobalt-60 Therapy, Mitchell,
J S. Cohen, M., and Snelling, M., Eds. (Interna-
tional Atomic Energy Agency, Vienna). [In press]
ICRP (1963). International Commission on Radiolog-
ical Protection, "Report of the RBE Committee to
the International Commissions on Radiological Pro-
tection and on Radiological Units and Measure-
ments," Health Phys. 9, 357.
ICRU (1973). International Commission on Radiation
Units and Measurements, Measurement of Ab-
sorbed Dose in a Phantom Irradiated by a Single
Beam of X or Gamma Rays, ICRU Report 23 (In-
ternational Commission on Radiation Units and
Measurements, Washington).
ICRU (1976). International Commission on Radiation
Units and Measurements, Determination of Ab-
sorbed Dose in a Patient Irradiated by Beams of X
or Gamma Rays in Radiotherapy Proce,dures,
ICRU Report 24 (International Commission on Ra-
diation Units and Measurements, Washington).
KIM, J. H., PINKERTON, A., and LAUGHLIN, J. S.
(1968). "Studies on the biological effectiveness of
high-energy electron beams at different depths in
tissue absorbing material," Radiat. Res. 33, 419.
KROHMER, J. s. (1965). "RBE and quality of electro-
magnetic radiation at depths in a water phantom,"
18
Radiat. Res. 24, 54 7.
LANDBERG, T., and SVAHN-TAPPER, G. (1976). "En-
bloc irradiation of tumours of the head and neck
and their lymphatics. I. Technique and dosimetry,"
Acta Radiol. Ther. Phys. Biol. 15, 129.
MOLLER, T. R., NORDBERG, u. B., GUSTAFSSON, T.,
JoHNSSON, J. E., LANDBERG, T. G., and SvAHN-
TAPPER, G., (1976). "Planning, control, and docu-
mentation of exernal beam therapy," Acta Radiol.
Suppl. 353.
SINCLAIR, W. K. (1962). "The relative biological effec-
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tiveness of22 MeVp X-rays, Cobalt-60 gamma rays,
and 200 KeVp X rays," Radiat. Res. 16, 336.
SINCLAIR, W. K. and KOHN, H. I. (1964). "The relative
biological effectiveness of high-energy photons and
electrons," Radiology 82, 800.
VAN DER LAARSE, R. (1976). "Pseudo optimization of
radiotherapy treatment planning," Brit. J. Radiol.
49, 450.
W AMBERSIE, A., DUTREIX, A., DUTREIX, J ., LEL·
LOUCH, J., MousTACCHI, E., and TuBIANA, M.
(1966). "Efficacite biologique relative d'un faisceau
d' electrons de 20 MeV en fonction de la profondeur,"
Int. J. Radiat. Biol. 10, 261.
WAMBERSIE, A., and DUTREIX, A. (1971). "ProblemeE
dosimetriques poses par la determinations de l'EBR
dans un large domaine d'energie (electrons de 15 ii
34 MeV, photons de 55 kV a 20 MV)," page 261 ir
Biophysical Aspects of Radiation Quality, IAE..A
Publication STl/PUB/286, (International Atomic
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WAMBERSIE, A., PRIGNOT, M., and GuEULETTE, J.
(1973). "A propose du remplacement du radium par
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 ICRU Reports

ICRU Reports are distributed by the ICRU Publications' office. Infor-

mation on prices and how to order may be obtained from:

ICRU Publications
P.O. Box 30165
Washington, D.C. 20014
U.S.A.

Downloaded from http://jicru.oxfordjournals.org/ at Universite Laval on July 9, 2016

The extant ICRU Reports are listed below.

ICRU Title
Report No.
lOb Physical Aspects of Irradiation (1964)
lOc Radioactivity (1963)
lOd Clinical Dosimetry (1963)
lOe Radiobiological Dosimetry (1963)
lOf Methods of Evaluating Radiological Equipment and
Materials (1963)
12 Certification of Standardized Radioactive Sources
(1968)
13 Neutron Fluence, Neutron Spectra and Kerma (1969)
14 Radiation Dosimetry: X Rays and Gamma Rays with
Maximum Photon Energies Between 0.6 and 50
MeV (1969)
15 Cameras for Image Intensifier Fluorography (1969)
16 Linear Energy Transfer (1970)
17 Radiation Dosimetry: X Rays Generated at Poten-
tials of 5 to 150 kV (1970)
18 Specification of High Activity Gamma-Ray Sources
(1970)
19 Radiation Quantities and Units (1971)
19S Dose Equivalent [Supplement to ICRU Report 19]
(1973)
20 Radiation Protection Instrumentation and Its Appli-
cation (1971)
21 Radiation Dosimetry: Electrons with Initial Energies
Between 1 and 50 Me V (1972)
22 Measurement of Low-Level Radioactivity (1972)
23 Measurement of Absorbed Dose in a Phantom Irra-
diated by a Single Beam of X or Gamma Rays
(1973)
24 Determination of Absorbed Dose in a Patient Irra-
diated by Beams of X or Gamma Rays in Radio-
therapy Procedures (1976)
25 Conceptual Basis for the Determination of Dose
Equivalent (1976)
19
20 · · · ICRU Reports

26 Neutron Dosimetry for Biology and Medicine (1977)

27 An International Neutron Dosimetry Intercompari-
son (1977)
28 Basic Aspects of High Energy Particle Interactions
and Radiation Dosimetry (1978)
29 Dose Specification for Reporting External Beam
Therapy with Photons and Electrons (1978)

Binders for ICRU Reports are available. Each binder will accommodate
from six to eight reports. The binders carry the identification, "ICRU
Reports," and come with label holders which permit the user to attach
labels showing the Reports contained in each binder.
The following bound sets of ICRU Reports are also available:
Volume I. ICRU Reports lOb. lOc. lOd. lOe, lOf
Volume II. ICRU Reports 12, 13. 14, 15, 16, 17, 18, 19, 19S, 20
Volume III. ICRU Reports 21, 22, 23, 24, 25, 26
(Titles of the individual Reports contained in each volume are given in

Downloaded from http://jicru.oxfordjournals.org/ at Universite Laval on July 9, 2016

the list of Reports set out above.)

The following ICRU Reports were superseded by subsequent Reports

and are now out of print:
ICR U Report No. Title and Reference•
1 Discussion on International Units and Standards for
X-ray Work. Brit. J. Radiol. 23, 64 (1927).
2 International X-ray Unit of Intensity, Brit. J. Radiol.
(new series) 1, 363 (1928).
3 Report of Committee on Standardization of X-ray
Measurements, Radiology 22, 289 (1934).
4 Recommendations of the International Committee for
Radiological Units, Radiology 23, 580 (1934).
5 Recommendationlj of the International Committee for
Radiological Units, Radiology 29, 634 (1937).
6 Recommendations of the International Commission
on Radiological Protection and of the Interna-
tional Commission on Radiological Units, National
Bureau of Standards Handbook 4 7 (U.S. Govern-
ment Printing Office, Washington, D.C., 1951).
7 Recommendations of the International Commission
for Radiological Units, Radiology 62, 106 (1954).
8 Report of the International Commission on Radiol-
ogical Units and Measurements (ICRU) 1956, Na-
tional Bureau of Standards Handbook 62 (U.S. Gov-
ernment Printing Office, Washington, D.C., 1957).
9 Report of the International Commission on Radiol-
ogical Units and Measurements (ICRU) 1959, Na-
tional Bureau of Standards Handbook 78 (U.S. Gov-
ernment Printing Office, Washington, D.C., 1961).
lOa Radiation Quantities and Units, National Bureau of
Standards Handbook 84 (U.S. Government Printing
Office, Washington, D.C., 1962).
11 Radiation Quantities and Units (International Com-
mission on Radiation Units and Measurements,
Washington, D.C., 1968).
• References given are in English. Some of the Reports were also published in other
languages.
Index

Aim of therapy, 3 Specification of target absorbed dose, 4, 11, 13-14

Curative treatment of malignant disease, 3 Complex treatments: general recommendations, 14
Palliative treatment of malignant disease, 3 Electron therapy, 14
Treatment of non-malignant disease, 3 Moving beam therapy, 13
Absorbed dose pattern, 4, 10, 14, 15 Stationary beams of photons, 11
Isodose plan, 10, 15 Variation in target absorbed dose, 4, 14
Representation of a spatial by a set of planar dose distributions, Specification point, 14
4, 14 Stationary beams of photons, specification of target absorbed dose

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Beam(s), 10 in, 11
Arrangement of, 10 Intersecting beams, 11
Modifying devices, 10 Opposed, equally weighted beams, 11
Weighting, 10 Opposed, unequally weighted beams, 11
Complex treatments, general recommendations, for specification of Single beam, 11
target absorbed dose in, 14 Target absorbed dose, 3-5, 14
Computers, 1, 5, 10 Maximum, 5, 10
for calculation of absorbed dose pattern, 1, 5, 10 Mean, 5, 10
for obtaining patient anatomy, 1 Median, 5, 10
for recording patient data and treatment procedures, 1 Minimum, 5, 10
Dose rate, 17 Modal, 5, 10
Electron therapy, specification of target absorbed dose in, 14 To be specified for reporting, 10
Fields sizes, 10 Variation in, 4,J4
For SAD, 10 Target area, 3, 5
For SSD, 10 Target volume, 3
Hot spots, 5, 14 Contents of, 3
In vivo dose measurements, 10 Delineation of, 3
Irradiated volume, 4 Description of, 3
Lattice (points), 4, 5 Number of target volumes, 3
In three-dimensional dose calculations, 4 Variation of during treatment, 3
In two-dimensional dose calculations, 5 Time-dose pattern, 17
Moving beam therapy, specification of target absorbed dose in, 13 Gap, 17
Occult disease, 3 Number of fractions, 17
Organs at risk, 4, 14 Overall time, 17
Planning sections, 4, 15 Tissue heterogeneity, 10
Construction of, 4 Treatment technique, 10, 17
Contents of, 4 Beam geometry, 10
Orientation of, 15 Beam modification devices, 10
Selection of, 4 Beam weighting, 10
Radiation quality, 10, 17 Field sizes, 10
RBE, 17 Patient positioning, 10
Recording of absorbed dose delivered, 1 Radiation quality, 10, 17
Computers in, 1 Treatment volume, 4
Purpose of, 1 Tumor volume, 3

21
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