By definition normalization means making conform to a standard.

¹ There are
multiple different ways to normalize isodose lines in order to meet a physician's required
coverage in a plan. The variability in site to site protocol means that normalization and
preferred methods can vary, all to reach a similar end goal. Some of the different methods a
treatment planning user can normalize are; to a target maximum or minimum, percent dose
covering a set percent of target volume (i.e. 100% covering 95% PTV), 100% at body
maximum dose, or using a reference point. There are many ways to normalize dose within a
plan. The end goal is to provide sufficient coverage of the prescription dose while
maximizing conformity and minimizing dose to critical healthy organs.

At VCU we typically normalize using body maximum. From shadowing and

experience talking to other dosimetrists this seems to be a less common method for
standard practice. Based on the views or preferences of the policies set in place, this is our
standard. When normalizing off of body max dose, the ‘hot spot’ in your plan will not show
isodose lines over 100%. For lack of a better term, you normalize down to find sufficient
PTV coverage. A typical range for normalization we are expected to meet for a 3D plan is
90-95%. This means that when I calculate dose to the plan I create, the hot spot will show
100% somewhere in the irradiated tissue volume. By adding field in fields or wedges, we
can adjust the dose distribution and push the areas of higher dose to those getting less
coverage. My plan may then show that the 92% line provides sufficient PTV coverage
needed to meet my physicians’ expectations. Using body maximum dose, we then can
normalize down to the 92% line. Essentially saying that, in order to conform to this new
standard, the 92% isodose line is now the 100% isodose line. The spots previously
receiving 100% of the dose will now become the hot spots. Dose to those areas is roughly
equivalent to the percentage they are above the normalization line (i.e. 100% is now a
108% when the plan is normalized to 92% line). These values will be represented by
absolute dose. This image shows absolute dose for a plan prescribed to 2500cGy at CTV
shown in translucent red. The blue isodose line represents 95% of the total body max dose
2500cGy. This represents a plan using body maximum dose, pre normalization.
 I understand that not every clinical site uses body maximum dose. A more common
technique is to normalize to a percent coverage. A typical value for this method would be
100% of the prescription dose covering 95% of the target volume. The effect is essentially
equivalent, but the method of removing the hot areas within the plan is slightly changed.
Since the normalization is designed to give the coverage of dose to the tumor volume, there
will be hot spots of dose within the irradiated volume. Those areas will be represented by a
value above 100%. These hot spots are at values related to the normalization percentage.
So when a dosimetrist asks the planning system to give 95% PTV coverage, those areas
must receive a higher dose in order to reach that percent coverage. The values you see
may be very high and that can indicate that the plan must be optimized through other
methods first before adding field in fields or wedges. A dosimetrist can then decide on an
isodose line that they want to remove and create the fields required to reduce the hot spot
areas to an acceptable level, say 107%.

Essentially the different normalization methods are different ways of accomplishing the
same goal. Normalization methods create modifiable means of adjusting isodose levels to a
PTV structure. There may only be so much optimization you can do within the constraints of
where the tumor resides. After diligent planning, normalization provides dosimetrists a way
to give proper coverage to the target volume.

1. Pickett B, Altieri G. Normalization: What does it really mean? Medical Dosimetry.

1992;17(1):15-27. doi:10.1016/0958-3947(92)90004-y