Principles of Isodose Planning

Isocenter
• Intersection of axis of rotation of the Gantry and the axis of rotation of the collimator for
the treatment unit.
• Once it rotates to 360 degrees, it forms a circle, and the central point is the isocenter.
Terms and Abbreviations for Tumor Localization or Simulation:
1. SAD – Source to Axis Distance (80/100 cm)
2. SSD – Source to Skin Distance
3. STD – Source to Tumor Distance
Dose Theory
• LET and RBE
o The effectiveness of ionizing radiation in living tissues depends on the partial
amount of energy deposited in living tissues.
o Since we’re using x-rays and gamma rays, which are electromagnetic radiation, our
LET kind of radiation is low energy because they’re highly penetrable, not easily
blocked. Unlike alpha and beta, they can easily be blocked.
o RBE – Effects of biological parts of human
▪ Deterministic – Produces higher dose over a short period of time
• Early effects
• Threshold value
▪ Stochastic – Produces low dose over a long period of time
• Late effects
• Non-threshold value
Dose Calculations (3 major factors)
1. Beam Energy
2. Field Size – The greater the field size, the greater the need for beam energy.
3. Distance from the source of radiation – If the distance from the source of radiation is
farther, the beam energy is higher
Note: These factors are used to calculate the dosage.
Other terms
• Dose
o Energy absorbed dose or energy deposited to the patient or tumor
o Rad/Gray
o 1 rad = 0.01 Gy
o 100 rads = 1 Gy
o cGy (centigray) – 10 cGy = 1 Gy
Note: Once you measure the background radiation, the unit is Sievert (Sv)
• Depth
o Distance beneath the skin surface where the prescribed dose to be delivered
(tumor).
• Separation
o Measurement of patient thickness from the beam entry to beam exit.
• Field size
o Set on the collimator in the treatment unit that delineates the size of the treatment
field at a preference distance.
o In the linear accelerator (radiation therapy), once the collimator is increased, the
field size is bigger (direct relationship).
▪ Multileaf collimator
o In general x-rays, once the collimator is increased, the field size is smaller (indirect
relationship).
Tissue Absorption Factors
• Attenuation
o Removal of energy from beam of ionizing radiation when it traverses matter by
disposition of energy in matter and by deflection of energy out of the beam.
o Helps to measure the attenuation of the beam of radiation.
o Attenuation occurs when the beam energy traverses the matter.
• 4 factors
o PDD – Percentage Depth Dose
▪ Ratio expressed as a percentage of absorbed dose at a given depth to the
absorb dose at a fixed reference depth.
▪ Dependent on Energy, Field size, Depth and SSD
o TAR – Tissue-Air Ratio
▪ Ratio of the absorbed dose at a given depth in phantom to the absorbed dose
at the same point in free space.
▪ We need to measure the tissue-air ratio because the air is also an attenuated
material. Air attenuates radiation.
▪ Dependent on Energy, Field size and Depth
o TPR – Tissue-Phantom Ratio
▪ Ratio of the absorbed dose at a given depth in phantom to the absorbed dose
at the same point at a reference depth in phantom.
▪ Commonly used for dose calibration.
▪ The phantom used is water
o TMR – Tissue-Maximum Ratio
▪ The ratio of the dose rate with a medium (water/phantom) to the dose rate
at the same point at the level of Dmax.
• The term Dmax refers to the maximum dose at 100%.
Law of Bergonie and Tribondeau
• Also known as Radiosensitive law
• Cancer cells are immature
o High metabolic level
o Always reproduce
o Stem cells are radiosensitive
o The younger the tissue, the more radiosensitive
• Normal cells are mature cells
o Once the normal cells reach a mature state, they stop reproducing.
o The older the tissue, the more radioresistant
• Metabolic level is directly proportional to radiosensitivity level.
• When the proliferation rate increases, radiosensitivity increases.
o Direct proportional
Clinical Method of Treatment
• A
o Protraction
▪ Delivery of dose over an extended period of time
▪ Not equal: If the dose prescribed by the doctors is 5000 cGy, On the first
day, you have to deliver the 500 cGy. On the second day, you have to deliver
the 300 cGy. Until you reach the dose of 5000 cGy,
o Fractionation
▪ Dividing of dose into a number of smaller doses distributed over a long
period of time.
▪ Equal dose: For example, if the dose prescribed by the doctor is 5,000 cGy,
then 5,000 cGy will be divided by 30 days. Then the patient can receive
150 cGy each day.
o 5 factors why fractionation is better than protraction?
▪ Recovery – can only be applied to normal cells; This is to recover the
normal cells in order to avoid the cell death
▪ Repopulation – can only be applied to normal cells; if the normal cells are
not repaired at any point in time, this will give them time to repopulate
(transfer).
▪ Re-oxygenation – can only be applied to cancer cells (highly oxygenated
cells; hyperoxia)
• Oxygen is the main key or formula in producing a free radical. Since
we used x-ray radiation (x-rays are uncharged particles) (the action
of DNA is indirect), once the radiation hits, it hits the water
molecule + oxygen, causing a free radical. Free radicals will be the
one to kill the DNA of cancer cells. This is referred to as radiolysis
of water
▪ Redistribution – can only be applied to cancer cells (highly oxygenated
cells; hyperoxia)
• Cell cycle phase (M, G1, S, G2) – to determine where is the
radiosensitive cell.
• G1 phase (growth) is the pre-DNA synthesis phase; intermediate (in
between radioresistant and radiosensitive); because its repair portion
accessible; G1 is the stage where the cell is preparing to divide
• The DNA synthesis phase is S. During this period, each DNA
molecule is replicated into 2 identical DNA molecules.
• During S phase, the chromosome is transformed from a structure
with 2 chromatids attached to a centromere to a structure with 4
chromatids attached to a centromere. The results is 2 pairs of
homologous chromatids, that is , chromatids with precisely the same
DNA content and structure.
• G2 phase is the post DNA synthesis gap of cell growth. This is
where it organizes and condenses the genetic material or starts to
condense the genetic materials and prepares to divide into the
mitosis.
• The next stage is M. M stands for mitosis. This is where the cell
actually partitions the two copies of the genetic material into the two
daughter cells. After M phase completes, cell division occurs and
two cells are left, and the cell cycle can begin again.
• While they are in cycle, there are parts that are radiosensitive and
there are parts that are radioresistant.
• Late S phase – This is the most radioresistant because its proportion
of repair is greater. Once it is greater, it is rare that it can be
radiosensitive to radiation.
• The highly radiosensitive phase is the G2 to M.
 ▪ Radiosensitivity – can only be applied to cancer cells (highly oxygenated
cells; hyperoxia)
• Dependent to redistribution
Note: It’s not necessary to give the high dosage to the patient unless needed. If we’re going to give
the high dosage every day, there is a possibility that the normal cells will malfunction or die.
Note: Our body is composed of 80% water molecules
• B
o Palliative treatment
▪ The treatment of the patient with a terminal illness and it’s not intended to
cure but rather to relieve the symptoms of their disease.
▪ It is required in a situation where tumors causing obstructive symptoms.
o Curative Treatment
▪ The treatment of the patient with the intent to cure their diseases or
condition
• C
o Pre-operative technique
▪ Done before and in preparation or surgical operation.
o Post operative technique
▪ Done after surgical operation.
Note: The pre and post operative technique is also used to reduced local recurrence which is
associated with the pain and obstruction and to prevent disease dissemination (propagation,
spreading) from the local site.
2 main aspects of radiation dosimetry
• Measurement of quantity of radiation emitted by the source.
• Measurement of quantity of radiation absorbed by the body tissues.
Dosimetry
• The concepts and measurements of quantity of radiation.
o Ionization chamber is to measure this quantity directly and are used to determine
the amount of radiation produced by x-ray equipment.
▪ Performed by the physicist in reading and they are the only one who used
this in terms of measurement in radiation.
• It is the design and monitoring of a technique for the precise application of a dose of
ionizing radiation to the tumor without irreparably damaging the surrounding normal
tissues.
Dosimetrist
• An individual who receive specific training in the aspect of dosage measurement and
calculation for radiation therapy.
 Gynecologic Cancers (Pelvic Cancer)

Thermoplastic mask used for head cases or whole brain cases; used by a pediatric patient.
This is painted mask to motivate them to undergo radiation therapy treatment,
Note: For pelvic cancer cases or gynecologic cancer cases, use pelvic mask wherein the body
of the patient immobilize.

Linear Accelerator belong to External Beam Radiation Therapy

Gynecologic Cancers
• These are tumors that originate in the female reproductive system and can be divided into
carcinomas of the following:
o Cervix
o Uterus
o Ovaries
o Vulva
o Vagina
Cervical Cancers
• These are histologically classified by their tissue of origin.
• The two primary types of cervical carcinomas are squamous carcinoma and
adenocarcinoma.
o Belongs to epithelial tissues (lining of the skin)
• Squamous cell carcinoma is the most common and accounts for 80% to 90% of cervical
cancers. These cancers originate in the squamous cells of the exocervix.
• The second most common type, adenocarcinoma, accounts for 10% to 20% of cervical
cancers and typically carries a worse prognosis.
Endometrial cancers
• These are usually arise in the lining of the uterus and begin to grow and invade the uterine
wall.
• The uterus is located in the pelvis between the bladder (posterior) and rectum (anterior). It
is divided into 2 parts:
o The body (corpus)
o Cervix
• The 3 inner layers of the uterus are divided into the
o Serosa (Parietal Peritoneum)
o Myometrium (Smooth Muscle)
o Endometrium (Mucous membrane)
• Endometrial cancers originate from the endometrium layer of the uterus. This layer is
greatly affected by fluctuations in estrogen levels.
• Most cases of endometrial cancer affect postmenopausal women at the age of 55 years and
older.
• Incidence rates of endometrial cancers are higher among white women but black women
have a higher mortality rate.
 We need to know where the lymph nodes are because cancer spreads to the lymphatic
system and must be treated.
Ovarian cancer
• Originates in the tissue of the ovaries, which is a female reproductive gland.
• The ovaries produces eggs (ova) for reproduction.
• Most ovarian cancers are either epithelial carcinoma or malignant germ cell tumors which
are more prevalent in younger women.
• Vulva cancers are uncommon malignancies that account for 4% of all gynecologic cancers
and less than 1% of all cancers in women. This is primarily a disease of elderly women
with more than half of the cases occurring in women over the age of 70 years.
o Vulva cancers are superficial (visible)
o Rare
o Vulva – outer layer of the vagina
▪ Labia majora (outer lips)
▪ Labia minora (inner lips)
 ▪ Clitoris
▪ Opening of the vagina (vestibule)
Note: Vaginal Cancer is not well understood. A strong correlation exists between human
papillomavirus (HPV) and the development of vaginal cancer. Other risk factors include smoking,
multiple sexual partners, sexual intercourse at an early age, sexually transmitted diseases (STD),
diethylstilbestrol exposure, immunosuppression and a history of vaginal irritation.
Vulva
• Outermost portion of the female genitalia
• The major parts includes the labia majora and labia minora, clitoris, and the area bound by
these three, which is the vestibule.
Vagina
• It is the muscular tube that extends 6 to 8 inches from the cervix of the uterus to the vulva.
• It is surrounded by the rectum, urethra and bladder, specifically anterior to the rectum and
posterior to the bladder.
Anatomy and Physiology
Cervix
• It is part of the female reproductive system
• It is also made up of the external genital organs, including the parts that make up the vulva
(the clitoris, vaginal lips and the opening to the vagina)
• The cervix is the lower, narrow part of a women’s uterus or womb.
• The cervix connects the main body of the uterus to the vagina or birth canal.
• It is about 2 cm (1 inch) long
• It is made up mostly of connective tissue and muscle.
• Cervix is divided into 2 main parts
o Endocervix – It is the inner part of the cervix lining the canal leading into the
uterus.
o Ectocervix (exocervix) – It is the outer part of the cervix. It is rounded, lip-like and
sticks out into the vagina.
• Main types of cells in the cervix
o Columnar cells line the endocervical canal. They are glandular cells that make
mucus. They are called columnar cells because they are tall and shapes like
columns.
o Squamous cells line the ectocervix and vagina. They are flat and thin like the
scales on a fish.
 CT image of the genitalia; Transverse plane
Screening
• Pap smears identify abnormal cells that may develop into cancer.
 • During a Pap examination, a healthcare provider inserts a speculum into the vagina to
reveal the cervix. The cells of the cervix are collected with a cervical brush and then
prepared for analysis underneath a microscope. Current guidelines recommend that women
have a Pap smear every 3 years beginning at the age of 21 years old.
Note: Colposcopy is performed on women with abnormal Pap smear results or at a high risk for
development of cervical cancer. This test uses a magnifying microscope to examine the cervix for
visible abnormalities.
• During a colposcopy, abnormal areas can be excised with a punch biopsy method.
o This type of biopsy removes a small piece of tissue from the cervix with use of
forceps.
Note: Cervical intraepithelial neoplasm (CIN) is a precancerous condition in which squamous cells
that line the cervix become dysplastic. This condition is not cancer and usually lasts years before
development into invasive cervical cancer.

Staging and Pathology

Conization
• It is performed when no tumor is visible on the cervix but the clinician suspects an
endocervical tumor. Cone biopsies offer 2 approaches for abnormal cell removal.
o Loop Electrosurgical Excision Procedure (LEEP) and the cold knife cone
biopsy. LEEP removes abnormal cells from the cervix with a thin wire loop heated
with electric current.
o The Cold Knife Biopsy Method uses a scalpel or laser for removal of tissue.
Imaging Studies
• The following diagnostic examinations to detect metastasis
o Chest X-ray
o Magnetic Resonance Imaging (MRI)
o Computed Tomographic (CT) Scan
o Positron Emission Tomography (PET)/CT Scan
o Cystoscopy
o Proctoscopy
• CT Scan and MRI are both equally effective in assisting clinicians to detect the extent of
lymph nodes involvement. PET/CT Scan is more sensitive than MRI or CT scan in
detection of lymph nodes and therefore has become the most widely used type of imaging
test in the staging of cervical cancer.
Staging
• The most commonly used staging systems for cervical cancer are the International
Federation of Gynecology and Obstetrics (FIGO) and the American Joint Commission on
Cancer (AJCC) and tumor node metastasis (TNM) staging systems
• The FIGO system is widely used by gynecologists and gynecologic oncologists. These 2
staging systems are very similar with the only difference being that the FIGO system
excludes stage 0.
 • Both staging systems classify cervical cancers based on the extent of the tumor (T), cancer
spread to lymph node (N) and the spread to distant sites (M)
Note: Squamous Cell Carcinoma (SCC) and Adenocarcinoma are the 2 most common tumors of
the cervix.

Prior to Radiation Therapy Treatment

• Patient Preparation
o Recommended baseline workup
▪ Complete Medical History
▪ Physical examination, including bimanual vaginal rectal examinations.
▪ Tumor diagram in 3D with measurements.
▪ Diagnostic procedure: Punch Biopsies (edge of gross tumor, 4 quadrants in
pre invasive lesions). All lesions must be confirmed by histopathological
examination.
o Laboratory Studies
▪ Complete blood count test – CBC should be normal
• Blood chemistry including creatinine level: creatinine clearance or
glomerular filtration rate from the creatinine in serum.
• Liver function tests should be obtained and monitored with the renal
function tests in those patients who may be receiving extended field
radiotherapy.
▪ Urine analysis
▪ Pregnancy test in patients of childbearing age.
▪ Optional: HIV testing and if positive
o Imaging studies
▪ Standard
 • Chest X-ray (anteroposterior (AP) and lateral)
• Intravenous Urography (IVU) or Ultrasound of the kidneys (not
necessary if CT or MRI is performed)
• CT of abdomen and pelvis with and without intravenous and oral
contrasts
▪ Optional
• MRI of the pelvis and without gadolinium
• F-fluorodeoxyglucose (FDG) PET scan or PET/CT Scan
Simulation (first step)
• Before simulation, the patient is asked to drink 20-30 minutes before the scan. This helps
to fill your bladder
• Patient is required to have a full bladder so that some of the bowels are pushed out of the
area that is going to be treated.
o The purpose of full bladder is to distend the large intestine in order for the patient
to avoid dehydration and to avoid diarrhea.
• During simulation, patient will lie on the treatment table. The radiation therapist will
position the patient in the precise way patient will ultimately be treated and then watch the
patient through a window while a CT scanner takes images on the treatment site. Patient
must lie still during simulation so that the exact area to be treated can be pinpointed.
• The radiation therapist may use special pads, body molds or other devices to help hold the
patient’s body comfortable in the proper position.
3D Image Guided Planning
• Highly recommended to improve the delineation of target structures and exclusion of
normal tissues including bowel, bladder and bone marrow.
• Intravenous contrast for CT scan be helpful in differentiation of reginal lymph nodes from
vessels and delineation from bladder.
• CT allows delineation of the uterus but does not differentiate tumor from normal uterus.
Note: Placement of a gold seed marks into the cervix or into the most distal visible or palpable
vaginal tumor extent is recommended.
• It is about the size of a grain of rice that are put in and/or around a tumor to show exactly
where it is in the body.
• Doctors are then able to target the tumor directly and give higher doses of radiation with
less harm to nearby healthy tissue.
• However, rigid vaginal marker, rectal marker or rectally administered CM are not
recommended.
 Gold seed markers or fiducial markers
Target Description
Primary Cervical Tumors GTV (Gross Tumor Volume): Entire uterus and tumor
extensions to parametria, uterosacral ligaments and vagina
based on imaging and implanted markers (from
palpation/inspection)
• Radiation oncologist – one who determines GTV

CTV (Clinical Target Volume): additional 0.7 cm to 1 cm

margin, 3 cm margin distal to the cervix or lowest vaginal
tumor extent

PTV (Planning Target Volume): +0.5 cm to 1 cm margin (to

account for setup variability)
Note: Contouring of normal structures includes the rectum (up to the rectosigmoid junction),
bowel (including large bowel above the rectum) and the intraperitoneal contents (small bowel and
mesentery) within 5 cm above the upper border of the target volume, bladder and femoral heads.
Note: Simulation position for cervix cancers is supine with arms above the head.
• Most comfortable
• Produce reproducibility
• Stabilizes the pelvis

Immobilization Device
• When patient is in simulation position, the following immobilization devices can be used
• Knee rest
o Relaxes lower back making patient more comfortable
o Minimizes rotation of pelvis
• Pelvic mark
o Disadvantages
▪ Lack of bony points for fixation
▪ Continuing of abdominal movement with respiration
 ▪ Alpha Cradle

Radiation Therapy Techniques

• Simulation and Field Arrangements
• Dose and Treatment Delivery
• Three-Dimensional Conformal Radiation Therapy
• Intensity-Modulated Radiation Therapy
• Target Volume Delineation
• Brachytherapy – IBRT; Internal Beam Radiation Therapy
Dose and Treatment Delivery
• Dose and Treatment Delivery
• External Beam Radiation Therapy (EBRT)
o 45-50 Gy in 25-28 daily fractions using 6-1.8 MV photon beams
• Treatment Techniques
o Box-field Technique (4 fields)
o AP/PA Para-aortic – AP (gantry angle is 0-degree); PA (gantry angle is 180-degree)
o AP/PA Pelvis with midline block (midline block for tumor so that it will be reserved
for Brachytherapy)
o Bilateral Parametrial Boost
o Brachytherapy

Para-aortic L1-L5
 Bilateral Parametrial Boost
Treatment fields/borders used in the treatment of endometrial cancer
Fields Borders
AP/PA Superior: top of L5
Inferior: bottom of the obturator foramina
Laterally: 2 cm beyond the bony margins of the pelvis inlet
Lateral Superior/inferior: as AP/PA fields
Anterior: in front of the pubic symphysis
Posterior: S2-23
3D CRT, IMRT, Target Volume Delineation
• IMRT
o If very poor differentiated, use this technique
o Used to modulate the beam
o Irregular shape
o More advanced than 3D CRT
o Expensive
o Consist of 7 fields (AP, PA, Obliques)
• Three-dimensional Conformal Radiotherapy (3D CRT) based on CT imaging allows the
delivery of radiation to the tumor target volume while limiting the dose to normal
surrounding structures. Thus, potentially contributing to minimizing the treatment related
toxicity
o Regular shape
o If low grade tumor, use the 3D CRT because it is composed of 4 fields (AP, PA,
Right and Left Lateral)
o Cheaper than IMRT
• Definitions of Gross Tumor Volume (GTV), Clinical Target Volume (CTV), Planning
Target Volume (PTV) and Internal Target Volume (ITV) in 3D-CRT and IMRT are as
follows:
 o GTV – The entire uterus (in inoperable cases)
o CTV – Vaginal cuff, obturator lymph nodes and external/internal or common iliac
lymph nodes
o PTV - Organs at risk to be contoured are bladder, small bowel, rectum, bone
marrow and the femoral heads

Each organs at risk corresponds to each color

Note: The histogram indicates the amount of dose received by each organ.
Field name Border Bony Landmark
AP-PA Fields Superior L4-L5 or L5-S1 intervertebral
space

Inferior Lower border of obturator

foreman. In the case of vaginal
extension, there should be a
distal margin of 3-4 cm. from
the most caudal extent of the
vaginal extent.

Latera 2 cm lateral to the pelvic brim

to adequately cover the
external iliac and obturator
nodes.

Lateral fields Superior L4-L5 or L5-S1 intervertebral

space

Inferior Lower border of the obturator

foramen. In the case of vaginal
 extension, there should be a
distal margin of 3-4 cm from
the most caudal extent of the
vaginal involvement.

Anterior Anterior face (cortex) of the

pubic symphysis

Posterior Include all the sacral hollow

with margin (1-1.5 cm)

Parametrial Boost
• Boosts the lateral parametrial is common practice at centers that treat significant numbers
of cervical cancer patients presenting with stages IIB and IIIB
• Generally, parametrial boost is initiated often 45-50 Gy has been delivered to the entire
pelvis and after the bulk of parametrial disease at presentation.
• The overall treatment time for the whole pelvis EBRT, intracavity BT and parametrial
boost should not exceed 8 weeks.
Para-aortic irradiation
• Prophylactic treatment – it is an advanced treatment or forward treatment.
• The incidence of pelvis lymph node involvement for patients with FIGO stages IB, IIB and
IIIB cervical cancer are approximately 15, 30, and 50% respectively.
• The incidence of para-aortic lymph node metastasis also increases with tumor stage of
about 5, 20 and 30% of patients with FIGO stage IB, IIB, IIIB disease, respectively, have
a para-aortic lymph node metastasis at diagnosis.
• For each stage, the risk of lymph node involvement is correlated with the tumor.
Adverse Effects of Radiotherapy and How to Manage it
• Anemia - low blood count
o Anemia is a frequent clinical feature of patients presenting with cervical cancer due
to several factors:
▪ Tumor and patient related factors
• Prolonged vaginal bleeding
• Poor nutritional condition
• Delayed diagnosis
• Advanced disease
• Renal failure secondary to chronic obstructive nephropathy
▪ Treatment related factors
• Bone marrow toxicity related to radiotherapy to the pelvis and/or
para-aortic nodes
• Concurrent chemotherapy
• Lack of supportive care during therapy (iron supplementation,
transfusions)
• In the presence of anemia, the effectiveness and outcomes of
radiotherapy are reduced due to the relative.