Plan Evaluation in

External Beam
Radiotherapy

BY
SIDHARTHA DEV PATTANAIK
RESIDENT MEDICAL PHYSICIST
HBCH/MPMMCC,VARANASI
 Introduction
In the age of modern technology, with conformal radiation the norm in
most clinics, the task of assessing plan quality, in terms of target coverage and
normal tissue sparing, has become increasingly important, as well as more
complicated. A large variety of widely available treatment techniques all aim
to achieve a high degree of conformality, along with adequate sparing of
critical structures.
A typical patient will have several treatment plans that include at
least one target volume and several critical organs. The doses to all of these,
as well as therelative importance of under and overdoses to targets and
organs at risk (OARs), need to be examined.
 Goals of Treatment Planning

• Prescription dose conforms to target

volume
• Normal tissues are not excessively
irradiated
• PTV receives uniform dose
• Doses to OARs do not exceed tolerance
values
 Plan evaluation will involves
Checking • Hot and Cold Spots and their
location
• Dose Prescription point or isodose • Conformity , homogeneity and
line.
other relevant Indices according to
• Global Dose Maxima. the demand of the plan.
• Dose volume Parameters of PTV • DVH shape and distribution
and OARs.
• Beam’s Eye view and DRRs
• Plan sum of phases if any. • Number of Mus
• Target Volume coverage by
prescribed doses and other isodose • Volume of Dose calculation
lines. • CT image length
Plan Evaluation
Evaluation could be broadly defined in two
categories:
1)Qualitative Analysis
2)Quantitative Analysis
Qualitative
analysis
• Slice by slice evaluation of dose distribution in terms of Isodose curves and
colour wash.
• BEV dose coverage.
• REV(Room’s eye view):planner can simulate any arbitrary viewing location
within the treatment room.
• Low dose spillage.
• Plan normalization point
• Global dose maxima
 Slice By Slice Evaluation

• Review Dose Distributions in all Slices.

• The target contour of each slice should be covered by minimum 95% of the
prescribed dose.
- One has to select as high a isodose level as possible.
• Identification of hot spots/cold spots
- Location of these hot spots should not be in OARs (Serial Organ)
 Beam’s eye view
• Observer’s viewing point is at the
source of radiation looking out
along axis of radiation beam.
• Demonstrates geometric coverage
of target volume by the beam
• Shielding & MLCs are design can be
verified on BEV ,
eg, we can check whether the
isocenter or the reference point used
for normalization is not blocked or is at
a safe distance from the MLC leaf.
• Beam’s Eye View (BEV) can indicate
whether OARs are appropriately
shielded by MLCs and jaws.
• Useful in identifying best gantry,
collimator, and couch angles to
irradiate target & avoid adjacent
normal structures by interactively
moving patient and treatment beam
ROOM’S EYE VIEW
 Room’s eye view
• The REV display provides a viewing • It also helps to view desirable dose
point simulating any arbitrary clouds in 3D and to identify the hot
location within the treatment room. spots in the 3D vision.
• The REV helps to better appreciate • Provides visual verification of field
overall treatment technique allignment and matching in 3D.
Geometry and placement of the
isocenter.
Plan Normalization
✓After the dose calculation is over,
the dose at some point has to be
normalized to 100%
✓ This point can be anywhere in the
grid: User’s choice
Check Global Dose
Maximum
✓ Not more than 107% for 3-D CRT,
may be up to 115% for IMRT.
✓Should be within CTV, preferably
within GTV.
✓The global dose maxima should not
be outside GTV.
 Hot spot
• Hot spot (ICRU 50,62) is defined as volume outside PTV that receives dose larger
than 100% of prescribed PTV dose and more than 15mm diameter.
• In case of critical organs even point dose is a hot spot.
• Volume : <15-20% of the PTV
• Magnitude : Overdosing exceeds 15% of the prescribed dose
<15 % volume at the 110% dose level
< 1% volume at the 115% level
Location : Within the CTV (Preferably GTV) acceptable ; not acceptable on the
periphery of PTV
• Global dose maxima should not be more than 107% for 3DCRT plans, can be higher
for IMRT , but preferably within 115%.
 Cold spot

• Volume : <1% of PTV

• Magnitude : Underdosing exceeds 5% of the Prescription dose
• Location : Periphery of PTV is acceptable, Never Acceptable within GTV and
CTV
Quantitative
Analysis
 Dose Statistics

• Provide quantitative information on the volume of the target or

critical structure and on the dose received by that volume.

• These key statistics can be calculated from the matrix of dose to

each volume element within the region of interest.
 Dose statistics includes
• Minimum Dose • Mean Dose
✓ Strong correlation between Target ✓ Indicator of Dose Uniformity within the
minimum dose and clinical outcome target volume

• Maximum Dose ✓ Should be very close to Prescribe dose

✓ Useful Tool for Critical Structures (Serial • Dose received by atleast 95% of
OARs) the volume.
✓ Typically Tolerance Dose • Volume irradiated to atleast 95%
of the prescribed dose.
 For Target Volumes

• Target volume maximal dose ideally should not be more than 5-7% of the
prescribed dose and minimum dose to the target volume should not be less
than 5% of pre scribed dose
• ICRU 83 report is used for describing IMRT has described D98%, D50%, and
D2%. (Dmax, Dmedian and Dmin)
• Dmax are checked in the dose color wash in each slice to note its location;
whether it is within the PTV
Example of differential DVHs and their corresponding cumulative DVHs. The dose–volume metrics,
Dnear-min = D98 %,D95 %, D50 % (median), and Dnear-max = D2 % are indicated for the PTV.
 For OARs

• In case of serial OARs, Dmax is checked as to whether it is limited to within

tolerance doses.
• In parallel OARs, Dmean is seen for analysis. Dmax is also noted to check
for any undue hot spots.
• Check plan sum of all phases of the treatment plan to ensure once more
that all dose parameters are within prescribed limits
 Dose Volume Histogram

• DVH summarizes the information contained in the 3D dose

distribution (in a graphical 2D format).
Types :
✓Cumulative DVH
✓Differential DVH
 Cumulative DVH
• Illustrates the volume of a structure receiving a given dose or greater
• Useful for indicating whether dose-volume constraints are met
 Differential DVH
• Illustrates the volume of the a structure receiving a given dose
• Useful for indicating maximum and minimum doses
• Nice tool for assessing PTV dose uniformity
 DVH Interpretation

• Whether PTV coverage is

adequate?
• Whether OARs are being
adequately spared?
• Target volume maximal
dose?
• Target volume minimal
dose?
• Serial OAR: Dnearmax
• Parallel OAR: D50%
 Dose Homogeneity using DVH
• A perfectly homogenous dose to the PTV would be characterized by :
✓A spike like delta function in the differential DVH
✓A vertical drop of the cumulative DVH line for the PTV
• in differential DVH it is usually a near Gaussian shape tightly distributed
around the mean.
• the standard deviation can also be a good tool homogeneity of dose
distributed inside the target.
 Demerits

• No spatial information regarding dose distribution .

• Location of HOT/ COLD spot
✓ Whether it occurred in one or several disconnected regions
✓ Cannot be the sole criterion for evaluation/ disclosing best plan
• Interpretation of the plot can be subjective and the implication of small
differences between DVH’s is poorely understood.
 Dosimetrical Indices
• Dose volume histogram (DVH) provides dose volume
coverage information. However, it fails to provide more
information like homogeneity , conformity etc. for which
some dosimetrical indices were introduced for better
Quantitative plan evaluation.
 Some of them are the
following:
1. Conformity index (CI).
2. Homogeneity index (HI). 5. Conformity number (CN).

3. Gradient index 6. Conformal Index (COIN)

4. Target coverage index (TCI). 7. Critical organ scoring index (COSI)

for the OAR
 Conformity Index (CI)
• It is defined as a ratio between the volume •
covered by the reference isodose (95%
isodose) and the target volume
designated as planned target volume
(PTV).
• Dose conformity characterizes the degree
to which the high-dose region conforms to
the target volume,
Conformity indexRTOG = VRI/TV
Where VRI = Reference isodose volume
and TV = Target volume.
ICRU, Wambersie and
Landberg 1999
CI = 1 indicates that 100% of a
prescription dose is delivered to the PTV,
and no dose is delivered to any adjacent
tissue.
• CI >1 indicates irradiated volume > target
volume.
• CI <1 indicates target volume is
partially irradiated
• Higher CI values indicate poorer dose
conformity to the PTV.
• CI values had been defined to determine the quality of
confirmation (RTOG)
1<CI<2 : comply with the treatment plan
2<CI<2.5 or 0.9<CI<1 : minor violation
CI>2.5 or CI<0.9 :major violation
• Drawbacks :
✓It can never take into account the degree of spatial intersection of two volumes or
their shapes.

Four possibility for CI=1

Shaded region: target volume
Dashed line: reference isodose
 Homogeneity index
• Homogeneity index (HI) is a simple and
fast scoring tool for analyzing and
quantifying dose homogeneity in the target
• HI of zero indicates that the absorbed-dose
distribution is almost homogeneous.
volume.

• HI is defined as
(D2% − D98% )
D50%
Where Dx% represents dose delivered to x%
of the target volume.
• Drawbacks:
✓No sufficient data regarding correlation between homogeneous dose distribution and
better clinical outcome
✓Non homogeneous dose distribution may help increase tumour control in case of
higher dose to high malignant tissue or radio resistant tissue density regions.
 Upper left panel shows the effect
of unequal beam weighting to
protect OARs.

Lower left panel shows the effect

of unequal beam weighting and
use of a wedge.

Upper right panel shows the effect

of many beam portal angles with
variable weighting.

Lower right panel indicates the

effect of 180 deg portal
separation and lack of avoidance
of the OARs

The PTV is in blue and the PRV is in orange. Dashed lines indicate
isodose lines.
 Dose Gradient Index
• DGI quantifies the dose fall off normal tissue sparing.
outside the target(PTV). • DGI is an important tool to evaluate
• DGI is the ratio of the volume of a SRS/SBRT plan , Lesser the DGI
50% prescribed dose to that of the value better is the fall off , better will
prescribed dose. be Normal Tissue sparing.

• DGI =V50%/V100%.
• The lower DGI value means a
steeper gradient of dose distribution
outside the target, as well as better
 Target coverage index (TCI)

• TCI refers to the exact coverage of PTV in a treatment plan for a given
prescription dose.
PTVPD represents PTV volume coverage at the
prescription dose.

PTV represents PTV volume.

 Conformity number (CN)

• Conformity number (CN) is a relative measurement of dosimetric target

coverage and sparing of normal tissues in a treatment plan.

Knoos et al (1998)

• PTVPD refers to PTV coverage at the prescription dose and PIV represents
prescription isodose surface volume
• The first fraction of this equation is a measure of the dosimetric target
coverage, and the second is a measure of how much normal tissue is
irradiated..

• 0<CN<1, where 1 is the ideal value

• CN approaching 0 indicates that either the target is underdosed or the
irradiation volume is very large when compared with the target volume.

• CN = 1 : perfect conformity, with the whole target receiving the prescription

dose and no normal tissue irradiation.

• CN = 0.:complete miss of the target .

• Demerits :
✓it does not yield any false positives. However, the product
of the two measures leads to a loss of information, so that
different plans, with vastly differing potential outcomes,
can yield identical values of CN.
 CONFORMAL INDEX(COIN) Baltas et al (1998).
• COIN is the product of the
conformation number (CN)and a
term accounting for critical organ
doses.

CN
 COIN value lies between
0 to 1
COIN=0 signifies that
atleast one of the critical
structures is fully irradiated
with the reference isodose
or complete miss of the
target .

The term C3 takes unwanted irradiation to the critical COIN=1 signifies complete
structure into account PTV coverage and no
reference dose or higher is
delivered to normal tissue
or any OAR
• Drawbacks :
✓It mixes information about target coverage, surrounding normal
tissue and specific OARs, and it is impossible to discern the
contribution of each term to the resultant COIN value.
✓COIN only accounts for OAR volumes receiving prescription doses
and higher. However, in many cases, OAR tolerances are lower than
tumour prescription doses
 Critical organ scoring index (COSI) for the OAR
Menhel J et al(2006)

• COSI is a measure of both target coverage and critical organ overdose.

• COSI = 1 − (V (OAR)>tol/TCI)
Where V (OAR)>tol is the fraction of volume of organ at risk receiving more
than tolerance dose, and
TCI is the target coverage index
• COSI approaches unity when the critical structure is completely spared
and the target coverage is unity.
Drawbacks :
✓ when COSI is less than one, it is unclear if this is due to a dosimetric miss in target coverage, or
an excess dose to an OAR.

✓ COSI, similar to other conformity indices, yields a false perfect score if the OAR is completely
spared,regardless of tumour coverage.
 2D representation of COSI versus CI Menhel J et al(2006)

• COSI addresses OAR overdoses and target underdoses; however, it contains

no information about overall plan conformity which is provided by CI.
• To overcome these problems and facilitate the choice of an optimal
treatment plan, Menhel J et al proposed a 2D representation of COSI
versus conformity index (CI), as defined by Lomax and Scheib (2003):
• CI = VT,PI/VPI
VT,PI is the volume of PTV receiving the prescription dose or more
VPI is the volume enclosed by the prescription isodose.
• The combination of CI and COSI compensates both for the loss of information contained
in the definition of COSI and CI when each is used separately. Thus, if COSI = 1 due to
complete organ sparing, but the target conformity is poor, this will be reflected in a low CI
value.
 Reliability of indices
• These Indices are good for fast scoring any plan but they are ratios i.e
Relative in nature.
e.g For a small PTV say volume 10 cc PTV , CI =2 is acceptable, but for large
PTV say volume 500 cc?
It won’t be acceptable.
• These indices are usually based on two or three points of the dose volume
histogram (DVH) curve, and do not reflect information from the whole DVH

Hence along with it Qualitative plan evaluation is also necessary

 Conclusion
• There are various ways to evaluate or score a plan.
• HI, CI and other indices give a quick method to score a plan ,but these are
relative in nature, should be used cautiously to evaluate a plan.
• DVH sum up the dose distribution in 2D graph , gives statistics to quickly
analyze the plan but throw away the spatial information .
• Evaluation slice by slice is a cumbersome process but give actual dose
distribution and give us chance to locate hot spots and cold spots.
• Hence both qualitative and quantitative evaluation together will help us to
choose or score a treatment plan .
 References
• Icru 83
• Slide share
• Physical and Radiobiological Evaluation of RadiotherapyTreatment PlanSuk Lee, Yuan
Jie Cao and ChulYong Kim
• The physics of radiation therapy by F.M KHAN.
• Assessing the quality of conformal treatment planning: a new tool for quantitative
comparison ;J Menhel1, D Levin1, D Alezra, Z Symon and R Pfeffer
• A CONFORMAL INDEX(COIN) TO EVALUATE IMPLANT QUALITY AND DOSE
SPECIFICATION IN BRACHYTHERAPY; BALTAS(1999)
• DOSE VOLUME HISTOGRAM: R. E. DRZYMALA
• PLAN EVALUATION PRESENTATION BY Mr. Narender Kumar
Thank you!!!