Normalization: Define normalization and how it impacts a plan.

Provide a visual of
before and after normalization is applied to help describe its impact.

Normalization basically alters the dose to meet the criteria that you, the dosimetrist,
have given it. You can think of it as a sound mixer board. You have all these volumes
that you can adjust individually for your guitars, vocals, bass, drums, etc. Once you
have your levels set correctly for each aspect, you have a master volume that can be
turned up and down for the entirety of your board. Normalization works the same way.
After applying field weights, wedges, etc., normalizations increase or decrease dose to
the entirety of the plan evenly.
When you get a prescription, what does the dose mean? Are we trying to achieve this
dose to a single point or to reach a certain volume? This is where normalization comes
in handy to adjust the monitor units to reach the desired amount of dose to cover a
certain amount of volume. Let us take for instance this plan that I created. I made one
plan without normalization and another with it. The plans are exactly the same except
for the normalization. Here it is without normalization.
  
The plan without normalization has satisfied the prescription. It can be seen at the
center point, isocenter, shows that our prescribed 5040 cGy has been reached. Though
this plan fits the criteria, this dose does not cover the entirety of the PTV. We can see
that the plan is very conformal with little to no hot spots. The issue here is that the
prescribed dose is not being received to the entirety of the volume.
Here is the plan with normalization.
Here we see that the dose has went up at our center, but we have better 100%
coverage for our volume. What we have essentially done is say that we agree with the
conformity of the dose, but we need more coverage of the 100% isodose line. What we
are saying is that from the unnormalized plan, make it to where the new 100% dose is
now the 94.25%. By converting this information, we have told the TPS to increase the
MUs to satisfy the amount of volume we are trying to get – specifically, it has increased
the monitor units by 100/94.25 = 1.06 or 6% more MUs for each field. You can see the
difference below.
The two DVHs that I posted with the plan, I zoomed in on the graph to show the 95% up
close. Because I did this, it looked as if the dose never reached 5040 cGy for the plan
without normalization. If I had not zoomed in on the DVH, we would have seen what
was happening with both plans. The prescription was for 5040 cGy to the esophagus.
The plan without normalization reached 100% dose but only covered roughly 20%
volume, because if we do not normalize the plan, we are telling the TPS to just reach
this dose to Isocenter no matter how much is covered. Once I normalized the plan to
100% dose covers 95% volume, the dose went up to allow better coverage. Hopefully,
that makes sense to what happened.
Here are some new images without it zoomed.
Above is without normalization. The dose reached 5040 cGy, but you can see that the
coverage is only about 20%. Normalization gives us the ability to manipulate the dose
and coverage to meet the needs of the prescribed dose. In this case we want 95% of
the dose to reach 100% of the volume.
Above is with normalization. Nothing else was changed with the plan other than this. We
now have 100% of the volume getting 95% of the prescribed dose.
Below is also a comparison of the two plans. The square line is without normalization
and the triangle line is with normalization.

You can see by adjusting the normalization we can get the proper amount of dose to the
volume.