Strategies For Radiation Therapy Treatment Planning

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SHAH•VIDETIC•SUH
STRATEGIES FOR RADIATION
XIA•GODLEY•
THERAPY TREATMENT PLANNING
Ping Xia, PhD • Andrew Godley, PhD
Chirag Shah, MD • Gregory M. M. Videtic, MD, CM, FRCPC
John H. Suh, MD
STRATEGIES
STRATEGIES FOR RADIATION THERAPY TREATMENT PLANNING

FOR RADIATION
Strategies for Radiation Therapy Treatment Planning provides radiation oncologists,
physicists, and dosimetrists with a step-by-step guide to implementing external beam
treatment plans that meet clinical requirements for each major disease site. As a
THERAPY TREATMENT
companion book to the Handbook of Treatment Planning in Radiation Oncology Second
Edition, this book focuses on the technical aspects of treatment planning and the major
challenges in creating highly conformal dose distributions, referenced to as treatment
plans, for external beam radiotherapy. To overcome challenges associated with each
step, leading experts at the Cleveland Clinic have consolidated their knowledge and
experience of treatment planning techniques, potential pitfalls, and other difficulties to
develop quality plans across the gamut of clinical scenarios in radiation therapy. PLANNING
The book begins with an overview of external beam treatment planning principles,
inverse planning and advanced planning tools, and descriptions of all components
in simulation and verification. Following these introductory chapters are disease-
site examples, including central nervous system, head and neck, breast, thoracic,
gastrointestinal, genitourinary, gynecologic, lymphoma, and soft tissue sarcoma. The
book concludes with expert guidance on planning for pediatric cancers and how to
tailor palliative plans. Essential for all radiation therapy team members, including
trainees, this book is for those who wish to learn or improve their treatment planning
skills and understand the different treatment planning processes, plan evaluation, and
patient setup.
KEY FEATURES:
• Provides basic principles of treatment planning
• Contains step-by-step, illustrated descriptions of the treatment planning process
• Discusses the pros and cons of advanced treatment planning tools, such as
auto-planning, knowledge-based planning, and multi-criteria based planning
• Describes each primary treatment site from simulation, patient immobilization,
and creation of various treatment plans to plan evaluations
• Includes instructive sample plans to highlight best practices
• Comes with access to the fully downloadable eBook
Recommended Shelving Category:
Oncology
PING XIA
ANDREW GODLEY
CHIRAG SHAH
GREGORY M. M. VIDETIC
An Imprint of Springer Publishing
11 W. 42nd Street
New York, NY 10036
www.springerpub.com
JOHN H. SUH
Editors
Ping Xia, PhD Andrew Godley, PhD

Staff Physicist Staff Physicist
Department of Radiation Oncology Department of Radiation Oncology
Taussig Cancer Center Taussig Cancer Center
Cleveland Clinic Cleveland Clinic
Cleveland, Ohio Cleveland, Ohio
Chirag Shah, MD Gregory M. M. Videtic, MD, CM, FRCPC

Staff Physician Staff Physician
Department of Radiation Oncology Department of Radiation Oncology
Taussig Cancer Center Taussig Cancer Center
Cleveland Clinic Cleveland Clinic
Cleveland, Ohio Cleveland, Ohio
John H. Suh, MD
Staff Physician
Department of Radiation Oncology
Taussig Cancer Center
Cleveland Clinic
Cleveland, Ohio
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Library of Congress Cataloging-in-Publication Data
Names: Xia, Ping, editor. | Godley, Andrew, editor. |

Shah, Chirag, editor. | Videtic, Gregory M. M., editor. | Suh, John,
editor.
Title: Strategies for radiation therapy treatment planning / editors, Ping
Xia, Andrew Godley, Chirag Shah, Gregory M. M. Videtic, John H. Suh.
Description: New York : Demos Medical Publishing, [2018] | Includes
bibliographical references.
Identifiers: LCCN 2018021687 | ISBN 9780826122445 | ISBN 9780826122674 (ebook)
Subjects: | MESH: Radiotherapy—methods | Radiotherapy Planning,
Computer-Assisted | Neoplasms—radiotherapy | Patient Care Planning
Classification: LCC RC271.R3 | NLM WN 250.5.R2 | DDC 616.99/40642—dc23
LC record available at https://lccn.loc.gov/2018021687
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18 19 20 21 22 / 5 4 3 2 1
I would like to dedicate this book to my dear mentor,
Dr. Lynn Verhey. Twenty-three years ago, when I was a
medical physics resident at the University of San Francisco,
Dr. Verhey advised me to be involved in treatment
planning, to be actively engaged in clinical practice,
and to advance technology in radiation oncology by
conducting research.
Ping Xia
CONTENTS
Contributors ix
Preface xiii
Share Strategies for Radiation Therapy Treatment Planning
1. Overview of External Beam Treatment Planning Principles 1

Ping Xia, Andrew Godley, Anthony Mastroianni, and John H. Suh
2. Inverse Planning and Advanced Treatment Planning Tools 11

Jeremy Donaghue, Ping Xia, Naichang Yu, John Greskovich,
and John H. Suh
3. Overview of Simulation and Verification 23

Lisa Zickefoose, Andrew Godley, Andrew Vassil, and Chirag Shah
4. Central Nervous System 37

Matt Kolar, John Potter, Salim Balik, Gennady Neyman, Joycelin
Canavan, and John H. Suh
5. Head and Neck Planning 55

Eric Murray, Ping Xia, Andrew Dorfmeyer, Nikhil Joshi, Daesung Lee,
and Shlomo Koyfman
6. Breast Cancer 103

Taoran Cui, Eric Murray, Eva Suarez, and Chirag Shah
7. Thoracic Cancer 127

Michelle Sands, Carol Belfi, Tingliang Zhuang, Michael Weller,
and Gregory M. M. Videtic
8. Gastrointestinal Radiotherapy 143

Anthony Magnelli, Lisa Zickefoose, Jennifer Archambeau,
Ehsan H. Balagamwala, and Gregory M. M. Videtic
9. Genitourinary Cancer 165

Salim Balik, Radoslaw Szwedowski, Elaine Kunka, Cory Hymes,
Omar Mian, George Engeler, and Chirag Shah
viii ■ Contents
10. Gynecologic Cancer 201
Susan Kost, Carol Belfi, D. Allan Wilkinson, Henry Blair, and
Sudha Amarnath
11. Lymphoma 227

Bingqi Guo, Cory Hymes, Sheen Cherian, and Gregory M. M. Videtic
12. Soft Tissue Sarcoma 235

Kyle Verdecchia, Lama Muhieddine Mossolly, Matt Kolar,
Eric Murray, Lanea Keller, and Chirag Shah
13. Pediatric Cancer 255

Nicky Vassil, Andrew Godley, Mihir Naik, and Erin Murphy
14. Palliative Treatment 269

Peng Qi, Kristan Pechatsko, Saju Rajan, and John H. Suh
Abbreviations 293
Index 297
CONTRIBUTORS
Sudha Amarnath, MD, Staff Physician, Department of Radiation

Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
Jennifer Archambeau, CMD, Dosimetrist, Department of Radiation

Ehsan H. Balagamwala, MD, Staff Physician, Department of Radiation

Salim Balik, PhD, Staff Physicist, Department of Radiation Oncology,

Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
Carol Belfi, CMD, Dosimetrist, Department of Radiation Oncology,

Henry Blair, MD, Staff Physician, Department of Radiation Oncology,

Joycelin Canavan, MD, Staff Physician, Department of Radiation

Sheen Cherian, MD, Staff Physician, Department of Radiation Oncology,

Taoran Cui, PhD, Physics Resident, Department of Radiation Oncology,

Jeremy Donaghue, MS, Staff Physicist, Department of Radiation

Andrew Dorfmeyer, CMD, Dosimetrist, Department of Radiation

George Engeler, MD, Staff Physician, Department of Radiation Oncology,

Andrew Godley, PhD, Staff Physicist, Department of Radiation Oncology,

John Greskovich, MD, Staff Physician, Department of Radiation Oncology,

x ■ Contributors
Bingqi Guo, PhD, Staff Physicist, Department of Radiation Oncology,
Cory Hymes, CMD, Dosimetrist, Department of Radiation Oncology,

Nikhil Joshi, Staff Physician, Department of Radiation Oncology, Taussig

Cancer Center, Cleveland Clinic, Cleveland, Ohio
Lanea Keller, MD, Staff Physician, Department of Radiation Oncology,

Matt Kolar, MS, Staff Physicist, Department of Radiation Oncology,

Susan Kost, PhD, Staff Physicist, Department of Radiation Oncology,

Shlomo Koyfman, MD, Staff Physician, Department of Radiation

Elaine Kunka, CMD, Dosimetrist, Department of Radiation Oncology,

Daesung Lee, MD, Staff Physician, Department of Radiation Oncology,

Anthony Magnelli, MS, Staff Physicist, Department of Radiation

Anthony Mastroianni, MD, Staff Physician, Department of Radiation

Omar Mian, MD, PhD, Staff Physician, Department of Radiation

Lama Muhieddine Mossolly, MS, Staff Physicist, Department of Radiation

Erin Murphy, MD, Staff Physician, Department of Radiation Oncology,

Eric Murray, CMD, Dosimetrist, Department of Radiation Oncology,

Mihir Naik, DO, Staff Physician, Department of Radiation Oncology,

Contributors ■ xi
Gennady Neyman, PhD, Staff Physicist, Department of Radiation
Kristan Pechatsko, BAR.T. (R)(T) CMD, Dosimetrist, Department of

Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland,
Ohio
John Potter, CMD, Dosimetrist, Department of Radiation Oncology,

Peng Qi, PhD, Staff Physicist, Department of Radiation Oncology, Taussig

Saju Rajan, MD, Staff Physician, Department of Radiation Oncology,

Michelle Sands, PhD, Physics Resident, Department of Radiation

Chirag Shah, MD, Staff Physician, Department of Radiation Oncology,

Eva Suarez, MD, Staff Physician, Department of Radiation Oncology,

John H. Suh, MD, Staff Physician, Department of Radiation Oncology,

Radoslaw Szwedowski, CMD, Dosimetrist, Department of Radiation

Andrew Vassil, MD, Staff Physician, Department of Radiation Oncology,

Nicky Vassil, CMD, Dosimetrist, Department of Radiation Oncology,

Kyle Verdecchia, PhD, Physics Resident, Department of Radiation

Gregory M. M. Videtic, MD, CM, FRCPC, Staff Physician, Department

of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland,
Ohio
Michael Weller, MD, Staff Physician, Department of Radiation Oncology,

xii ■ Contributors
D. Allan Wilkinson, PhD, Staff Physicist, Department of Radiation
Ping Xia, PhD, Staff Physicist, Department of Radiation Oncology, Taussig

Naichang Yu, PhD, Staff Physicist, Department of Radiation Oncology,

Lisa Zickefoose, CMD, Dosimetrist, Department of Radiation Oncology,

Tingliang Zhuang, PhD, Staff Physicist, Department of Radiation

PREFACE
This book began when Dr. Gregory Videtic suggested that our physics
and dosimetry groups develop a companion to his Handbook of Treatment
Planning in Radiation Oncology second edition, for which he is the senior
editor, to cover the strategies of treatment planning. After reviewing previous
treatment planning texts, we realized that there is a lack of prescriptive instruc-
tion books for treatment planning in modern radiation therapy. Therefore, this
book would not only be a partner for the current “Handbook,” but also a neces-
sity on its own.
The original “Handbook” provides indications and requirements for clin-
ical treatment planning aspects. Our book details the technical aspects of
how to achieve those requirements, including patient positioning, creation
of patient-specific bolus, beam angle configurations, and inverse planning
optimization approaches. Our book is written for everyone involved in treat-
ment planning, whether they are looking to commence or enhance their skills,
including dosimetrists, physicists, and physicians. This book is organized
as the original “Handbook” was, by body site or system; however, planning
strategies for one treatment site can be applied to others. For example, the
Head and Neck chapter has the most comprehensive approach to inverse plan-
ning optimization, but this can be applied to all sites.
For each site, there is a description of patient simulation, including immo-
bilization, setup, isocenter placement, and any special considerations such
as motion management. The plan goals for each treatment site are tabulated,
followed by recipes to achieve them from the simplest planning technique
to the most advanced planning technique. For simple 3D conformal plans,
the recipes include the field arrangement and portal shape design (both with
many figures), beam weighting, and selection of dose normalization point.
For advanced techniques such as intensity-modulated radiation therapy,
volumetric modulated radiation therapy, and stereotactic body radiation
therapy, the recipes provide details of creation of optimization structures and
multiple stage optimizations. Each chapter concludes with plan evaluation,
comparing achieved doses to the clinical planning goals. There are three
introductory chapters. The first describes the types of treatment plans and the
general process of treatment planning. The second chapter explains the prin-
ciples and limitations of current inverse planning optimization algorithms,
and discusses the application of auto-planning, knowledge-based planning,
and multi-criteria optimization to overcome these limitations. Although
xiv ■ Preface
each chapter has site-specific simulation details, a chapter on simulation
is included to cover the available immobilization equipment and general
principles of simulation, including patient safety procedures.
This book was a team effort from the entire Cleveland Clinic Radiation
Oncology Department, including dosimetrists, physicists, radiation oncolo-
gists, and therapists, even though they may not all be listed as co-authors.
What we described in this book reflects our current practice at Cleveland
Clinic. Our experiences are based on a particular treatment planning system,
but no specific planning system of therapy equipment is being endorsed, and
the methods described to achieve the quality plans are agnostic to the plan-
ning system used. We would like to acknowledge Peng Qi, PhD, medical
physicist, who generously offered to generate all the dose volume histograms
used in the book. Lastly, we would like to thank our co-editors Dr. Chirag
Shah, Dr. Gregory Videtic, and Dr. John Suh, who encouraged us and care-
fully reviewed each chapter.
Ping Xia
Andrew Godley
OVERVIEW OF EXTERNAL
BEAM TREATMENT
1 PLANNING PRINCIPLES
Ping Xia, Andrew Godley,

Anthony Mastroianni, and John H. Suh
What is Treatment Planning?..........................................................................1

The Importance of Treatment Planning .........................................................2
Treatment Plan Preparation............................................................................2
SSD Versus SAD Treatment Planning.............................................................2
Treatment Target Volumes and Planning Margins ........................................5
Treatment Plan Types ......................................................................................5
Prescription and Normalization Methods ......................................................7
Open Field, Wedged Field, and Field-in-Field .................................................7
Forward Planning Versus Inverse Planning ...................................................9
Boost: Sequential Versus Integrated..............................................................9
IMRT and VMAT Delivery Methods .............................................................. 10
WHAT IS TREATMENT PLANNING?

■ Treatment planning consists of two components: clinical treatment plan-
ning and technical treatment planning.
■ Clinical treatment planning refers to the treatment intent, treatment modal-
ity, and treatment dose scheme (total prescription dose and number of
fractions).
■ Technical treatment planning refers to the details of patient positioning,
placement of radiation beams, and the aperture shapes of radiation beams
designed to achieve highly conformal radiation dose distributions to the
treatment target volumes (delineated by radiation oncologists in the clinical
planning process) while protecting the critical organs.
■ This book focuses on technical treatment planning, especially for external
beam treatments. Throughout the book, we refer to the technical component
of treatment planning as the treatment plan.
2 ■ Strategies for Radiation Therapy Treatment Planning
THE IMPORTANCE OF TREATMENT PLANNING
■ The quality of a treatment plan can vary drastically, primarily depending on
the following technical parameters:
● The radiation beam orientation (or beam angles) in combination with the
treatment couch angles

● The number of beams
● Radiation beam energies
● Beam shapes (portals) or number of sub-shapes (apertures or segments)
TREATMENT PLAN PREPARATION

■ This section covers the initial planning steps after simulation (discussed in
Chapter 3) is completed.
■ Define the isocenter of a plan by either directly importing the coordinates
of the isocenter from the CT simulation or locate the three markers (called
BBs) in the planning CT and place the isocenter in the center of the axis
defined by the three markers.
■ Remove the CT couch from the CT scan, which often contains metal and
does not reflect the treatment couch. Immobilization devices on the CT
couch, which will be used in treatment, should not be removed.
■ If the planning CT is acquired with oral contrast, manually override the
contrast density with the tissue density since the contrast will not be admin-
istered during daily treatment.
■ If a large metal implant (such as hip prostheses), which may introduce
image artifacts, is present, manually override the artifact region with a uni-
form tissue density of 1 gm/cm3.
■ Verify all contours to ensure there are no small holes inside or dots outside
of any contours due to the use of contouring tools.
■ Table 1.1 (A and B) lists the standard names for all organs at risk (OAR)
used at the Cleveland Clinic. Use of standard OAR names is important
for plan evaluation (see discussion in subsequent chapters) and for future
outcome studies.
SSD VERSUS SAD TREATMENT PLANNING

■ The SSD treatment method sets the source-to-skin (patient) distance (SSD)
to a defined integer: 100 cm, 105 cm, or 110 cm.
■ The SAD treatment method sets the source-to-axis (isocenter) distance
(SAD) to an accelerator dependent integer: 100 cm.
■ For treatment simplicity and efficiency, most modern treatments with pho-
ton beams use the SAD treatment method.
1: Overview of External Beam Treatment Planning Principles ■ 3
TABLE 1.1
(A) Standard Names for Brain and Head and Neck Sites
Brain Head and Neck
GTV_XXXX* OPTIC_ PET_MTV LIPS

NRV_L
CTV_XXXX* OPTIC_ MR_GTV MANDIBLE
NRV_R
PTV_XXXX* PITUITARY CT_GTV OPTIC_NRV_L
GTV_YYYY* RETINA_L GTV_XXXX OPTIC_NRV_R
CTV_YYYY* RETINA_R CTV_XXXX ORAL_CAVITY
PTV_YYYY* SPINAL_ PTV_XXXX PAROTID_L
CORD
BRAIN SPINAL_ CTV_YYYY PAROTID_R
CORD_PRV5
BRAINSTEM TEMP_ PTV_YYYY PHARYNX
LOBE_L
BRAINSTEM_ TEMP_ AVOIDANCE PITUITARY
PRV5 LOBE_R
CHIASM HIPPO_L BRAIN SKIN
COCHLEA_L HIPPO_R BRAINSTEM SPINAL_CORD
COCHLEA_R HIPPO_L_ BRAINSTEM_ SPINAL_CORD_
PRV5 PRV5 PRV5
GLOBE_L HIPPO_R_ CHIASM SUBMANDIBULAR_
PRV5 L
GLOBE_R COCHLEA_L SUBMANDIBULAR_
R
HYPOTHALMUS COCHLEA_R SUPRAGLOTTIC
LENS_L CONSTRICTOR TEMP_LOBE_L
LENS_R ESOPHAGUS TEMP_LOBE_R
GLOBE_L TM_JOINT_L
GLOBE_R TM_JOINT_R
LARYNX TONGUE
LENS_L TRACHEA
LENS_R
*GTV_XXXX and GTV_YYYY where XXXX and YYYY are the prescription doses
in cGy. If there are more prescription dose levels, add GTV, CTV, and PTV in the same
fashion.
(continued)
TABLE 1.1 (continued)
(B) Standard Names for Breast, Thorax, Pelvis, Prostate, and GYN Sites
Breast Thorax Pelvis Prostate GYN
TUMOR_ GTV_XXXX* GTV_XXXX PTV_XXXX GTV_XXXX

BED
BREAST_L CTV_XXXX* CTV_XXXX PTVN_ CTV_XXXX
YYYY
BREAST_R PTV_XXXX* PTV_XXXX BLADDER PTV_XXXX
HEART BONE ANAL_ BLADDER_ CTV_YYYY
CANAL CTV
LUNG_L BRONC_TREE BLADDER FEMUR_L PTV_YYYY
LUNG_R CARINA BONE FEMUR_R BLADDER
WHOLE_ ESOPHAGUS CAUDA_ LYMPH_ BONE
LUNG EQUINA NODES
SPINAL_ HEART FEMUR_L PENILE_ FEMUR_L
CORD BULB
KIDNEY_L FEMUR_R PROSTATE FEMUR_R
KIDNEY_R KIDNEY_L PROSTATE_ KIDNEY_L
BED
BOWEL KIDNEY_R RECTUM KIDNEY_R
LIVER BOWEL SEM_VES LG BOWEL
LUNG_L LIVER RECTUM
LUNG_R PENILE_ SACRUM
BULB
WHOLE_LUNG PROSTATE SM BOWEL
SPINAL_CORD RECTUM
SPINAL_ SACRUM
CORD_PRV5
TRACHEA SEM_VES
STOMACH
SPINAL_
CORD
SPINAL_
CORD_PRV5
TESTIS
*GTV_XXXX and GTV_YYYY where XXXX and YYYY are the prescription doses in
cGy. If there are more prescription dose levels, add GTV, CTV, and PTV in the same fashion.
CTV, clinical target volume; GTV, gross tumor volume; MTV, metabolic target volume;
PTV, planning target volume; PTVN, planning target volume of lymph nodes.
TREATMENT TARGET VOLUMES AND PLANNING MARGINS
■ The goal of treatment planning is to achieve the required dose coverage of
the planning target volume (PTV). Typically, adequate PTV dose coverage
means 95% of the PTV receiving the prescription dose.
■ The PTV is expanded from the gross tumor volume (GTV), clinical target
volume (CTV), and the internal target volume (ITV), which is the GTV or
CTV plus motion.
■ The amount of the expansion is called the planning margin. This expansion
can be uniform in three dimensions or nonuniform, depending on the clini-
cal treatment planning intent.
■ The planning margins account for subclinical involvement, the variations
inherent in patient setup, and inter- and intra-treatment motion.
TREATMENT PLAN TYPES

■ From simple to complex, treatment plan types include 2D, 3D, conformal
arc, dynamic conformal arc, intensity modulated radiation therapy (IMRT),
and volumetric modulated arc therapy (VMAT).
■ A 2D plan is based on 2D images, obtained from a conventional simulator.
This type of plan is rarely used today.
■ A 3D plan is based on CT images from a CT simulator, typically consisting
of one to four beams with either square or rectangular beam shapes (open
beams) or simply modified beam shapes from the open field. Figure 1.1
shows a typical four-field box plan for a whole pelvis treatment.
■ A conformal arc plan typically uses a number of cones (in 4, 5 to 17.5
mm diameter with an increment of every 2.5 mm for Varian TrueBeam
SRS package and other vendor specific cone sizes) and delivers these coni-
cally shaped beams in full or partial arcs. Conventional linear accelerator
(linac)-based stereotactic radiosurgery (SRS) plans typically use numerous
conformal arcs to create highly conformal dose distributions.
■ A dynamic conformal arc plan uses the multi-leaf collimator (MLC) to
shape each aperture of an arc beam. These apertures conform to the PTV
(with a defined margin) that is projected on the discretized angles (every
2°–4°) of the arc beam.
■ IMRT plans typically use multiple fixed-angle beams (seven to nine
beams). Each IMRT beam consists of multiple segments with variable
beam intensities measured by monitor units (MU). The composite fluence
from the segments of an IMRT beam comprises the intensity modulation.
Figure 1.2 shows individual segment shapes and a composite fluence from
these segments.
4-Field box
Dose distributions
49 Gy
45 Gy
35 Gy
FIGURE 1.1 Dose distributions of a typical four-field box plan. Note the hot
spot of 49 Gy in blue. The hot spot is defined as the areas that are encompassed
by the isodose lines greater than the prescription dose (45 Gy in this case).
(a) Composite
Fluence
FIGURE 1.2 A composited fluence map and individual segment shapes.

■ VMAT plans consist of one or more arcs. The difference between the VMAT
plans and dynamic conformal arc plans is that the aperture shape for each
discrete angle (every 2°–4°) does not simply encompass the entire PTV,
enabling better protection of critical OARs while still providing conformal
dose coverage to the PTV.
PRESCRIPTION AND NORMALIZATION METHODS

■ Prescription is the intent of the treatment while normalization is the scaling
of the plan required to achieve the prescription dose.
■ The plan can be normalized to a point or a volume. The intent is typically
to achieve the adequate dose coverage to a target volume of 90% to 100%,
which should be specified in the prescription or in institutional protocols.
■ Point-based normalizations are typically used for simple 3D plans, but also for
highly conformal SRS or stereotactic body radiation therapy (SBRT) plans.
■ The normalization point is commonly the isocenter. When the isocenter
falls in or near a heterogeneous region (bone, metal, air), a new calculation
point in a homogeneous region (tissue) is needed to normalize the plan.
■ For SRS or SBRT, the maximum dose point can also be the normalization
point. This has the advantage that the prescription isodose line indicates the
plan homogeneity.
■ Volume-based normalization can represent a mean dose to a target, or the
volume covered by a required dose (e.g., dose to 95% of the treatment target).
OPEN FIELD, WEDGED FIELD, AND FIELD-IN-FIELD

■ An open field is a radiation aperture consisting of uniform intensity where
the field shape may be constructed to block critical structures while still
exposing the PTV to radiation. Figure 1.3 is a typical lateral open field shape
for whole brain treatment.
■ A wedged field decreases linearly the radiation intensity from one side of an
open field to the other. Figure 1.4 shows dose distributions from an anterior
posterior/posterior anterior (AP/PA) plan with a wedge added to the AP
beam to compensate for non-flat anterior sternum.
■ A wedged field can be achieved by inserting a physical wedge in the beam,
or by sweeping an upper jaw from one side of the field to the other.
■ A segment is an incomplete radiation portal because it is not fully opened
to expose the entire projection of the PTV from a specific beam angle.
A simple intensity modulated field can be created by manually construct-
ing a few segments with different intensities. This is done to reduce high
dose regions. Figure 1.5 shows multiple segments manually created for
one of the tangential fields of a whole breast treatment. This is also termed
field-in-field.
FIGURE 1.3 A typical lateral open field shape for whole brain treatment.
30.4, 30, 20, 15Gy
FIGURE 1.4 An anterior wedge was used to shape the dose distribution.
Segment 1 Segment 2 Segment 3 Segment 4
FIGURE 1.5 Four manually created segments for one of the tangential fields for
a whole breast treatment.
FORWARD PLANNING VERSUS INVERSE PLANNING
■ In forward planning, beam apertures are created for all beam directions
with their relative weights adjusted to obtain the desired dose distributions.
2D, 3D, conformal arc, and conformal dynamic arc plans are created using
forward planning.
■ In inverse planning, the desired dose objectives are first entered (more dis-
cussion in Chapter 2) and then computer optimization derives the required
dose distribution from either multiple fixed angle beams or arcs. In a 3D
plan, the dose distribution is fairly uniform, while in inverse planning, the
dose per beam is deliberately nonuniform, or intensity modulated.
■ The inverse planning optimization can either be two-step or direct. In two-
step optimization, the fluence of each beam or arc is first determined, then
converted into multiple segments using a leaf sequencing algorithm. In
this two-step optimization, the beam fluence is an ideal intensity profile,
which does not consider constraints of the deliverability of each treatment
machine. The second step of leaf sequencing incorporates the constraints of
deliverability, which reduces the quality of the fluence plan.
■ In direct optimization, the beam or arc segments are optimized directly to
obtain the desired dose distribution while taking into account treatment
machine parameters, thus ensuring a deliverable plan, with no loss of quality.
■ Fixed gantry IMRT (see following discussion) and VMAT plans are created
using inverse planning.
BOOST: SEQUENTIAL VERSUS INTEGRATED

■ The prescription doses to the primary tumor, lymph nodes, and other
intended targets may differ, depending on the clinical treatment intent.
Typically, the lymph nodes and other targets may be prescribed a lower
dose compared to the primary tumor.
■ To deliver a higher dose to the primary tumor, either a sequential boost or
simultaneously integrated boost (SIB) method can be used.
■ The sequential boost method requires two or more plans, depending on
the number of planned boosts. This method delivers the same daily dose
to both primary tumor and other targets that are planned to receive a lower
total dose.
■ The SIB method requires one plan, delivering different daily doses to the
different target volumes simultaneously. Typically, the SIB method pro-
duces more conformal dose distributions than delivering the boost sequen-
tially. Logistically, the SIB method is simpler.
■ The sequential boost is advantageous when the desired prescription doses
to different tumor volumes differ significantly.
IMRT AND VMAT DELIVERY METHODS
■ Typically, an IMRT plan is delivered by a linear accelerator equipped with
an MLC. It is the MLC that creates the complex segments to deliver the
optimized dose distribution. Although it is possible to deliver IMRT with
rectangular jaw fields only, it is much slower.
■ Dynamic delivery or sliding window refers to the segments of a fixed gantry
angle IMRT field being delivered by sweeping MLC leaves from one side
of the field to the other while the radiation beam remains “on.”
■ Step-and-shoot refers to the segments of a fixed angle IMRT field being
delivered in a sequence of moving MLC leaves (step) and then radiation
beam on (shoot).
■ VMAT delivery is achieved with the gantry continually rotating during
delivery. The MLC leaves are also constantly moving as in dynamic IMRT
delivery.
■ Depending on the capabilities of the accelerator, the rate of gantry rotation
may be constant or variable, and the dose rate may also vary during delivery.
■ By varying the gantry rotation and dose rate, a more modulated plan can
be delivered. Variable gantry rotation speed can also quicken the delivery.
■ During IMRT and VMAT delivery, some linear accelerators require the
secondary jaws (both x and y jaws) to remain open at the largest open field
projection of an IMRT beam or a VMAT arc. Therefore, the jaws are not
following (or conformal) to each segment. Leakage through MLC leaves,
particularly for a VMAT plan, can be non-negligible. Modern accelerators
allow the jaws to track the MLC position at each segment to block this
leakage.
■ To minimize the leakage from MLC during VMAT delivery, non-zero col-
limator angles (typically greater than 10°) should be used to minimize dose
from any remaining MLC leakage.
■ A special linear accelerator called TomoTherapy delivers IMRT plans with
intensity modulated, rotating fan beams while the patient slides through the
accelerator, delivering radiation slice-by-slice similar to how CT images
are acquired.
INVERSE PLANNING AND
ADVANCED TREATMENT
2 PLANNING TOOLS
Jeremy Donaghue, Ping Xia, Naichang Yu,

John Greskovich, and John H. Suh
Inverse Planning Basics ............................................................................... 11

Manually Iterative, Staged IMRT Planning .................................................. 14
Advanced Planning Tools ............................................................................. 15
Auto-Planning Process.................................................................................. 15
Knowledge-Based Planning (KBP) ............................................................... 17
Multi-Criteria Optimization (MCO) ................................................................ 18
Comparing Three Advanced Planning Tools................................................ 20
References .................................................................................................... 21
INVERSE PLANNING BASICS

■ An ideal plan would have the prescribed isodose conform to the planning
target volume (PTV) while having a minimal dose to the nearby organs at
risk (OAR).
■ The conventional 3D plan contains radiation portals with blocks that geometri-
cally shape to the projections of the PTV in the beam’s eye views with block
margins to correct for the beam penumbra. This planning principle works best
if PTVs and OARs are spatially separated, and no OARs are in the beam paths.
■ Using modulated beam intensities (fluence map, an example shown in
Figure 1.2 in Chapter 1) and beams from multiple directions, intensity
modulated radiation therapy (IMRT) plans can overcome the OAR dose
limitations of 3D plans. In addition, IMRT plans use inverse planning with
computational optimization to determine the fluences that can produce the
desired isodose distributions.
■ To obtain an optimal plan, inverse planning includes the following three
key components:
● Planning objectives
● Cost function that measures goodness of a plan
● Optimizer (search engine) to minimize the cost function
■ For users or planners, clearly defining the planning objectives is the most
important and the most challenging aspect because the treatment goals may
compete with each other. The mathematic cost function is inadequate to
describe a clinically desirable 3D dose distribution, which can be consid-
ered a 3D geometric problem.
■ A generic cost function can be defined with the following equation:
n
∑ i =1 wi fi ( x ) (Eq. 2.1)
where n is the number of planning objectives, wi (>0) is the weight factor,

and fi(x) is the individual objective cost function.
■ The weight factor provides users the ability to emphasize the importance
of certain planning objectives, which will be discussed in greater detail in
the later chapters.
■ The typical cost function used in most commercially available treatment
planning systems use the quadratic function, which minimizes the mean
differences between the desired dose and resultant dose. The most com-
mon search engine is a gradient-based optimizer that only accepts changes
resulting in a decrease of the cost function.
■ For parallel organs, dose-volume-based cost functions are needed.
■ Using the gradient search algorithm, the dose-volume-based cost function
can have multiple minima, and thus the final solution may not have the low-
est cost (the best solution; see Figure 2.1).
■ A cost function that can have multiple minima (showed in Figure 2.1) is
known as a non-convex problem (see Figure 2.1A compared to convex
problem B). The non-convex cost can be trapped in a local minimum
(1–3). That means the optimizer thinks that it cannot further reduce
the cost, but there is a better solution available (a global minimum in
Figure 2.1A).
■ Table 2.1 lists numerous types of planning objectives that are used in the
remainder of the book. We also point out whether a specific type of planning
objective is convex or non-convex with additional notes about how to apply
these planning objectives to the different types of structures such as PTV,
parallel OARs, or serial OARs.
■ Table 2.2 shows simple planning objectives used for inverse planning. The
objective value listed in the last column is the weight x (from [Eq. 2.1]) for
the specific planning objective. The lower the value, the closer the objective
is to being met. The optimizer will focus on the functions with the higher
objective value during the optimization process.
2: Inverse Planning and Advanced Treatment Planning Tools ■ 13
Global
minimum
Local
minima
(A) Non-convex function
Global and local

minimum
(B) Convex function
FIGURE 2.1 (A) Illustration of local minima and global minima during
optimization with a non-convex function. (B) Illustration of convex function
where only one minimum exists for optimization.
TABLE 2.1 Types of Planning Objectives, Definition, and Their Application

Objective Function
Function Type Definition How to Apply
Min/Max Dose Convex Maximum or minimum Apply to PTVs

dose to any point and serial OARs
Min DVH Non-convex Dose to % volume > Apply to PTVs
defined dose
Max DVH Non-convex Dose to % volume Apply to parallel
< defined dose OARs and PTVs.
(continued)
TABLE 2.1 Types of Planning Objectives, Definition, and Their Application
(continued)
Objective Function
Function Type Definition How to Apply
Max EUD Convex Controls the distribution Apply to parallel

of the entire ROI. Equal to OARs (a = 1)
mean dose with a = 1
Uniform Dose Non-convex Dose to the entire volume Apply to PTVs
is uniform
DVH; dose volume histogram; EUD, equivalent uniform dose; OAR, organs at risk;
PTV, planning target volume; ROI, region of interest.
MANUALLY ITERATIVE, STAGED IMRT PLANNING

■ The use of the gradient search algorithm and dose-volume-based cost func-
tion, optimization for a complex case (e.g., head and neck treatment) with
numerous sensitive structures requires multiple, manual iterations, also
termed staged planning or warm starts.
■ On the first stage (the first round optimization), planners start with planning
objectives for the PTVs, critical structures, and the ring structure (see more
descriptions in later chapters). The ring structure is used to avoid dose spill-
age to the unspecified normal tissue.
■ On the second round optimization, without resetting IMRT beams (warm
start), the planners add more planning objectives for additional OARs.
TABLE 2.2 An Example of User Entered Planning Objectives

Target % Objective
Structure Type (cGy) Volume Weight Value* a
PTV_6525 Max DVH 6851 3 95 0.0003447

PTV_6525 Min Dose 6520 95 0.0029542
PTV_6525 Uniform 6525 40 0.064708
Dose
SPINAL_CORD Max Dose 3500 0.1 0
PAROTID_L Max DVH 2000 30 0.3 0
SUBMANDIBULAR_L Max EUD 3250 15 0.0045086 1
SUPRAGLOTTIS Max EUD 3000 2.4 0.0101495 1
*Objective Value is calculated by the optimizer.
DVH, dose volume histogram; EUD, equivalent uniform dose; PTV, planning target volume.
■ This process can be repeated multiple times to improve plan uniformity and
conformity while further reducing the dose to all OARs.
■ This manual iterative process is time-consuming for complex cases with
many OARs.
■ Additional tuning structures (mentioned in Chapter 5) can be added to fur-
ther guide the optimizer to remove the hot or cold spots.
ADVANCED PLANNING TOOLS

■ Modern treatment planning systems are implementing advanced plan-
ning tools. These tools include: auto-planning, multi-criteria optimization
(MCO), and knowledge-based planning (KBP).
■ The auto-planning described in the following section is based on the
Pinnacle treatment planning system from Philips (version 9.10 or later). The
KBP is based on Eclipse treatment planning system from Varian Medical
Systems. The MCO is based on RayStation planning system.
AUTO-PLANNING PROCESS
■ The multiple manual iterative planning process can be automated by an
auto-planning module. With the auto-planning module, a six-stage planning
will be executed automatically.
■ Auto-planning is a progressive optimization process. Users enter the plan-
ning goals for the treatment targets and OARs as shown in Tables 2.3 and
2.4. Note that planning goals are not exactly the same as planning objectives
mentioned earlier.
■ On the advanced settings (shown in Figure 2.2), users can set the steepness
of dose gradient and desired dose uniformity. For a conventional IMRT
plan, the dose gradient is set to 2 cm and dose uniformity is set to 107%.
For stereotactic body radiation therapy (SBRT) plans, the dose gradient is
set to 1 cm (the lowest number) and dose uniformity is set to 170%. The
highest dose uniformity index is 250% for a single fractioned brain lesion.
■ During auto-planning, the user’s planning goals are translated into planning
objectives similarly to manual optimization. Table 2.5 is an example of how
the planning goals from Tables 2.3 and 2.4 are translated into the planning
objectives. In this case, four planning goals are translated into 21 planning
objectives during progressive planning.
TABLE 2.3 An Example of Target Planning Goals for a Spine SBRT Case
Structure Target cGy
Tumor L5 1800
TABLE 2.4 An Example of OAR Planning Goals for a Spine SBRT Case
Target
Structure Type cGy % Volume Priority Compromise
Ring Max Dose 1750 High Yes

L5 Thecal Sac Max Dose 1200 High Yes
L5 Thecal Sac Max DVH 800 5 High Yes
DVH, dose volume histogram; OAR, organs at risk; SBRT, stereotactic body radiation
therapy.
■ Extra tuning structures and the associated planning objectives are automati-
cally added. The planning objectives (and weights) that are translated from
the user’s planning goals are also automatically adjusted, resulting in the final
doses to some OARs being lower than the goal dose entered by the planner.
■ Because the auto-planning algorithm used is not as flexible as manual mul-
tiple stage planning, additional manual optimization may still be required
after auto-planning completes.
■ Auto-plans can serve as a good benchmark for plan quality control.
FIGURE 2.2 An example of advanced parameter setting for auto-planning. This

example is set for an SBRT spine case.
OARs, organs at risk; ROI, region of interest; SBRT, stereotactic body radiation therapy.
TABLE 2.5 An Example of How Auto-Planning Translates the Planning
Goals from Tables 2.3 and 2.4 into Objectives in Regular Inverse Planning
Structure Type Target cGy % Volume Weight
BodyMinusTarget Max Dose 614.786 0.125

BodyMinusTarget Max Dose 720 2.9131
L5 Thecal Sac Max DVH 760 5 100
L5 Thecal Sac Max DVH 577.818 5 0.125
L5 Thecal Sac Max Dose 1140 100
L5 Thecal Sac Max Dose 624.392 0.125
L5 Thecal Sac_EN Max Dose 1200 44.920
Ring Max Dose 1072.79 0.125
Ring Max Dose 1662.5 100
Ring_EN_AP Max Dose 1750 100
TargetSurround_AP Max Dose 1077.55 0.125
TargetSurround_AP Max Dose 1620 100
Tumor L5 Max Dose 1973.27 32.5
Tumor L5 Max Dose 1973.27 35
Tumor L5 Min Dose 1818 65
Tumor L5 Min Dose 1800 8.75
Tumor L5–TS_AP Min Dose 1800 8.75
Tumor L5–TS_AP2 Min Dose 1800 8.75
Tumor L5–TS_AP3 Max Dose 1973.27 35
DVH, dose volume histogram.
KNOWLEDGE-BASED PLANNING (KBP)

■ Based on a large training dataset of prior clinical treatment plans for a spe-
cific cancer site, KBP utilizes machine learning algorithms to build a model
to predict patient-specific planning objectives for a new patient.
■ The key for success in KBP is to create a reliable model that can predict
patient-specific planning objectives that are realistic and achievable.
■ The KBP algorithms proposed by Yuan et al. (4) introduce a series of quan-
titative measures to capture the patient-specific anatomical and diametrical
characteristics, capturing the spatial characterization of an OAR shape rela-
tive to the PTV.
■ The advantage of this KBP method is that the model is based on abstract
features of the anatomy. The model itself is free of patient plans and image
data; therefore, the model is transferable to other institutions without access
to the training database.
MULTI-CRITERIA OPTIMIZATION (MCO)

■ MCO is an optimization process that generates many different plans (Pareto
plans) for the treatment planner to navigate through to find what is the best
(desired) plan possible.
■ This process requires a set of dose constraints (anchor points) which must
be met in all plans, and a set of dose objectives (tradeoffs). The dose objec-
tives are used to generate the plans that are used for navigation.
■ The dose constraints must contain at least one min (dose volume histogram
[DVH]) dose function (normally specifying a PTV) and one max (DVH)
dose function. At least two dose objectives (tradeoffs) are required.
■ Tradeoff functions are normally set to an ideal (unrealistic) goal to allow
for the most navigable space.
■ Once the dose constraints and trade-off objectives are defined by the users,
the multiple plans are generated.
● A minimum of 2 × (the number of tradeoffs) + 1 plan (e.g., five plans for
two tradeoffs) is the suggested number of plans to generate. To increase

MCO flexibility, a maximum of 4 × (the number of tradeoffs) + 1 plan
(e.g., nine plans for two tradeoffs) can be created.
● Before an MCO starts, a feasibility check is performed to verify that all
dose constraints set as anchor points are possible to achieve. If the set dose
constraints are not feasible, the MCO will not start. After new, feasible dose
constraints are entered by the user, the Pareto plan generation will begin.
■ The MCO plans permit users to examine the trade-off of the planning objec-
tives. For example, decreasing dose to an OAR could lead to an increased
hot spot in another area or in another structure. An example of the available
navigable space is shown in Figure 2.3.
■ Once a planning goal has been met, the tradeoff navigation panel (see
Figure 2.4) can be locked so that there will be no further changes to the
goal that will result in this goal being violated with subsequent navigations
(dose distributions can get better, but not worse). This also limits the search
space that is available for the tradeoffs of other OARs (see Figure 2.5).
■ As the number of the locked OAR tradeoffs increase, the available naviga-
tion space decreases.
■ After the tradeoffs of all OARs are adjusted and set to the desired settings,
the optimized plan is converted into a deliverable plan.
Available pareto plan dose distributions
1.0
0.8
Volume (Relative)
0.6
0.4
ROI
PTV_7000
0.2 PTV_5600
PAROTID_R
0.0 PAROTID_L
0 1000 2000 3000 4000 5000 6000 7000 8000
Dose (cGy)
FIGURE 2.3 An example of the navigable (possible) DVHs for the listed ROIs.
DVHs, dose volume histograms; PTV, planning target volume; ROI, region of interest.
FIGURE 2.4 An example of the MCO navigation panel.

EUD, equivalent uniform dose; MCO, multi-criteria optimization.
Available pareto plan dose distributions once the left parotid is locked
1.0
0.8
Volume (Relative)
0.6
0.4
ROI
PTV_7000
0.2 PTV_5600
PAROTID_R
PAROTID_L
0.0
0 1000 2000 3000 4000 5000 6000 7000 8000
Dose (cGy)
FIGURE 2.5 After locking the tradeoff for the certain structures, the search
space in DVHs are narrowed.
DVHs, dose volume histograms; PTV, planning target volume; ROI, region of interest.
● Since the conversion process to a deliverable plan uses a dose mimick-

ing function, there is a “ROI Selection” option available so that possible
structures that were not included in the MCO generation process can
be included in the conversion process. These types of structures would
include possible PTVs (if a different PTV was used for optimization), and
possible normal tissue or OAR structures in the treatment area.
● Typically, 2–3 conversions are needed, resulting in the best representa-
tion of the optimized plan.

■ After conversion, if the plan quality is still not satisfactory, the optimization
function that is used to generate the MCO plans can be included as a func-
tion while using a standard manual optimization process. New objectives
can be added to generate a desirable plan.
■ The main benefit of MCO is in cases where there are multiple competing
clinical goals, requiring compromises.
COMPARING THREE ADVANCED PLANNING TOOLS

■ In the ideal world, a treatment planning system should include all three
advanced planning tools described in the previous section. The KBP pre-
dicts patient-specific planning objectives that are feasible and achievable.
Through multiple rounds of optimizations, the auto-planning tool can auto-
matically create a plan that meets the predicted planning objectives from
KBP. If there are trade-offs among the PTVS and OARs dose constraints,
the multiple criteria optimization can present tradeoff solutions for planners
and physicians to make decisions.
MCO Auto-Planning KBP
63 Gy, 60 Gy, 51 Gy, 45 Gy, 35 Gy,
OARs Goals MCO Auto- KBP

planning
Brainstem <60 Gy 59.47 Gy 60.99 Gy 59.95 Gy
Chiasm <56 Gy 50.15 Gy 55.59 Gy 55.44 Gy
FIGURE 2.6 Comparing a partial brain case planned with three advanced
planning tools, including dose distributions on a single slice and maximum
point dose to the brainstem and chiasm.
KBP, knowledge-based planning; MCO, multi-criteria optimization; OARs, organs at
risk.
■ Using two full arc volumetric modulated arc therapy (VMAT) beams, a
partial brain case was planned retrospectively using auto-planning, KBP,
and MCO planning tools without further optimization. The prescription
dose is 60 Gy to the high dose PTV (HD-PTV, solid orange in Figure 2.6)
and 51 Gy to the low dose PTV (LD-PTV, solid blue in Figure 2.6). The
brainstem is near the HD-PTV. Figure 2.6 shows the dose distributions and
the maximum dose to 0.03 cc of the brainstem and chiasm.
■ The MCO plan achieved the lowest maximum doses to the brainstem and
chiasm, but it was less homogeneous and the 35 Gy dose line spread out to
the contralateral brain. The auto-plan was the most uniform plan but had the
highest maximum dose to the brainstem and chiasm.
REFERENCES
1. Qiuwen W, Djajaputra D, Wu Y, et al. Intensity-modulated radiotherapy op-
timization with gEUD-guided dose–volume objectives. Phys Med Biol.
2003;48(3):279–291. doi:10.1088/0031-9155/48/3/301.
2. Jeraj R, Wu C, Mackie TR. Optimizer convergence and local minima er-
rors and their clinical importance. Phys Med Biol. 2003;48(17):2809–2827.
doi:10.1088/0031-9155/48/17/306.
3. Rowbottom CG, Webb S. Configuration space analysis of common cost func-
tions in radiotherapy beam-weight optimization algorithms. Phys Med Biol.
2002;47(1):65–77. doi:10.1088/0031-9155/47/1/305.
4. Yuan L, Ge Y, Lee WR, et al. Quantitative analysis of the factors which affect
the interpatient organ-at-risk dose sparing variation in IMRT plans. Med Phys.
2012;39(11):6868–6878. doi:10.1118/1.4757927.
OVERVIEW OF SIMULATION
3 AND VERIFICATION
Lisa Zickefoose, Andrew Godley,

Andrew Vassil, and Chirag Shah
Immobilization............................................................................................... 23
Reusable Devices ..................................................................................... 23
Single Use Devices ................................................................................... 25
Special Devices ......................................................................................... 27
Patient Setup ................................................................................................ 28
Motion Management .................................................................................... 29
Compression ............................................................................................. 29
Gating and Breathing Management........................................................ 29
4D-CT ......................................................................................................... 30
Internal Target Volume .............................................................................. 31
Scan Acquisition and Virtual Simulation..................................................... 31
Patient Marking............................................................................................. 32
Quality Assurance and Charting .................................................................. 32
IMMOBILIZATION
Reusable Devices
■ Component systems are available that combine to act as an immobilization
device for multiple different sites including:
● A prone belly board with different sized inserts for patient sizes
(Figure 3.1). This allows for anterior-superior bowel displacement and

is often used for 3D pelvic treatment.
● Supine thoracic immobilization may be performed with various degrees
of angle blocks and arm rests which can be attached to assist in patient
comfort and setup for breast and lung cancer treatment (Figure 3.2).
● A prone breast system which has different heights for differences in
patient body habitus, with a sliding bridge to treat the left or right breast
(Figure 3.3). This allows displacement of the breast anteriorly. Its use
FIGURE 3.1 Prone belly board.
FIGURE 3.2 A thoracic immobilization device with angled sponges and a hand
rest.
FIGURE 3.3 Prone breast board.

3: Overview of Simulation and Verification ■ 25
FIGURE 3.4 A conformal body bag with a vacuum tight plastic body cover to
limit patient motion.
may be considered to reduce cardiac dose for patients with left breast
cancer and to reduce skin toxicity for larger breast cases.
■ Conformal bag systems can be used for immobilization. These systems
consist of a bag with interlocking beads in which the air is removed in order
to conform to the patient. They are available in various sizes including full
body. A thin plastic sheet may be used on top of the system with a device that
removes the air between the sheet and the patient to create a vacuum seal
for further immobilization, which is often used for extracranial stereotactic
body radiotherapy. See Figure 3.4.
Single Use Devices

■ Thermoplastic masks aid in patient position reproducibility for central ner-
vous system and head and neck cases. They are made of a polymer material
which becomes flexible when heated in either a water bath or a special oven.
Some masks have additional material for extra reinforcement (typically
along the chin or forehead) allowing for even more stable immobilization.
● Three-point (reinforced and non-reinforced) are for head only treat-
ments. Different methods to affix to the treatment couch are available,

such as L-brackets with foam holders (Figure 3.5) or press in fasteners.
● Five-point (reinforced and non-reinforced) are for head and neck treatments
as they allow for immobilization of the shoulders, as shown in Figure 3.6.

● An open-face mask can be used to reduce patient anxiety and include
reinforcements along the chin and forehead to achieve equivalent immo-

bilization to closed face masks.
(A) (B)
FIGURE 3.5 (A) A head mask, with three points of attachment to the treatment
couch. A standard head pad (blue) is seen, along with the isocenter cross mark
and BB. (B) Reinforced mask.
● The thermoplastic material may continue to shrink after it has been made.
There are various techniques that can be used to aid with mask shrinkage.
Making a mask with a shim in place (typically 2 mm) may avoid mask
tightness at the accelerator. Another method is to make the mask and
allow time for complete drying (some manufacturers state 95% rebound
within 10 minutes) then remove the mask for a minute before putting it
back on the patient and performing the scan.
● Body masks are available, which can be used for chest, abdomen, or
pelvis treatments.
● Body masks can be used for the pelvis with leg separators to allow for
better immobilization of the legs and pelvis.
FIGURE 3.6 A five-point mask, reinforced along the chin.

FIGURE 3.7 A standard, reusable head pad (blue), with a custom, single use
conformal pad (light blue).
■ Custom head pads may also be used to aid in reproducibility and are help-
ful to keep the neck at a reproducible angle when treating head and neck
sites (Figure 3.7). These are placed on top of the reusable head pads, which
have a limited range of shapes. The custom pads conform to the individual
patient’s anatomy.
■ An alpha cradle device uses a chemical foam placed inside of a plastic bag
or pre-made mold in order to help conform to the area of interest.
Special Devices
■ A bite block or mouthpiece is a custom device placed in the mouth, above
the tongue, in order to immobilize the tongue for head and neck treatments.
● A plastic airway is wrapped in dental wax (Figure 3.8).
● Patients bite to make indentations in the dental wax to aid in placement
reproducibility.
■ Bolus material is sometimes placed or made during the simulation to help
either bring the dose to the surface or act as a compensator.
● Superflab types of bolus may be used to facilitate bringing dose closer to
the skin surface and degrade electron energy when using surface collima-
tion with lead cut-outs. This type of bolus comes in several thicknesses.
It can also be made with a sticky surface to aid in reducing air gaps with
the patient’s skin.
● Aquaplast bolus can be used on irregular surfaces. This type of bolus comes
in large sheets and can be cut and shaped as necessary. It can be heated in a
water bath or special oven to allow for flexibility. It can then be placed over
a surface to help conform as it dries. This high degree of conformality helps
with lesions on the scalp or head and neck area (Figure 3.9).
FIGURE 3.8 A bite block covered in dental wax.
PATIENT SETUP
■ The patient should be placed in a reproducible and comfortable position so
he or she is able to hold the position for the entire treatment using immobi-
lization devices as an aid.
■ Depending on the area being treated, the simulation therapist must be mind-
ful of possible treatment techniques which may be used (e.g., arms up when
treating thorax so planners can have greater degrees of freedom with beam
direction).
■ Also consider clearance of the gantry head around the patient.
■ The physician, in conjunction with the simulation therapist, should docu-
ment with wires or markers any scars, old tattoos (if the patient has been
previously treated), or areas of pain.
FIGURE 3.9 An aquaplast bolus placed around the larynx outside the mask.
Ideally, the patient is scanned with bolus in place for treatment planning.
MOTION MANAGEMENT
■ Sites including lung, liver, breast, and pancreas are affected by respiratory
motion. This motion may be accounted for via margins that represent the
extent of motion as determined by fluoroscopy or 4D-CT imaging (internal
target volume, ITV), reducing the motion (compression), and adapting the
treatment (gating and tracking).
Compression
■ Compression is the simplest form of motion management. It can be an
indexed belt applied across the epigastrium of the patient to restrict a
patient’s respiration; see Figure 3.10A.
■ Devices are also available to compress the abdomen via a plate system
involving an adjustable bridge over the patient, with a screw pushing the
plate into the abdomen of the patient. The heights of the plate and the bridge
are recorded at simulation for reproducible setup (Figure 3.10B).
Gating and Breathing Management

■ Breathing management systems can be utilized to help the patient maintain
a breath hold, either at end inspiration or end expiration. They consist of a
mask that the patient wears and a spirometer to measure breathing volume.
The spirometer aids the patient in successfully holding his or her breath at a
reproducible volume. Multiple breath holds are often required to complete
radiation delivery, so it is vital that the breath holds are reproducible.
■ Gating allows the patient to breathe freely, only delivering the radiation
when the patient is in a predefined phase or amplitude of the respiratory
cycle. Gating requires information on the patient’s breathing. This is typi-
cally acquired by measuring the position of the chest of the patient. A reflec-
tive marker placed on the chest can be tracked by a camera. The chest itself
(A) (B)
FIGURE 3.10 (A) A compression belt; bellows for measuring 4D-CT phase can
also be seen. (B) An abdominal compression bridge.
can be tracked with a pair of cameras. A belt with a pressure gauge can also
be used to measure the expansion and contraction of the chest. Lung phases
are labeled as 0% end inspiration, 50% end expiration, and 100% end inspi-
ration. Thus, utilizing inspiration gating may deliver radiation from the 80%
to 20% phase and expiration gating from 30% to 70%.
■ Treating at inspiration has the advantage of a larger lung volume, which
will make meeting lung volume dose constraints easier. Treating during
inspiration also moves the heart away from the chest wall for left breast
patients.
■ With free breathing, the time spent at inspiration is less than the time spent
at expiration, so gated inspiration treatments will take longer to deliver.
Expiration is also called the home position, as expiration is more consis-
tent than inspiration, with the anatomy being more reproducible at end
expiration than end inspiration, as the anatomy depends on how much the
patient breathes in.
4D-CT
■ 4D-CT is recommended when treating sites where motion is expected.
4D-CT visualizes motion over the entire respiratory cycle.
■ Examination of tumor motion with 4D-CT can help to determine whether
compression or breathing management techniques can account for motion,
or whether another approach needs to be utilized.
■ As in gating, 4D-CT uses a similar surrogate to measure the phase or ampli-
tude of breathing (e.g., a pressure sensing belt worn during CT acquisition).
This enables a CT to be reconstructed into images of 10 or 20 phases of
breathing. It is preferable to use the same surrogate during the 4D-CT as
will be used to measure breathing during treatment.
■ The 4D-CT is a cine image playing through the 10 or 20 phases of breathing,
visualizing the motion. A number of 3D images can be generated from the
4D cine, including maximum, minimum, and average intensity projections.
These images determine the maximum, minimum, or average of each voxel
over the 10 or 20 phases and use that intensity for the reconstructed 3D-CT
(Figure 3.11).
■ An average intensity projection estimates the appearance of the anatomy
in a pre-treatment cone-beam CT, which is taken over a minute, and so the
anatomy is averaged over a few breathing cycles.
■ A maximum intensity projection is useful for estimating the range of
motion of a lung tumor, as the tumor’s intensity is much higher than
the lung. While this scan can be used for contouring a tumor volume, it
should not be used for calculating the treatment plan, as the densities are
incorrect.
0% phase 50% phase MIP Free Breathing
FIGURE 3.11 Images to show 0% phase (inspiration), 50% phase (expiration),

maximum intensity project, and free breathing CT.
MIP, maximum intensity projection.
Internal Target Volume

■ The tumor can be contoured on each phase of the 4D-CT. The 10 or 20
contours can then be combined to reflect the entire range of motion of the
tumor. This volume is referred to as the ITV. It is further expanded to create
the planning treatment volume, to account for patient setup and anatomy
changes.
SCAN ACQUISITION AND VIRTUAL SIMULATION

■ After the patient is in a comfortable position, acquire a scout scan on the
scanner (also referred to as a pilot scan). The scout can be in the anterior
posterior (AP), lateral or both directions.
■ The AP scout is used to verify if the patient is straight along the superior/
inferior axis.
■ If the patient needs to be straightened, repeat the scout and reverify.
■ The scout scan is then used to determine the extent or range of the CT scan.
■ Take anatomy into consideration when determining the length of the scan.
In particular, critical structures being treated should be scanned in their
entirety, and the appropriate amount of spine should be scanned for accu-
rately counting of vertebral levels if needed.
■ Intravenous, oral, or rectal contrast may be requested by the physician to
help delineate both targets and organs at risk during the planning process.
■ Slice thickness should be 3 mm or less depending on the size of the volume
being targeted. Small treatment volumes and stereotactic body radiation
therapy should use smaller slice thicknesses.
FIGURE 3.12 Green laser lines to show the location of the isocenter and patient
marking.
■ Once the scan is acquired, it may be imported into virtual simulation

software.
■ The virtual simulation allows for the placement of the isocenter and may
also provide field delineation tools.
■ The physician should be present at the time of simulation to confirm the
placement of the isocenter.
■ If possible, the isocenter should be placed in the tumor volume to avoid
pre-treatment shifts of the patient at the time of treatment.
PATIENT MARKING
■ Once the isocenter location is determined, the coordinates can be sent to the
laser marking system.
■ The patient should be marked using three points whenever possible by plac-
ing a mark on the anterior or posterior surface along with triangulation or
leveling marks on the sides (Figure 3.12).
■ The skin is marked with semi-permanent markers. The simulation therapist
then either gives the patient permanent tattoos at these marks or stickers
may be placed over the marker to ensure the marks are present for treatment.
■ The simulation therapist should be mindful to place these marks on a patient
area that will be as stable as possible to assist in reproducibility.
QUALITY ASSURANCE AND CHARTING

■ The following steps are evaluated during the simulation process to ensure
the highest possible quality and safety for patients.
■ A simulation request document is completed by the physician to describe:
1. Treatment site or sites
2. Patient position
3. Immobilization devices
4. Markers (scar wires, etc.)
5. Bolus use
6. Contrast use
7. Motion management use
8. Scan borders
9. Start date
■ The simulation therapists and physicians should perform a “Time Out”
procedure before the scan takes place. The first “Time Out” is done with
the therapists and the physician before the patient is brought into the room.
● Verify the patient’s name and birth date.
● If the patient is female, verify that the patient is not pregnant.
● Review the consent form and verify the treatment site.
● Open the patient prescription in the record and verify system to confirm
dose and any previous radiation treatments.

● Review the patient’s simulation request document to verify physician’s
requested setup is met.

■ After the therapist and physician agree on the setup, the patient can be
brought into the room, and a second “Time Out” is performed. The patient
verifies their name, date of birth, and the site being treated.
■ After the patient is set up in a comfortable position and the simulation thera-
pists are ready to perform the scan, a third “Time Out” procedure should
be performed at the CT console to verify all information was entered into
the scanner correctly (name, medical record number, patient orientation,
scan protocol).
■ After placing the isocenter, it is useful to rescan the isocenter with one axial
rotation scan to record the isocenter marked position.
■ The patient marks are covered by radio-opaque markers on all three iso-
center marks. An axial slice scan is then acquired. The position of the
radio-opaque markers is then compared to what was marked in the virtual
simulation software. This scan also provides documentation of isocenter
marking on the patient body. The planners should verify the isocenter loca-
tion using this document against the isocenter coordinate imported into the
treatment planning system.
■ Photos of the patient setup are taken and entered in the patient’s chart for
verification.
■ The simulation therapist takes pictures of all patient marks and label tattoos
(and old tattoos if present) in the pictures.
■ All treatment devices should be imaged from several angles and docu-
mented to assure the setup can be reproduced by the treating therapists.
■ All setup instructions are entered in the patient’s chart in a clear, prescrip-
tive format. Templates help to ensure any radiation therapist can read the
instructions and easily know how to treat the patient accurately.
■ Example template for partial or whole brain:
SITE: PARTIAL OR WHOLE BRAIN
SETUP INSTRUCTIONS:
PT SUPINE ORFIT BOARD
#5 PAD
3 PT MASK
LAMBSWOOL
BLUE RING
LP-KS-B
BAND FEET
TREATMENT INSTRUCTIONS:
CBCT: FREQUENCY | TOLERANCE | START ANGLE |

ALIGNMENT
SHIFTS/SSDS:
BOOST: (None, to follow, simultaneous)
■ Example template for thorax:
SITE: LUNG/ESOPH/ABDOMEN
SETUP INSTRUCTIONS:
H-0 ORFIT SYSTEM
#5 PAD
SHORT POLES IN B & D
BOTH ARMS UP
KS-B ONLY
BAND FEET
B LINE-TRIANG: ORIGIN:

ALIGNMENT
SHIFTS/SSDS:
■ Example template for head and neck:
SITE: HEAD AND NECK
SETUP INSTRUCTIONS:
PT SUPINE ON ORFIT BOARD
MOLDCARE ON #2 PAD
5 PT MASK
MOUTHPIECE
BLUE RING ON ABD
LAMBSWOOL
LP-KS-B
BAND FEET
REMIND PT NOT TO SWALLOW DURING CBCT AND TX

ALIGNMENT
SHIFTS/SSDS:

4 CENTRAL NERVOUS SYSTEM
Matt Kolar, John Potter, Salim Balik, Gennady Neyman,

Joycelin Canavan, and John H. Suh
Simulation and Immobilization .................................................................... 37

3D Conformal Planning ................................................................................ 39
Intensity Modulated Radiation Therapy (IMRT) and Volumetric
Modulated Arc Therapy (VMAT) Planning Principles .................................. 39
Planning Objectives and Evaluation ........................................................... 41
Simultaneous Integrated Boost (SIB).......................................................... 45
Gamma Knife and Linear Accelerator-Based Stereotactic
Radiosurgery ................................................................................................. 47
GK Planning .................................................................................................. 51
General Principles of GK Radiosurgery .................................................. 51
GK Planning Goals .................................................................................... 51
Stereotactic Localization of the Image Study ......................................... 52
GK Shot Placing Strategy ......................................................................... 52
Prescription Isodose Lines ....................................................................... 53
Inverse Planning Module.......................................................................... 53
SIMULATION AND IMMOBILIZATION

■ Patients are immobilized with a three-point reinforced thermoplastic mask,
with the head in a neutral position.
● Non-reinforced masks are used for palliative patients.
● Masks used for definitive cases are reinforced under the chin and around
the forehead to aid with setup reproducibility over time.

■ Masks are attached to a narrow low attenuation board that extends beyond
the end of the treatment couch.
■ Extending the couch increases the flexibility to use non-coplanar beam ori-
entations without collision of the gantry and treatment couch.
■ Head pads are used for patient comfort. It is important to have multiple head
pad sizes or custom moldable pads (see Figure 3.7 in Chapter 3).
■ Intravenous contrast may be used to enhance the visibility of the tumors in
planning CT images.
■ The CT slice thickness is usually 3 mm but could be reduced to 1 mm if needed.
■ To minimize isocenter shifts, physicians place the isocenter in the center of an
estimated volume with consideration given if it is a right or left brain lesion.
■ MRI is required to help delineate the target and critical structures. Fusion
of the MRI to the planning CT is required. T1 with contrast, T2, and fluid
attenuated inversion recovery (FLAIR) MRI studies are used to delineate
the lesion and normal structures. Consider using preoperative studies to
delineate the initial size and location of the lesion. Postoperative scans are
typically used for planning purposes. See Figure 4.1.
■ The gross tumor volume (GTV), clinical target volume (CTV), and plan-
ning target volumes (PTV) are contoured by the physician.
■ GTV is defined as the primary tumor, to include all visible abnormalities
demonstrated on MRI and resection cavity. GTV should be delineated on
every CT slice.
■ CTV expansions are determined by the physician but expansions vary by
tumor type and typically respect natural boundaries to tumor spread such
as bone, ventricles, and dura.
■ PTV expansions are typically 3 to 5 mm margin around the CTV depending
on comfort level of daily patient positioning. Typically, a smaller margin of
3 mm is used with daily image guidance.
■ Organs at risk (OARs) are contoured by the physician from a list of stan-
dardized names and colors.
■ OAR standardization benefits planning by reducing the chance of structures
being overlooked.
■ Another benefit of contour standardization is retrieval of data for research.
T1 Weighted T2 Weighted FLAIR
FIGURE 4.1 The three standard MRI sequences used for treatment planning,
left to right are T1 weighted, T2 weighted, and FLAIR.
FLAIR, fluid attenuated inversion recovery.
4: Central Nervous System ■ 39
3D CONFORMAL PLANNING
■ 3D treatment plans are typically normalized to the isocenter or a calculation
point if the isocenter is not located in a high dose region. The planning goal
is to cover 95% of the PTV with the prescribed dose.
■ Due to the average depth of treatment, 6 or 10 MV beam energies are typi-
cally used, although 15 MV can be used for large patients.
■ The isocenter should be placed to accommodate accelerator limitations with
dynamic wedge field sizes and multi-leaf collimator (MLC) leaf limits.
■ For unilateral brain tumors, avoid beams that enter through the unaffected
side (although in rare circumstances, a lightly weighted beam may be
required from the unaffected side).
■ A typical beam arrangement is five beams, with one or two non-coplanar
beams and avoiding an entrance beam on the unaffected side.
■ If non-coplanar beams are to be used and vertex beams are utilized, the CT
data set must encompass the entire cranium.
■ The dose grid should encompass the entire cranium and all contours for
accurate dose volume histograms (DVHs).
■ When utilizing vertex fields, make sure the planning system does not extend
the CT superiorly to avoid falsely copying the most superior CT slice of
the cranium.
■ Dose grid size affects computational speed, so a smaller grid size will increase
planning time. A 4 × 4 × 4 mm3 grid is adequate except when PTVs and OARs
have small volumes, then a 3 × 3 × 3 mm3 grid size should be considered.
■ Using non-coplanar beams requires close attention to the exit dose through
the patient’s oral cavity, orbits, lens, lips, spinal cord, and brainstem, as in
Figure 4.2.
■ A block margin of typically 0.7 cm to 1 cm around the PTV is a reasonable
starting point to achieve adequate dose coverage to the PTV.
■ Wedges are the primary isodose manipulation tool, followed by manually
defined segments to fine-tune the dose distribution.
■ Manually created segments are useful to reduce or move hot spots to an
intended location within the PTV.
■ These manual segments can also be used to limit dose to a critical structure
such as optic nerves by moving an MLC leaf to reduce dose to within speci-
fied limits. The example in Figure 4.3 demonstrates a segment with three
manually adjusted leaves to reduce dose to the right and left optic nerves.
INTENSITY MODULATED RADIATION THERAPY (IMRT) AND VOLUMETRIC

MODULATED ARC THERAPY (VMAT) PLANNING PRINCIPLES
■ MRI is required to help delineate the target and critical structures. Fusion of
the MRI to the planning CT is required. T1 with contrast, T2, and FLAIR
FIGURE 4.2 A non-coplanar beam avoids exiting through the eyes, but the
beam will be shaped to avoid the brainstem.
MRI sequences are used to delineate the lesion and critical structures.
Consider using preoperative studies to demonstrate the initial size and loca-
tion of the lesion.
■ 6 MV or 10 MV beam energies are typically used for treatment.
Optic-NRV-L
Optic-NRV-R
FIGURE 4.3 MLC leaves pulled in to create a segment to reduce dose to the
optic nerves.
MLC, multi-leaf collimator.
■ The plan is typically normalized to a PTV mean dose.
■ Choose an appropriate isodose line (IDL) to cover 95% of the PTV with
the prescribed dose.
■ To determine dose accurately for small critical structures, the dose grid can
be reduced to 2 × 2 × 2 mm3.
■ Placing the isocenter in the middle of the PTV is desirable but not necessary
to achieve planning constraints. Ideally, isocenter shifts should be avoided
to maintain daily setup accuracy.
■ For IMRT planning, five coplanar beams are a good starting point. A non-
coplanar field or two from the vertex may be helpful to increase conformity
and uniformity of the isodose distribution.
■ For VMAT dynamic arc planning, two full (360°) coplanar arcs are a reason-
able starting point. Limiting the arc to 356° (from 182° to 178°) can avoid
linear accelerator start/stop issues at 180°.
■ A second approach for VMAT uses a full arc, followed by a partial arc on
the affected side, or a partial vertex arc.
■ A vertex or non-coplanar arc may be necessary to achieve critical structure
limits and PTV coverage. Use extreme caution implementing non-coplanar
arcs to avoid potential collisions of the gantry with the couch or patient.
PLANNING OBJECTIVES AND EVALUATION

■ Physicians may provide a complete objective list for planning. If objectives
are met easily by the optimizer, then it is recommended to lower doses to
those structures further.
■ Objectives to start initial planning include the following OAR dose
limitations:
● Lens 7 Gy maximum dose
● Retina 45 to 50 Gy maximum dose
● Optic nerve 55 Gy maximum dose
● Optic chiasm 56 Gy maximum dose
● Cochlea 34 Gy mean dose
● Pituitary 45 Gy maximum dose
● Brainstem 60 Gy maximum dose
● Spinal cord 45 Gy maximum dose
● PTV 95% coverage of the prescribed dose
● CTV 98% coverage of the prescribed dose
● GTV 99% coverage of the prescribed dose
■ Ring volumes can be used during optimization to focus the dose to the
PTV (Figure 4.4). The initial tightest ring (orange) is limited to 50% of the
prescription dose; the outer ring (green) is limited to 30% of the prescribed
dose.
FIGURE 4.4 Two ring structures; inner ring (orange) is limited to 50% of the
prescription dose, the outer ring (green) is limited to 30% of the prescribed
dose.
■ To create the inner ring, expand the PTV by 5 mm and expand a ring based
on the 5 mm contour. If the simultaneous integrated boost (SIB) technique
is used, then expand both PTVs by 5 mm and create a ring based on the 5
mm expansion.
■ Both rings are within the external contour of the patient.
■ Quantitative plan evaluation goals are given in Tables 4.1 to 4.3.
■ DVHs are another form of quantitative evaluation.
■ Further qualitative evaluation of the plan is necessary. Often a plan meets
desired objectives and dose limits, but the IDL distribution may be unaccept-
able as to where the optimizer placed the dose. Each axial slice should be
reviewed in absolute dose. The standard IDLs recommended are the 105%,
100%, 95%, 90%, 80%, 70%, 60%, 50%, and the hot spot. Evaluation of
the low IDLs is very useful for reviewing conformality of the plan and
appropriate beam weighting.
TABLE 4.1 Treatment Plan Goals for 40.05 Gy Prescription

Primary Goal Secondary Goal
Structure Type Dose (cGy) Volume Dose (cGy) Volume
GTV_4005 Min DVH 4005 99%

CTV_4005 Min DVH 4005 98%
(continued)
TABLE 4.1 Treatment Plan Goals for 40.05 Gy Prescription (continued)
PTV_4005 Min DVH 4005 95%

BRAIN Max DVH 4205 0.03 cm3 4285 0.03 cm3
BRAINSTEM Max DVH 4105 0.03 cm3 4205 0.03 cm3
COCHLEA_R Mean Dose 3400
COCHLEA_L Mean Dose 3400
SPINAL_CORD Max DVH 4105 0.03 cm3 4205 0.03 cm3
GLOBE_R Max DVH 4000 0.03 cm3
GLOBE_L Max DVH 4000 0.03 cm3
LENS_R Max DVH 700 0.03 cm3
LENS_L Max DVH 700 0.03 cm3
OPTIC_NRV_R Max DVH 4105 0.03 cm3 4205 0.03 cm3
OPTIC_NRV_L Max DVH 4105 0.03 cm3 4205 0.03 cm3
CHIASM Max DVH 4105 0.03 cm3 4205 0.03 cm3
RETINA_R Max DVH 4000 0.03 cm3
RETINA_L Max DVH 4000 0.03 cm3
CTV, clinical target volume; DVH, dose volume histogram; GTV, gross tumor volume;
PTV, planning target volume.
TABLE 4.2 Treatment Plan Goals for 50.4 Gy Prescription

GTV_5040 Min DVH 5040 99%

CTV_5040 Min DVH 5040 98%
PTV_5040 Min DVH 5040 95%
BRAINSTEM Max DVH 5040 0.03 cm3 5292 0.03 cm3
COCHLEA_R Mean Dose 3400 4500
COCHLEA_L Mean Dose 3400 4500
SPINAL_CORD Max DVH 4500 0.03 cm3
(continued)
TABLE 4.2 Treatment Plan Goals for 50.4 Gy Prescription (continued )

CHIASM Max DVH 5100 0.03 cm3 5292 0.03 cm3
TABLE 4.3 Treatment Plan Goals for 54 Gy Prescription

GTV_5400 Min DVH 5400 99%

CTV_5400 Min DVH 5400 98%
PTV_5400 Min DVH 5400 95%
BRAINSTEM Max DVH 5500 0.03 cm3
3
SPINAL_CORD Max DVH 4500 0.03 cm 5000 0.03 cm3
CHIASM Max DVH 5400 0.03 cm3
RETINA_R Max DVH 4500 0.03 cm3 5000 0.03 cm3
RETINA_L Max DVH 4500 0.03 cm3 5000 0.03 cm3
SIMULTANEOUS INTEGRATED BOOST (SIB)
■ SIB is delivered with IMRT or VMAT and is an efficient technique to incor-
porate the boost into a single treatment plan, keeping overall treatment
times shorter to minimize tumor cell repopulation and minimize patient
inconvenience.
■ Planning is similar to that of a typical IMRT or VMAT plan.
■ The plan prescription will be for the highest dose: for example, 200 cGy
for 30 fractions to 60 Gy; the plan also has a volume prescribed to 51 Gy.
■ Planning objectives will include prescribing the PTV_60 to 60 Gy and
PTV_51 to a minimum dose of 51 Gy and a maximum dose of 53.55 Gy
(105% of 51 Gy).
■ Typical doses to critical structures are given in Tables 4.4 and 4.5.
■ Planning the boost volume simultaneously with the initial edema volume
results in greater control of the dose distribution and greater control of doses
to critical structures. See Figures 4.5 and 4.6 for the result.
■ When planning an SIB case, the optimizer will struggle with overlapping
PTVs that have differing dose objectives. To avoid this issue, one should
expand the high dose PTV by 2 mm calling the expansion 2 mm_exp, while
keeping the physician contoured low dose PTV the same (no expansion).
Limit overlap between the low dose planning PTV and 2 mm_exp contour.
The planning system now has two distinct PTVs to use efficiently.
TABLE 4.4 Treatment Plan Goals for 59.4 Gy Boost, 54.45 Gy Volume
GTV_5940 Min DVH 5940 99%

CTV_5940 Min DVH 5940 98%
PTV_5940 Min DVH 5940 95%
GTV_5445 Min DVH 5445 99%
CTV_5445 Min DVH 5445 98%
PTV_5445 Min DVH 5445 95%
3
(continued)
TABLE 4.4 Treatment Plan Goals for 59.4 Gy Boost, 54.45 Gy Volume
(continued )

TABLE 4.5 Treatment Plan Goals for 60 Gy Boost, 51 Gy Volume

GTV_6000 Min DVH 6000 99%

CTV_6000 Min DVH 6000 98%
PTV_6000 Min DVH 6000 95%
GTV_5100 Min DVH 5100 99%
CTV_5100 Min DVH 5100 98%
PTV_5100 Min DVH 5100 95%
3
(continued)
TABLE 4.5 Treatment Plan Goals for 60 Gy Boost, 51 Gy Volume
(continued )

GAMMA KNIFE AND LINEAR ACCELERATOR-BASED

STEREOTACTIC RADIOSURGERY
■ Stereotactic radiosurgery (SRS) was pioneered by Lars Leksell in 1951 as
a means of treating intracranial diseases with radiation to avoid surgery.
■ Gamma Knife (GK) and linear accelerators (linacs) are the most commonly
used technologies for SRS.
■ GK SRS is traditionally performed by attaching a stereotactic head frame to
the patient’s skull for immobilization and localization. MRI and CT images
(or angiogram for arteriovenous malformation cases) are acquired for con-
touring and treatment planning. Radiation delivery is completed the same
day. See “GK Planning” section in this chapter for further details.
■ The newest GK version (Icon) is capable of frameless radiosurgery using
thermoplastic masks instead of a rigid head frame. GK Icon also adds an
onboard cone beam CT (CBCT).
■ Linac (linear accelerator) SRS is typically performed with thermoplastic
masks.
65, 60, 51, 45, 30 Gy
FIGURE 4.5 Dose distributions for an SIB plan.

SIB, simultaneous integrated boost.
100
75
Relative Volume (%)
BRAINSTEM
GLOBE_L
GLOBE_R
50 LENS_L
LENS_R
OPTIC_NRV_L
OPTIC_NRV_R
25
0
0 20 40 60
Dose (Gy)
100
75
Relative Volume (%)
CTV_5100
CTV_6000
GTV_5100
50
GTV_6000
PTV_5100
PTV_6000
25
0
0 20 40 60
Dose (Gy)
FIGURE 4.6 The DVHs for the SIB plan shown in Figure 4.5.
PTV, planning target volume; SIB, simultaneous integrated boost.
■ Before the advent of linac-based imaging, head frames were also required
and are still applied today when the physician deems that higher accuracy
is necessary.
■ When there is no head frame, SRS treatment planning and delivery can be
completed on different days, and the treatment can also be fractionated.
■ Use of thermoplastic masks for immobilization increases the overall patient
comfort. Nevertheless, the head frame is usually well tolerated and allows
decreased intra-fractional motion throughout a long treatment session.
■ GK SRS treatment times are typically longer compared to linac-based
SRS. Moreover, treatment times get longer as the source activity
decreases. GK sources should be replaced every 5 years given the half-
life of cobalt-60.
■ Linac SRS treatment times have been significantly reduced with the advent
of flattening filter free modes.
■ Linac SRS can also use a single isocenter to treat multiple brain lesions at
once, further reducing the treatment time compared to GK, which must treat
each lesion in sequence.
■ Linac SRS treatment planning is achieved via the inverse planning process
where the planner determines objectives for OARs, targets, and confor-
mity, and the computer-based planning system optimizes the treatment
beams.
■ In GK, forward planning is typically performed, with the planner placing
GK shots to cover the target(s). There are limited GK inverse planning
tools.
■ Plan quality and OAR sparing of GK and linac-based SRS can be consid-
ered comparable, though this is an active area of research, with more studies
needed as the technologies develop.
■ Figure 4.7 is an example of a vestibular schwannoma case treated with
12 Gy in a single fraction using GK. Figure 4.8 is the same case planned for
linac delivery using three non-coplanar arcs. Overall plan quality as well as
OAR sparing are similar for both plans.
12 Gy
10 Gy
6 Gy
3 Gy
FIGURE 4.7 A GK-based SRS plan for a vestibular schwannoma. Tumor–solid

green; brainstem–solid pink; cochlea–solid purple.
GK, gamma knife; SRS, stereotactic radiosurgery.
12 Gy
10 Gy
6 Gy
3 Gy
FIGURE 4.8 A linac-based SRS plan made with three non-coplanar VMAT
arcs for a vestibular schwannoma. Tumor–solid green; brainstem–solid pink;
cochlea–solid purple.
SRS, stereotactic radiosurgery; VMAT, volumetric modulated arc therapy.
■ Often times there is a tradeoff between plan quality (conformality, heteroge-

neity) and OAR sparing. This is shown in Figure 4.9, where the plan quality
degrades as the objective weight for cochlea increased during optimization
to reduce its mean dose to less than 4 Gy to limit hearing loss. We prioritize
100% coverage of tumor over dose to cochlea.
12 Gy
10 Gy
6 Gy
3 Gy
FIGURE 4.9 Dose distributions for a linac-based SRS plan, using three non-
coplanar VMAT arcs for a vestibular schwannoma. In this plan, the cochlea
dose is pushed more aggressively than the plan for the same case shown in
Figure 4.8. Tumor–solid green; brainstem–solid pink; cochlea–solid purple.
SRS, stereotactic radiosurgery; VMAT, volumetric modulated arc therapy.
GK PLANNING
General Principles of GK Radiosurgery
■ GK requires 3D imaging, a high degree of dose conformity, steep dose
gradient, and accuracy of beam delivery less than 1 mm.
■ GK radiation is from the gamma decay of cobalt-60, which has an average
energy of 1.25 MeV and half-life of 5.3 years.
■ Perfexion and the newer GK Icon models use 192 cobalt sources in a cone-
based geometry, distributed between eight sectors which are all focused at
one point.
■ The sources can be collimated with sizes of 4, 8, or 16 mm.
■ Older GK models (B, C, and 4C) use 201 sources in semi-spherical geom-
etry with collimator sizes of 4, 8, 14, and 18 mm.
■ GK is for cranial irradiation, and has typically used a frame attached to the
patient’s head for immobilization.
■ GK Icon has CBCT on board imaging and infrared tracking to allow for
mask-based treatments. This allows for fractionated treatments.
■ Treatment time depends on source strength, number of targets, shape, size,
and prescription, and can vary between 10 minutes to several hours.
GK Planning Goals
■ Radiation Therapy Oncology Group (RTOG) Conformity Ratio (PITV):
The ratio of the volume encompassed by the prescription dose to the tumor
target volume. Typically, the PITV is less than or equal to 2 (except for
very small targets). For tumor targets that are adjacent to critical struc-
tures, the PITV should be less than or equal to 1.5.
■ RTOG Homogeneity Ratio (MD/PD): The ratio of the maximum dose within
the treatment volume to the prescription dose has to be less than or equal to 2.
■ Target coverage ratio: the ratio of the target volume getting the prescribed
dose to the target volume.
■ Selectivity ratio: the ratio of the target volume getting the prescribed dose
to the whole volume getting the prescribed dose.
■ Paddick conformity index (PCI): target coverage ratio multiplied by selec-
tivity ratio.
■ PCI is inversely proportional to RTOG conformity index with proportional-
ity constant equal to the square of target coverage. When the target coverage
is 100%, the PCI is the inverse of the PITV conformity ratio.
■ Gradient Index: The ratio of the volume getting half of the prescribed dose
to the volume getting the prescribed dose. This index should be less than
three, but is not as critical as conformity and inhomogeneity ratios.
■ Coverage of the target should be 99% to 100%.
■ Typically, margins are not used for GK unless a resection cavity from a brain
metastasis patient is being treated. The typical margin around the resection
cavity is 2 mm.
Stereotactic Localization of the Image Study

■ Frame based: Patient is localized with respect to markers on the indicator
box which covers the patient’s head and attaches to the frame during imag-
ing. Typical definition errors (mean/maximum) are: 0.3/0.5 mm for CT and
0.5/1.0 mm for MRI.
■ Mask based: Patient is localized only by CBCT, in which the skull and some
cranial anatomy can be viewed.
GK Shot Placing Strategy

■ Larger shots are placed first, preferably in the center of the target without
too much overlap of the shots (Figure 4.10).
■ Smaller shots are then placed between the larger shots.
■ To minimize the low dose spillage, try to keep the center of the shots inside
the target.
FIGURE 4.10 Typical GK plan. Tumor–green; brainstem–brown; prescription

isodose line–yellow; geometrical shots projections–blue, shot numbers–red.
GK, Gamma Knife.
■ When placing shots, keep at least 4 mm clearance from the collimator. The
planning system reports the clearance of each shot.
■ If a required shot causes a clearance issue, change the gamma angle. This
will cause the frame, and hence patient’s head, to be tilted from 90° (neu-
tral), to 70° (extension), or 110° (flexion) during delivery of that shot.
■ Target coverage can be adjusted by changing the position, relative weight,
gamma angle, and collimator size for each shot.
■ Use of smaller diameter collimators at the interface between the target and
organ at risk can be beneficial because of the sharper penumbra.
■ Dynamic shaping or different gamma angles can be utilized to minimize
radiation dose to critical organs.
Prescription Isodose Lines

■ Historically GK plans have been prescribed to the 50% IDL. This is due to
the shot profile having the sharpest dose falloff at 50% IDL.
■ Usually 50% is a minimum isodose that can be prescribed to, and still main-
tain the required inhomogeneity ratio less than or equal to 2.
■ Higher prescription IDLs can be used to minimize treatment time, or reduce
the size of a shot. Higher isodose prescriptions increase the spread of low
dose. This will be reflected in a higher gradient index.
Inverse Planning Module

■ Inverse planning can ease the planning especially for large spherical shaped
targets.
■ It consists of two independent functions: placement (filling) and
optimization.
■ The filling places shots to cover the target and creates a preliminary estimate
of a dose distribution. The optimization improves the dose distribution by
adjusting the weights and position of the shots to minimize a dose coverage
cost function.
■ The optimization process can be controlled by changing requested target
coverage, selectivity, dose gradient, and treatment time.
5 HEAD AND NECK PLANNING
Eric Murray, Ping Xia, Andrew Dorfmeyer, Nikhil Joshi,

Daesung Lee, and Shlomo Koyfman
Simulation ..................................................................................................... 55
General Planning Principles ........................................................................ 57
Specific Case Planning ................................................................................. 65
T2 N0 M0 Squamous Cell Carcinoma of the Glottis (Where Nodal
Treatment Is Deemed Necessary) ........................................................... 70
T2 N2b M0 Squamous Cell Carcinoma of the Base of Tongue ............ 76
T4b N0 M0 Esthesioneuroblastoma of the Nasal Cavity ...................... 80
T2 N0 M0 Squamous Cell Carcinoma of the Scalp ............................... 81
T2b N1 M0 Malignant Neoplasm of Connective Tissue of Head,
Face, and Neck.......................................................................................... 85
Re-Irradiation ................................................................................................ 86
T3 N0 M0 Squamous Cell Carcinoma of the Tonsil Re-Irradiation ....... 86
T4b N2b M0 P16+ Malignant Neoplasm of the Right Tonsil
Re-Irradiation ............................................................................................ 90
Special Cases................................................................................................ 95
Two Isocenter Treatment Plan for a T4b N0 M0 Teratocarcinoma
of the Ethmoidal Sinus ............................................................................. 95
Cases Involved With Pacemaker ............................................................ 102
Reference .................................................................................................... 102
SIMULATION
■ Simulate with a five-point reinforced mask with the head in the neutral posi-
tion and shoulders down for all head and neck (HN) cases.
■ Simulate with a three-point reinforced mask for scalp cases or treatments
not involving neck nodes.
■ For cancer sites of the oral cavity, oropharynx, nasopharynx, nasal cavity,
and paranasal sinuses, a bite block wrapped in wax (for teeth impression) is
inserted into the mouth on the top of the tongue for stability. This bite block
creates a space between the tongue and the hard palate.
■ The low neck is slightly elevated and immobilized with a patient specific
cushion (shown in Chapter 3, Figure 3.7).
■ Simulate with intravenous contrast to facilitate contouring lymph nodal
chains and gross tumor.
■ Use radio-opaque markers (BBs) and wire to demarcate skin lesions and
scars.
■ For tumors involving the skin, use 5 mm bolus to increase the skin dose.
Typically, multiple-field intensity modulated radiation therapy (IMRT)
plans and volumetric modulated arc therapy (VMAT) plans increase skin
dose when compared to conventional opposed lateral fields.
■ Use wax or ear plugs to enhance dose in nasal cavity or ear canal. If the
nasal cavity is too big due to resection, use a water-filled balloon as a bolus.
■ For superficial lesions, moldable bolus can be applied outside of the mask
after simulation. Ensure the mask has good skin contact (minimize the air
gap) in the area of the superficial lesions while making the mask. Add pos-
terior gel bolus before the mask is created (Figure 5.1).
■ Isocenter placement
● To minimize isocenter shifts, the physician places an isocenter during
simulation at the center of the estimated total treatment volume, particu-

larly at the center of the volume’s superior/inferior extent.
● For VMAT plans and IMRT plans with beams arranged around the
patient, consider arc/beam clearance depending on the specific treatment

machine.
Anterior Bolus
Mask
Posterior Bolus
(A) (B)
FIGURE 5.1 (A) An axial CT image illustrates the head mask made to be snug
near the posterior bolus on the cushion. (B) An anterior bolus can be added
during treatment planning after CT simulation.
5: Head and Neck Planning ■ 57
FIGURE 5.2 An axial image shows the typical isocenter location and how the
table vertical is measured. The red line in the figure removes the CT table from
treatment plan.
● For Varian accelerators, use a vertical value of 22 cm or less for full arc
VMAT plans to ensure clearance. Vertical distance is measured from
the table top to the isocenter as shown in Figure 5.2. The red line in
Figure 5.2 shows where the CT table is removed from the planning CT.
● With a 6D treatment table, consider placing the isocenter close to the
midline even for ipsilateral tumor volumes to allow for better clearance.
GENERAL PLANNING PRINCIPLES

■ The fusion of a diagnostic study (PET scan, MRI, or contrast CT) with the
treatment planning CT is useful to facilitate the delineation of the gross
disease or positive lymph nodes.
■ The gross tumor volume (GTV), clinical target volume (CTV), and planning
target volumes (PTV) will be drawn by the attending physician. The expan-
sions from CTV to PTV are typically 2.5 to 3 mm with the use of daily image
guided radiation therapy (IGRT) and 5 mm without daily image guidance.
■ Accuracy of contouring is extremely important. Normal structures that
are not contoured cannot be evaluated or protected. Missing or inaccurate
organs at risk (OARs) may result in an unintended dose distribution result-
ing in excess dose to normal tissue. Table 5.1 lists the typical normal struc-
tures contoured for HN cases.
■ Additional structures for planning HN IMRT
TABLE 5.1 A List of Typical Normal Structures Contoured for HN Cases
BRAIN LARYNX PAROTID_R TEMP_LOBE_L

BRAINSTEM LENS_L PAROTID_R_PTV TEMP_LOBE_R
BRAINSTEM_ LENS_R PITUITARY TRACHEA
PRV3
CHIASM LIPS SPINAL_CORD LACRIMAL_L
COCHLEA_L MANDIBLE SPINAL_CORD_ LACRIMAL_R
PRV5
COCHLEA_R OPTIC_ SUBMANDIBULAR_ BRACHIAL_
NRV_L L PLEXUS_L
OARPHARYNX OPTIC_ SUBMANDIBULAR_ BRACHIAL_
NRV_R L_PTV PLEXUS_R
OARPHARYNX_ ORAL_ SUBMANDIBULAR_ HYPOPHARYNX_
PTV CAVITY R AVOID
ESOPHAGUS ORAL_ SUBMANDIBULAR_ THYROID
CAVITY_ R_PTV
PTV
GLOBE_L PAROTID_ SUPRAGLOTTIC
L
GLOBE_R PAROTID_ SUPRAGLOTTIC_
L_PTV PTV
HN, head and neck; PTV, planning target volume.
● PTV planning structure: When planning an SIB (simultaneous integrated

boost) IMRT plan, the inverse planning optimizer becomes more effi-
cient if the PTVs do not overlap one another (share any voxels) to avoid
conflicting planning objectives, resulting in a PTV-LD (low dose) and
PTV-HD (high dose).
● Then create a planning PTV-LD, named as PTV-LD-Obj (objective), to
allow permissible dose fall-off using the following as a rule of thumb:
■ Obtain the ratio (X) of high dose / low dose, and then expand (X-1)/0.5
(in cm) of the PTV-HD. A planning PTV is created by subtracting the

expanded PTV-HD from the PTV-LD. The thin line in Figure 5.3 is
the PTV-LD-Obj.
● For example, there are PTV-7000 and PTV-5600, the ratio of PTV doses
is 7000/5600 = 1.25 so expand PTV-7000 by (1.25–1)/0.5 = 0.5 cm. So
the PTV-5600-obj is the PTV-7000 expanded by 0.5 cm subtracted from
PTV-5600.
● Create two dose ring structures (Figure 5.4). The first dose ring is cre-
ated by expanding 1 cm of all combined PTVs, and then subtracting that
FIGURE 5.3 The thin line (orange) is the PTV-LD-Obj created following the
rules of thumb described in the text. PTV-HD is in solid purple and PTV-LD is
in solid orange.
PTV, planning target volume; PTV-LD (low dose); PTV-HD (high dose).
FIGURE 5.4 The first dose ring is pink, and the second dose ring is aqua. The
PTV-HD is purple and PTV-LD is orange.
PTV, planning target volume; PTV-LD (low dose); PTV-HD (high dose).
expansion from the external contour. The first dose ring is constrained
with a maximum dose of 50% of the highest prescription dose during
optimization.
● The second dose ring is created by expanding 3 cm of the combined
PTVs, and then subtracting that expansion from the external contour. The
second dose ring is constrained with a maximum dose of 30% to 35% of
the highest prescription dose during optimization.
■ Avoidance structures
● A posterior neck contour can minimize any low dose spillage. The second
dose ring can serve the same purpose.

● A midline avoidance contour can help to push the dose away from the lar-
ynx, supraglottis, esophagus, trachea, and OARPharynx (constrictors).

● Based on the shape of the isodose lines, additional dose shaping avoid-
ance contours can be created ad hoc during planning to limit dose to

specific areas or OARs. Similar ad hoc contours can be added to eliminate
hot and cold spots.
● Automatic planning, discussed in Chapter 2, mimics these steps, but
the plan created from automatic planning may still require further fine-
tuning.
■ 6 MV is typically used for HN IMRT or VMAT plans as a higher energy may
compromise dose coverage of targets close to the skin surface.
■ IMRT is generally treated with nine fields equally spaced around the patient
● Preferred beam angles are 0°, 40°, 80°, 120°, 160°, 200°, 240°, 280°,
320° with the 0° beam being AP following IEC (International Electro-

technical Commission) convention.
● Generally 7 to 10 segments per beam (70–90 total segments).
● Calculation time is faster for IMRT but delivery time is longer when
comparing to VMAT plans.

● IMRT plans for HN are not as conformal as VMAT plans; see a compari-
son example in Figure 5.5.

■ VMAT plans generally use two full arcs
● The first arc is 182–178° with the collimator off 0° (e.g., 10°) and the
second arc returning 178–182° (collimator 350°). The 2° off from 180°
avoids ambiguity in the gantry rotation direction of the linear accelerator.
● Calculation time for a VMAT plan depends on the computational
power of the planning system (hardware), dose grid resolution, and

grid size.
■ Unless using a posterior bolus, shown in Figure 5.2, adding bolus after
delineation of the tumor volume is preferred although it requires more
time to create the bolus during planning. The bolus created during treat-
ment planning provides better conformity to the regions needing bolus
(Figure 5.6).
VMAT Plan IMRT Plan
60, 54, 51.30, 45, 40, 35 Gy
FIGURE 5.5 Comparing VMAT and IMRT plans for the same patient. Notice
the higher conformality in the 35 Gy isodose line (yellow) in the VMAT plan.
IMRT, intensity modulated radiation therapy; VMAT, volumetric modulated arc therapy.
■ Bolus can be created using the treatment planning system tools, or the plan-
ner can create a region of interest (ROI) and override the density to 1 gm/
cm3 to mimic a specific thickness of bolus.
■ In vivo measurement is recommended to ensure adequate dose under the
bolus.
■ Air gaps between the mask and the patient skin may be filled by either
superflab, ultrasound gel, or a similar product that is deemed appropriate.
■ Dose grid and resolution
● The dose grid size affects computational time. For a large tumor volume,
such as HN, a 4 × 4 × 4 mm3 dose grid provides adequate resolution.
FIGURE 5.6 Bolus created in the treatment planning system. The yellow
wireframe represents 5 mm bolus. Note: Care must be taken not to cover the
patient’s eyes or airways.
● Changing from 4 × 4 × 4 mm3 to 3 × 3 × 3 mm3 dose grid does not sig-
nificantly alter the dose coverage to the tumor or maximum dose to the
critical structures.
● In the case of a very small tumor volume (such as retreatment of a recur-
rence), reducing the dose grid to 3 × 3 × 3 mm3 or smaller should be

considered.
● The dose grid size should cover all normal structures and all target vol-
umes. Inadequate dose grid size can result in an inaccurate dose volume
histogram (DVH).
■ Beam weight and prescription
● Before optimization, all beams are set to equal weight. The prescription
dose, number of fractions, and plan normalization must also be set.

● Typical choices to normalize a plan are: ROI minimum, mean or maxi-
mum dose, or point dose (either maximum dose, isocenter, or other

defined points).
● If planned for multiple dose levels (simultaneously integrated boost),
only one dose level is entered in the prescription. Typically prescribe

to the high dose PTV while examining the dose coverage of the other
PTVs.
■ Optimization parameter setting for nine-field IMRT (applicable to Pinnacle
users, there are similar parameters for other planning systems):
● Use a minimum of 25 iterations; 30 to 40 is preferred.
● Set the convolution dose calculation at iteration 8.
● If available, use DMPO (direct machine parameter optimization) on all
beams.
● Set the maximum number of segments to 70; increase if unable to achieve
planning goals.
● Set the minimum segment area to 12 cm2.
● Set the minimum segment monitor units (MU) to 4 (depending on treat-
ment machine characterization).

● Set the minimum numbers of leaf pairs to 10. A higher number of leaf
pairs along with a larger minimum segment area eliminates very small
segments.
■ Optimization parameter setting for VMAT plans (applicable to Pinnacle
users; there are similar parameters for other planning systems)
● Use a minimum of 25 iterations; 30 to 40 is preferred.
● Set convolution dose at iteration 8.
● Choose SmartArc optimization.
● Set jaw size to the treatment machine allowed maximum and then choose
the option of “set current jaws as Max.” This setting avoids the optimizer
opening up the jaws beyond the allowable maximum. For example, for
Varian machines, set X1 = 14.5 cm, X2 = 14.5 cm, Y jaws are set to cover
the length of all PTVs plus a margin (maximum Y1 = Y2 = 20 cm for
Truebeam accelerators, and Y1 = Y2 = 10.5 cm for Edge accelerators).
● Set “Allow jaw motion.” This setting allows the jaw size to decrease for
small tumor volumes and track the multi-leaf collimator (MLC) if the
accelerator is commissioned for it.
● Either manually set two arcs with two different collimator angles or cre-
ate one arc and let Pinnacle create a mirror arc during optimization.
● Set the final gantry spacing to every 4°.
■ Plan objectives for optimization

● Most commercial planning systems employ the gradient search method for
the inverse planning algorithm. Due to the nature of this search method,
plans involving multiple critical structures require multiple stage planning.
● The first set of planning objectives includes the PTVs and dose rings.
● Without resetting the beams (referred to as “warm start”), add three to
five normal structure planning objectives on the second stage and then
continue to optimize.
● Use maximum dose objectives for serial structures such as the spinal
cord, brain stem, or optic nerves.

● Use the mean dose (or max equivalent uniform dose [EUD] with a = 1)
objective for the parallel structures such as parotid glands, oral cavity,
and larynx.
● It is possible to use both max and mean dose objectives on serial struc-
tures to control the low dose shape.

● Min DVH and Max DVH are the least strict dose objectives.
● Min Dose and Max Dose are stricter dose objectives than Min DVH and
Max DVH.
● Uniform dose is the most strict dose objective. This objective requires
the optimizer to achieve uniform dose for all voxels within the PTVs.
● Evaluate the optimization result and identify structures that do not meet
their planning goal. Modify the planning objectives of these structures by

increasing their weighting factors and reducing the limit doses. Continue
optimization without resetting the beams.
● Repeat manual iterative process until the normal structure goals are met.
The final stage of the optimization is to achieve the PTV dose coverage.
● This manual process is mimicked by auto-planning processes, described
in Chapter 2.
● There are two approaches in this manual process.
■ The approach described here determines the lowest possible dose limit
to the normal structures first, and then recovers the PTV dose coverage
at the end.
■ The other approach is to achieve the optimal PTV dose coverage first,
and then slowly reduce the dose of each normal structure progressively.
● One can trick the optimizer to achieve the desired PTV dose coverage
with the following tips:
■ Set the dose objective of the PTVs slightly higher than prescribed. For
example: ask for a minimum dose of 7100 cGy instead of 7000 cGy
as prescribed.
■ Expand the PTVs by 1 mm, named as the planning PTV-Obj.
■ Create cold and hot spots contours if there are cold or hot regions
inside the PTVs. To create cold spots for a selected PTV, convert the
current prescription isodose line into an ROI, and then subtract the ROI
from the PTV. To create a hot spot, directly convert the hot isodose line
into an ROI (shown in Figure 5.7).
● The weight of each planning objective is relative, and is directly applied
to the objective value calculation.

● Start the highest weight at 10 and the lowest at 0.1. Progressively increase
the weight for the planning objective that is difficult to achieve.

● Keep decreasing the dose in the normal structures even if it is below the
tolerance, which provides opportunity for re-irradiation if the tumor recurs.

■ Plan evaluation
● Plan evaluation consists of qualitative and quantitative evaluation. The
qualitative evaluation is to visually examine the isodose distributions on
(A) (B)
FIGURE 5.7 (A) The thin line (yellow) is the resultant isodose line of 70 Gy.
(B) The thin line (orange) is the dose compensation region (or ROI, named as
D70) added to optimization objectives to improve the PTV (in solid green) dose
coverage.
PTV, planning target volume; ROI, region of interest.
each axial image. The quantitative evaluation is to examine the DVHs and
institutionally defined endpoints.
● Both qualitative and quantitative evaluations are important.
● Reviewing isodose distributions on each axial image can identify unex-
pected hot and cold spots inside and outside PTVs and unexpected low
dose spillages to non-specified normal tissue. During the review, view a
full set of isodose lines (e.g., 107%, 105%, 100%, 90%, 80%, 70%, 60%,
and 50% of the prescription dose). It is a good practice to evaluate actual
doses rather than relative doses.
● Quantitatively reviewing DVHs ensures the plan meets the specific dose
endpoints.
● Evaluating DVHs alone is not sufficient since it only evaluates the normal
structures that are contoured. It lacks spatial information.

● Dose to 99% of the GTV (D99%) should equal the prescription dose.
● Dose to 98% of the CTV (D98%) should equal the prescription dose.
● Dose to 95% of the PTV (D95%) should equal the prescription dose.
● The plan maximum point dose should be less than 110% of the highest
prescription dose.
● Typically, the maximum point dose is defined as the dose received by
0.03 cc.
● The typical Cleveland Clinic normal tissue dose constraints for larynx
and oropharynx are listed in Table 5.2. Table 5.3 lists the normal tissue
dose constraints for nasopharynx and base of skull tumors.
■ Adaptive planning
● For patients with large lymph nodes (>3 cm in diameters), an adaptive
planning is scheduled after 3 to 4 weeks of treatment.

● Adaptive planning is also for patients with >10% of weight loss, inac-
curate setup due to ill-fitting mask, or inconsistent setup observed from

daily cone beam CT (CBCT) images.
● For adaptive plan, a new CT is acquired with the same isocenter from
the initial plan. The adaptive plans are planned using the same dose
constraints as the initial plan to ensure the same plan quality and dose
constraints are met. The dose and fractions are adjusted in the prescrip-
tion in the record and verify system to reflect the adjusted course of
treatment.
SPECIFIC CASE PLANNING

■ All cases that are discussed in the following have been planned and treated
on a Varian machine such as Trilogy, Edge, or Truebeam.
TABLE 5.2 Lists of Typical Normal Tissue Dose Constraints for Larynx and Oropharynx
CCF Larynx CCF Oropharynx
Normal Tissue Ideal Variation Acceptable Ideal Variation Acceptable
BRAIN N/A N/A N/A N/A

BRAINSTEM Max Dose 2500 cGy Max Dose 3000 cGy Max Dose 2500 cGy Max Dose 3500 cGy
BRAINSTEM_PRV3 Max Dose 3500 cGy Max Dose 3800 cGy Max Dose 3500 cGy Max Dose 4000 cGy
CHIASM Max Dose 500 cGy Max Dose 500 cGy Max Dose 500 cGy Max Dose 1000 cGy
COCHLEA_L Mean Dose 500 cGy Mean Dose 700 cGy Mean Dose 500 cGy Mean Dose 1000 cGy
COCHLEA_R Mean Dose 500 cGy Mean Dose 700 cGy Mean Dose 500 cGy Mean Dose 1000 cGy
*OARPHARYNX Mean Dose 4000 cGy Mean Dose 4500 cGy Mean Dose 4500 cGy Mean Dose 5000 cGy
ESOPHAGUS Mean Dose 2500 cGy Mean Dose 3500 cGy Mean Dose 2500 cGy Mean Dose 3500 cGy
GLOBE_L Max Dose 500 cGy Max Dose 500 cGy Max Dose 500 cGy Max Dose 700 cGy
GLOBE_R Max Dose 500 cGy Max Dose 500 cGy Max Dose 500 cGy Max Dose 700 cGy
LARYNX N/A N/A Mean Dose 3000cGy Mean Dose 3500cGy
LENS_L Max Dose 500 cGy Max Dose 500 cGy Max Dose 500 cGy Max Dose 700 cGy
LENS_R Max Dose 500 cGy Max Dose 500 cGy Max Dose 500 cGy Max Dose 700 cGy
LIPS Mean Dose 700 cGy Mean Dose 1000 cGy Mean Dose 700 cGy Mean Dose 2000 cGy
(continued
TABLE 5.2 Lists of Typical Normal Tissue Dose Constraints for Larynx and Oropharynx (continued)

OPTIC_NRV_L Max Dose 500 cGy Max Dose 500 cGy Max Dose 500 cGy Max Dose 1000 cGy
OPTIC_NRV_R Max Dose 500 cGy Max Dose 500 cGy Max Dose 500 cGy Max Dose 1000 cGy
ORAL_CAVITY Mean Dose 3000 cGy Mean Dose 3500 cGy Mean Dose 3000 cGy Mean Dose 3500 cGy
*PAROTID_L Mean Dose 2200 cGy Mean Dose 2600 cGy Mean Dose 2400 cGy Mean Dose 2600 cGy
*PAROTID_R Mean Dose 2200 cGy Mean Dose 2600 cGy Mean Dose 2400 cGy Mean Dose 2600 cGy
PITUITARY Mean Dose 300 cGy Mean Dose 300 cGy Mean Dose 300 cGy Mean Dose 300 cGy
SPINAL_CORD Max Dose 3500 cGy Max Dose 3800 cGy Max Dose 3500 cGy Max Dose 3800 cGy
SPINAL_CORD_PRV5 Max Dose 3800 cGy Max Dose 4000 cGy Max Dose 3800 cGy Max Dose 4000 cGy
*SUBMANDIBULAR_L Mean Dose 3900 cGy Mean Dose 3900 cGy Mean Dose 3900 cGy Mean Dose 3900 cGy
*SUBMANDIBULAR_R Mean Dose 3900 cGy Mean Dose 3900 cGy Mean Dose 3900 cGy Mean Dose 3900 cGy
*SUPRAGLOTTIC Mean Dose 4500 Mean Dose 5000 Mean Dose 4500 Mean Dose 5000
cGy cGy cGy cGy
TEMP_LOBE_L N/A N/A N/A N/A
TEMP_LOBE_R N/A N/A N/A N/A
TRACHEA Mean Dose 2500 cGy Mean Dose 3500 cGy Mean Dose 2500 cGy Mean Dose 3500 cGy
(continued
TABLE 5.2 Lists of Typical Normal Tissue Dose Constraints for Larynx and Oropharynx (continued)

LACRIMAL_R N/A N/A N/A N/A

BRACHIAL_PLEXUS_L Max Dose 6300 cGy Max Dose 6600 cGy Max Dose 6300 cGy Max Dose 6600 cGy
BRACHIAL_PLEXUS_R Max Dose 6300 cGy Max Dose 6600 cGy Max Dose 6300 cGy Max Dose 6600 cGy
†
HYPOPHARYNX_AVOID Mean Dose 5000 cGy Mean Dose 5500 cGy Mean Dose 5000 cGy Mean Dose 5500 cGy
‡
THYROID V30 < 60, V45 < 50 V30 <60, V45 <50
*Evaluate the (OAR–PTV) structure if the OAR is overlapped with the PTV.
†
This OAR has high variability during contouring.
‡
OARs applied to the Ipsilateral cases only.
CCF, Cleveland Clinic Foundation.
TABLE 5.3 Lists of Typical Normal Tissue Constraints for Nasopharynx
and Base Skull Tumors
CCF Nasopharynx/Base of Skull
Normal Tissue Ideal Variation Acceptable
BRAIN Mean Dose 500 cGy Mean Dose 700 cGy

BRAINSTEM Max Dose 5600 cGy Max Dose 6000 cGy
BRAINSTEM_PRV3 Max Dose 6000 cGy Max Dose 6300 cGy
CHIASM Max Dose 5600 cGy Max Dose 5600 cGy
COCHLEA_L Mean Dose 3000 cGy Mean Dose 3500 cGy
COCHLEA_R Mean Dose 3000 cGy Mean Dose 3500 cGy
*OARPHARYNX Mean Dose 4500 cGy Mean Dose 5000 cGy
ESOPHAGUS Mean Dose 2500 cGy Mean Dose 3500 cGy
GLOBE_L Max Dose 4500 cGy Max Dose 5000 cGy
GLOBE_R Max Dose 4500 cGy Max Dose 5000 cGy
LARYNX Mean Dose 3000 cGy Mean Dose 3500 cGy
LENS_L Max Dose 700 cGy Max Dose 1000 cGy
LENS_R Max Dose 700 cGy Max Dose 1000 cGy
LIPS Mean Dose 700 cGy Mean Dose 2000 cGy
MANDIBLE 105% of RX <1 cc 105% of RX <5cc
OPTIC_NRV_L Max Dose 5500 cGy Max Dose 5600 cGy
OPTIC_NRV_R Max Dose 5500 cGy Max Dose 5600 cGy
ORAL_CAVITY Mean Dose 3000 cGy Mean Dose 3500 cGy
*PAROTID_L Mean Dose 2600 cGy V30 <50%
*PAROTID_R Mean Dose 2600 cGy V30 <50%
PITUITARY Mean Dose 3000 cGy None if in volume
SPINAL_CORD Max Dose 3500 cGy Max Dose 4500 cGy
SPINAL_CORD_PRV5 Max Dose 3800 cGy Max Dose 4800 cGy
*SUBMANDIBULAR_L Mean Dose 3900 cGy Mean Dose 3900 cGy
*SUBMANDIBULAR_R Mean Dose 3900 cGy Mean Dose 3900 cGy
*SUPRAGLOTTIC Mean Dose 4500 cGy Mean Dose 5000 cGy
TEMP_LOBE_L Max Dose 7000 cGy, Max Dose 7200 cGy,
mean Dose 2000 cGy mean Dose 2300 cGy
TEMP_LOBE_R Max Dose 7000 cGy, Max Dose 7200 cGy,
mean Dose 2000 cGy mean Dose 2300 cGy
(continued)
TABLE 5.3 Lists of Typical Normal Tissue Constraints for Nasopharynx
and Base Skull Tumors (continued)
CCF Nasopharynx/Base of Skull
Normal Tissue Ideal Variation Acceptable
TRACHEA Mean Dose 2500 cGy Mean Dose 3500 cGy

LACRIMAL_L V20 <25%, Mean Dose V20 <25%, Mean
2000 cGy Dose 2000 cGy
LACRIMAL_R V20 <25%, Mean Dose V20 <25%, Mean
2000 cGy Dose 2000 cGy
BRACHIAL_PLEXUS_L Max Dose 6300 cGy Max Dose 6600 cGy
BRACHIAL_PLEXUS_R Max Dose 6300 cGy Max Dose 6600 cGy
†
HYPOPHARYNX_AVOID N/A N/A
‡
THYROID V30 <60, V45 <50
*Evaluate the (OAR–PTV) structure if the OAR is overlapped with the PTV.
†
This OAR has high variability during contouring.
‡
OARs applied to the ipsilateral cases only.
CCF, Cleveland Clinic Foundation; OAR, organs at risk; PTV, planning target volume.
T2 N0 M0 Squamous Cell Carcinoma of the Glottis (Where Nodal

Treatment Is Deemed Necessary)
■ Two coplanar full arcs with 6 MV photons.
■ Two dose level PTVs: PTV_6525 cGy and PTV_5220 cGy in 29 fractions.
■ The first set of planning objectives for the two PTVs is listed in Table 5.4.
■ This initial set of planning objectives pushes all high dose into the high
dose PTV.
■ The second set of planning objectives is listed in Table 5.5.
● Place a Max Dose objective on the spinal cord PRV5 (spinal cord expand-
ing by 5 mm) while evaluating the actual spinal cord.

● Place Max EUD (mean dose) on parotid glands and submandibular
glands with a lower dose limit than the actual goals of 2200 cGy for the
parotid gland and 3900 cGy for the submandibular glands.
■ The third set of planning objectives is listed in Table 5.6.
■ After two stages of progressive planning, evaluate the plan, make appropri-
ate changes to the existing planning objectives, and then add the third set
of planning objectives.
■ Note changes in the weights on the parotid glands and submandibular
glands from Table 5.5 to Table 5.6.
■ The added planning objectives have a lower dose than the desired dose
limits with low weights of only 0.1.
TABLE 5.4 The First Set of Planning Objectives for a Case of T2 N0 M0
Squamous Cell Carcinoma of the Glottis
Target Dose
ROI Type (cGy) % Volume Weight gEUD
PTV_6525 MIN DOSE 6525 10

PTV_6525 MAX DVH 6851 2% 10
PTV_5220_OBJ MIN DOSE 5220 10
PTV_5220_OBJ MAX DOSE 5873 10
RING MAX DOSE 3262 4
RING22 MAX DOSE 2200 4
DVH, dose volume histogram; EUD, equivalent uniform dose; PTV, planning target
volume; ROI, region of interest.
■ In this case, the planning goals are to achieve:

● Lips: mean 500 cGy (low mean will also keep max dose low).
● Oral cavity: mean 2000 cGy.
● Mandible: no planned goal as structure was away from the PTVs. The
mean dose objective is to shape the low dose isodose lines.
TABLE 5.5 The Second Set of Planning Objectives for a Case of T2 N0 M0

Target
Dose %
ROI Type (cGy) Volume Weight gEUD

PTV_6525 MAX DVH 6851 2% 10
SPINAL_CORD_ MAX DOSE 2500 0.1
PRV5
PAROTID_R MAX EUD 1500 0.1 1
PAROTID_L MAX EUD 1500 0.1 1
SUBMANDIBULAR_R MAX EUD 3000 0.1 1
SUBMANDIBULAR_L MAX EUD 3000 0.1 1
TABLE 5.6 The Third Set of Planning Objectives for a Case of T2 N0 M0
Target
Dose %

PTV_6525 MAX DVH 6851 2% 10
SPINAL_CORD_PRV5 MAX DOSE 2500 2
LIPS MAX EUD 250 0.1 1
ORAL_CAVITY MAX EUD 1100 0.1 1
MANDIBLE MAX EUD 1000 0.1 1
SUPRAGLOTTIS MAX EUD 4000 0.1 1
TRACHEA MAX EUD 2800 0.1 1
ESOPHAGUS MAX EUD 2200 0.1 1
● Supraglottis: no constraint as it is a glottis tumor. The mean dose objec-

tive is to shape the high dose isodose lines.
● Trachea: mean dose 4000 cGy.
● Esophagus: mean dose 3000 cGy.
■ The fourth set of planning objectives is listed in Table 5.7.

■ Evaluate the plan, make appropriate changes to the existing objectives, and
then add a fourth set of objectives.
■ Note changes in the weights of the supraglottis and trachea.
■ New objectives added
● OARPharynx: mean dose 4500 cGy. A higher weight was added based
on the isodose distribution.

● Thyroid: minimize dose as low as possible.
● R_Hypopharynx Avoid (shown as a green thin line contour in Figure 5.8):
mean dose 5500 cGy. A higher weight is added to this structure based on
TABLE 5.7 The Fourth Set of Planning Objectives for a Case of T2 N0 M0
Target
Dose %

PTV_6525 MAX DVH 6851 2% 10
TRACHEA MAX EUD 2800 1 1
OARPHARYNX MAX EUD 3800 1.5 1
THYROID MAX EUD 5000 0.1 1
R_HYPOPAHRYNX MAX EUD 5000 1 1
AVOID
MID AVOID MAX EUD 2500 1 1
the isodose distributions from the previously set of planning objectives.

Figure 5.8 shows the improvement in the dose distribution.
● A midline avoidance structure. As shown in Figure 5.9, this structure is
manually created to help push dose off the midline OARs. Add the struc-
ture to the DVH, evaluate the mean dose to this structure, and then add a
planning objective based on the current mean dose. If the current mean is
3000 cGy, ask for a planning objective of 200 to 1500 cGy.
FIGURE 5.8 A Hypopharynx-R avoid structure (green line) is manually

contoured. The resultant isodose line 52.20 Gy (purple) is carved in. The PTV
is in solid blue. The posterior constrict is in organ line.
■ The fifth set of planning objectives is listed in Table 5.8.

● Evaluate the plan and make appropriate changes to the existing objec-
tives, then add a new block of objectives.
FIGURE 5.9 A midline avoidance structure (in solid purple) is manually

contoured to push the dose off the midline OARs.
OARs, Organs at risk.
TABLE 5.8 The Fifth Set of Planning Objectives for a Case of T2 N0 M0
Target
Dose %

PTV_6525 MAX DVH 6851 2% 50
AVOID
PTV_6525 UNIFORM 6225 40
DOSE
PTV_5220_OBJ UNIFORM 5220 50
DOSE
● At this stage of planning, most OARs are at or below the acceptable

dose goals. This round of optimization is to improve dose coverage to
the PTVs.
● Be aware that when the PTV dose coverage improves, the doses to the
normal ROIs will increase as well.
● The new planning objective added to the PTVs is uniform dose. This
planning objective will smooth out the dose across the entire PTV while
getting the dose coverage back to 95%. This is a gradual process and may
take a few optimization runs (do not reset beams, warm start) before the
desired PTV coverage is achieved.
■ The sixth set of planning objectives is listed in Table 5.9.
● Evaluate the plan, make appropriate changes to the existing objectives,
and then add a new set of planning objectives.

● If dose coverage is not achieved on either PTVs, increase the weights
on the PTVs. Add additional objectives to improve dose coverage to

PTV_5220.
■ The seventh set of planning objectives is listed in Table 5.10.
■ Evaluate the plan, make appropriate changes to the existing objectives, and
then add a new set of planning objectives. The dose coverage to the PTVs is
better, but still not meeting the goals. Further increase the weight on PTVs
as shown in Table 5.10.
■ Add three new objectives to further improve the dose distributions and dose
coverage to the low dose PTV.
● Spinal cord PRV5 is added with a mean dose to reduce the dose to the
entire length of the spinal cord.

● A posterior neck tuning structure (shown in Figure 5.10) was created to
avoid the low dose spillage into this region.
T2 N2b M0 Squamous Cell Carcinoma of the Base of Tongue

■ Two coplanar VMAT full arcs with 6 MV photons.
■ Simultaneously integrated boost plan of PTV_7000 cGy and PTV_5600
cGy in 30 fractions.
■ As shown in Figure 5.11, the high dose PTV is in the right base of tongue
and neck.
■ The right brachial plexus is contoured due to its proximity to the high dose
PTV.
■ A midline avoid is drawn to protect the larynx and supraglottis. A mean dose
objective is added for it.
■ Optimal parotid sparing.
■ The final dose distribution is shown in Figure 5.12A. The DVHs of
PTV_7000, PTV_5600, right brachial plexus, larynx, and supraglottis are
shown in Figure 5.12B. Despite close proximity to the high dose PTV, these
critical structures were adequately protected.
TABLE 5.9 The Sixth Set of Planning Objectives for a Case of T2 N0 M0
Target
Dose %

PTV_6525 MAX DVH 6851 2% 70
PTV_5220_OBJ MAX 5873 70
DOSE
RING MAX 3262 4
DOSE
RING22 MAX 2200 4
DOSE
SPINAL_CORD_PRV5 MAX 2500 2
DOSE
AVOID
DOSE
DOSE
PTV_5220_OBJ MIN DVH 5220 100% 70
TABLE 5.10 The Seventh Set of Planning Objectives for a Case of T2 N0 M0
Target
Dose %

PTV_6525 MAX DVH 6851 2% 80
AVOID
DOSE
DOSE
PTV_5220_OBJ MIN DVH 5220 100% 95
SPINAL_CORD_PRV5 MAX EUD 1200 1 1
D52 MIN DOSE 5220 65
POST NECK MAX EUD 1500 1 1
FIGURE 5.10 A tuning structure (pink) is added to the posterior neck.
FIGURE 5.11 Contours for a T2 N2b M0 squamous cell carcinoma of the base
of tongue. The light yellow contour is manually drawn as a midline structure to
shape the dose distribution. Dark green—PTV_7000, light blue—PTV_5600,
brown—R brachial plexus, yellow—midline avoid, red—larynx.
73.50, 70.0, 56.0, 45.0 Gy

(A)
100
90
80
70
60 BRACHIAL_PLEXUS_R
Volume (%)
LARYNX
50
PTV_5600
40 PTV_7000
SUPRAGLOTTIS
30
20
10
0
0 10 20 30 40 50 60 70
Dose (Gy)
(B)
FIGURE 5.12 Dose distributions (A) and DVHs (B) for the case shown in
Figure 5.11 (b).
DVHs, dose volume histograms; PTV, planning target volume.
T4b N0 M0 Esthesioneuroblastoma of the Nasal Cavity

■ Five non-coplanar VMAT arcs, including three full coplanar arcs, and two
short arcs from 330° to 30°, with a couch angle of 270°, aiming toward the
nasal cavity between the globes (shown in Figure 5.13).
■ 6 MV photons
■ SIB plan with PTV_6000 cGy and PTV_5400 cGy in 30 fractions
FIGURE 5.13 Five non-coplanar VMAT arcs, including three full arcs at 0˚
couch angle, and two short arcs with a 270˚ couch angle.
VMAT, volumetric modulated arc therapy.
■ High dose PTV between the globes

■ Desirable dose constraints to critical structures.
● Maximum dose to the eye globes (D0.03 cc) <50 Gy and mean dose
<15 Gy.
● Maximum dose to the temporal lobes (D0.03 cc) <60 Gy, and mean dose
<17 Gy.
● Maximum dose (D0.03 cc) to the brain stem <45 Gy.
● Mean dose of the lacrimal glands <10 Gy.
● Mean dose of the cochlea <15 Gy.
● Achieve good midline sparing (OARPharynx, supraglottis, larynx, and
esophagus).
● The final dose distribution is shown in Figure 5.14A. Notice that 20 Gy
isodose line (light green) is off both eye globes and 30 Gy isodose line
(blue) is off the larynx on the right panel of Figure 5.14A (red line con-
tour). The DVHs of PTV_6000, PTV_5000, R/L globes, lacrimal glands,
and optic nerves are shown in Figure 5.14B, meeting the dose constraints
defined previously.
T2 N0 M0 Squamous Cell Carcinoma of the Scalp

■ Two coplanar VMAT full arcs with 6 MV photons.
■ PTV_6000 cGy in 30 fractions.
■ 5 mm sticky bolus posteriorly under head on custom cushion (shown in
Figure 5.15).
■ 5 mm molded hard bolus on top of mask.
63.0, 60.0, 54.0, 45.0, 30.0, 20.0 Gy
(A)
100
90
80
70 GLOBE_L
GLOBE_R
Volume (%)
60 LACRIMAL_L
50 LACRIMAL_R
OPTIC_NRV_L
40 OPTIC_NRV_R
PTV_5400
30 PTV_6000
20
10
0
0 10 20 30 40 50 60
Dose (Gy)
(B)
FIGURE 5.14 Final dose distributions (A) and DVHs (B) for a T4b N0 M0
Esthesioneuroblastoma of the nasal cavity. In (A), notice that 20 Gy dose line
(light green) is off both eye globes and the 30 Gy dose line (blue) is off the
larynx (red line contour). The eye-R, eye-L, brain stem, spinal cord, lacrimal
glands are contoured. Solid green is the PTV-HD, and solid blue is PTV-LD.
DVHs, dose volume histograms; PTV, planning target volume; PTV-HD (high dose);
PTV-LD (low dose).
■ Expand the PTV by 1 cm and subtract it from the normal brain. The partial
brain (shown in Figure 5.16) is named as avoidance to decrease the low dose
spillage to the normal brain.
FIGURE 5.15 A 5 mm molded hard bolus on top of the mask.
■ Dose constraints to the critical structures

● Brain: mean dose <22 Gy.
● Brain stem: maximum dose (D0.03 cc) <20 Gy.
● Eye globes: mean dose <7 Gy.
FIGURE 5.16 Avoidance structure (in pink) for a case of T2 N0 M0 squamous

cell carcinoma of the scalp.
● Temporal lobes: mean dose <15 Gy.
● Optic chiasm and nerves: maximum dose (D0.03 cc) <7 Gy.
● Lens: maximum dose <7 Gy.
● The final dose distributions are shown in Figure 5.17A. The DVHs of the
PTV_6000, brain, avoidance, and temporal lobes are shown in Figure
5.17B, meeting the dose constraints defined previously.
63.0, 60.0, 45.0, 30.0 Gy

(A)
100
90
80
70
AVOID
60
Volume (%)
BRAIN
50 PTV_6000
TEMP_LOBE_L
40 TEMP_LOBE_R
30
20
10
0
0 10 20 30 40 50 60
Dose (Gy)
(B)
FIGURE 5.17 Dose distributions in axial and sagittal images (A) and DVHs (B)
for a T2 N0 M0 squamous cell carcinoma of the scalp. In (A), solid green is the
PTV. Light green is the added bolus. Isodose lines of 63.0 Gy, 60.0 Gy, 45.0
Gy, and 30.0 Gy are shown in (A).
DVHs, dose volume histograms; PTV, planning target volumes.
T2b N1 M0 Malignant Neoplasm of Connective Tissue of Head, Face,
and Neck
■ Three non-coplanar VMAT arcs, including two full arcs and one non-copla-
nar arc from 2-178 with the table at 270˚.
■ Non-coplanar beam concentrated on the scalp.
■ 6 MV photons.
■ SIB plan with PTV_6800 cGy and PTV_6120 cGy in 34 fractions.
■ 1 cm bolus posteriorly under head on the custom cushion.
■ 5 mm molded hard bolus on the mask. Pay special attention to keep the
bolus off the right eye (shown in Figure 5.18).
■ Desirable dose constraints to the critical structures
● Brain stem: maximum dose (D0.03 cc) <25 Gy.
● RT temporal lobe: mean dose <17 Gy.
● LT temporal lobe: mean dose <10 Gy.
● RT cochlea: mean dose <15 Gy.
● LT cochlea: mean dose <7 Gy.
● Spinal cord: Maximum dose (D0.03 cc) <35 Gy.
FIGURE 5.18 Three-dimensional rendering of bolus for a T2 N0 M0 squamous

cell carcinoma of the scalp.
● RT eye globe: maximum dose (D0.03 cc) <50 Gy.
● LT eye globe: maximum dose (D0.03 cc) <40 Gy.
● RT lacrimal gland: mean dose <40 Gy. Not a high priority and may not
be able to spare the gland due to the disease.
● RT optic nerve: maximum dose <20 Gy.
● LT optic nerve: maximum dose <10 Gy.
● L parotid: mean dose <5 Gy.
● Midline avoidance structure: mean dose <20 Gy.
● The final dose distributions are shown in Figure 5.19A. The DVHs
of PTV6800, PTV_6120, brain stem, right cochlea, right globe, right
lacrimal gland, right optic nerve, and spinal cord are shown in Figure
5.19B, meeting the dose constraints defined previously.
RE-IRRADIATION
T3 N0 M0 Squamous Cell Carcinoma of the Tonsil, Re-Irradiation
■ Four non-coplanar VMAT arcs, including two full coplanar arcs and two
short non-coplanar arcs from 330° to 30°, with a couch angle of 270°.
■ Non-coplanar beams help to reduce dose to the spinal cord.
■ Lock asymmetric jaws (shown in Figure 5.20) during optimization while
avoiding the cord from all arcs.
■ 6 MV photons.
■ PTV_6200 cGy in 31 fractions.
■ The initial treatment plan was fused with the new planning CT to assess the
total dose to the spinal cord.
■ The spinal cord was contoured in two parts: normal spinal cord and a high
risk spinal cord, which is in both the current and previously treated fields
(shown in Figure 5.21).
■ For re-irradiation cases, it is important to obtain a composite dose distribu-
tion between the old and new plans and document the best estimated total
dose to all critical structures.
■ Because of different patient positions between the old and new plans, either
rigid or deformable image registration can be used to perform image fusion.
Neither deformable nor rigid image registration is accurate, and thus the
composited dose is an estimation.
■ Dose constraints for the critical structures
● Brainstem: maximum dose (D0.03 cc) <10 Gy.
● Spinal cord: maximum dose <10 Gy.
● High risk spinal cord: maximum dose <6 Gy.
● RT parotid: V30 <50%.
● LT parotid: mean dose <5 Gy.
● Larynx: mean dose <15 Gy.

71.40 Gy
68.00 Gy
61.20 Gy
55.00 Gy
45.00 Gy
34.00 Gy
(A)
100
90
80
70 BRAINSTEM
COCHLEA_R
Volume (%)
60 GLOBE_R
LACRIMAL_R
50 OPTIC_NRV_R
PTV_6120
40 PTV_6800
SPINAL_CORD
30
20
10
0
0 10 20 30 40 50 60 70
Dose (Gy)
(B)
FIGURE 5.19 The final dose distributions (A) and DVHs (B) for a T2 N0 M0
squamous cell carcinoma of the scalp. Solid-green is the PTV-LD and solid
blue is the PTV-LD. Solid light green outside mask is the bolus. Isodose lines
of 71.40 Gy, 68.0 Gy, 61.20 Gy, 55.0 Gy, 45.0 Gy, and 34 Gy are shown in (A).
DVHs, dose volume histogram; PTV, planning target volume; PTV-LD (low dose).
● Supraglottis: mean dose <35 Gy.

● OARpharynx: mean dose <35 Gy.
■ The final dose distributions and DVHs are shown in Figure 5.22A,B. As
shown in Figure 5.22B, the maximum dose to the high-risk spinal cord is
<6 Gy.
FIGURE 5.20 To protect the spinal cord that received previous radiation, the
asymmetric jaws (in red) are locked to shield that portion of the spinal cord.
FIGURE 5.21 Contours for a re-irradiation of T3 N0 M0 squamous cell

carcinoma of the tonsil. The PTV is solid green, the high risk spinal cord is
delineated in maroon, and normal spinal cord is delineated in bright green. The
light green is the 6 Gy isodose line from the re-irradiation plan.
(A)
100
90
80
70
Volume (%)
60 BRAINSTEM
HIGH_RISK_CORD
50 PTV_6200
SPINAL_CORD
40
30
20
10
0
0 10 20 30 40 50 60
Dose (Gy)
(B)
FIGURE 5.22 Final dose distributions (A) and DVHs (B) for a re-irradiation of
T3 N0 M0 squamous cell carcinoma of the tonsil case.
DVHs, dose volume histogram; PTV, planning target volume.
T4b N2b M0 P16+ Malignant Neoplasm of the Right Tonsil Re-Irradiation
■ Two coplanar VMAT full arcs
■ 6 MV flattening filter free to get high dose rate
■ 4000 cGy in five fractions (stereotactic body radiation therapy [SBRT])
■ Planned per RTOG 3507 guidelines (1)
■ GTV
● The GTV represents the clinically (via physical examination) or radio-
graphically visible tumor, denoted as GTV_4000. PET images can assist

in the delineation of the GTV but one should not exclusively rely on them
due to the uncertainties of PET images.
● The positive nodes must be included in the GTV and are defined as those
greater than 1.5 cm in the longest axis or >1 cm in the shortest axis,
a cluster of 3 or more borderline size nodes, radiographic evidence of
extra-nodal extension (ENE), a node of any size with evidence of necro-
sis, or a node with a standard uptake value (SUV) above 4 on PET/CT.
● A patient who underwent aggressive biopsy or subtotal resection with
a biopsy/resection bed in association with the radiographically vis-

ible gross target disease, must have the entire biopsy/resection bed
included in the GTV. This residual tumor plus biopsy/resection bed
GTV must have its largest maximum dimension <5 cm to meet eligi-
bility criteria.
■ CTV
● None
■ PTV
● PTV_4000 is an isotropic expansion of the GTV to account for internal
motion and residual setup error. The PTV is defined as a 3 mm expansion

of the GTV in three dimensions. If the PTV overlaps a critical OAR (e.g.,
spinal cord or brain stem) or its associated PRV, the dose coverage to the
PTV can be reduced from the desired ≥95% coverage to ≥85%, as per the
dose constraints in RTOG 3507 protocol.
■ Dose prescription
● The prescribed dose is 40 Gy in five fractions to >95% of the PTV. Treat-
ment course is 10 to 15 days with a minimum of 40 hours to a maximum

5 days in between fractions.
● For this SBRT approach, the recommended prescription isodose line
should be between 80% to 90% but may range from 75% to 95% with
the plan maximum dose as 100%.
● Any dose >105% of the prescription dose should occur within the PTV
and not within the normal tissues outside the PTV.

● A dose grid of 2 × 2 × 2 mm3 is required.
■ Special planning notes

FIGURE 5.23 The carotid artery (green line) and carotid-PRV (light yellow) is
excluded from the GTV (solid blue). Solid green is the PTV.
GTV, gross tumor volume; PTV, planning target volume.
● Dose ring: first expand all of the PTVs by 5 to 7 mm, and then subtract
the expansion from the external contour. The planning objective to the
dose ring is limited to the maximum dose at 50% of the highest prescrip-
tion dose.
● The optimization weight for the dose ring is higher than the weight of the
PTV. This is opposite from the standard HN IMRT planning.
● PTV_4000 OBJ is created to exclude the Carotid-PRV (2 mm expansion)
to avoid a high dose in the carotid artery (as shown in Figure 5.23).
● Table 5.11 lists the first set of planning objectives.
TABLE 5.11 The First Set of Planning Objectives for a T4b N2b M0 P16+
Malignant Neoplasm of the Right Tonsil Re-Irradiation
Target Dose
ROI Type (cGy) % Volume Weight gEUD

PTV_4000_OBJ MAX DVH 4400 2% 2
TABLE 5.12 The Second Set of Planning Objectives for a T4b N2b M0 P16+
Target %
ROI Type Dose (cGy) Volume Weight gEUD

BRAINSTEM_PRV3 MAX DOSE 800 0.1
COCHLEA_R MAX EUD 700 0.1 1
COCHLEA_L MAX EUD 150 0.1 1
SPINAL_CORD_ MAX DOSE 800 1
PRV5
● Table 5.12 lists the second set of planning objectives.

■ Evaluate the plan, make appropriate changes to the existing objectives,

● Table 5.13 lists the third set of planning objectives.
TABLE 5.13 The Third Set of Planning Objectives for a T4b N2b M0 P16+
Target
ROI Type Dose (cGy) % Volume Weight gEUD

BRAINSTEM_ MAX DOSE 800 0.1
PRV3
SPINAL_CORD_ MAX DOSE 800 1
PRV5
CAROTID_R MAX DOSE 4200 5
and then add a new set of objectives.
■ Note: the weight in the carotid is higher than that of the PTV, allowing
the optimizer to push high dose away from the carotid.

● Table 5.14 lists the fourth set of planning objectives.
and then add new block of objectives.

■ Objective weight on the carotid is increased from 5 to 15.
● Table 5.15 lists the fifth set of planning objectives.

■ Evaluate the plan, make appropriate changes to the existing objectives

■ Objective weight on the carotid was increased from 15 to 25.
■ Add in a uniform dose and increase the weight of the PTV objective.
● Table 5.16 lists the sixth (final) set of planning objectives.

■ The plan dose goals of all OARs are met, except for the carotid.
TABLE 5.14 The Fourth Set of Planning Objectives for a T4b N2b M0 P16+
Target
Dose %

TABLE 5.15 The Fifth Set of Planning Objectives for a T4b N2b M0 P16+
Target
Dose %

DOSE
TABLE 5.16 The Sixth Set (Final) of Planning Objectives for a T4b N2b
M0 P16+ Malignant Neoplasm of the Right Tonsil Re-Irradiation
Target
Dose %
ROI Type (cGY) Volume Weight gEUD

(continued)
TABLE 5.16 The Sixth Set (Final) of Planning Objectives for a T4b
N2b M0 P16+ Malignant Neoplasm of the Right Tonsil Re-Irradiation
(continued)
Target
Dose %
ROI Type (cGY) Volume Weight gEUD

DOSE
■ The weight of the carotid is increased from 25 to 35 and the objective

dose is lowered to 4000 cGy.
■ The final dose distribution shown in Figure 5.24A. The DVHs for
PTV_4000, brainstem, carotid, and spinal cord are shown in Figure

5.24B, meeting the dose constraints.
● Table 5.17 lists the final treatment plan goal doses versus achieved doses.
SPECIAL CASES
Two Isocenter Treatment Plan for a T4b N0 M0 Teratocarcinoma of the
Ethmoidal Sinus
■ This case contains an extended volume shown in Figure 5.25. This volume
exceeded the 21 cm field length limit of an Edge accelerator (Varian).
■ The 2.5 mm leaf width of the Edge is preferred to achieve the better confor-
mity between the eyes. Rather than switching to an accelerator with a larger
field size, a VMAT plan with two isocenters is employed.
■ The isocenters were placed so that there was 5 cm of overlap when the
beams had a collimator of 0. Overlap is important as it allows the optimizer
44.0 Gy
40.0 Gy
36.0 Gy
32.0 Gy
28.0 Gy
24.0 Gy
(A)
100
90
80
70
BRAINSTEM
Volume (%)
60
CAROTID_R
50 PTV_4000
SPINAL_CORD
40
30
20
10
0
0 10 20 30 40
Dose (Gy)
(B)
FIGURE 5.24 The final dose distributions (A) and DVHs (B) for a T4b N2b M0
P16+ malignant neoplasm of the right tonsil re-irradiation. Note the hot spot is
away from the carotid (thick light green line). The conformity index, the ratio
of prescription dose to the PTV (solid green), is 1.03. (continued)
to feather out any match lines between the upper and lower arcs. This means
the largest field size can be 32 cm in total.
■ Daily imaging and setup will be discussed later in this section.
■ Isocenters are to be placed in the same X (lateral) and Z (sagittal) axis.
TABLE 5.17 The Final Treatment Plan Goals for a T4b N2b M0 P16+ Malignant Neoplasm of the Right
Tonsil Re-Irradiation
Primary Goal Secondary Goal Primary Achieved
Structure Type Dose (cGy) Volume Dose (cGy) Volume cm3 Dose* (cGy) Volume* Result
PTV_4000 Min DVH 4000 95% 3015.5 95.20% Met

3 3
PTV_4000 Max DVH 5000 0.03 cm 4809.4 0.0 cm Met
SPINAL_CORD Max DVH 800 0.03 cm3 1000 0.03 778.5 0.0 cm3 Met
SPINAL_CORD_PRV5 Max DVH 1000 3 cm3 1200 0.03 1041.7 0.01 cm3 Met
BRAINSTEM Max DVH 1000 0.03 cm3 1200 0.03 813.6 0.0 cm3 Met
BRAINSTEM_PRV5 Max DVH 1200 0.03 cm3 1400 0.03 961.4 0.00 cm3 Met
CAROTID_R Max DVH 4200 0.03 cm3 4400 0.03 4508.3 4.47 cm3 Met
MANDIBLE Max DVH 4200 0.03 cm3 4110.1 0.00 cm3 Met
ORAL_CAVITY Mean Dose 2500 1049.7 Met
SUBMANDIBULAR_R Mean Dose 2500 2342.1 Met
SUBMANDIBULAR_L Mean Dose 2500 487.7 Met
LARYNX Mean Dose 2000 44 Met
OARPHARYNX Mean Dose 2000 1438.2 Met
PAROTID_R Mean Dose 1500 1486.5 Met
PAROTID_L Mean Dose 1500 224.6 Met
*Volume is at primary goal dose and dose is at primary goal volume.
DVH, dose volume histogram; PTV, planning target volume.
Superior iso Inferior iso
FIGURE 5.25 The coronal views of the superior isocenter and inferior isocenter
location. The two green lines define the overlap regions.
■ The difference between the superior and inferior isocenters in the Y (longi-
tudinal) axis should be in an easy increment for the therapist to shift daily,
For example 16 cm, not 15.7 cm.
■ Superior isocenter, three non-coplanar arcs
● Beam 1: 182–178°, collimator 10°.
● Beam 2: 178–182°, collimator 350°.
● Beam 3: 2–178°, couch 270°, collimator 90°.
● Beam 3 is concentrated on the high dose volume between the globes.
■ Inferior isocenter, two coplanar arcs

● Beam 1: 182–178°, collimator 350°
● Beam 2: 178–182°, collimator 10°
■ 6 MV photons
■ SIB with PTV_6300 cGy, PTV_5600 cGy, and PTV_3150 cGy in 35
fractions
■ PTV planning objective structures
● PTV_6300_OBJ was created by excluding the left optic nerve with
1.5 mm PRV. The planning goal is to have the nerve maximum dose
<63 Gy.
● PTV_5600_OBJ was created by excluding a 5 mm expansion of the
PTV_6300.
● PTV_3150_OBJ was created by excluding a 7 mm expansion of both the
PTV_6300 and PTV_5600.

■ All beams (both isocenters) are planned with one prescription.
■ All beams have the equal weights before starting optimization.
■ All PTV-OBJs are used in the optimization instead of the PTVs.
■ The planning objectives
● Dose to 95% of the PTV_6300 >6300 cGy.
■ Dose to 25% of the PTV <6615 cGy (105% of prescription dose).
■ Dose to 3% of the PTV >6741 cGy (107% of prescription dose).
■ Dose to 97% of the CTV >6300 cGy due to the nearby left optic nerve
dose constraint.
● D95% to PTV_5600 and PTV_3150 is 5600 cGy and 3150 cGy, respec-
tively
● The maximum dose to the brain stem <55 Gy.
● Mean dose to R/L cochlea <35 Gy.
● The maximum dose to the spinal cord <38 Gy.
● The maximum dose to R/L globes <50.5 Gy, and mean dose <20 Gy.
● V20 Gy to R/L lacrimal glands <25%.
● Mean dose to R/L lens <8 Gy; 10 Gy variation acceptable.
● The maximum dose to R-Optic Nerve <61 Gy.
● The maximum dose to L-Optic Nerve <63 Gy.
● The maximum dose to Optic Chiasm <45 Gy.
● Mean dose to R/L parotids <26 Gy.
● Mean dose to larynx <25 Gy.
● Mean dose to supraglottis <25 Gy.
● Mean dose to esophagus <20 Gy.
● Mean dose to OARPharynx <35 Gy.
● Mean dose to lips <10 Gy.
● Mean dose to oral cavity <35 Gy.
■ This was a very difficult case with a large volume. The prescription dose of
6300 cGy exceeds dose tolerance to the optic apparatus.
■ Use the highest weight on PTVs to improve dose coverage.
■ Add multiple new planning objectives to the PTVs to further improve
the dose coverage while keeping doses to the normal structures below
tolerance.
■ Min Dose, Uniform Dose, Min DVH, and creating planning objectives for
the cold spots in PTVs such as D63, D56, and D31.5 achieve this.
■ Both a max and mean dose planning objective were needed for the follow-
ing structures: brain stem, spinal cord, globes, and optic nerves.
■ Optic nerve max dose objective was 57 Gy and a weight of 100 upon com-
pletion of the plan.
■ A midline avoidance structure was created in the junction region to improve
dose sparing of all midline OARs.
■ Multiple iterations of optimization were needed to achieve the planning goals.
■ The final dose distributions are shown in Figure 5.26A,B. The DVHs for
PTV_6300, PTV_5600, PTV_3150, and numerous normal structures are
shown in Figure 5.26C–E, meeting the dose constraints defined previously.
66.15 Gy
63.00 Gy
56.00 Gy
45.00 Gy
31.50 Gy
20.00 Gy
63.0, 61.74, 59.85 Gy
(A) (B)
100
90
80
70
GLOBE_L
GLOBE_R
Volume (%)
60
LACRIMAL_L
50 LACRIMAL_R
OPTIC_NRV_L
40 OPTIC_NRV_R
30
20
10
0
0 10 20 30 40 50 60
Dose (Gy)
(C)
FIGURE 5.26 Final dose distributions (A, B) and DVHs (C–E) for a T4b N0
M0 Teratocarcinoma of the ethmoidal sinus case using two isocenters. In (A),
isodose lines of 63.0 Gy, 61.74 Gy, and 59.85 Gy are shown along with the
optic nerves and PTV-HD (solid purple). In (B), isodose lines of 66.15 Gy, 63.0
Gy, 56.0 Gy, 45.0 Gy, 31.50 Gy, and 20 Gy are shown. The PTV-HD is in solid
purple, and PTV-LD in solid pink (the whole brain). (continued)
DVHs, dose volume histograms; PTV, planning target volume; PTV-HD (high dose);
PTV-LD (low dose).
100
90
80
70
BRAINSTEM
Volume (%)
60 ORAL_CAVITY
PAROTID_L
50
PAROTID_R
40 SPINAL_CORD
30
20
10
0
0 10 20 30 40 50 60
Dose (Gy)
(D)
100
90
80
70 ESOPHAGUS
LARYNX
Volume (%)
60 OARPHARYNX
PTV_3150
50 PTV_5600
40 PTV_6300
SUPRAGLOTTIS
30
20
10
0
0 10 20 30 40 50 60
Dose (Gy)
(E)
FIGURE 5.26 (continued)
■ Treatment delivery
● Daily CBCT is aligned to the superior isocenter only. After treating the
superior isocenter, move the treatment couch to the inferior isocenter

and then treat.
● Alignment of daily CBCT focused on the optic nerves and base of skull.
Avoid the use of large rotation corrections which could cause an incorrect
alignment of the inferior isocenter.
● An orthogonal film pair for the inferior isocenter may be taken to verify
the setup, but shifts should not be made since it will invalidate the planned
overlap, resulting in unexpected hot and cold spots in the overlap regions.
● A second set of triangulation markers are made on the patient’s mask after
the first day verification to ensure straightness of the patient’s position.
● If at any time the physician wishes to verify the inferior isocenter using
CBCT, acquire the CBCT after treatment to prevent any confusion dur-
ing treatment.
● Schedule for a longer treatment time.
Cases Involved With Pacemaker

■ There are a few treatment techniques for when a pacemaker is present
within or near the treatment area.
■ Skip arcs may be used to avoid the entrance dose in VMAT plans.
■ Or full VMAT arcs may be used with jaw tracking
● Place extremely strict dose objectives on the pacemaker during the opti-
mization. For example, set planning objective of maximum dose to 1 Gy

to the pacemaker.
● The optimizer will completely block off the pacemaker as the gantry
rotates around the patient.

● A typical maximum dose <2 Gy can be achieved.
■ Using IMRT technique, truncate the beams of the affected side to stay off
the pacemaker.
■ Use a conventional anterior posterior (AP) supraclavicular field with the
pacemaker blocked while matching to IMRT fields (half beam blocked) that
treat the superior part of the treatment volume.
REFERENCE
1. NRG Oncology. NRG Oncology protocols. https://www.nrgoncology.org/
Clinical-Trials/Protocol-Table
6 BREAST CANCER
Taoran Cui, Eric Murray, Eva Suarez, and Chirag Shah
Simulation ................................................................................................... 103

Opposed Tangents ...................................................................................... 104
Regional Nodal Irradiation ......................................................................... 114
Intensity Modulated Radiation Therapy (IMRT) and Volumetric
Modulated Arc Therapy (VMAT) .................................................................. 123
References .................................................................................................. 125
SIMULATION
■ Patient is immobilized with arms supported, wedge sponge under the knees
for comfort, and feet bound with rubber band to ensure the patient is straight.
Further details are discussed in Chapter 3.
■ Patient supine
● Patients are positioned with both arms above the head.
● Patient’s chin should be raised and turned away from treatment side.
● Patient should be inclined so that the sternal angle is as close to zero to
limit clearance issues. This will put the sternum parallel to the table. See
Figure 6.1.
● Physician places radio-opaque wires to delineate the superior, inferior,
medial, and lateral field borders after the patient is properly positioned.
Physician may also opt to place wires on incision sites.
■ Patient prone
● Prone technique should be considered when treating a patient with pen-
dulous breasts that does not require comprehensive nodal irradiation and
tumor cavity is away from the chest wall. The purpose of this position is
to reduce skin folds and to move target tissue away from the chest wall.
● Patient is set up prone on a specially designed immobilization device
with both arms above the head, the ipsilateral breast falling anteriorly,
and the contralateral breast displaced posteriorly away from the treat-
ment fields.
FIGURE 6.1 The sternal angle. Red line represents the treatment table.
● Patients treated in the prone position are usually treated with opposed
tangent technique. The treatment planning principles are the same as
those used in supine position, which will be discussed.
■ Motion management
● For left-side breast cancers consider using moderately deep inspiration
breath hold (DIBH) treatment to reduce the dose to the heart.

● Moderately deep inspiration breath-hold can be achieved using breathing
control devices, described in Chapter 3.

● Depending on patient-specific anatomy, not all patients undergoing
DIBH will see an increase in distance from the heart to the chest wall,
and therefore a reduction in heart dose.
● Simulate patient with and without breath-hold and measure the distance
from edge of the heart to the chest wall.
OPPOSED TANGENTS
■ Isocenter placement
● In the cranial/caudal direction, the isocenter is placed at the mid-point
between the superior and inferior wires.

● At this level, the isocenter is placed lateral to the chest wall in the middle
of the breast volume, as shown in Figure 6.2.

● The patient is then tattooed on the central axis on the medial (sternum)
and lateral (affected side) borders (labeled as lasers in treatment planning

system).
6: Breast Cancer ■ 105
FIGURE 6.2 Coronal view of the isocenter placed for opposed tangents. Green
lines represents the field borders.
● An additional point labeled as ASU (anterior set up) is then added. This
point is at the same depth as the isocenter and directly posterior to the
sternum tattoo. See Figure 6.3.
■ Beam setup
● Beam angles should be selected so that the posterior borders of the two
tangents do not diverge into the ipsilateral lung, and do not cross into the
contralateral breast, as shown in Figure 6.4.
FIGURE 6.3 Isocenter placed during simulation (green), and the ASU point
(blue).
ASU, anterior set up.
FIGURE 6.4 A pair of opposed tangents. Note that the posterior borders of the
two beams are non-divergent.
● The collimator angles of the beams are set so that the posterior border of
beams is approximately parallel to the chest wall to ensure uniform lung
exposure or “bite,” as shown in Figure 6.5.
● The superior-inferior and the median-lateral field borders are determined
by the radio-opaque wires placed during the simulation.
FIGURE 6.5 Collimator rotation of an opposed tangent parallel to the chest wall
to ensure uniform lung bite. Lung is shown as blue contour and heart as orange
contour.
● If no radio-opaque wires are available, the fields should be large enough
to cover the whole breast with a 1 cm margin superiorly, 2 cm margin
inferiorly, 1 to 2 cm margin posteriorly into the lung (lung bite) in order to
account for possible respiratory motion, and 2 to 3 cm margin anteriorly
into the air (usually referred to as “flash”), as shown in Figure 6.6.
● High tangent fields are created by increasing the field size superiorly toward
but not including the humeral head (within 2 cm). This allows for more
comprehensive coverage of level I of the axilla, as shown in Figure 6.7.
● The beam energy is predominantly determined by the separation, which
is defined as the distance between the entrances of the two tangential

beams. If the separation is less than 22.5 cm, 6 MV photons should be
used; if 22.5 to 30 cm, 10 MV photons or a mix of 6/10 MV photons
should be used; otherwise 15 MV or 18 MV photons can be used in order
to improve dose uniformity. However, the use of the higher energy photon
will decrease skin dose. If the lumpectomy cavity is in close proximity
to the skin with large separation, bolus over the cavity/scar can be used
to increase skin dose (and cavity dose).
■ Bolus
● A 5 mm tissue-equivalent bolus may be used to increase the skin dose in
post-mastectomy patients.
FIGURE 6.6 Opposed tangent beam with half-beam block technique. MLCs are
closed to achieve 2 to 3 cm lung bite and to block the heart. Lung in blue and
heart in orange.
MLCs, multi-leaf collimators.
FIGURE 6.7 High tangent beam. Lung in green and heart in red.
● The bolus should be created to cover the whole chest wall with 2 to 3 cm
margins in every direction (see Figure 6.8). The edge of the bolus must
be outside the field.
● Two prescriptions, with and without bolus, are recommended. Treating
the bolus fields over the first part of the treatment is preferred as it reduces
the likelihood of bolus being missed compared to treating with bolus
every other day.
■ Plan the prescriptions with and without bolus individually to achieve
optimal uniformity in either plan. Simply adding a bolus to the plan

without bolus may result in undesired hot and cold spots.
(A) (B)
FIGURE 6.8 Bolus (green) in a 3D view (A) and an axial view (B). Bolus should
be large enough to cover the whole breast/chest wall treated with margin.
■ Our institutional policy is to treat the first 13 fractions with the bolus
on daily, then remove the bolus for the remaining 12 fractions. The
decrease in treatment planning and delivery has resulted in a decrease in
machine overrides and treatment errors regarding the bolus placement.
● Daily bolus is used for all fractions with inflammatory breast cancer.
■ Planning
● The left and right lung, spinal cord, heart, and contralateral breast are
considered as the organs at risk and should be contoured prior to plan-

ning. Additional structures to be considered include the brachial plexus
and thyroid. Normal breast volumes can be contoured per the RTOG
atlas (1).
● The ipsilateral lung beyond the lung bite, and the heart when the left
breast is treated, should be blocked to reduce excess dose in cases where

coverage is not sacrificed.
● The plan is normalized to a calculation point to achieve a uniform dose
distribution inside the breast.

■ The calculation point is placed within the breast tissue anterior to the
chest wall. This point should neither be in air nor adjacent to bone.
● Calculate the dose distribution of the open opposed tangent fields; adjust
the weights of the fields and the location of the calculation point to ensure
100% (95% minimum) prescription dose covers the target volume with
uniform distribution. The hot spot should be less than 120% of the pre-
scription dose with two open tangent fields, otherwise consider switching
to or adding higher energy photon beams.
● Multi-leaf collimator (MLC) is the preferred collimation method. If
MLC is not available, a virtual or dynamic wedge may be considered. A

physical wedge in the medial beam should always be avoided due to the
scattered dose to the contralateral breast.
● Forward planning using field-in-field technique is commonly used (see
further discussion later in this chapter) to eliminate hot spots.

■ The hot spots can be eliminated by adding segments to the field start-
ing with adding a segment to one of the open tangent fields. Turn on
the 3D isodose cloud of 3% less than the current maximum dose in
the beam’s eye view. Add a block to cover the hot spot cloud in the
segment. Compute the dose and increase the weight of the new seg-
ment until the current maximum dose is reduced and lock the weight
of the segment. The process is illustrated in Figures 6.9 and 6.10.
■ Calculation point should be visualized in the digitally reconstructed
radiograph (DRR) and set to a diameter of twice the depth of maxi-

mum dose deposition (Dmax) of the beam energy (e.g., 2 × 1.5 cm for
6 MV). During the planning process, the MLC in any segment should
not cover this point.
(A)
(B)
FIGURE 6.9 Before (A) and after (B) adding a new control point to eliminate
a hot spot. MLCs were first drawn in the new control point to block a 118%
hot spot, shown in red in (A). When the weights of the new control point were
increased to 9%, the hot spot was removed (B).
MLCs, multi-leaf collimators; MU, monitor units.
110
(A)
(B)
(C)
FIGURE 6.10 Cooling down an opposed tangent breast plan by adding control
points. One, two, and three control points were used in subfigures A, B and C,
respectively. The red, purple, and yellow isodose lines represent 112%, 109%,
and 100% of the prescription dose, respectively.
■ Add a new segment to the other tangent field to eliminate the next hot
spot, typically 3% less than the one blocked in the last segment.
■ Repeat this process by adding segments on either field alternatively until
the hot spot is below 107% (hypofractionated), 115% (standard fraction-

ation) of the prescription dose, optimally below 105%. The weight of the
open tangent field (the first control point) is typically around 80%.
● Another way to reduce hot spots of a plan is to add another pair of open
field opposed tangent beams with the same setup but a higher photon
energy. The weight of each of the higher energy beams is dependent on
two factors: maintaining dose coverage of the breast tissue and minimiz-
ing hot spots.
● An acceptable opposed tangent plan should have 95% to 98% prescrip-
tion dose covering the whole breast with hot spots less than 105% to
107% of the prescription dose.
● V20Gy, V10Gy, and V5Gy of the ipsilateral lung should be less than
15%, 35%, and 50%, respectively for tangent only cases. The V5Gy of
the contralateral lung should be less than 10%. The mean heart dose
should be less than 4 Gy. An example of dose constraints used for patients
prescribed with 40.05 Gy in 15 fractions is shown in Table 6.1.
TABLE 6.1 Treatment Plan Goals for Unilateral Breast Plan Prescribed
With 40.05 Gy in 15 Fractions
TUMOR_BED Min DVH 4750 98%

TUMOR_BED Max Dose 5750 0.03 cc 6000 0.03 cc
BREAST_ Max DVH 310 0.03 cc
CONTRA
BREAST_ Max DVH 186 5% 310 5%
CONTRA
LUNG_IPSI Max DVH 500 10% 500 15%
LUNG_CONTRA Max DVH 2000 15% 2000 20%
HEART Max DVH 2000 5% 2500 5%
HEART Max DVH 1000 30% 1000 35%
HEART Mean Dose 400 500
DVH, dose volume histogram.
● For left-side breast treatment, the mean heart dose can be reduced from 4
Gy without breath-hold to 1 Gy with breath-hold treatment.
■ Electron boost
● An en face electron field may be used to irradiate the lumpectomy cavity
or tumor bed, as seen in Figure 6.11.

● Radio-opaque wires are usually placed during the simulation, which help
to identify the incision.

● The electron field should always use a source-to-skin (patient) distance
(SSD) setup with the isocenter at the surface. Usually, the isocenter is
placed so that the shifts from the ASU point to the isocenter are integer
numbers for the convenience of patient setup.
● The electron field is shaped by a cut-out whose size should be the tumor
bed plus a 1.5 to 2 cm margin in every direction with the minimum

electron cone size possible.
● The dose is usually prescribed to a calculation point, which is placed on
the central axis of the electron field at a depth equal to the reference point
depth, Dmax of the electron energy.
FIGURE 6.11 Setup of an en face electron boost to a tumor bed (red contour).
The tumor bed is covered by the 90% isodose line (green line). Note that the
isocenter (red point) is placed at the patient skin for an SSD setup and the
calculation point (yellow point), which the dose is prescribed to, is placed at the
Dmax of the electron energy on the central axis.
Dmax, depth of maximum dose deposition; SSD, source-to-skin (patient) distance.
● Change the electron energy and the depth of calculation point until the
tumor bed with a 2 to 3 cm expansion laterally is covered by 90% of the
prescription dose.
● If the tumor bed is too deep and is not adequately covered by an electron
field, a mini-photon boost may be considered. A typical beam arrange-
ment is opposed tangents with a block margin around the tumor bed. If
the physician prefers a more conformal isodose distribution, an en face
photon or electron beam may be added. This beam should carry the least
weight as possible to minimize dose to the lung and/or heart.
REGIONAL NODAL IRRADIATION

■ Mono-isocentric technique with half-beam block
● The isocenter is placed at the border between the supraclavicular (SCV)
field and the tangent fields. This point should be on the most inferior axial
CT slice that includes the clavicular head, at a posterior depth of the axil-
lary nodes, lateral to the chest wall (see Figure 6.12).
● This technique reduces the divergence of the tangent fields into the SCV
field. However, with half-beam blocking tangent fields, it limits the

breast/chest wall field to half the jaw size, that is 20 cm field length for a
typical accelerator with maximum field size of 40 cm. It also eliminates
the option to rotate the collimator.
● The superior and the posterior field borders are determined by the loca-
tion of the beam isocenter. The field should always be large enough to
include 2 to 3 cm lung bite and 2 cm anterior skin flash, as shown previ-
ously in Figure 6.6.
● The mono isocenter technique is preferred because of its efficiency in
planning. It also eases patient setup and reduces potential setup errors.
FIGURE 6.12 Isocenter placement for breast and nodal irradiation using three
to four fields.
■ Two-isocenter technique
● The two-isocenter technique is used when breast/chest wall field is too
large for mono-isocentric technique or the lung dose constraints were not
met (see discussion that follows).
● The isocenters for the SCV field remain the same as the mono-isocenter
technique. The isocenter for the tangent fields is placed at the middle of
the breast, similar to the opposed tangents discussed previously.
● Add 5° to10° couch kick and collimator rotation of about 5° to the tan-
gent fields so that the divergence of the superior border of the tangent
beams matches with the inferior border of the SCV/ posterior axillary
boost (PAB) fields. The exact couch kick and collimator angle can be
determined by either visualizing in the 3D view, as seen in Figure 6.13,
or calculating using the following equation (2).
■ Given the tangential field length L and the source to isocenter distance
D, an angle ϵ is first defined so that tan ϵ = L/2D.

■ The collimator angle q and the couch kick angle q of the tangential
C T
field can be determined that sin qC = −tan ϵ / tan qG and sin qT = sin
ϵ / sin qG. qG is the gantry angle.
■ In most cases, there is L << D, and the above equations can be simpli-
fied using tan ϵ ≈ sin ϵ ≈ ϵ.

■ SCV beam
● 6/10 MV photon beam is generally used.
● The prescription point is typically set at the depth of the SCV fossa and
superior to the clavicle to ensure adequate dose coverage to the SCV

nodes. However, the depth of the prescription point may be adjusted
based on body habitus.
● A standard SCV field includes an anterior (AP) field with half-beam
block inferiorly.
(A) (B)
FIGURE 6.13 Beam border match between an SCV and opposed tangent fields
in 3D (A) and coronal (B) views.
SCV, supraclavicular field.
● SCV field size is patient and disease specific. The RTOG breast atlas (1)
may be used as a reference to contour the SCV nodes.
● Angle the SCV field 10° to 15° away from the affected side to avoid
irradiating the spinal cord.

● Thyroid, humeral head, and acromioclavicular (AC) joints should be
blocked with MLCs if they are in the field. See Figure 6.14A.
● In some patients, an opposed posterior (PA) field (rather than posterior
axillary boost) may be needed to get appropriate dose to SCV fossa while
minimizing hot spots seen with only an AP field.
● Hot spots in a SCV field may also be eliminated by adding segments as
previously described for tangent fields

■ PAB
● A PAB field is included when the SCV field does not adequately cover
the axilla dosimetrically.

● If the mono-isocentric technique is used, a PA field with half-beam block
inferiorly can be used to cover the axillary lymph nodes.

● 6 MV photon beam is typically used; however 10 MV may be considered
for wider patients.

● Thyroid, humeral head, and the ipsilateral lung should be blocked if in
the field. See Figure 6.14B.

● The PAB field is usually assigned to the same prescription as the SCV
beam and shares the same calculation point. The weight of PAB field is
usually around 10% to 20% (80%–90% to the AP SCV beam).
● Adjust the location of the calculation point to ensure the coverage to the
axilla. If necessary, a segment may be added to eliminate any hot spots.

■ Opposed tangent beams
● The planning of the tangents is the same as described above for treat-
ments excluding lymph nodes, except that due to the laterality of the
isocenter, the lateral tangent length will be shorter than the medial, usu-
ally by 1 to 2 cm.
■ Composite plan evaluation
● With either mono or two isocenter plans, there is generally a cold spot at
the match line between the SCV/PAB fields and the tangents. A segment
may be added to the SCV field to feather out this cold match.
■ With all prescriptions turned on, a segment is added to the SVC field
with the inferior jaw opened 3 to 5 mm into the tangent fields. The
weight of the segment is then adjusted until a uniform prescription dose
is achieved across the whole field. See Figures 6.15 and 6.16. Additional
blocking or segments may be needed to decrease any hot spots.
● If the V20 of the ipsilateral lung is greater than 35%, the SCV isocen-
ter can be shifted superiorly. This will decrease the V20 of the ipsilat-
eral lung by decreasing the lung volume included in the SCV field. For
(A)
(B)
FIGURE 6.14 Field shape of SCV (A) and PAB (B) fields.
PAB, Posterior axillary boost; SCV, supraclavicular field.
(A)
(B)
FIGURE 6.15 Isodose feathering at match line of an SCV and opposed tangent
fields with cold match (A), and with a 35% weighted SCV segment (B). Yellow
isodose line is the prescription dose of 50 Gy, green line is 45 Gy.
mono-isocentric cases, if breast fields then exceed 20 cm, a two isocen-

ter set up should be used.
■ Internal mammary (IM) node irradiation: Partially wide tangents
● Partially wide tangents use standard tangential fields with an expanded
posterior border to cover the IM nodes; see Figure 6.17.

● The light field for the medial tangent may will project across midline.
Contralateral breast tissue should be protected if possible by displacing

the contralateral breast laterally at time of simulation and each time for
each treatment.
● Heart or lung in the tangents should be blocked when possible, but over-
all dose to these structures will typically be higher than with standard
tangents.
● The lateral tangent is created by opposing the medial field. Note, the
MLC will need to be modified due to projection of the beam in relation

to the anatomic position of the IM nodes.
(A)
(B)
FIGURE 6.16 The two segments for an SCV field. One with the original field
size (A), and one with the inferior jaw opening (B).
■ IM node irradiation: Abutting electron fields

● If the ipsilateral lung dose is too high with the partially wide tangent
technique, then an electron field abutted to the tangents may be utilized.

● Mono-isocentric technique is the preferred method for delivery of the
SCV/PAB and tangent fields when using an abutted electron field.

● The SCV/PAB fields are planned as previously described.
● The tangent fields are set up with a steeper angle so the medial chest wall
or breast tissue is not covered.

● There should be no more than a 2 cm lung bite.
● The medial aspect of the chest wall that is missed with the tangents will
be treated with the electron field.

(A)
(B)
FIGURE 6.17 Medial partially wide tangent field (A), and lateral partially wide
deep tangent to include the IM nodes (B). IM nodes are shown in pink.
IM, Internal mammary.
● The electron field should be designed to be as en face to the skin surface

as possible.
● The electron field matches the tangent field at skin surface. See Figure 6.18.
● Field borders are as follows:
■ Superior is defined by the inferior border of the SCV.
(A) (B)
FIGURE 6.18 IM electron field abutting the medial tangent field in DRR (A)
and 3D view (B).
DRR, digitally reconstructed radiograph; IM, Internal mammary.
■ Inferior is defined by the inferior length of the medial tangent.

■ Lateral abuts the tangent and the medial border is typically just across
midline to assure there is an adequate margin on the IM nodes.

● Energy is chosen to cover the IM nodes. In some cases, the electron field
will need to be split into two fields with different energies due to the
change in depth along the length of the field.
● A cold triangle will appear at depth due to the electron and tangent field
having different beam angles.
● Due to the cold match at depth, the match line of the tangent field and
electron field needs to be shifted (feathered) during treatment.
● Tangent gantry angles are rotated by 5° to 7° making sure to cover the
extent of the initial cold spot at depth. Rotation is dependent on the
patient’s anatomy. Do not split gross disease or a tumor bed.
● Electron field is then modified.
■ Keep the same medial border.
■ Lateral border then abuts the new gantry angle on the skin surface.
■ No change in field length. See Figure 6.19.
● The lateral shift is usually no greater than 2 cm.

● This match line should be moved once during the course of treatment
typically at the midpoint of the treatment course, or when the bolus for
chest wall irradiation is removed.
● Plan evaluation
■ With all prescriptions turned on, the initial cold spots (indicated by the
red arrows in Figure 6.20A and 6.20B) will be washed out, as shown in
(A) (B)
FIGURE 6.19 Field setup before (A) and after (B) a junction change for an
electron IM field (green and yellow) matched to photon tangents (red and blue).
IM, Internal mammary.
(A) (B)
50 Gy
45 Gy
40 Gy
20 Gy
(C)
FIGURE 6.20 A patient treated with junction change technique with (A) initial
tangent beams and IM electron field, (B) shifted fields, and (C) composite dose
plan. The red arrows indicate the cold spots before and after the junction change.
The yellow line is the prescription dose of 50 Gy (100%), pink line 45 Gy (95%),
green line 40 Gy (90%), and the blue line is 20 Gy line to demonstrate lung dose.
IM, internal mammary.
Figure 6.20C. Dose to this area should be covered optimally by 95%
of the prescription dose although 90% of prescription dose may be
acceptable, particularly for IM nodes.
■ If excessive hot spots are in the tangent fields due to the scatter from the
electrons, additional MLC or segments can be added to the tangents to
remove or decrease these hot spots.
■ Dose constraints used for patients prescribed with 50 Gy in 25 frac-
tions are shown in Table 6.2.
INTENSITY MODULATED RADIATION THERAPY (IMRT) AND VOLUMETRIC

MODULATED ARC THERAPY (VMAT)
■ IMRT or VMAT techniques may be considered for certain cases in order to
achieve both improved conformality and to reduce radiation dose to normal
tissue structures.
TABLE 6.2 Planning Goals for Breast Plan Including Regional Nodes
Prescribed 50 Gy in 25 Fractions
Dose Dose
Structure Type (cGy) Volume (cGy) Volume
TUMOR_BED Min DVH 5700 98%

TUMOR_BED Max Dose 6900 0.03 cc
LN_SCV Min DVH 4750 95% 4500 90%
LN_SCV Max Dose 5500 0.03 cc 5750 0.03 cc
LN_AXILLA Min DVH 4750 95% 4500 90%
LN_AXILLA Max Dose 5500 0.03 cc 5750 0.03 cc
LN_IM Min DVH 4500 95% 4500 90%
LN_IM Max Dose 5500 0.03 cc 5750 0.03 cc
BREAST_CONTRA Max Dose 310 0.03 cc 500 0.03 cc
BREAST_ CONTRA Max DVH 410 5%
LUNG_IPSI Max DVH 2000 30% 2000 35%
LUNG_ IPSI Max DVH 1000 50% 1000 60%
LUNG_ IPSI Max DVH 500 65% 500 70%
LUNG_ CONTRA Max DVH 500 10% 500 15%
HEART Max DVH 2500 5% 3000 5%
HEART Max DVH 1500 10% 1500 15%
HEART Mean Dose 400 500
DVH, dose volume histogram; IM, Internal mammary; SCV, supraclavicular field.
■ IMRT/VMAT is not routinely needed and should only be used after the
above non-IMRT plans are attempted.
■ The application of IMRT/VMAT is limited by the maximum field size
allowed. For example, the maximum field size is 40 × 32 cm and 26 × 32 cm
for IMRT/VMAT on Varian Truebeam and Edge accelerators, respectively.
■ VMAT should be delivered with two to three partial arcs avoiding the con-
tralateral breast and lungs.
■ IMRT may be delivered using four to nine fields depending on the overall
length and shape of the volume.
■ IMRT might be preferred to VMAT for planning target volumes (PTVs) of
irregular shapes, because only one segment is allowed at a gantry angle for a
VMAT arc, whereas multiple segments could be applied for an IMRT beam
in order to achieve a more modulated and complex fluence at a gantry angle.
(A) (B)
(C) (D)
FIGURE 6.21 Beam arrangement and isodose distribution of a left chest wall
re-irradiation case in axial (A), coronal (B), sagittal (C), and 3D views (D). The
isocenter was placed at the centroid of the PTV. Green color wash indicates the
PTV. A 1 cm bolus was added. DIBH was utilized.
DIBH, deep inspiration breath hold; PTV, planning target volume.
■ Targets used with IMRT/VMAT should be trimmed to exclude skin in order
to achieve homogeneous coverage to the targets. An evaluation PTV may be
created to achieve this which removes a 3 mm skin rind in post-mastectomy
cases and 5 mm rind in post-lumpectomy cases.
■ The optimization of an IMRT/VMAT breast plan is similar to other sites
described in this book.
■ An example IMRT plan is provided in Figure 6.21.
■ If needed, skin dose may be difficult to achieve without the use of motion
management. To combat this, it is recommended that a 1 cm bolus be added
to the patient and the PTV is expanded 3 to 5 mm into the bolus to account
for the patient breathing.
■ Motion management is preferred for all IMRT/VMAT cases. Holding the
patient in the same position during treatment allows for a more accurate
treatment delivery, and for optimal heart and lung sparing.
REFERENCES
1. White J, Tai A, Arthur D, et al. Breast cancer atlas for radiation therapy plan-
ning: consensus definitions. Radiat Ther Plann. 2011:1–71.
2. Siddon RL. Solution to treatment planning problems using coordinate transfor-
mations. Med Phys. 1981;8:766–774. doi:10.1118/1.594853.
7 THORACIC CANCER
Michelle Sands, Carol Belfi, Tingliang Zhuang,

Michael Weller, and Gregory M. M. Videtic
Immobilization............................................................................................. 127
Image Acquisition ....................................................................................... 128
Localization ................................................................................................. 129
Beam Energy............................................................................................... 129
3D Treatment Planning .............................................................................. 130
IMRT and VMAT Treatment Planning ......................................................... 135
SBRT Treatment Planning .......................................................................... 138
IMMOBILIZATION
■ 3D and modulated radiation therapy (intensity modulated radiation therapy
[IMRT] or volumetric modulated arc therapy [VMAT])
● The patient should be positioned supine.
● Arms are held above the head, a pole is used as a hand grip to help main-
tain this position.

● If patient is unable to lift arm on unaffected side, it may be left next to
the side of the body.

● If patient is unable to lift arm on affected side, consider use of akimbo
positioning; however the clinician can best determine the positioning

based on tumor location.
● The pole and hand positions should be recorded so the position can be
reproduced at treatment.
● A triangular shaped foam cushion can be placed under the patient’s knees
to improve patient comfort.

● An elastic band around the feet will help prevent lower body movement.
● Tumor motion management is important for patients treated with
IMRT and VMAT, particularly for stereotactic body radiation therapy

(SBRT).
■ SBRT
● The patient position is similar to the positions described in the previous
section with a supine body position and arms above head.

● The patient’s torso and legs are immobilized in a full body bag (see
Figure 3.4 in Chapter 3 and description).

■ Approaches to motion management, based on clinician assessment of
patient appropriateness and need.
● Physically limit range of tumor motion using abdominal compression
■ For example, a compression belt or plate can be placed below the
patient’s rib cage to minimize the extremes of the breathing cycle

(Figure 3.10 in Chapter 3).
■ Compression level should be documented in the simulation note and
be reproduced at treatment.
● Breath hold technique using active breathing coordinator (ABC) device
■ ABC restricts patient’s breathing for fixed intervals by preventing
expiration.
■ ABC requires patients to be coachable, and be capable of holding their
breath for 15 to 20 seconds.

■ A percentage of maximum lung volume (typically 80%) will be set as
a threshold at the CT simulation.

■ ABC prevents target motion but prolongs treatment time by a factor
of 4 or 5 because delivery is interrupted for the patient to recover his

or her breath.
● Free breathing
■ Patients with severe respiratory limitations may intrinsically have lim-
ited tumor motion and can therefore be treated without devices.

■ An internal target volume (ITV) is used to account for tumor motion.
IMAGE ACQUISITION
■ 3D and modulated radiation therapy (IMRT or VMAT)
● 4D CT images will be acquired to capture the tumor range of motion
during the respiration cycle.

● The ITV can be contoured on the maximum intensity projection (MIP)
CT and checked against the 10 phases of the 4D CT to ensure the ITV

fully encompasses the range of motion of the tumor.
● The ITV generated by gross tumor volume (GTV) motion will then be
expanded by standard expansions to create a planning target volume

(PTV).
● A free breathing CT is also acquired.
● Contrast may be used at the time of simulation

7: Thoracic Cancer ■ 129
■ SBRT
● With abdominal compression
■ 4D CT images will be acquired to capture the tumor range of motion
during the respiration cycle for patients treated with free breathing.
■ The ITV will be contoured on the 10 phase image sets of the 4D CT to
fully encompass the range of motion of the tumor.

■ In lung SBRT, GTV = clinical target volume (CTV).
■ The PTV will encompass the ITV with a fixed margin.
● Breath-hold CT with ABC
■ GTV = ITV
■ PTV = GTV + margin
■ To define system-based issues, three sets of CT images with ABC are
taken to confirm reproducibility of the breath hold and detect drift.
LOCALIZATION
■ The isocenter is typically placed at the center of the visible tumor volume
during simulation.
■ For 3D treatments, MV ports are taken at the time of treatment to ensure
bony anatomy alignment.
■ More rigorous image guidance techniques are used for SBRT/IMRT/VMAT
treatments.
● Cone-beam CT (CBCT) should be used to ensure that the tumor volume
on the day of treatment falls into the PTV contour from the simulation CT.
● The CBCT and the simulation CT are aligned and approved by both
the physician and physicist at the accelerator. The determined alignment

shifts are made prior to each treatment.
● CBCTs are taken for every fraction of SBRT. For conventionally fraction-
ated radiation therapy (RT), CBCT may be acquired with every fraction
or with the first five fractions then once weekly.
● After shifts, orthogonal kV or MV images are also taken to confirm the
correct shifts were made. The orthogonal images are approved by physi-
cian before the first treatment.
● If ABC is being used, the imaging should be acquired during breath hold.
BEAM ENERGY
■ 3D plans
● The most appropriate energy for thoracic is 6 MV because of the low
density of lung.
● 10 MV photons can be used if the beam path traverses a substantial
amount of soft tissue.

■ IMRT and VMAT
● 6 MV photons are to be used.
● 10 MV beams can be used for VMAT or certain IMRT beams if the beams
are passing through a substantial amount of soft tissue.

■ SBRT
● 6 MV beams are used.
● Flattening filter free (FFF) beams, if available, may be preferred for
SBRT due to their high dose rate that decrease treatment time, especially
important if breath hold techniques are being used.
■ Treatment planning volumes
● The physician will contour and expand several target volumes which
should be associated with the following plan goals for the majority of
treatment plans.
● GTV should have 99% prescription dose coverage.
● ITV should have 98% prescription dose coverage.
● The PTV will be a 5 mm to 1 cm expansion of the ITV or CTV and should
have 95% prescription dose coverage.
3D TREATMENT PLANNING
■ A free breathing CT is typically used for 3D planning (average projection
CT is used for SBRT planning) because of the better image quality for
normal tissue delineation.
■ After the appropriate CT data set has been imported into the treatment plan-
ning system, the following steps should be taken:
● Import the PTV, ITV, CTV, GTV contours as applicable.
● Import or contour the organs at risk (OARs) including whole lung, heart,
and spinal cord volumes, at a minimum.

● Ensure the treatment planning system recognizes the isocenter placed at
the CT simulation as the planning isocenter.

● Coordinates and anatomical region of the imported isocenter must match
what was marked at the simulation.

● Contour and override any contrast to the density of water (1 g/cm3).
● Set the prescription dose.
● Draw a dose grid over the area of interest.
● Encompass the whole lung (right and left) in your dose grid.
● An appropriate dose grid size for a 3D plan is ≤0.4 cm × 0.4 cm × 0.4 cm.
● Beam angle selection is described for each case below.
● After determining the beam angle, create a block for each beam around
the PTV.
■ It is common for the superior and inferior block margin to be larger
than other directions to ensure adequate dose coverage in those regions.

■ For a nonuniform block margin, first create an expanded PTV contour
including the nonuniform margin.
■ Block margin should be between 0.7 cm and 1 cm, which is the typical
beam penumbra.
■ Anterior posterior/posterior anterior (AP/PA) beam setup
● For a tumor located in mediastinum, AP and PA beams are preferred
beam setups for tumor coverage while minimizing normal lung irradia-
tion.
● A superior-inferior (sup-inf) wedge may be used if the chest thickness
changes in this direction.

● If the tumor volume is such that the PA field will enter through the spinal
cord, the posterior beam can be set at an oblique angle to avoid a high
dose region in the spinal cord as shown in Figure 7.1. Alternatively, an
off-cord plan can be used after the spinal cord tolerance is reached.
● The angle chosen should be a balance between avoiding the spinal cord
and avoiding unnecessary exit dose through the contralateral lung.

● A good rule of thumb is to have a minimum distance of 0.5 to 1 cm
between the oblique field edge and the spinal cord if possible.
● Using an oblique angle may also introduce the need for a wedge as shown
in Figure 7.1 to account for the increased overlap with the AP beam on
the right side of the patient.
FIGURE 7.1 The beam arrangement for an AP and posterior oblique beam. The
oblique field is an adequate distance from the spinal cord. The posterior oblique
beam includes a lateral wedge and the AP beam includes a superior-inferior
wedge.
AP, anterior posterior.
64.0, 60.0, 50.0, 45.0, 20.0 Gy 64.0, 60.0, 50.0, 45.0, 20.0 Gy
(A) (B)
100
75
Relative Volume (%)
GTV_2000
LUNG_L
LUNG_R
50
SPINAL_CORD
WHOLE_LUNG
25
0
0 20 40 60
Dose (Gy)
(C)
FIGURE 7.2 Isodose lines for a two-field lung plan with a prescription of 60
Gy. Although a two-field plan is not often used for a prescription of 60 Gy, this
is an example of a two-field plan that meets all planning goals.
GTV, gross tumor volume.
● An example plan with isodose lines and a dose volume histogram (DVH)
is given in Figure 7.2.
■ Three-field setup
● A common three-field beam arrangement includes an AP beam, a PA
beam, and a posterior oblique field.

● Example: Beam 1 = 0°, Beam 2 = 180°, Beam 3 = 210° (shown in
Figure 7.3).
FIGURE 7.3 A traditional three-field beam arrangement.
● The posterior oblique field angle should be off the spinal cord but it
should also avoid unnecessary exit dose in the contralateral lung.
● The posterior beam is most commonly used as the off cord beam because
the AP beam divergence would require a larger oblique angle.
● Wedges will most likely be needed on the two posterior beams.
● Example wedge angles (shown in Figure 7.3) are 45° for the PA beam and
30° for the posterior oblique beam, with wedge heels adjacent.
● The anterior beam may require a sup-inf wedge if the chest thickness
changes along the length of the tumor as seen in Figure 7.4, where the
wedge angle for the AP beam is 15°.
FIGURE 7.4 A superior-inferior wedge can be used to compensate for the

curvature of the chest wall. Without a wedge, superior hot spots may be present
due to less tissue between the surface and the tumor volume and inferior cold
spots due to more tissue between the surface and the tumor volume.
● In general, most three-field beam arrangements have a “Y” shape which
can be altered to get better tumor volume covered.
● A three-field clinically acceptable plan with a 60 Gy prescription is
shown in Figure 7.5.

■ Four-field and other 3D planning techniques
● Adding additional beams to a three-field lung plan may allow for better
dose distribution and reduction of hot spots.

● An example of a four-field beam arrangement is shown in Figure 7.6.
Beam 1 = 10°, Beam 2 = 60°, Beam 3 = 130°, and Beam 4 = 190°.

● One technique that can reduce the heart dose is to deliver the AP beam
with a table rotation or kick.

● To determine if a table kick is necessary, a sagittal view of the AP beam
with the heart contour visible can be used.

● As shown in Figure 7.7 the heart is blocking the tumor volume in the AP
beam direction.
● By kicking the table to 270° and using a gantry angle of 25° a more
advantageous setup to avoid the heart is achieved, as shown in Figure 7.7.

● One final technique that can be used to lower the dose in a hot spot
region is to use multiple segments on a beam to block out the high dose
region.
65.0, 60.0, 45.0, 30.0 Gy 65.0, 60.0, 45.0, 30.0 Gy

(A) (B)
FIGURE 7.5 A three-field clinically acceptable plan with a prescription of

60 Gy in 30 fractions. Beam angles include 0°, 210°, and 165° with hot spots
around 110% of prescription dose, (A) axial view with beam arrangements and
(B) coronal dose distribution.
48.5, 45.0, 35.0, 20.0 Gy
FIGURE 7.6 A four-field beam arrangement with corresponding isodose

distribution for a prescription dose of 45 Gy.
IMRT AND VMAT TREATMENT PLANNING

■ IMRT or VMAT can be used if:
● The planning goals or OAR dose constraints, shown in Table 7.1, are not
met with a 3D plan.

● The OAR constraints are met but an IMRT or VMAT plan can provide a
significant dose reduction when compared to 3D planning.
(A) (B)
FIGURE 7.7 (A) shows an AP beam with a gantry angle of 0° and no table
kick. The two solid purple lines represent the beam block that includes a 1 cm
expansion of the PTV. (B) shows a table kick of 270° and a gantry angle of 25°.
Image (B) includes less heart volume (orange ROI) when the beam comes in at
an angle with the same beam block expansion.
AP, anterior posterior; PTV, planning target volume; ROI, region of interest.
TABLE 7.1 For a Prescription of 60 Gy, the Primary Goals Should Be Met
for a Lung Plan.
Primary Goal Primary Achieved
Dose Dose*
Structure Type (cGy) Volume (cGy) Volume* Result
GTV Min Dose 6000 99% 6126 99.99% Met

CTV Min DVH 6000 98% 5633.5 99.20% Met
ITV Min DVH 6000 98% 5876.9 99.91% Met
PTV Min DVH 6000 95% 5328.4 95.77% Met
Esophagus Mean Dose 3400 2117.8 Met
Esophagus Max DVH 5500 33% 6339.1 20.56% Met
Heart Max DVH 6000 33% 6463 2.78% Met
Heart Max DVH 4500 66% 6463 10.01% Met
Heart Max DVH 4000 100% 6463 12.58% Met
Whole Lung Max DVH 2000 37% 6601.2 29.77% Met
Whole Lung Mean Dose 2000 1784.6 Met
3 3
Heart Max DVH 5050 0.03 cm 3858.7 0.0 cm Met
For achieved results, refer to the plan in Figure 7.9
ITV, internal target volume; PTV, planning target volume.
● Figures 7.8 and 7.9 show the DVH differences and the isodose distribu-
tion differences between a VMAT and 3D plan.
■ IMRT beam angles or VMAT arcs should be focused on the side ipsilateral
to the tumor.
● For example, left sided tumor may have beams between 178° and about
330° depending on clearance and tumor location.

■ Techniques to get an optimal lung VMAT or IMRT plan
● As a general principle, circumferential delivery by VMAT is to be avoided
due to the integral dose being delivered to the whole lung, independent
of the numerical values on the DVH. Partial-arc VMAT is preferred in
the chest.
● Ring structures around the PTV can be used to promote dose fall off.
● Using the dose fall off rule of thumb of 5% per mm, a 1 cm ring can be
created around the PTV. A maximum dose constraint of 50% of the pre-
scription dose can be put on the tissue outside of this 1 cm ring.
100
75
Relative Volume (%)
3D_Comp
VMAT
ESOPHAGUS
50 HEART
LUNG_L
LUNG_R
SPINAL_CORD
25 WHOLE_LUNG
0
0 20 40 60
Dose (Gy)
FIGURE 7.8 The DVHs for a 3D plan (solid) and a VMAT plan (dashed) are
shown.
DVHs, dose volume histograms; VMAT, volumetric modulated arc therapy.
● Once the lung volume receiving 20 Gy (V20) constraint is met the max
equivalent uniform dose (EUD) or mean dose of the whole lung can be
used as an objective to spare more lung tissue.
● The maximum dose constraint should be aggressive for the spinal cord
if it is a reasonable distance from the tumor to take advantage of using
VMAT or IMRT.
64.0, 60.0, 45.0, 25.0 Gy
FIGURE 7.9 The isodose line distributions are shown for the 3D plan (left)
and VMAT plan (right). Of note, the 25 Gy isodose line (dark blue) avoids the
spinal cord, the prescription dose line (yellow) is much more conformal to the
volume, and the hot spots (red) are reduced.
● If the heart is in the PTV and the physician wants that region covered
by the prescription dose a “Heart-PTV” volume (subtract the PTV from
heart volume) and a “Heart+PTV” volume (subtract the “Heart-PTV vol-
ume from the heart) should be created.
● “Heart-PTV” can have a more aggressive maximum EUD placed upon it
without losing PTV coverage.
● “Heart+PTV” can have a uniform dose objective equal to the prescription
dose. This will help provide coverage to the region without increasing the
dose above the prescription dose.
● If the plan is too hot, a contour can be made from the 105% to 110%
isodose lines and a maximum dose constraint objective can be placed
upon that contour.
SBRT TREATMENT PLANNING

■ For patients who will be treated while free breathing, the average CT scan
should be used for treatment planning for more accurate dose calculation
and as the reference CT for image guidance using CBCT.
■ For patients treated with free breathing, an ITV is generated using all phases
of the 4D CT. PTV is to be generated by adding 5 mm uniform margin to
the ITV.
■ Contours must be moved from the scan they were drawn on to the planning
scan. For example, fuse the average CT scan with the 4D CT, to move the
ITV to the average scan for planning.
■ Draw a dose grid over the area of interest.
● In the interest of minimizing optimization time, the dose grid may be
drawn to cover only the PTV plus a 4 to 5 cm margin in all directions.

● Before final dose calculation however, the dose grid must be expanded to
encompass the whole lung volume.

● An appropriate dose grid size for the initial optimization is ≤0.4 cm ×
0.4 cm × 0.4 cm; however, final optimization and dose calculation should
be complete at maximum dose grid of 0.3 cm × 0.3 cm × 0.3 cm.
■ Treatment planning techniques
● 3D coplanar or non-coplanar beams, static gantry angle IMRT, or VMAT
can be used to delivery highly conformal dose to the target while sparing
OARs.
● For a tumor with large motion, static gantry angle IMRT (6–7 beams) with
limited number of segments, 3D conformal (7–10 beams), or dynamic

conformal arcs (4–6 arcs) is recommended.
■ For VMAT, start planning by creating two arcs attached to the isocenter.
● For a right-sided lesion, the beams can start at 182° and end at 0° to 30°
depending on location of tumor and patient clearance.

● For left-sided lesions, the beams can start at 178° and end at 0° to 330°
depending on location of tumor and patient clearance.
● The second arc should start where the first arc ended and travel in the
opposite direction.
● A minimum of 340° should be used between all the arcs according to
Radiation Therapy Oncology Group (RTOG) protocols.

● Collimator must not be 0° to avoid streaking from the inter-leaf trans-
mission.
● Usually the two VMAT beams have different collimator angles to pro-
vide more degrees of freedom with different multi-leaf collimator (MLC)

directions, for example, 20° and 340°.
■ Identify planning volume coverage goals as well as OAR limits.
■ Add a 2 cm ring around the PTV to promote dose conformality.
● Tissue outside this 2 cm ring can be used as a planning structure and dose
conformality structure; see Figure 7.10.

● For example, set the maximum dose in a 2 cm ring (around PTV, orange
ring in Figure 7.10) equal to the prescription dose to achieve conformality
60.0, 50.0, 35.0, 25.0 Gy
FIGURE 7.10 The green region is the PTV with a minimum dose objective of
60 Gy. The orange region is the 2 cm PTV ring with a max dose objective of
60 Gy to promote the conformality of the prescription dose. The yellow region
is an additional 2 cm ring (outer circumference 4 cm from the PTV) with a
maximum dose objective of 30 Gy.
TABLE 7.2 Planning Objectives for SBRT Lung for a Prescription of 50 Gy
Structure Type Dose (cGy) Volume Weight
PTV Min Dose 5000 – 35

PTV Max Dose 6200 – 15
2 cm Ring Max Dose 5000 – 10
Outside 2 cm Ring Max Dose 2500 – 35
Whole Lung Max DVH 2000 9% 3
Cord Max Dose 760 – 1
Esophagus Max Dose 950 – 1
PBT Max Dose 1250 – 1.5
PBT Max EUD 600 – 0.1
Trachea Max Dose 570 – 0.5
Heart Max Dose 1200 – 3
DVH, dose volume histograms; EUD, equivalent uniform dose; PBT, proximal bronchial
tree; PTV, planning target volume; SBRT, stereotactic body radiation therapy.
and maximum dose in outer 2 cm ring (yellow ring in Figure 7.10) equal
to 50% of prescription dose to promote steep dose falloff.
■ Hot spots are acceptable in SBRT but should be within the PTV according
to protocol and physician guidelines.
■ Figure 7.10 shows a hot spot using isodose lines of 60 Gy for a 50 Gy
prescription.
■ Dose constraints for OARs for different dose fractionation schemes are
listed in national protocols for lung SBRT.
■ Sample SBRT planning objectives are shown in Table 7.2 and a sample
scorecard based off the RTOG 0813 protocol is shown in Table 7.3.
■ Consulting RTOG protocols is recommended for referencing OAR
constraints.
TABLE 7.3 Treatment planning goals for 50 Gy in Five Fractions for Lung
SBRT
Dose Dose*
PTV Min DVH 5000 95% 4838.2 99.81% Met
PTV Min DVH 4500 99% 4838.2 100% Met
IPSI BP Min Dose 3200 42.2 Met
3 3
Heart Mean DVH 3200 15 cm 1261.9 0.0 cm Met
Heart Max Dose 5250 1261.9 Met
Trachea Max DVH 1800 4 cm3 502.5 0.0 cm3 Met
Trachea Max Dose 5250 502.5 Met
PBT Max DVH 2750 4 cm3 1351.5 0.0 cm3 Met
PBT Max Dose 5250 1351.5 Met
Esophagus Max DVH 2750 5 cm3 997.9 0.0 cm3 Met
Esophagus Max Dose 5250 997.9 Met
Whole Lung Max DVH 2000 10% 6252.6 6.36 cm3 Met
Cord Max DVH 2250 0.25 cm3 830.5 0.0 cm3 Met
Cord Max DVH 1350 0.5 cm3 830.5 0.0 cm3 Met
Heart Max Dose 3000 830.5 Met
Note that OAR goals will not be consistent for different SBRT fractionations and
prescriptions. The achieved doses correspond to the plan in Figure 7.10
DVH, dose volume histograms; OAR, organs at risk; PBT, proximal bronchial tree;
PTV, planning target volume; SBRT, stereotactic body radiation therapy.
GASTROINTESTINAL
8 RADIOTHERAPY
Anthony Magnelli, Lisa Zickefoose,

Jennifer Archambeau, Ehsan H. Balagamwala,
Esophageal Cancer External Beam Radiation Therapy (EBRT) .............. 144

Patient Setup and Immobilization ......................................................... 144
Planning Technique................................................................................. 144
Pancreas Fractionated EBRT ..................................................................... 147
Motion Management Techniques .......................................................... 147
Target Delineation ................................................................................... 148
Pancreas SBRT ........................................................................................... 150
Rectal Cancer EBRT ................................................................................... 154
Anal Cancer EBRT....................................................................................... 158
Liver SBRT ................................................................................................... 160
Reference .................................................................................................... 163
ESOPHAGEAL CANCER EXTERNAL BEAM RADIATION THERAPY (EBRT)
Patient Setup and Immobilization
■ Supine, head-first.
■ Immobilization: arms above head, holding grip bars to aid in reproducibility.
■ Angle sponge under knees for comfort.
■ Feet banded to prevent movement during treatment.
■ If cervical esophagus is to be treated, a five-point mask may be preferable
for immobilization.
■ In some scenarios, use of oral contrast may make gross tumor volume
(GTV) contouring easier.
■ Isocenter marked in simulation and tattooed.
Planning Technique
■ Target delineation
● GTV in esophagus and involved nodes, based on CT, esophagogastro-
duodenoscopy (EGD), endoscopic ultrasound (EUS), and PET/CT.

● Clinical target volume (CTV): includes GTV expanded by 4 cm superior
and inferior, and 1 cm radially. Includes regional nodal basins at risk.

● Prescription dose should cover >98% of the CTV.
● planning target volume (PTV): 1 cm superior and inferior, and 1 cm radial
expansion of the CTV.

● Prescription dose should cover >95% of the PTV.
■ Prescription
● Definitive dose range: 50.4 Gy in 1.8 Gy/fraction or 50 Gy in 2 Gy/
fraction.
● Preoperative dose range: 41.4 Gy to 50.4 Gy in 1.8 to 2 Gy/fraction.
● Postoperative dose range: 45 Gy to 50.4 Gy in 1.8 to 2 Gy/fraction.
■ Intensity modulated radiation therapy (IMRT) planning

● Volumetric modulated arc therapy (VMAT) or IMRT planning can be
employed.
● For VMAT, avoid complete arcs since integral dose to lungs will be too high.
● For IMRT, seven to nine equally spaced coplanar beams are suggested.
■ 3D planning
● Conventional three-beam arrangement has parallel opposed anterior pos-
terior/posterior anterior (AP/PA) fields with an off-cord posterior oblique

beam.
● Visualizing the spinal cord in a beam’s eye view can assure that the
posterior oblique field avoids the spinal cord (termed off-cord), as in

Figure 8.1.
● Create a block margin of 0.7 cm to 1.0 cm around the PTV in order to
achieve 95% dose coverage.

8: Gastrointestinal Radiotherapy ■ 145
FIGURE 8.1 An MLC block presented in a beam’s eye view of an oblique beam
to avoid the spinal cord (green) for an esophagus case.
MLC, multi-leaf collimator.
● Balance the dose to the spinal cord and lungs when increasing the weight-
ing on the posterior oblique field (Figure 8.2).
● Consider a superior-inferior wedge if the patient thickness varies drasti-
cally, as illustrated in Figure 8.3.

■ Refer to Tables 8.1 and 8.2 for organs at risk (OARs) dose constraints for
41.4 Gy and 50.4 Gy prescriptions, respectively.
41.4 Gy 39.33 Gy 20.0 Gy

41.4 Gy 39.33 Gy 20.0 Gy
(A) (B)
FIGURE 8.2 Dose distributions on two axial images in (A) and (B) of an
appropriately weighted three-field esophagus plan.
FIGURE 8.3 An anterior wedged in the superior-inferior direction to account

for change in patient thickness in this direction.
TABLE 8.1 Planning Goals for Esophageal Cancer Plan Treating to

4140 cGy
Primary Goal
Structure Type Dose (cGy) Volume
GTV_4140 Min DVH (%) 4140 99%

PTV_4140 Min DVH (%) 4140 95%
Heart Max DVH (cc) 5200 0.03 cc
Heart Mean Dose 3500
Heart Max DVH (%) 4000 100%
Whole lung Max DVH (cc) 5544 0.03 cc
Whole lung Mean Dose 2000
Whole lung Max DVH (%) 3000 20%
Spinal cord Max DVH (cc) 5000 0.03 cc
Liver Max DVH (%) 3000 30%
Liver Mean Dose 2100
DVH, dose volume histograms; GTV, gross tumor volume; PTV, planning target volume.
TABLE 8.2 Planning Goals for Esophageal EBRT Plan Treating to 5040 cGy
Dose Dose
Structure Type (cGy) Volume (cGy) Volume
GTV_P Min DVH (%) 5040 99%

CTV_5040 Min DVH (%) 5040 98%
PTV_5040 Min DVH (%) 5040 95%
PTV_5040 Max DVH (%) 6000 10%
Heart Mean Dose 3500
Heart Max DVH (%) 4000 50% 4000 55%
Whole lung Max DVH (cc) 5544 0.03 cc 5695 0.03 cc
Whole lung Mean Dose 2000 2100
Whole lung Max DVH (%) 3000 20% 3000 25%
Whole lung Mean Dose 1800
Spinal Cord Max DVH (cc) 4500 0.03 cc 5000 0.03 cc
Whole Kidney Max DVH (%) 2000 30% 2000 40%
Liver Max DVH (%) 3000 30% 3000 40%
Liver Mean Dose 2100 2500
CTV, clinical target volume; DVH, dose volume histograms; EBRT, external beam
radiation therapy; GTV, gross tumor volume; PTV, planning target volume.
PANCREAS FRACTIONATED EBRT

■ Supine, head-first with arms above head.
■ Patient is immobilized with a custom-made body conforming bag or equiva-
lent rigid system, with use of motion management (e.g., abdominal compres-
sion belt) per clinician preference and patient compliance (see Figure 3.10
in Chapter 3).
■ Arms above head, to allow for better gantry angle clearance.
■ IV and oral (small bowel) contrast per clinician preference and disease
presentation.
■ Isocenter preferentially placed in the tumor volume and tattooed at time of
simulation.
Motion Management Techniques

■ 4D CT and free breathing CT are both acquired during simulation.
■ Ensure that the 4D CT bellows are placed outside the treatment field.
■ If tumor excursion is greater than 1 cm, a breathing control technique such
as active or passive breath hold or gated treatment should be considered to
minimize the internal target volume (ITV).
Target Delineation
■ GTV: gross tumor and pathologically/radiographically abnormal lymph
nodes.
■ CTV: 0.5 to 1.0 cm expansion of GTV to include microscopic disease and
include nodal basins at risk.
■ PTV: 0.5 to 1.0 cm expansion of CTV to account for motion and patient
setup error.
■ OARs: liver, stomach, duodenum, small bowel, large bowel, spinal cord,
right and left kidneys.
Planning Technique
■ 3D conformal or IMRT (VMAT) should be used with IMRT being the pre-
ferred option.
■ Prescription
● 45 to 54 Gy in 1.8 to 2.0 Gy/fraction.
● Prescribe doses greater than 54 Gy, if clinically appropriate based on the
location of tumor and consideration of minimizing risk of postoperative

positive margins.
■ Planning process
● If patient is given contrast (IV or oral), consider over-riding the density
of the contrast in the CT to 1.0 gm/cm3.

● Create any additional planning contours as needed.
● If multiple dose levels are prescribed at one time, that is simultaneous
integrated boost (SIB), the optimizer will run more effectively if the
tumor volumes prescribed to different dose levels are separated, avoid-
ing conflicting objectives.
● This can be achieved by using a simple empirical formula: obtain the
ratio of [high dose (Gy)]/[low dose (Gy)] = X, and then expand the HD-
PTV by (X−1)/0.5 (cm). A planning PTV is created by subtracting the
expanded HD-PTV from the LD-PTV.
● For example, a treatment plan with a high dose of 56 Gy and a low
dose of 50.4 Gy yields 0.22 cm. Round up to give a 0.3 cm buffer to

ensure a sufficient space between the low dose and high dose PTVs
(see Figure 8.4).
● If HD-PTV (as shown in Figure 8.4) is adjacent to a critical structure
such as the duodenum or small bowel, create a planning HD-PTV (named

FIGURE 8.4 High (green) and low dose (cyan) PTVs, with buffer between them
for dose fall off to make plan optimization easier.
PTVs, planning target volumes.
HD-PTV-obj) that has a 3 mm space between the HD-PTV-obj and the

duodenum or small bowel.
● The use of HD-PTV-obj will help achieve dose constraints to the critical
structure.
● Dose rings are created to keep the dose conformal (see Figure 8.5).
FIGURE 8.5 An example of two dose rings: yellow ring is 1 cm from both
PTVs and blue ring is 3 cm from both PTVs and extends to the patient’s
surface.
● Typical beam energies used are 6 to 10 MV.
● Avoid beams entering through nearby critical structures.
● For VMAT, with a centrally placed isocenter, full arcs (182°–178°) are
preferred.
● Use a non-zero collimator angle (e.g., 10° on one arc and 350° on the other).
● Set up the dose grid size and resolution balancing the effects on computa-
tion time and accuracy.
● Begin optimization process by entering objectives for planning volumes
and dose rings trying to achieve desired coverage (Table 8.3).
● Before the next optimization stage, add OAR objectives like those in
Table 8.4, changing weights as needed to achieve the lowest possible
doses to all critical structures.
● Keep adjusting the objectives and weights until the planning goals
(Table 8.5) are achieved or exceeded.
● Max equivalent uniform dose (EUD) objectives can be used to lower the
mean dose of a parallel structure.
● Max dose objectives reduce the maximum point doses of a structure and
work well in conjunction with the Max EUD objective.
● A sample dose volume histogram (DVH) is given in Figure 8.6, with
tabulated results in Table 8.5. The corresponding isodose distribution is
shown in Figure 8.7.
PANCREAS SBRT
■ Immobilization with a custom-made body conforming bag or equivalent
rigid system.
TABLE 8.3 Target Planning Objectives Used in the First Stage of

Optimization
Target
Structure Type cGy % Volume Weight
5040 for planning Min Dose 5040 1

5040 for planning Max Dose 5282 1
PTV_5600 Min Dose 5600 1
PTV_5600 Max DVH 5880 3 1
Normal tissue Max Dose 2800 1
Low Dose Normal tissue Max Dose 1680 1
DVH, dose volume histogram; PTV, planning target volume.
TABLE 8.4 Planning Objectives Including OARs for Second Stage of
Optimization
Structure Type Target cGy % Volume Weight
5040 for planning Min Dose 5040 2

5040 for planning Max Dose 5282 2
PTV_5600 Min Dose 5600 10
PTV_5600 Max DVH 5880 3 10
Normal tissue Max Dose 2800 1
Low Dose Normal tissue Max Dose 1680 1
Kidney_R Max EUD 800 0.1
Kidney_L Max EUD 500 0.1
Duodenum Max Dose 5100 0.1
Duodenum Max EUD 2700 0.1
DVH, dose volume histogram; EUD, equivalent uniform dose; OARs, organs at risk;
■ IV and oral (small bowel) contrast per clinician preference and disease
presentation.

■ As above for liver SBRT.
Planning Technique
■ VMAT or IMRT
● VMAT: full arcs may be optimal due to the central location of most pan-
creatic tumors. Two coplanar VMAT arcs are normally used for planning,
spanning from 182° to 30°.
● IMRT: seven to nine coplanar equally spaced beams in range of 182° to
30° are suggested.

● GTV + 5 mm = LD-PTV.
● 3 mm expansion of nearby OARs (bowel, duodenum, stomach, etc.)
subtracted from the LD-PTV to form HD-PTV, illustrated in Figure

8.8.
■ Prescriptions
● Prescription dose is based on achievability of OAR constraints.
TABLE 8.5 Fractionated Pancreatic EBRT: Treatment Planning Goals and Doses Achieved by Plan Shown in Figure 8.4
Primary Goal Secondary Goal Primary Achieved
Structure Type Dose (cGy) Volume Dose (cGy) Volume Dose* (cGy) Volume* Result
PTV_5600 Min DVH (%) 5600 95% 5340.4 95.5% Met

GTV Min DVH (%) 5040 99% 5074.4 100% Met
PTV Min DVH (%) 5040 95% 4667.2 95.8% Met
Liver Mean Dose 2800 405.3 Met
Liver Max DVH (%) 3000 30% 4545.5 0.316% Met
Stomach Max DVH (cc) 5300 0.03 cc 2321.5 0 cc Met
Stomach Max DVH (%) 4500 25% 2321.5 0% Met
Small Bowel Max DVH (cc) 5300 0.03 cc 4839.1 0 cc Met
Small Bowel Max DVH (%) 4500 25% 4839.1 0.022% Met
Large Bowel Max DVH (cc) 5300 0.03 cc 3886.9 0 cc Met
Large Bowel Max DVH (%) 4500 50% 3886.9 0% Met
Duodenum Max DVH (cc) 5300 0.03 cc 5740.7 0.006 cc Met
Duodenum Max DVH (%) 4500 33% 5740.7 29.8% Met
Spinal Cord Max DVH (cc) 4500 0.03 cc 2324.0 0 cc Met
Kidney_R Max DVH (%) 1500 15% 2000 20% 4939.9 14.0% Met
Kidney_L Max DVH (%) 1500 15% 2000 20% 1352.5 0% Met
DVH, dose volume histogram; EBRT, external beam radiation therapy; GTV, gross tumor volume; PTV, planning target volume.
100
75 DUODENUM
LG_BOWEL
Relative Volume (%)
PTV_5040
PTV_5600
50 SM_BOWEL
SPINAL_CORD
STOMACH
25
0
0 10 20 30 40 50
Dose (Gy)
FIGURE 8.6 DVHs for a conventionally fractionated pancreas case.

● Planning goal is 40 Gy in five fractions to the HD-PTV if possible. Pre-

scription to the LD-PTV is decreased in 2.5 Gy/fraction increments until
OAR constraints are achieved.
■ Plan for a highly conformal dose distribution with the steep dose falloff.
See Figure 8.9.
■ OARs and dose constraints are given in Table 8.6.
58.8 Gy
56.0 Gy
50.4 Gy
28.0 Gy
FIGURE 8.7 A representative isodose distribution for a conventionally

fractionated pancreatic case.
OARs + 5mm
Bowel
Stomach
Duodenum
HD PTV
LD PTV
FIGURE 8.8 Contours of the HD-PTV and LD-PTV for a pancreas SBRT plan,
along with nearby sensitive structures.
HD, high dose; LD, low dose; OARs, organs at risk; PTV, planning target volume;
SBRT, stereotactic body radiation therapy.
RECTAL CANCER EBRT

■ Prone most typically, head-first.
40.0 Gy
35.0 Gy
25.0 Gy
FIGURE 8.9 Dose distributions for an SBRT pancreas case, demonstrating an

excellent conformality of the 35 Gy and 25 Gy isodose lines relative to the high
and low dose PTVs, respectively.
PTVs, planning target volumes; SBRT, stereotactic body radiation therapy.
TABLE 8.6 Planning Goals for OARs in Pancreas SBRT
Primary Goal
Cord Max DVH 3000 0.5 cc

Duodenum Max DVH 3000 0.5 cc
Duodenum Max DVH 1800 5 cc
Small Bowel Max DVH 3000 0.5 cc
Small Bowel Max DVH 1950 5 cc
Small Bowel Max DVH* 2500* 5 cc*
Large Bowel Max DVH 3200 0.5 cc
Esophagus Max DVH 3200 0.5 cc
Combined Kidney Mean Dose 1000
Stomach Max DVH 3000 0.5 cc
Stomach Max DVH 2500 5 cc
*Secondary constraint.
DVH, dose volume histogram; OARs, organs at risk; SBRT, stereotactic body radiation
therapy.
■ Belly board is used to allow bowel to fall away, limiting dose to small bowel
(Figure 3.1).
■ Angle sponge under ankles.
■ Feet generally are not banded when prone, at clinician’s discretion.
■ The bladder should be full and an anal marker placed.
■ Per clinician preference and disease presentation (extent of regional nodal
involvement), patients may be simulated supine, with head first, arms across
chest (i.e., no belly board); consider use of IMRT in this scenario.
Planning Technique
● GTV in rectum and involved nodes, based on CT, MRI, EUS, PET/CT,
and physical exam.

● CTV-GTV and nodal basins at risk: consider perirectal nodes (mesorectal
fascia), pre-sacral nodes, internal iliac nodes, and common iliac nodes up
to the bifurcation (classically at L5–S1).
● If the tumor is a clinical T4 with anterior extension into an adjacent organ,
the CTV should include the external iliac nodal region.

● If the tumor involves the anal sphincter/canal or vagina, include the ingui-
nal nodes in the CTV.

● PTV is a 5 mm expansion around the CTV.
● When indicated, PTV_boost is a 1 to 2 cm expansion of the GTV.
■ Prescription
● Rectal EBRT is typically preoperative.
● 45 Gy/25 fractions/1.8 Gy per day.
● Boost: three fractions at 1.8 Gy per day.
● Total dose: 50.4 Gy to PTV_boost.
■ For IMRT planning including inguinal nodes, please refer to the section on
treatment planning for anal cancer.
■ 3D planning
● Classic technique: three-field coplanar of PA with right and left lateral
fields; see Figure 8.10.

● Classic field borders for the PA field (adjusted based on PTV contours)
■ Inferior border: At least 3 cm below the inferior extent of the cancer
or at least 1 cm below the level of the pelvic floor for cancers located
≤5 cm from the anal verge marked at the time of simulation.
■ Superior border: L5/S1 vertebral junction.
■ Lateral borders: 1.5 to 2 cm lateral to the bony pelvis at the widest point.
● Lateral field borders
■ Superior and inferior borders are the same as the PA field.
FIGURE 8.10 A typical three-field arrangement, PA and two lateral fields, for a
rectal case with wedges in the lateral fields.
PA, posterior anterior.
TABLE 8.7 Planning Goals for Rectal EBRT
Primary Goal
GTV_5040 Min DVH (%) 5040 99%

CTV_5040 Min DVH (%) 5040 98%
PTV_5040 Min DVH (%) 5040 95%
PTV_5040 Min DVH (%) 4687.2 98%
PTV_5040 Max DVH (%) 5292 10%
PTV_5040 Max DVH (%) 5544 5%
PTV_5040 Max DVH (cc) 5796 0.03 cc
CTV_4500 Min DVH (%) 4500 98%
PTV_4500 Min DVH (%) 4500 95%
Bladder Max DVH (cc) 5040 0.03 cc
Bladder Mean Dose 3500
Small bowel Max DVH (cc) 4500 100 cc
Small bowel Max DVH (cc) 5000 10 cc
Large bowel Max DVH (cc) 4500 135 cc
Large bowel Max DVH (cc) 5000 45 cc
Femur R Max DVH (%) 4000 40%
Femur R Max DVH (cc) 5000 0.03 cc
Femur L Max DVH (%) 4000 40%
Femur L Max DVH (cc) 5000 0.03 cc
CTV, clinical target volume; DVH, dose volume histogram; EBRT, external beam
■ Anterior: Cover the lower common and internal iliacs and approxi-
mately the anterior one third of the acetabulum.
■ Posterior: 1 cm behind the sacrum.
● Wedges on the lateral beams are typically used.

● OAR dose constraints as given in Table 8.7.
● Representative isodose distribution is shown in Figure 8.11.
46 Gy 25 Gy
FIGURE 8.11 A typical isodose distribution for a three-field rectal plan.
ANAL CANCER EBRT

■ Simulated supine, head-first.
■ Patient’s legs should be in a frog leg position to minimize the inguinal skin
reaction.
■ Custom-made vacuum bag or equivalent rigid set up.
■ Index leg position for reproducibility.
■ Arms across chest.
■ Full bladder, anal marker placed.
■ Custom-made bolus, as needed.
Planning Technique
● GTV in anus and involved nodes, based on CT, MRI, PET/CT, and physi-
cal exam
● CTV-GTV plus at-risk regional nodal basins.
● Multiple CTVs may be needed depending on the extent of nodal disease.
● Elective nodal CTV includes the common iliac, internal and external iliac
nodes, presacral nodes, perirectal nodes, and inguinal nodes.

● PTV: Minimum 1 cm expansion around the CTV
■ Should be trimmed 3 to 5 mm from the skin surface if skin is not
involved.
■ If skin involved, bolus to be added over the PTV at the skin surface.
■ Prescription
● T2N0: Primary tumor PTV: 50.4 Gy in 28 fractions at 1.8 Gy per fraction;
nodal PTV: 42 Gy in 28 fractions at 1.5 Gy per fraction.

● T3N0 or T4N0 disease: Primary tumor PTV: 54 Gy in 30 fractions at
1.8 Gy per fraction; nodal PTV: 45 Gy in 30 fractions at 1.5 Gy per fraction.
● For node positive disease: Primary tumor PTV: 54 Gy in 30 fractions at
1.8 Gy in 30 fractions. For involved nodes ≤3 cm, involved PTV: 50.4 Gy

in 30 fractions at 1.68 Gy per fraction. For involved nodes greater than
3 cm, involved PTV: 54 Gy in 30 fractions at 1.8 Gy per fraction.
■ IMRT planning
● VMAT: depending on the width of the PTV, three arcs may be needed for
adequate field coverage.

● IMRT: seven to nine equally spaced coplanar beams. If the PTV is too
wide, some beams may need to be split on Varian accelerators.

● OAR dose constraints are listed in Table 8.8.
● A representative isodose distribution is shown in Figure 8.12.
TABLE 8.8 Planning Goals for Anal EBRT

GTV_5400 Min DVH (%) 5400 99%

CTV_5400 Min DVH (%) 5400 98%
PTV_5400 Min DVH (%) 5400 95%
CTV_4500 Min DVH (%) 4500 98%
PTV_4500 Min DVH (%) 4500 95%
Bladder Max DVH (%) 3500 50% 3500 92%
Bladder Max DVH (%) 4000 35% 4000 68%
Bladder Max DVH (%) 5000 5% 5000 11%
Iliac Crests Max DVH (%) 3000 50%
Bowel Max DVH (%) 4000 30%
CTV, clinical target volume; DVH, dose volume histogram; EBRT, external beam
57.6 54.0 51.3 48.6 45.0 32.4 27.0 16.2 Gy
FIGURE 8.12 Primary PTV (orange) and nodal PTV (purple) for an anal case
with representative dose distribution for a VMAT plan.
PTV, planning target volume; VMAT, volumetric modulated arc therapy.
LIVER SBRT
■ Immobilization with a custom-made body conforming bag or equivalent
rigid system.
■ IV and oral (small bowel) contrast usage per clinician preference and dis-
ease presentation.

■ Liver motion due to breathing can be significant, so efforts should be made
to limit or account for tumor displacement.
■ Techniques for motion management follow.
■ Controlled breathing
● Deep inspiration breath hold (DIBH) allows the patient to breathe in and
hold a predefined volume of air with each breath. The volume is defined
as a percentage of the patient’s maximum lung capacity, typically 70%
to 80%.
● In theory, DIBH should reproduce the tumor position with each breath
hold if the patient can comply with the breath hold (manual or device
aided). Therefore, this technique is patient dependent.
● Reproducibility should be verified by acquiring three CT scans under
breath hold and by performing co-registration of image sets to evaluate
system stability.
● After aligning to bony structures from verification CT scans, compare the
positions of the liver edge as a surrogate for tumor position, between the
three scans. If the displacement of the liver edge between image sets is
greater than 1.0 cm, patient may require further coaching or may not be
a good candidate for DIBH.
■ 4D-CT
● CT acquisition is binned into 10 breathing phases representing the full
range of motion.
● 4D-CT and normal breathing CT are both acquired during simulation.
● GTV is contoured on each phase of the 4D-CT and combined to form an ITV.
● Normal structures and OARs are contoured on the free breathing CT and
then transferred to the planning CT (average intensity projection CT) via

bony alignment. During this transfer, some normal tissue may require
additional contour adjustments because of organ motion.
■ Respiratory gating
● Use the same respiratory gating device for the simulation and treatment.
● Typically, a user-defined gating threshold (i.e., 80% of the inhale phase)
is used as a treatment window. This window should be patient specific.
Planning Technique
■ Plans can be created using VMAT or IMRT
● VMAT: depending on the laterality of the tumor, a partial arc is typically used
to avoid gantry collision issues as well as to minimize dose to normal liver.

One to two partial coplanar arcs are sufficient, spanning from 182° to 30°.
● IMRT: seven to nine equally spaced coplanar beams are suggested.
● GTV (or ITV if present) expanded by 5 mm to form PTV.
■ Prescriptions
● 54 Gy in 18 Gy fractions.
● 45 Gy in 15 Gy fractions.
● 50 Gy in 10 Gy fractions Radiation Therapy Oncology Group (RTOG
1112) (1).
● Prescription dose is adapted to meet OAR constraints (RTOG 1112).
■ An SBRT liver plan for highly conformal dose distribution with steep dose
falloff outside of target volume (see Figure 8.13).
■ OARs and their dose constraints are shown in Tables 8.9 and 8.10.
60 Gy
50 Gy
30 Gy
25 Gy
60 Gy
50 Gy
30 Gy
25 Gy
(A) (B)
60 Gy
50 Gy
30 Gy
25 Gy
(C)
FIGURE 8.13 Representative axial (A), sagittal (B), and coronal (C) views of a
liver SBRT plan.
TABLE 8.9 Planning Goals for Liver SBRT of 50 Gy in Five Fractions

(RTOG 1112)
Primary Goal
Liver (excluding GTV) Mean Dose 1300

Max DVH 1500 700 cc
Spinal Cord Max DVH 2500 0.5 cc
Heart Max DVH 3000 30 cc
Small Bowel Max DVH 3000 0.5 cc
(continued)
TABLE 8.9 Planning Goals for Liver SBRT of 50 Gy in Five Fractions
(RTOG 1112)
Primary Goal

Combined Kidney Mean Dose 1000
DVH, dose volume histogram; GTV, gross tumor volume; RTOG, Radiation Therapy
Oncology Group; SBRT, stereotactic body radiation therapy.
TABLE 8.10 Planning Goals for Liver SBRT of 54 Gy in Three Fractions

(Timmerman)
Primary Goal
Liver (excluding GTV) Mean Dose 900

Heart Max DVH 2400 15 cc
Heart Max DVH 3000 0.03 cc
Esophagus Max DVH 1770 5 cc
Stomach Max DVH 3900 10 cc
Small Bowel Max DVH 1770 5 cc
Large Bowel Max DVH 2400 20 cc
Combined Kidney Max DVH 1440 200 cc
DVH, dose volume histogram; GTV, gross tumor volume; SBRT, stereotactic body
radiation therapy.
REFERENCE
1. Radiation Therapy Oncology Group. Randomized phase III study of sorafenib
versus stereotactic body radiation therapy followed by sorafenib in hepatocel-
lular carcinoma. https://www.nrgoncology.org/Clinical-Trials/Protocol-Table
9 GENITOURINARY CANCER
Salim Balik, Radoslaw Szwedowski, Elaine Kunka,

Cory Hymes, Omar Mian, George Engeler, and
Chirag Shah
Conventional Fractionated Prostate.......................................................... 166

Target Volumes and Organs at Risk (OARs) .......................................... 166
Planning Objectives ................................................................................ 166
Treatment Planning ................................................................................ 168
Prostate SBRT ............................................................................................. 172
Target Volumes and OARs ...................................................................... 175
Low Dose Rate (LDR) Brachytherapy ........................................................ 183
Bladder Treatment ...................................................................................... 187
Testis Treatment.......................................................................................... 193
3D Planning ............................................................................................. 195
References .................................................................................................. 199
CONVENTIONAL FRACTIONATED PROSTATE
■ Patients are positioned with a knee cushion with feet banded together to
provide a comfortable and reproducible position.
■ Patients are simulated with a comfortably full bladder and an empty
rectum.
■ Patients are advised to drink a defined volume of fluid prior to simulation
and daily treatments to keep the bladder volume consistent.
■ Education on dietary modifications can help with compliance and reproduc-
ibility of rectal volumes.
■ Daily kilo-voltage (kV) cone beam CT (CBCT) is typically acquired to
directly align to the prostate (soft-tissue) for intact prostate treatments. The
alignment focus for prostate bed and concurrent treatment of pelvic lymph
nodes is at the discretion of the radiation oncologist but may include align-
ment to pelvic anatomy or to surgical clips in the setting of post-prostatec-
tomy cases.
■ The typical planning margin with daily kV-CBCT for intact prostate cases
is 5 to 8 mm in all directions except 5 mm posteriorly to limit rectal dose.
Target Volumes and Organs at Risk (OARs)

■ Detailed discussion of target and OAR delineation for intact prostate, pros-
tate bed, and pelvic lymph nodes is included in the sister handbook (1).
Planning Objectives
■ External beam radiation therapy (EBRT) can be used for intact prostate
cases, with pelvic lymph nodes or after prostatectomy in the adjuvant or
salvage setting.
■ EBRT can also be combined with a brachytherapy boost.
■ Typical prescription is 75.6 to 79.2 Gy in 1.8 to 2 Gy per fraction for intact
prostate treatment.
■ Moderately hypofractionated radiotherapy using 60 (3.0 Gy/fraction) to
70 Gy (2.5 Gy/fraction) is also commonly utilized with intact prostate cases.
■ Pelvic nodal irradiation is 45 to 50.4 Gy at 1.8 to 2 Gy per fraction.
Hypofractionation of pelvic nodal volumes remains controversial.
■ Traditionally, two sequential plans were required for concurrent treatment
of the prostate and pelvic nodes. The first plan is for the prostate and pelvic
lymph nodes to 45 to 50.4 Gy (1.8-2 Gy per fraction) and the second plan
is the prostate boost to 75.6 to 80 Gy.
■ The order of treatment can be reversed. Treating the boost plan first may
ease the management of acute side effects such as diarrhea.
9: Genitourinary Cancer ■ 167
■ Alternatively, the prostate and lymph nodes can be planned with a simul-
taneous integrated boost (SIB) method. For example, the prostate can be
treated with a hypofractionated regimen to 70 Gy and the pelvic lymph
nodes to 50.4 Gy in 28 fractions.
■ Two planning examples will be described below. The first case is an SIB case
with a hypofractionated prostate course with concurrent treatment of the pelvic
lymph nodes and the second is a conventional fractionation intact prostate case.
■ The hypofractionated prostate/pelvic lymph nodes case will be performed
using traditional manual iterative optimization. The prostate only case will
be planned using the treatment planning system’s auto planning feature
(Pinnacle; Philips, Andover, MA, USA).
■ Treatment planning goals for the hypofractionated prostate and pelvic nodes
case and for the conventional fractionation prostate case are presented in
Tables 9.1 and 9.2, respectively.
● These planning goals are typically more stringent than allowed in RTOG/
NRG clinical protocols or QUANTEC (quantitative analyses of normal

tissue effects in the clinic) (2,3).
■ Depending on patient anatomy, dose constraints may need to be adjusted at
the discretion of the treating physician.
TABLE 9.1 Treatment Planning Goals for a Hypofractionated 70/50.4 Gy in

28 Fractions for Prostate/Pelvic Lymph Nodes Plan
Dose Dose*
Structure/ROI Type (cGy) Volume (cGy) Volume* Result
CTV_7000 Min DVH 7000 98% 7018 99.9% Met

PTV_7000 Min DVH 7000 95% 6330 95.2% Met
CTV_5040 Min DVH 5040 98% 4930 99.6% Met
PTV_5040 Min DVH 5040 95% 4267 98.5% Met
BLADDER Max DVH 6000 15% 7480 11.8% Met
FEMUR_R Max DVH 5000 5% 4339 0.0% Met
FEMUR_L Max DVH 5000 5% 5072 0.06% Met
SMALL BOWEL Max DVH 5100 0.03 cm3 5169 0.00 cm3 Met
PENILE BULB Mean Dose 5100 3808 Met
RECTUM Max DVH 6000 15% 7303 6.26% Met
* Volume is at primary goal dose and dose is maximum or minimum depending on the
goal type.
CTV, clinical target volume; DVH, dose volume histogram; PTV, planning target volume;
ROI, region of interest.
TABLE 9.2 Treatment Planning Goals for Conventional Fractionation
Prostate
Structure/ROI Type Dose (cGy) Volume
CTV Min DVH Rx 98%

PTV Min DVH Rx 95%
Bladder Max DVH 7000 10%
Rectum Max DVH 4000 35%
Femur Max DVH 5000 5%
Small Bowel Max Dose 5200 0.03 cm3
Large Bowel Max Dose 5200 0.03 cm3
Penile Bulb Mean Dose 5250
ROI, region of interest; Rx, prescription.
■ Treatment planning for the prostate bed and other regimens are performed
similarly to the two cases reviewed but with different planning goals.
■ Typical planning goals for the prostate bed (70 Gy, 2 Gy/Fx) are presented
in Table 9.3.
Treatment Planning
GENERAL PRINCIPLES
■ Standard techniques include IMRT (intensity modulated radiation therapy)
or VMAT (volumetric modulated arc therapy).
■ Typical energies are 6 to 15 MV. Higher energies may be beneficial when
treating patients with a larger body habitus.
■ Energies higher than 10 MV are typically avoided due to increased neutron
dose from IMRT plans. With direct aperture based IMRT and VMAT plans,
the total MUs have been significantly reduced compared to previous IMRT
plans; thus the concern for neutron dose is decreased. For patients with a
large body size, use of photon energy higher than 10 MV may improve plan
uniformity.
■ VMAT offers more conformal plans with less treatment time than step and
shoot IMRT.
■ VMAT plans require a collimator rotation to minimize the interleaf leakage
(while less important, this is also good practice for IMRT fields).
TABLE 9.3 Treatment Planning Goals for a Post-Prostatectomy Case
(70 Gy, 2 Gy/fx)
Structure/ROI Type Dose (cGy) Volume
Prostate Bed Min DVH 7000 99%

PTV_7000 Min DVH 7000 95%
Femur Max DVH 4500 5%
Small Bowel Max DVH 5000 1%
Small Bowel Max DVH 4500 20 cm3
Sigmoid Max DVH 6500 5 cm3
Sigmoid Max DVH 4500 20 cm3
Penile Bulb Mean Dose 5000
DVH, dose volume histogram; PTV, planning target volume; ROI, region of interest.
■ For step and shoot IMRT plans with direct aperture optimization, a typical
setting for prostate only treatment plans includes 40 to 50 total segments
(around five segments per beam), 4 cm2 minimum segment area, and a
minimum of 4 monitor units (MU) per segment.
■ Common IMRT fields
● Five fields: 220°, 290°, 0°, 70°, 140°
● Seven fields: 210°, 255°, 310°, 0°, 50°, 105°, 150°
● Nine fields: 200°, 240°, 280°, 320°, 0°, 40°, 80°, 120°, 160°
● Seven or nine fields are preferred over five fields to achieve a more con-
formal plans.
■ Common VMAT fields
● Two full arcs: 182°–178°, 176°–184° with a collimator rotation of 5° to
15°
● A third full arc may be added with a collimator angle near 90°. The third
arc is helpful for concurrent treatment of pelvic lymph nodes.

■ For patients with a hip prosthesis, lateral beam angles going through hip
prosthesis should be avoided. Split arcs may also be helpful in this scenario.
PLAN OPTIMIZATION
■ Both VMAT and IMRT optimizations can be carried out with iterative
(staged) optimization, depending on the specific treatment planning system.
■ All example plans shown in this section used two full VMAT arcs.
■ Avoidance structures, tuning structures, and rings are used although dose
fall-off settings in some treatment planning systems may be sufficient.
■ Optional avoidance structures for prostate/prostate bed (“av” stands for
avoid)
● Ring 3 cm: 4 cm ring around (PTV + 3 cm)
● Ring 1 cm: 2 cm ring around (PTV + 1 cm)
● BladAv1: bladder − (PTV + 1 cm)
● RectAv1: rectum − (PTV + 1 cm)
● SigAv1: sigmoid − (PTV + 1 cm)
● BowAv1: bowel − (PTV + 1 cm)
● BladAv2: bladder − (PTV + 2.5 cm)
● RectAv2: rectum − (PTV + 2.5 cm)
● SigAv2: sigmoid − (PTV + 2.5 cm)
● BowAv2: bowel − (PTV + 2.5 cm)
Case 1: Hypofractionated Prostate/Pelvic Lymph Nodes (70/50.4 Gy,

2.5 Gy/1.8 Gy/Fraction)
■ Inverse optimization is performed in 4 stages, as described in Tables 9.4
and 9.5.
● Stage 1: initial planning objectives.
● Stage 2: add avoidance structures.
● Stage 3: adjust weights.
● Stage 4: add planning objectives for newly created structures to improve
dose coverage for the PTVs and minimize dose to OARs.

■ In stage 4, create two low dose structures to improve dose coverage to the
PTVs by subtracting the PTVs from the current 70 Gy and 50.4 Gy iso-
dose lines (IDL–PTV). Set the minimum dose planning objectives for these
structures (Table 9.5).
● D7000 = 70 Gy IDL–PTV_7000
● D5040 = 50.4 Gy IDL–PTV_5040
● Stage 4 optimization results in better dose coverage to the PTVs while
pushing dose away from OARs. This optimization is run for 30 iterations.
■ Other avoidance structures and planning objectives may be added to
further reduce dose to the OARs until the dose coverage of the PTVs is
compromised.
■ The prescription dose is normalized to a chosen isodose line (e.g., 98%) for
a desired PTV dose coverage. Large changes in normalization after optimi-
zation may result in some arcs being undeliverable (due to breaching gantry
angle speed set in machine settings).
TABLE 9.4 First 3 Stages of Planning Objectives for a Prostate and Pelvic
Lymph Node (70/50.4 in 28 Fractions) Case
Weight
Structure/ Target % (Stages 1 Weight*
ROI Type (cGy) Volume and 2) (Stage 3)
Step 1 (optimize for 60 iterations)

PTV_7000 Min DVH 7000 100 10 10
PTV_7000 Max Dose 7280 1 10
PTV_7000 Uniform 7140 1 50
Dose
Plan 5040 Min DVH 5040 100 10 10
Plan 5040 Max DVH 5292 5 1 1
Ring 1 cm Max Dose 3500 1 1
Ring 3 cm Max Dose 2460 1 1
Step 2 (add following and optimize for 60 iterations)
BladAv1 Max Dose 3500 1 1
RectAv1 Max Dose 3500 1 1
BowAv1 Max Dose 3500 1 1
SigAv1 Max Dose 3000 1 10
BladAv2 Max Dose 3000 1 10
RectAv2 Max Dose 3000 1 10
BowAv2 Max Dose 3000 1 10
SigAv2 Max Dose 3000 1 10
Plan 5040 = PTV_5040 – PTV_7000.
*Adjust the weights for objectives in stage 3 and perform optimization for 30 iterations.
TABLE 9.5 Stage 4 of Optimization

Weight
Structure/ROI Type Target (cGy) % Volume (Stage 4)
Stage 4 (optimize for 30 iterations)

D7000 Min Dose 7020 40
D5040 Max Dose 5060 40
Bladder Max DVH 2300 70 5
Rectum Max DVH 2400 70 5
Small Bowel Max DVH 1500 70 5
DVH, dose volume histogram; ROI, region of interest.
■ Evaluate the plan with isodose lines (Figure 9.1A), dose volume histogram
(DVH; Figure 9.1B), and treatment plan goals (Table 9.1).
Case 2: Prostate Only Irradiation (76 Gy, 2 Gy/fx)

■ This case is planned with the auto planning feature in Pinnacle (Pinnacle;
Philips, Andover, MA, USA).
■ We generated the following avoidance structures for auto planning:
● RectPush: A simple cylindrical structure (3 cm diameter) posterior to the
rectum as shown in Figure 9.2A to push dose away from posterior rectum.
● BladAv: bladder – clinical target volume (CTV)
● RectAv: rectum – (PTV_7600 + 3 mm)
■ Auto planning optimization goals and advanced settings are presented in

Tables 9.6 and 9.7.
■ If needed, one can optimize the plan further after auto planning until all
planning goals are achieved.
■ Limit the maximum point dose within the PTV to less than 110%. Specially,
avoid the hot spot near the interface between the prostate and rectal wall.
■ For this case, the plan achieved all planning goals shown in Table 9.2. The
final dose distributions and DVH are shown in Figures 9.2A and 9.2B.
PROSTATE SBRT
■ Due to the high degree of plan conformality and sharp dose gradients with
SBRT, intra-fraction monitoring is recommended.
■ Fiducial markers can be utilized and should be placed at least 4 days
prior to simulation. Fiducial markers can be tracked during treatment
using triggered imaging with Varian machines (TrueBeam, Varian, Palo
Alto, CA) with a tolerance of 2 mm. If any of the fiducial markers move
beyond this tolerance, treatment is paused and resumed when the fiducial
marker is back within tolerance, or the kV-CBCT is repeated and patient
realigned.
■ A rectal balloon can immobilize the prostate and improve the definition of
the interface between the anterior rectal wall and prostate.
■ If available, hydrogel spacer insertion between the rectum and prostate
can reduce rectal dose. Unless the radio-opaque version is used, hydrogel
is not clearly visible on the planning CT and kV-CBCT. MRI simulation
is useful to visualize the spacer while the patient is positioned in the
treatment position. Rectal balloon placement may be omitted if hydrogel
spacer is used.
73.5 Gy
70 Gy
50.4 Gy
45 Gy
35 Gy
(A)
100
90
BLADDER
80
CTV_7000
70 FEMUR_L
FEMUR_R
Volume (%)
60 PENILE_BULB
50 PTV_5040
PTV_7000
40 RECTUM
30 SM_BOWEL
20
10
0
0 10 20 30 40 50 60 70
Dose (Gy)
(B)
FIGURE 9.1 (A) Isodose lines of a VMAT plan for hypofractionated prostate/
pelvic lymph nodes case. (B) DVH.
79.8 Gy
76 Gy
45 Gy
38 Gy
(A)
100
90
80
70
Volume (%)
60 BLADDER
CTV_7600
50 PTV_7600
40 RECTUM
30
20
10
0
0 10 20 30 40 50 60 70 80
Dose (Gy)
(B)
FIGURE 9.2 (A) Isodose lines for the auto-planned conventional 76 Gy prostate
plan. (B) DVH.
CTV, clinical target volume; DVH, dose volume histogram; PTV, planning target volume.
TABLE 9.6 Auto Planning Target and Organ at Risk Optimization Goals
Structure/
ROI Type Dose (cGy) % Volume Priority Compromise
PTV_7600 Target 7600 NA NA NA

Rectum Max DVH 6500 35% Medium None
Rectum Max DVH 4000 55% Medium None
BladAv Max Dose 6500 50% Medium None
BladAv Max Dose 400 70% Medium None
RectAv Max Dose 7000 Low None
RectPush Max Dose 2200 Low None
■ An MRI is also useful in delineating the prostate apex and penile bulb. A
retrograde urethrogram can be performed during CT simulation to assist if
MRI is unavailable.
■ The patient is simulated with a full bladder to reduce the dose to the bladder
and displace bowel out of the field.
Target Volumes and OARs

■ Per Cleveland Clinic protocol, two targets are delineated, the high dose
PTV (HD-PTV) and low dose PTV (LD-PTV).
● HD-PTV: (a) expand the prostate CTV 3 mm uniformly except posteriorly;
(b) expand the urethra, rectum, and bladder 3 mm uniformly; (c) subtract
(b) from (a), to define the HD-PTV. Seminal vesicle CTV is excluded.
● The LD-PTV is a 3 mm expansion of the prostate and seminal vesicle (if
contoured) CTVs (except posteriorly).
TABLE 9.7 Auto Planning Settings

Settings Value
Tuning Balance 10%

Dose Fall-Off Margin 2.6 cm
Hot-Spot Maximum Goal 105%
Use Cold Spot ROI Yes
Engine Type Biological
Maximum iteration 50
ROI, region of interest.
HD-PTV
Urethra
LD-PTV
Anterior Rectum
Lateral Rectum
Rectal
Baloon
Posterior Rectum
FIGURE 9.3 Contouring of PTVs and rectum according to Cleveland Clinic

prostate SBRT protocol.
HD, high dose; LD, low dose; PTVs, planning target volumes; SBRT, stereotactic body
radiation therapy.
■ Typically, the prescription dose is 36.25 Gy in five fractions with 95% of

the LD-PTV receiving 36.25 Gy and 99% of the CTV receiving 36.25 Gy.
Fifty percent of the HD-PTV (or mean dose) receives 50 Gy. For lower risk
patients, the HD-PTV prescription dose may be reduced to 40 Gy instead
of 50 Gy.
■ The rectal wall is contoured by subtracting the balloon contour from a 3 mm
expansion of the balloon contour. The wall contour is then split into three,
with lateral walls as one contour, and anterior and posterior walls. Each
section of rectal wall has separate dose constraints (Figure 9.3).
Planning Objectives
■ For five-fraction SBRT, Table 9.8 lists the dose constraints (4).
■ Normal tissue tolerance for the 50 Gy HD-PTV is listed in Table 9.9. These
tolerance doses are usually easy to achieve, so tighter dose objectives are
used as planning objectives, and are presented in Table 9.10. The planning
objectives for the 40 Gy HD-PTV are also listed in Table 9.10.
TABLE 9.8 Normal Tissue Dose Constraints for Five-Fraction Prostate SBRT
Volume Max Max Point Endpoint
Risk Structure Volume (Gy) Dose (Gy)† (≥ Grade 3)
Rectum* <3.5 cc 50 55 Proctitis/fistula

<20 cc 37.5
Bladder Wall <15 cc 20 38 Cystitis/fistula
Ureter 45
Penile Bulb <3 cc 30 Impotence
Femoral Heads <10 cc 30 Necrosis
Colon* <20 cc 32.5 52.5 Colitis/fistula
*Avoid circumferential irradiation.
†
Point dose defined as 0.035 cc or less.
Treatment Planning
GENERAL PRINCIPLES
■ Our institutional protocol for prostate SBRT has been previously pub-
lished (5).
■ VMAT is the preferred technique with 10 MV FFF (flattening filter free)
beams to take advantage of the high dose rate (2400 MU/min) while lower-
ing the peripheral dose. 6 MV FFF can also be used if 10 MV FFF is not
available.
TABLE 9.9 Tolerance Doses as Listed in the Cleveland Clinic Prostate

SBRT Protocol
HD-PTV 50 Gy
Risk Structure Volume Dose (Gy)
Anterior Rectum <0.03 cc 50 Gy

<1 cc 45 Gy
Lateral Rectum <3 cc 40 Gy
Posterior Rectum <0.03 cc 22.5 Gy
Bladder <0.03 cc 48.3 Gy
<20% 30 Gy
Urethra <0.03 cc 50 Gy
<1 cc 45 Gy
HD, high dose; PTV, planning target volume; SBRT, stereotactic body radiation therapy.
TABLE 9.10 Planning Objectives for 40 Gy HD-PTV and 50 Gy HD-PTV
Prostate SBRT
HD-PTV 40 Gy HD-PTV 50 Gy
Risk Structure Volume Dose (Gy) Volume Dose (Gy)
Anterior Rectum <0.03 cc 38.1 Gy <0.03 cc 45 Gy

<1 cc 38.1 Gy
Lateral Rectum <3 cc 21.8 Gy <3 cc 21.8 Gy
Posterior Rectum <0.03 cc 19 Gy <0.03 cc 19 Gy
Bladder <0.03 cc 40 Gy <0.03 cc 45 Gy
<20% 18.3 Gy <20% 18.3 Gy
Urethra <0.03 cc 40 Gy <0.03 cc 45 Gy
<1 cc 38.9 <1 cc 40 Gy
HD, High dose; PTV, planning target volume; SBRT, stereotactic body radiation
therapy.
■ Collimator rotation is required for VMAT plans to minimize the interleaf

leakage.
■ To speed up the planning process, inverse optimization is performed using
a higher (e.g., 4 mm) resolution dose grid that covers a small area around
the PTV (PTV + 2 cm). After a desired treatment plan is achieved, dose is
recomputed at 3 mm or smaller resolution.
■ Typically, two full arc fields are used: 182°–178° and 176°–184° with non-
zero collimator angles; for example, 20 and 340.
■ With a single arc, the SBRT plan quality is degraded without reducing treat-
ment time since the total MUs are similar when comparing two arc VMAT
plans to one arc VMAT plans.
■ Adding a third arc does not usually improve plan quality significantly but
may cause undeliverable plans because three arc plans force the optimizer
to reduce the dose rate unnecessarily, which may violate the maximum
gantry speed limit.
INVERSE PLANNING
■ In the following example for a case delivering 40 Gy to the HD-PTV, the
inverse planning is completed in two stages.
■ Rings should be used in treatment planning systems such as Pinnacle
(Philips, Andover, MA, USA) and can enhance plans in other treatment
planning systems such as Eclipse and RayStation (dose-fall-off settings
may be enough for ideal anatomies).
■ Tuning structures
● Ring 2 mm: 1 cm ring around (LD-PTV + 2 mm)
● Ring 1 cm: 1 cm ring around (LD-PTV + 1 cm)
● Ring 2 cm: 2 cm ring around (LD-PTV + 2 cm)
● LD only: LD-PTV – HD-PTV
Stage 1
■ Set objectives as shown in Table 9.11, stage 1 and perform optimization
for 40 iterations:
■ After stage 1, we usually achieve a plan that meets all the goals listed in
Table 9.9 for 40 Gy HD-PTV, but we would like to further reduce dose to
the OARs without compromising PTV coverage which is performed in
stage 2.
Stage 2
■ Add the stage 2 objectives shown in Table 9.11 to the existing ones. The
added planning dose objectives for the listed OARs are very low but are
associated with very low weights. We do not want to change the composite
objective value too much since we already have a good plan.
TABLE 9.11 Inverse Planning Objectives for SBRT Prostate Stages 1–2
Structure/ROI Type Target (cGy) % Volume Weight
Stage 1
HD-PTV Min DVH 4000 55 5
LD-PTV Min Dose 3625 5
LD only Max DVH 3750 1 8
Ring 2 mm Max Dose 3300 1
Ring 1 cm Max Dose 2000 1
Urethra Max Dose 3800 2
Anterior Rectum Max Dose 3625 3
Lateral Rectum Max EUD 1000 1
Posterior Rectum Max Dose 1300 1
Stage 2
Ring 2 cm Max Dose 1500 0.5
Ring 1 cm Max EUD 1000 0.1
Rectum Max EUD 800 0.1
Bladder Max EUD 800 0.1
DVH, dose volume histogram; EUD, equivalent uniform dose; HD, high dose;
LD, low dose; PTV, planning target volume; ROI, region of interest.
PLAN EVALUATION
■ Isodose lines (Figure 9.4A), DVH (Figure 9.4B), and treatment plan goals
(Table 9.12) are used to evaluate the final plan which is calculated with
3 mm resolution dose grid using a collapsed cone convolution algorithm.
44 Gy
40 Gy
36.25 Gy
20 Gy
15 Gy
10 Gy
5 Gy
(A)
100
90
80
70
ANT_RECTUM
Volume (%)
60 BLADDER
50 HD-PTV
LAT_RECTUM
40 LD-PTV
30 PENILE_BULB
POST_RECTUM
20
URETHRA
10
0
0 5 10 15 20 25 30 35 40 45
(B) Dose (Gy)
FIGURE 9.4 (A) Isodose lines with five-fraction SBRT 40 Gy plan. (B) DVH.
DVH, dose volume histogram; HD, high dose; LD, low dose; PTV, planning target
volume; SBRT, stereotactic body radiation therapy.
TABLE 9.12 Treatment Plan Goals for the SBRT Prostate Plan Shown in
Figure 9.4
Primary
Primary Goal Secondary Goal Achieved
Structure/ Dose Dose Dose*
ROI Type (cGy) Volume (cGy) Volume (cGy) Volume* Result
HD-PTV Min 4000 50% 4000 40% 3561 60.1% Met

DVH
LD-PTV Min 3625 95% 3314 95.3% Met
DVH
Prostate Min 3625 99% 3561 99.9% Met
DVH
Anterior Max 3810 0.03 cm3 4000 0.03 cm3 3823 0.03 cm3 Met
Rectum DVH
Lateral Max 2180 3 cm3 4000 0.03 cm3 2868 0.39 cm3 Met
Rectum DVH
Posterior Max 1900 0.03 cm3 2250 0.03 cm3 1170 0.00 cm3 Met
Rectum DVH
Bladder Max 4000 0.03 cm3 4200 0.03 cm3 3839 0.00 cm3 Met
DVH
Bladder Max 1830 20% 3000 20% 3839 19.4% Met
DVH
Urethra Max 4000 0.03 cm3 4500 0.03 cm3 3953 0.00 cm3 Met
DVH
Urethra Max 3890 1 cm3 4500 0.03 cm3 3953 0.01 cm3 Met
DVH
*Volume is at primary goal dose and dose is maximum or minimum depending on the
goal type.
DVH, dose volume histogram; HD, high dose; LD, low dose; PTV, planning target
volume; ROI, region of interest; SBRT, stereotactic body radiation therapy.
COMPARISONS
■ For the 40 Gy HD-PTV, Figure 9.5 and Table 9.13 show a comparison of
three plans using one, two, or three arcs with 10 MV Flattening filter free
(FFF) energy. Two arcs are ideal in terms of plan quality, OAR sparing, and
treatment duration.
■ Figure 9.6 and Table 9.14 show a comparison of two plans for a 40 Gy HD-PTV
case using 6 MV FFF and 10 MV FFF beams. Even though both plans meet
constraints, total treatment time for the 10 MV FFF plan (because of fewer MU
to deliver and higher dose rate) is shorter. Also the 10 MV FFF plan had lower
dose to the peripheral normal tissue, that is lower whole body V5Gy and V10Gy.
44 Gy
40 Gy
36.25 Gy
20 Gy
15 Gy
10 Gy
5 Gy
1 arc 2 arcs
3 arcs
FIGURE 9.5 Comparison of one, two, and three arc prostate SBRT plans.
TABLE 9.13 Comparison of One, Two, and Three Arc Prostate SBRT Plans
HD-PTV 40 Gy
Structure/OAR Type One Arc Two Arcs Three Arcs
LD-PTV V36.25Gy 95% 95% 95%

CI 1.00 0.99 0.99
HD-PTV V40 Gy 78% 69% 66%
Bladder Max Dose 41.1 Gy 39.8 Gy 39.6 Gy
Mean Dose 8.4 Gy 8.2 Gy 8.3 Gy
Rectum Max Dose 38.9 Gy 38.2 Gy 38.6 Gy
Mean Dose 9.6 Gy 9.3 Gy 9.3 Gy
Whole Body V20Gy 257 cc 248 cc 249 cc
V10Gy 1151 cc 1081 cc 1058 cc
V5Gy 3614 cc 3591 cc 3633 cc
Total MU MU 2337 2486 2555
CI, conformity index (V36.25Gy/VLD-PTV); HD, high dose; LD, low dose;
MU, monitor units; OAR, organs at risk; PTV, planning target volume; SBRT, stereotactic
body radiation therapy; VXGy, volume of X Gy isodose line.
44 Gy
40 Gy
36.25 Gy
20 Gy
15 Gy
10 Gy
5 Gy
6 FFF 10 FFF
FIGURE 9.6 Comparison of 6 MV FFF and 10 MV FFF prostate SBRT plans.

FFF, flattening filter free; SBRT, stereotactic body radiation therapy.
LOW DOSE RATE (LDR) BRACHYTHERAPY

■ The procedure is performed while patient is in the dorsal lithotomy position
and under general anesthesia.
■ Transrectal ultrasound (TRUS) images are acquired for planning and to
guide needle insertion. Axial slices are captured in 5 mm intervals starting
1 cm above the base and ending 1 cm below the apex of the prostate.
■ To order the appropriate number of seeds, a pre-plan can be created based
on TRUS images acquired pre-operatively.
TABLE 9.14 Comparison of Prostate SBRT Plans With 2 Arcs of 6 MV FFF

or 10 MV FFF
HD-PTV 40 Gy
Structure/OAR Type 6 MV FFF 10 MV FFF
LD-PTV V36.25Gy 95% 95%

CI 1.00 0.99
HD-PTV V40 Gy 71% 69%
Bladder Max Dose 40 Gy 39.8 Gy
Mean Dose 8.2 Gy 8.2 Gy
Rectum Max Dose 38.7 Gy 38.2 Gy
Mean Dose 9.3 Gy 9.3 Gy
Whole Body V20Gy 248 cc 248 cc
V10Gy 1285 cc 1081 cc
V5Gy 4013 cc 3591 cc
Total MU MU 2780 2486
FFF, flattening filter free; HD, high dose; LD, low dose; MU, monitor units; OAR, organs
at risk; PTV, planning target volume; SBRT, stereotactic body radiation therapy.
■ Target volumes and OARs
● The prostate, bladder, and rectum are contoured by the physician.
● No PTV is defined but the prescription is defined to cover the prostate
gland with 3 to 5 mm margins. Smaller margins <2 mm are used near the
rectum. Smaller or larger margins can be used depending on the char-
acteristics (e.g., National Comprehensive Cancer Network [NCCN] risk
classification) of the cancer.
● While the urethra is not well visualized on the TRUS, the use of a Foley
catheter or contrast injection is typically unnecessary.

● The ultrasound probe is adjusted so that the expected location of the ure-
thra in the mid-gland is aligned at the midline (D column in the needle

template).
Planning Objectives
■ Prostate is prescribed to receive 144 Gy (for 125I) or 125 Gy (for 103Pd).
■ V150% of the prostate (volume receiving at least 150% of prescription)
≤50%.
■ V200% of the prostate ≤20%.
■ D90% (dose to 90% of the prostate) should be around 115% of the prescrip-
tion dose.
■ Dose to the central area of prostate (near urethra) should be <150% of
prescription dose.
■ Volume of the rectum receiving prescription dose (e.g., 144 Gy for 125I)
should be less than 1 cm3.
Treatment Planning
GENERAL PRINCIPLES
125
■ I (Iodine-125, T1/2 = 60 days, 28 keV photon) or 109Pd (Palladium-109,
T1/2 = 17 days, 21 keV photon) are commonly used radioactive isotopes.
■ A protocol using pretreatment planning with commercial software
(Variseed, Varian) will be reviewed.
■ The quality of the implant will be evaluated with a 1 month post-implanta-
tion (not described here) scan.
■ For additional details of the procedure, see the sister handbook (1).
PLANNING
■ A modified uniform peripheral loading procedure and treatment plan is
described step by step below. While there will be differences for every
patient, in general the treatment planning procedure will be similar.
■ The template to guide the insertion of the needles is superimposed on the
ultrasound images. The two-dimensional template has 5 mm graduations,
as shown in Figure 9.7, where the vertical axis is from 0.5 cm to 5.5 cm and
the horizontal axis is from A to G, alternating between capital and lowercase
letters at 5 mm increments.
■ Axial TRUS images are acquired starting two slices (1 cm) cranial to and
ending two slices (1 cm) caudal to the prostate as shown in Figure 9.8.
■ Radioactive seeds are available in two formats: loose seeds and stranded
seeds. The loose seeds are mainly used in the center of the prostate gland
where the urethra is located. The stranded seeds are loaded in the periphery
of the prostate. The minimum separation of seeds within a needle is 1 cm.
In order to avoid seed clustering, our process is to place needles either at
the intersection of the lower case letters and integer numbers (e.g., a1 and
f3 as shown in Figure 9.9A) or at the intersection of the upper case letters
and half numbers (e.g., A1.5, F.3.5 as shown in Figure 9.9B).
■ First, starting from the base of the prostate (Figure 9.9A), we load the needles
uniformly inside the prostate. By selecting the function of “through the target
extent” in the planning system, the needles will be loaded with a sequence of
seed-and-spacer automatically, resulting in 1 cm seed separation in all needles.
■ Second, we load needles in the periphery of the prostate (as shown in
Figure 9.9B) and repeat the function of “through the target extent” to load
the needles with seed-and-spacer automatically. The number of needles and
their placement are determined by prostate volume.
FIGURE 9.7 TRUS image acquired intra-operatively. The prostate (red) and
rectum (blue) are delineated by the physician. Overlaid grid (in red) represents
the template used to guide the needle insertion.
TRUS, transrectal ultrasound.
FIGURE 9.8 An example case of 12 axial images (5 mm thickness) acquired

with TRUS. The prostate gland contours (red) are shown from image #3 to
image #10. The bladder (yellow) and rectum (blue) are also contoured.
TRUS, transrectal ultrasound.
■ Third, after needle placement, certain seeds will be removed to achieve a
conformal dose distribution to the prostate while protecting the urethra and
rectum (as shown in Figure 9.10).
■ The plan is evaluated based on dosimetric endpoints (Table 9.15), isodose
lines (Figure 9.10), and needle loading (Figure 9.11).
BLADDER TREATMENT
■ Patient is simulated in the supine position with both comfortably full and
empty bladder scans to determine the extent of bladder volume change.
Either CT scan is available for treatment planning, depending on the treat-
ment intent (see below).
(A)
(B) (C)
FIGURE 9.9 (A) Needles are placed uniformly inside of the prostate gland.
(B) Needles are placed in peripheral of the prostate. Pink line is the prescription
(144 Gy) isodose line. Light blue is 150% and green is 200% isodose lines. Upper
right corner of each needle, the number of seeds for that needle is indicated.
FIGURE 9.10 Adjusting the plan of Figure 9.9. Images #5, #7, and #9 show
selected seeds are removed to achieve conformal dose distribution to the
prostate while protecting the urethra and rectum. For example, in #9, seeds
at locations of a3, f3, b4, e4 are removed. #11 Seeds are added to improve
coverage at the apex.
TABLE 9.15 Dosimetric Endpoints Achieved for LDR Prostate Seed

Implant Case
Structure/ROI Type Result*
Prostate V200% 19.9%

(Volume: 38.6 cm3) V150% 52.1%
V100% 99.9%
D100% 95.1%
D90% 120.1%
D50% 152.5%
Rectum V100% 0.9 cm3
Bladder V100% 0.0 cm3
*Vxx% is the volume that receive xx% of prescription dose (144 Gy) for prostate in %
of total volume and for bladder and rectum, the actual volume (in cm3). Dxx% is the min
dose received by xx% of prostate volume in % of prescription dose.
LDR, low dose rate; ROI, region of interest.
1 2
4.5 o o o o 3 o o o 3 o o o o
2 4 5 6
4.0 o o o 3 o 5 o 5 o 3 o o o
7 8
3.5 o o 3 o o o o o o o 3 o o
9 10 11 12 12 14
3.0 o 3 o 3 o 2 o 2 o 3 o 3 o
15 16
2.5 o o 3 o o o o o o o 3 o o
17 18 19 20 21 22
2.0 o 4 o 5 o 3 o 3 o 5 o 4 o
22 24 25 26
1.5 o o 3 o 3 o o o 3 o 3 o o
27 28 29 30 21 22
1.0 o 3 o 3 o 2 o 2 o 3 o 3 o
0.5 o o o o o o o o
A a B b C c D d E e F f G
FIGURE 9.11 Final treatment plan: Circles are the needles placing seeds on odd
numbered images and the triangles are on even numbered images. The numbers
are the number of seeds per needle.
■ Small bowel contrast can help delineate loops of small bowel adjacent to
the bladder.
■ Intravenous contrast may be utilized to visualize the pelvic vessels and
lymph nodes. However, as the contrast collects in the bladder shortly after
administration in a patient with normal glomerular filtration, density over-
ride of the contrast may be needed.
■ The preferred treatment planning CT for whole bladder treatment is the
empty bladder scan, which is more reproducible day to day by asking the
patient to void immediately prior to treatment.
■ In patients receiving concurrent treatment of the pelvic nodes, a full blad-
der may displace the small bowel out of the pelvis, minimizing the bowel
dose.
■ If a partial bladder boost is considered, either the full or empty bladder scan
may be utilized; this may be individualized at the time of target delineation
by the treating physician.
■ Bladder mapping by the urologist at the time of cystoscopy and/or a treat-
ment planning MRI fused to the simulation CT may be helpful in defin-
ing gross disease within the bladder and extravesicular spread for more
advanced disease, respectively.

■ For detailed target and OAR definitions, please refer to the sister handbook (1).
Planning Objectives
■ Rectum V55 Gy <50%
■ Femurs V0.03 cc <45 Gy
■ Small bowel V0.03 cc <60 Gy and V100 cc <45 Gy
Treatment Planning
GENERAL PRINCIPLES
■ 3D planning is standard unless planning goals are not achieved.
■ IMRT/VMAT with daily image guidance may be utilized to reduce the
bowel dose and potentially associated toxicities as demonstrated in bladder
(6) as well as other pelvic cancers (prostate, rectal, gynecologic).
■ For details of dose and fractionations used for bladder radiotherapy, please
refer to the sister handbook (1).
3D PLANNING
Beam Selection
■ Four field is the standard field arrangement.
■ Anterior posterior (AP) (0°), posterior anterior (PA) (180°), right lateral
(270°), left lateral (90°) using 6, 10, or 15 MV beam energies.
■ Higher energies are preferred if a patient has a large separation.
Forward Planning
■ AP/PA borders: Superior L5/S1; Inferior bottom of obturator foramen; lat-
eral 2 cm bony pelvis blocking femurs (see Figure 9.12A).
■ Lateral borders: 1 to 3 cm around bladder, split the rectum posteriorly
keeping superior and inferior borders from the AP/PA field (Figure 9.12B).
■ Fields should be weighted 70% AP/PA, 30% laterals to reduce dose to the
femurs.
■ To reduce hot spots, use wedges on the lateral fields and weight AP/PA
fields to achieve the smallest hot spot. Field in field may be used to improve
plan uniformity while maintaining adequate dose coverage to the PTV.
■ Resulting dose distribution is shown in Figure 9.13.
IMRT/VMAT
■ If planning goals are not achieved using a four-field technique, IMRT/
VMAT is recommended.
■ IMRT/VMAT may also be utilized for whole bladder or partial bladder
boost plans.
(A) (B)
FIGURE 9.12 Field borders for bladder whole pelvis field (A) AP and
(B) lateral. Green contour shown is the PTV.
AP, anterior posterior; PTV, planning target volume.
50.6 Gy
46 Gy
45 Gy
23 Gy
FIGURE 9.13 3D bladder plan. Green color wash is the PTV.

■ Dose escalation using an integrated boost IMRT technique to target gross
disease is being evaluated in prospective studies.
Beam Selection
■ Typically two full arcs are used with a non-zero degree collimator angle.
■ For example: 182° to 178° gantry angle and 10° collimator angle and reverse
arc of 176° to 184° with 350° collimator angle.
■ 6 or 10 MV beams are used. Higher energy (15 MV or greater) is avoided
if possible to reduce neutron dose.
■ If VMAT is not available, IMRT can be used with nine equally spaced, non-
opposing gantry angles every 40°, that is 0°, 40°, 80°, 120°, 160°, 200°,
240°, 280°, 320°.
Inverse Planning
■ The following steps in inverse optimization are applicable to both VMAT
and IMRT. IMRT planning process is typically faster but treatment delivery
time is longer.
■ Set minimum dose objectives for the PTV, CTV, and GTV.
■ Expand the PTV by 1 cm and 3 cm.
■ Create a ring structure (ring 1 cm) by using the following equation: Body –
(PTV + 1 cm), and set the planning objective of maximum dose to 50% of
the prescription dose to the ring 1 cm.
■ Create a second ring structure (ring 3 cm) by using the following equation:
Body – (PTV + 3 cm), and set the planning objective of maximum dose to
35% of the prescription dose to the ring 3 cm.
■ Add the planning objectives for critical structures. For example for the plan
shown in Figure 9.14: rectum “Max DVH” 40 Gy <40% of volume; femurs
“Max Dose” <45 Gy; and small bowel “Max Dose” <50 Gy.
■ After running the optimization using these objectives through 50 iterations,
add a maximum mean dose planning objective for the rectum, femurs, and
small bowel. Set for 2 Gy less than the currently achieved and progres-
sively lower the planning objectives by 2 Gy until dose coverage to PTV
is compromised.
■ The plan shown in Figure 9.13 is replanned using VMAT. The resulting
isodose lines (Figure 9.14), DVHs and treatment plan goals (Table 9.16)
show the improvement in plan conformality.
■ Using the auto-planning function in the Pinnacle system as discussed in
Chapter 2, one can create a VMAT or IMRT plan with the parameters shown
in Table 9.17.
■ A second example for VMAT planning is done in three steps to treat the
internal/external iliac lymph nodes to 40 Gy, boost the bladder by 14 Gy to
50.6 Gy
46 Gy
45 Gy
23 Gy
FIGURE 9.14 VMAT plan isodose lines. PTV is shown in green color wash.
54 Gy, and then boost the bladder tumor a further 10 Gy to 64 Gy as shown

in Figure 9.15A, B, and C, respectively.
■ Each plan was generated using two VMAT arcs and using a similar tech-
nique as described in the previous example. A composite of these three
plans is shown in Figure 9.16. The treatment plan goals for the composite
plan is shown in Table 9.18.
TESTIS TREATMENT
■ In general, patients are simulated supine in a custom body conforming
bag. The bag should be tightly molded around the patient to ensure daily
reproducibility.
■ The patient’s arms are extended above his head to avoid being irradiated.
■ A testicular shield (clam shell) is used when necessary to spare the remain-
ing testicle.
TABLE 9.16 Treatment Plan Goals for the Bladder VMAT Plan Shown in
Figure 9.14
Structure/ Dose Dose*
ROI Type (cGy) Volume (cGy) Volume* Result
CTV_4600 Min DVH 4600 98% 4648 99.9% Met

PTV_4600 Min DVH 4600 95% 4216 95.2% Met
Rectum Max DVH 4313 15% 4809 12.0% Met
LG Bowel Max DVH 4671 10% 4749 0.2% Met
SM Bowel Max DVH 4500 50 cm3 4775 2.0 cm3 Met
SM Bowel Max DVH 5000 1% 4775 0.0% Met
Femur_R Max DVH 5000 1% 2184 0.0% Met
Femur_L Max DVH 5000 1% 2008 0.0% Met
goal type.
ROI, region of interest; VMAT, volumetric modulated arc therapy.
TABLE 9.17 Auto Planning Target and Organ at Risk Optimization Goals
for VMAT Bladder Plan
Structure/
ROI Type Dose (cGy) % Volume Priority Compromise
PTV_4600 Target 4600 NA NA NA

Rectum Max Dose 4600 High None
Rectum Mean Dose 3200 High None
Bowel Mean Dose 1000 High None
Ring 1 cm Max Dose 2300 High None
Ring 3 cm Max Dose 1610 High None
Normal Max Dose 4605 High None
Tissue
Avoidance structures are prepared as explained in previous section. Normal
Tissue: Body–PTV.
PTV, planning target volume; ROI, region of interest; VMAT, volumetric modulated arc
therapy.
194
40 Gy 14 Gy
30 Gy 10 Gy
(A) (B)
10 Gy
6 Gy
(C)
FIGURE 9.15 VMAT plan isodose lines for (A) bladder and internal/external
iliac lymph nodes PTV to 40 Gy, (B) 14 Gy boost bladder PTV to 54 Gy, and
(C) 10 Gy boost the bladder tumor to 64 Gy total. Red color wash is the bladder
tumor boost volume.

■ For stage I testicular seminoma patients, para-aortic irradiation using an
AP/PA field arrangement may be considered as adjuvant therapy as shown
in Figure 9.17 (7).
■ Some cases may require a “dogleg” or “hockey stick” setup (Figure 9.18)
with definitions for the GTV, CTV, PTV, para-aortics, and ipsilateral pelvic
lymph nodes discussed in the sister handbook (1).
3D Planning
■ Typical prescription is 20 Gy in 10 fractions to the middle plane using an
AP/PA beam arrangement (Figure 9.19).
■ Beams are setup with 0.7 to 1 cm block margins around the PTV for ade-
quate dose coverage while accounting for penumbra. To protect OARs such
as the kidneys, block shape may be edited.
70.4 Gy
64 Gy
54 Gy
45 Gy
32 Gy
FIGURE 9.16 Composite dose for the sequential bladder VMAT plans.
Figure 9.16
GTV Bladder Min DVH 6400 99% 6437 99.9% Met

Tumor
CTV_Bladder Min DVH 5400 98% 5293 100% Met
CTV Int-Ext Min DVH 4000 98% 4645 100% Met
Iliac LNs
PTV_6400 Min DVH 6400 95% 6348 99.6% Met
PTV_6400 Max DVH 6912 0.03 cm3 6705 0.0% Met
PTV_5400 Min DVH 5400 95% 4962 99.7% Met
CTV_4000 Min DVH 4000 98% 4645 100% Met
PTV_4000 Min DVH 4000 95% 4247 100% Met
(continued)
Figure 9.16 (continued)

Sigmoid Max DVH 6500 10% 5999 0.0% Met
Sigmoid Max DVH 6000 10% 5999 0.0% Met
3 3
Bowel Max DVH 4500 50 cm 5640 10.5 cm Met
Bowel Max DVH 5000 1% 5640 0.6% Met
goal type.
PTV, planning target volume; ROI, region of interest; VMAT, volumetric modulated arc
therapy.
FIGURE 9.17 Treatment field for stage I testicular seminoma cancer lymph
node chain. Red is inferior vena cava and blue is aorta. CTV is shown in purple.
CTV, clinical target volume.
FIGURE 9.18 Treatment field for stage II testicular seminoma. CTV is shown
in green.
22 Gy
20 Gy
19 Gy
18 Gy
10 Gy
FIGURE 9.19 Resulting isodose distributions with AP/PA fields.

AP/PA, anterior posterior/posterior anterior.
■ Beams with an energy greater than or equal to 10 MV are typically used due
to a large separation in pelvis.
■ If there is PET avid or MRI/CT visible disease within the para-aortic nodal
chain, the prescription dose to this area may be boosted to 30 to 36 Gy.
REFERENCES
1. Khan MK, Tendulkar RD, Stephans KL, Ciezki JP. Genitourinary radiotherapy.
In: Videtic G, Vassil AD, eds. Handbook of Treatment Planning in Radiation
Oncology. New York, NY: Demos Medical Publishing; 2011:117–142.
2. Michalski JM, Gay H, Jackson A, et al. Radiation dose-volume effects in radi-
ation-induced rectal injury. Int J Radiat Oncol Biol Phys. 2010;76:S123–S129.
doi:10.1016/j.ijrobp.2009.03.078.
3. Viswanathan AN, Yorke ED, Marks LB, et al. Radiation dose-volume effects
of the urinary bladder. Int J Radiat Oncol Biol Phys. 2010;76:S116–S122.
doi:10.1016/j.ijrobp.2009.02.090.
4. Timmerman RD. An overview of hypofractionation and introduction to this
issue of Seminars in Radiation Oncology. Semin Radiat Oncol. 2008;18:215–
222. doi:10.1016/j.semradonc.2008.04.001.
5. Kotecha R, Djemil T, Tendulkar RD, et al. Dose-escalated stereotactic body
radiation therapy for patients with intermediate- and high-risk prostate cancer:
initial dosimetry analysis and patient outcomes. Int J Radiat Oncol Biol Phys.
2016;95:960–964. doi:10.1016/j.ijrobp.2016.02.009.
6. Søndergaard J, Holmberg M, Jakobsen AR, et al. A comparison of morbid-
ity following conformal versus intensity-modulated radiotherapy for uri-
nary bladder cancer. Acta Oncol. 2014;53:1321–1328. doi:10.3109/02841
86X.2014.928418.
7. Wilder RB, Buyyounouski MK, Efstathiou JA, Beard CJ. Radiotherapy
treatment planning for testicular seminoma. Int J Radiat Oncol Biol Phys.
2012;83:e445–e452. doi:10.1016/j.ijrobp.2012.01.044
10 GYNECOLOGIC CANCER
Susan Kost, Carol Belfi, D. Allan Wilkinson, Henry Blair,

and Sudha Amarnath
Whole Pelvis Radiation Therapy (WPRT) ................................................... 201

Patient Simulation and Localization ..................................................... 201
Planning Targets and Goals ................................................................... 202
Critical Structure Objectives .................................................................. 203
3D Conformal Planning .......................................................................... 203
Intensity Modulated Planning ................................................................ 204
Example: Endometrial Cancer ............................................................... 207
Example: Cervical Cancer ...................................................................... 210
Example: Vulvar Cancer .......................................................................... 211
Example: Vaginal Cancer ........................................................................ 213
High Dose Rate (HDR) Brachytherapy ...................................................... 216
Patient Simulation and Localization ..................................................... 216
Planning Targets and Goals ................................................................... 216
Critical Structure Objectives .................................................................. 216
HDR Planning .......................................................................................... 216
Example: Vaginal Cuff Brachytherapy ................................................... 217
Example: Tandem and Ring for Cervical Cancer .................................. 220
Example: Tandem and Ring for Uterine Cancer ................................... 222
Example: Interstitial Implant .................................................................. 224
References .................................................................................................. 226
WHOLE PELVIS RADIATION THERAPY (WPRT)

Patient Simulation and Localization
■ Patient is positioned supine.
■ Immobilization devices (see Chapter 3) are used for daily reproducibility
of trunk and leg position.
■ Bolus over inguinal or vulvar regions may be needed to bring dose to the
surface.
■ Treatment of the vulvar region requires positioning the patient’s legs apart
or into a frog-leg position to allow for bolus placement.
■ It may be best to not simulate with the bolus, but instead add it during plan-
ning so that the exact thickness and extent of the bolus can be determined
based on the tumor volume.
■ The patient is instructed to have a full bladder during the simulation. During
treatment, a full bladder lowers the dose received by the bladder wall and
adjacent small bowel. Radio-opaque markers (anus, vaginal introitus,
vaginal cuff, and/or cervix) are placed by the physician to identify these
structures during CT simulation. If intensity modulated radiation therapy
(IMRT) or volumetric modulated arc therapy (VMAT) is being used, after
the simulation with a full bladder, the patient is instructed to void com-
pletely. A second CT is acquired with an empty bladder with the same mark-
ers in place as with the full bladder scan.
■ The patient’s rectum should not be overly full of stool or gas at time of
simulation and treatment. A change in rectum content will impact the daily
treatment volume position, especially in IMRT or VMAT plans.
■ All attempts should be made to keep a patient’s colostomy bag empty before
simulation and treatment and preferably out of the treatment area if possible.
■ In patients with a large panniculus abdomen, it can be difficult to have a
reproducible daily setup and have large variations in source-to-skin (patient)
distance (SSD).
■ It is recommended that, if present, the panniculus be taped up or secured
using thermoplastic mask material into the thorax region in order to remove
it from the treatment area and facilitate daily setup.
■ Treatments should include daily or weekly cone-beam CT (CBCT) for
localization and alignment. Bone is typically used to align the CBCT to
the planning CT.
Planning Targets and Goals

■ The physician will delineate target volumes with a list of planning objectives.
■ Typically the primary tumor and lymph nodes are contoured as a single
clinical target volume (CTV).
■ Prescription dose is 45 Gy in 25 fractions (1.8 Gy per fraction) if a brachy-
therapy boost is to follow or 50 Gy in 25 fractions (2 Gy per fraction)
without a boost.
■ Target volumes
● 99% of the gross tumor volume (GTV) should receive the prescribed dose.
● 98% of the CTV should receive the prescribed dose.

10: Gynecologic Cancer ■ 203
● 95% of the planning target volume (PTV) should receive the prescribed
dose.
● Depending on the disease site, structures such as the uterus, vagina,
vulva, and cervix may be contoured and evaluated for dose coverage.
Critical Structure Objectives

■ Normal structures to be contoured include the entire rectum, bladder, small
bowel, large bowel, femoral heads, spinal cord, external genitalia, and pos-
sibly the sacrum for dose volume histogram (DVH) evaluation purposes.
■ Planning objectives for prescription dose of 45 Gy are:
● Bladder: less than 35% volume receives 45 Gy (V45 Gy <35%).
● Rectum: maximum point dose of 110% prescription dose (49.5 Gy) and
less than 60% volume receives 30 Gy (V30 Gy <60%).

● Small bowel: maximum point dose of 53 Gy and less than 30% volume
receives 40 Gy (V40 Gy <30%).

● Left and right femoral heads: maximum point dose of 50 Gy and less than
15% volume receives 30 Gy (V30 Gy <15%).

● Spinal cord: maximum point dose of 45 Gy.
■ Kidneys may be included as critical structures depending on tumor volume

extent. Dose constraint for left and right kidneys is for less than one-third
of their volume to receive 15 Gy (V15 Gy <33%).
3D Conformal Planning
■ Standard field setup is a four-field box with anterior posterior (AP), posterior
anterior (PA), and right and left lateral beams when the para-aortic lymph
nodes are not treated.
■ Physician will provide CTV/PTV contours with margins or set anatomical
field borders to block appropriate normal tissue structures:
● Superior border set at the L4–L5 or L5–S1 vertebral interspace.
● Inferior border set to the bottom of the obturator foramina or the lowest
extent of disease with a 3 cm margin.

● Lateral borders set 2 cm beyond lateral margins of the true bony pelvis.
● Anterior border set to anterior margin of the pubic symphysis.
● Posterior border extends through the S2–S3 interface.
■ Beam energy is generally 10 MV although higher beam energies

(15–18 MV) may be required for larger patients.
■ Density overrides may be needed
● Any oral, rectal, or intravenous contrast used for CT simulation will need
a density override to 1 gm/cm3.

● Markers placed to delineate structures such as the vagina, anus, and cer-
vix should be given a density override to that of air.

■ Wedges and segments can be used to optimize the dose distribution, elimi-
nating hot spots in normal structures, especially if a brachytherapy boost
is to follow.
● If a wedge is used, the placement of isocenter is important to allow indi-
vidual jaw/leaf positions to stay within field size limits of the accelerator.
● If segments are used to eliminate hot spots, turning the collimator to 270°
on some beams may allow more flexibility in shaping the segments (see
Figure 10.1).
● The minimum monitor units (MU) of each segment should be greater
than 3.
■ Plan is typically prescribed to the isocenter, choosing a percentage
isodose line that provides optimal dose coverage across the entire treat-
ment area.
■ When segments are used, a separate dose normalization point may be
needed; particularly the normalization point should not be covered by multi-
leaf collimator (MLC) leaves of the segment. Otherwise, the entire plan will
be hot, negating the value of adding segments to reduce hot spots.
Intensity Modulated Planning

■ Intensity modulated therapy (either IMRT or VMAT) is used for extended
field treatment including para-aortic lymph nodes.
■ VMAT provides faster treatment times and better overall dose conformity.
■ IMRT with fixed beams can be used if VMAT is not available.
FIGURE 10.1 Example of combining a segmented leaf position (right) with an

open field (left) to lower rectal hot spots to 5% or less. The segmented field has
a weight of 6% of the total beam MU. Yellow line is CTV, green is PTV.
CTV, clinical target volume; MU, monitor units; PTV, planning treatment volume.
■ VMAT typically takes longer to optimize and to compute the dose com-
pared to IMRT plans.
■ IMRT beam arrangement
● Typically nine beams are used that are spaced 40° apart to prevent oppos-
ing beams (0°, 40°, 80°, 120°, 160°, 200°, 240°, 280°, and 320°).
● Seven fields can be used if there is concern for the patient being able to
tolerate extended treatment time. Typical beam angles are then 0°, 45°,
80°, 160°, 200°, 270°, 315° to prevent opposing beams.
● For patients with a hip prosthesis or pin, beam angles will be modified
such that there is no beam entrance through the prosthesis or pin.

● It is still possible to use a lateral beam ± 15° by setting an asymmetric
jaw to exclude any region of the metal hardware within the entrance
of the beam and locking the jaw to prevent its movement during opti-
mization.
● Some CTV/PTV will inevitably be blocked in this beam as well; how-
ever, the other beams will compensate for the missing dose during opti-
mization. A lateral beam angle is the best way to spare dose to the rectum,
enabling rectal dose constraints to be met.
■ VMAT beam arcs
● Planning usually includes two full arcs with one starting at 182° and
rotating clockwise to 178°, and the second arc, rotating counterclock-

wise, from 178° to 182°.
● Sometimes adding a third arc yields better plan quality but planning with
two arcs should be attempted first to simplify the plan.

● It is most important to set a collimator angle of at least 10° rotation on all
arc beams to minimize the effect of inter-leaf leakage.

● For patients with a hip prosthesis or pin, arc angles need to be modified
to restrict the beam from entering that region. Four partial arcs can be
used.
● For example, if the patient has a right hip pin, the partial arcs can span
from 182° to 238° and 334° to 178° in the clockwise direction and then
return sweeping the same angles in the counterclockwise direction. Beam
arcs should be chosen based on the individual patient’s femoral head or
pin location.
■ Inverse planning process for IMRT and VMAT
● The plan is typically normalized to the mean dose of the PTV. The pre-
scription dose is expressed as a percentage of this PTV mean dose, nor-

mally from 95% to 98%.
● Create a ring contour 7 to 10 mm away from the PTV to protect normal
tissues and allow for a tighter dose distribution. The maximum dose to
the ring should be no more than 50% of prescribed dose.
● Dose grid should be large enough to cover the PTV and all critical structures.
● If bolus is not used, the PTV may need to be shaved 3 mm within the
external contour; otherwise, extra MUs will be applied to that region
during optimization in an attempt to achieve the dose coverage of the
PTV, resulting in unwanted hot spots in that region.
● The planning objectives and weights for a 45 Gy pelvis plan are given
in Table 10.1.
● The ring contour is added to control the dose to all other normal structures
not included in the planning objectives, such as the femoral heads and
kidneys, keeping them below max dose of the ring of 2250 cGy. If the ring
contour alone is not effective in controlling dose to normal structures, add
explicit objectives for specific normal structures during manual iteration
of optimization.
● After the first optimization run, the approximate mean doses to structures
such as the rectum and bladder can be used to modify the planning objec-
tives and weights for subsequent runs of optimizations.
● For subsequent optimization runs, without resetting the beams, add a
maximum equivalent uniform dose (EUD) or mean dose objective to the
critical structures several Gy less than the mean dose achieved in the previ-
ous optimization to continue to decrease the dose to organs at risk (OARs).
● The weight for the minimum dose and uniform dose objectives for the
PTV can be increased to 10 to 15 in an attempt to increase dose coverage
of the PTV while eliminating hot spots.
● On additional optimization runs, lower mean dose objectives to nor-
mal structures, especially the small bowel and rectum as brachytherapy
may follow. The plan is fully optimized when 95% PTV dose coverage
becomes impossible due to the optimizer’s attempt at lowering doses to
normal structures.
TABLE 10.1 Treatment Plan Objectives of 45 Gy Pelvis Plan
Structure Objective Dose Value (cGy) Weight
CTV_4500 Min Dose 4500 3

PTV_4500 Min DVH @ 98% 4500 3
PTV_4500 Uniform Dose 4500 3
Ring Max Dose 2250 1
Small Bowel Max Dose 4500 1
Large Bowel Max Dose 4500 1
Bladder Max Dose 4500 1
Rectum Max Dose 4500 1
CTV, clinical target volume; DVH, dose volume histograms; PTV, planning target volume.
● If the plan fails to obtain the PTV dose coverage after optimization, a new
planning PTV contour may be created by adding a 1 mm expansion on
the true PTV, without extending into sensitive structures such as the small
bowel. Adding a planning objective for this contour of prescription dose
to 99% of the volume (min DVH objective) typically improves the dose
coverage to the actual PTV.
● Example IMRT and VMAT plans are given in Figure 10.2 and DVH
comparison is shown in Figure 10.3. The VMAT plan is more conformal
and reduces dose to OARs.
Example: Endometrial Cancer

■ Follow general patient immobilization and simulation principles described
for WPRT.
■ Prescription: 45 to 50 Gy in 25 fractions (1.8–2 Gy per fraction)
● Treat to 45 Gy if a brachytherapy boost will follow.
■ The treatment area includes the primary tumor and full nodal coverage.
● The physician will delineate the GTV, CTV, and PTV on the CT scan or
set up box borders for a four-field plan.

■ OARs: Per “Critical Structure Objectives” for WPRT including right and
left kidneys if para-aortic lymph nodes are treated.
4750 cGy
4500 cGy
4000 cGy
3500 cGy
FIGURE 10.2 Axial (upper) and sagittal (lower) views of the dose distribution
achieved for a nine-field IMRT plan (left) versus two full arc VMAT plan (right).
IMRT, intensity modulated radiation therapy; VMAT, volumetric modulated arc therapy.
100
90
SS-IMRT
80
VMAT
70
Volume (%)
60
BLADDER
50 CTV_4500
FEMUR_L
40 FEMUR_R
LG_BOWEL
30 PTV_4500
RECTUM
20
SM_BOWEL
10
0
0 10 20 30 40
Dose (Gy)
FIGURE 10.3 DVH comparison for nine-field IMRT plan (solid line) and two
full arc VMAT plan (dashed line).
CTV, clinical target volume; DVH, dose volume histogram; IMRT, intensity modulated
radiation therapy; PTV, planning target volume; SS-IMRT, step and shoot intensity
modulated radiation therapy; VMAT, volumetric modulated arc therapy.
■ 3D conventional WPRT with borders depending on nodal coverage is the

standard planning technique.
■ Field margins include GTV and CTV defined by physician (see Figure 10.4).
FIGURE 10.4 Anterior and right lateral views of field margins for endometrial
cancer treated with 3D conventional WPRT. Yellow line is CTV, green is PTV.
CTV, clinical target volume; PTV, planning target volume; WPRT, whole pelvis radiation
therapy.
■ Include pre-sacral lymph nodes when there is cervical stromal invasion.
■ Para-aortic lymph nodes included if involved.
■ The resulting dose distribution is shown in Figure 10.5 and the DVH in
Figure 10.6.
■ IMRT/VMAT can be used for extended fields and/or if treating para-aortic
lymph nodes.
■ Intensity modulated planning is being used more commonly in the postop-
erative setting and can be considered with proper contouring. The IMRT
and VMAT plans in Figure 10.2 are examples of using intensity modulated
planning for postoperative endometrial cancer. The solid green contour is
the PTV including the surgical bed and lymph nodes.
4675 cGy
4500 cGy
4000 cGy
2250 cGy
FIGURE 10.5 Axial (top), sagittal (bottom left), and coronal (bottom right)
views of the dose distribution obtained from 3D conventional WPRT using the
fields in Figure 10.5 for endometrial cancer.
WPRT, whole pelvis radiation therapy.
100
90
80
70 BLADDER
CTV_4500
Volume (%)
60
FEMUR_L
50 FEMUR_R
LG_BOWEL
40 PTV_4500
RECTUM
30
SM_BOWEL
20
10
0
0 10 20 30 40
Dose (Gy)
FIGURE 10.6 Example DVH for CTV, PTV, and normal structures from 3D
conventional WPRT for endometrial cancer.
Example: Cervical Cancer

for WPRT.
■ Two separate CT scans (one with full bladder and another with empty
bladder) may be acquired and fused for outlining an internal target volume
(ITV) when modulated techniques are used with an intact uterus.
■ Prescription: 45 to 50 Gy in 25 fractions (1.8–2 Gy per fraction).
■ The treatment area includes the primary tumor, parametrium, and pelvic
lymph nodes.
■ The physician will delineate the GTV, CTV, and PTV on the CT scan or
setup box borders for a four-field plan.
■ OARs: Per “Critical Structure Objectives” for WPRT including right and
left kidneys if para-aortic lymph nodes are treated.
■ Field margins include GTV and CTV defined by physician.
■ AP/PA borders extend superiorly to cover L4–L5 with a 4 cm margin infe-
riorly or to the bottom on the obturator foramen to include the pelvic floor
and extend 2 cm laterally to the bony pelvis.
■ Lateral borders should be set according to “3D Conformal Planning” for
WPRT, with posterior coverage of at least 1.5 cm behind anterior surface of
the sacrum (see Figure 10.7).
■ If para-aortic lymph nodes are being treated, half-beam blocked AP/PA
upper fields can be used to control kidney dose with four fields (beam angles
0°, 90°, 180°, 270°) for the remaining whole pelvis.
■ The junction can be moved with asymmetrical jaws if needed using a single
isocenter.
■ A midline block at 40 Gy may also be added to the four-field plan to avoid
excess dose to implant region when the patient receives a brachytherapy
boost to the primary disease site.
■ The resulting dose distribution for a 45 Gy plan is given in Figure 10.8.
Example: Vulvar Cancer

for WPRT except:
● Patient should be positioned frog legged or have legs spread enough for
proper bolus placement and to remove legs from blocking the treatment
field area.
FIGURE 10.7 Anterior and right lateral views of field margins for cervical
cancer treated with 3D conventional WPRT. Green line is GTV, yellow is
uterus, and blue is lymph nodes, all included in the treatment field.
GTV, gross tumor volume; WPRT, whole pelvis radiation therapy.
4800 cGy
4500 cGy
3500 cGy
3000 cGy
2250 cGy
views of the dose distribution obtained from 3D conventional WPRT for
cervical cancer using the fields shown in Figure 10.8. Green contour is GTV,
yellow is uterus, and blue is lymph nodes.
GTV, gross tumor volume; WPRT, whole pelvis radiation therapy.
● Conformal patient bags may be used for leg immobilization and repro-
ducibility, especially for IMRT or VMAT treatment.
● Lymph nodes, vulva, anus, and any incisions should be wired.
■ Prescription: 45 to 56 Gy in 25 to 28 fractions (1.8–2 Gy per fraction) for

postoperative microscopic disease or 54 to 72 Gy in 28 to 35 fractions (2 Gy
per fraction) for postoperative gross disease.
● Treat up to 72 Gy (if this is safely achievable to normal structures) if
patient does not receive chemotherapy.

● Brachytherapy boost to primary tumor can be considered.
■ The treatment area includes the primary tumor, inguinal lymph nodes, obtu-
rator lymph nodes, and internal and external iliac lymph nodes if pelvic
lymph nodes are negative, or up to the common iliac lymph nodes if pelvic
lymph nodes are positive.
■ The physician will delineate the GTV, CTV, and PTV on the CT scan.
■ OARs: Per “Critical Structure Objectives” for WPRT.
■ WPRT using IMRT is the standard planning technique.
■ 6 MV photons should be used when dose coverage close to the surface is
a required.
■ A 5 to 10 mm bolus covering the groin and vulvar regions may be needed.
This is typically not placed during CT simulation and is instead added by
the dosimetrist during planning.
■ If IMRT is not available, 3D planning can be used with a wider AP field
which does not treat the femoral heads along with a narrower PA field.
Dose to the inguinal area can be supplemented with an anterior electron
field.
■ Dose to gross disease can be increased using a 3D boost plan or a perineal
en-face electron field. If an electron field is used, the patient is put in the
lithotomy position and the gantry is centered between the legs to deliver
dose directly to vulvar region with bolus applied.
■ The resulting dose distribution for a 46 Gy, 7 field step and shoot IMRT plan
is given in Figure 10.9.
Example: Vaginal Cancer

for WPRT.
■ In addition, introitus markers are placed during CT simulation.
■ Prescription: 45 to 50 Gy in 25 fractions (1.8–2 Gy per fraction)
● Treat up to 70 + Gy (as safely achievable to normal structures) if using
external beam alone.

● Brachytherapy alone can be considered for stage I patients.
■ The treatment area includes the primary tumor, pelvic lymph nodes, ingui-
nal lymph nodes, or both.
■ The physician will delineate the GTV, CTV, and PTV on the CT scan or
setup box borders for a four-field plan.
■ OARs: Per “Critical Structure Objectives” for WPRT.
■ Field margins include GTV and CTV defined by the physician.
■ Pelvic field border is extended inferiorly to cover the entire vagina and 3 cm
below the lowest extent of disease.
■ For involvement of the distal one third of the vagina, lateral borders should
extend to include inguino-femoral lymph nodes with the superolateral bor-
der at the anterior superior iliac spine, the lateral borders at the greater
5060 cGy
4600 cGy
3600 cGy
2300 cGy
views of an example dose distribution obtained from IMRT WPRT for vulvar
cancer.
IMRT, intensity modulated radiation therapy; WPRT, whole pelvis radiation therapy.
trochanter, and the inferior border at the inguinal crease or 2.5 cm below
the ischium; see Figure 10.10.
■ A 5 mm bolus to inguinal lymph nodes may be needed. This is typically
not placed during CT simulation and is instead added by the dosimetrist
during planning.
■ If only AP/PA fields are used and there will be a brachytherapy boost to fol-
low, a midline block can be added after 20 Gy is delivered to decrease the
dose to the bladder and rectum.
■ The resulting dose distribution for a 45 Gy plan is given in Figure 10.11.
■ IMRT and VMAT planning is becoming more commonplace due to the
ability to control dose to organs at risk compared to 3D conformal WPRT
planning.
FIGURE 10.10 Anterior and right lateral views of field margins for vaginal
cancer treated with 3D conventional WPRT. Yellow line is CTV, green is PTV.
CTV, clinical target volume; PTV, planning target volume; WPRT, whole pelvis radiation
therapy.
4775 cGy
4500 cGy
3500 cGy
2250 cGy
views of the dose distribution obtained from 3D conventional WPRT using the
fields in Figure 10.11 for vaginal cancer.
HIGH DOSE RATE (HDR) BRACHYTHERAPY
Patient Simulation and Localization
■ The treatment applicator is inserted into the patient prior to CT simulation
in either the operating room or brachytherapy procedure room.
■ Patient may be placed under general anesthesia, conscious sedation, or local
anesthesia during applicator insertion depending on the applicator type.
■ MRI simulation may be performed to provide improved soft tissue contrast
for better CTV delineation.
● MRI safe applicators must be used.
● Target delineation is typically done on a T2 weighted image.
● The MRI can be fused to the CT image set for better catheter visualization.
■ The position of the applicator may be verified by CT, ultrasound, or planar

x-ray before each fraction.
Planning Targets and Goals

■ The physician will delineate a target volume for treatment.
■ The prescription dose and fractionation depend on the treatment site and
type of cancer.
■ Guidelines from GEC-ESTRO (1) describing how to report target dose cov-
erage from brachytherapy depend on treatment site and may include:
● D90% and D100%, the dose delivered to 90% and 100% of the volume
respectively.
● V100%, the volume receiving 100% of the prescription dose.
Critical Structure Objectives

■ Normal structures to be contoured include the bladder and rectum and pos-
sibly the small bowel and sigmoid colon depending on proximity to the
applicator.
■ GEC-ESTRO recommends reporting the dose to 0.1 cc, 1.0 cc, and 2.0 cc
of the bladder, rectum, and sigmoid, respectively.
■ For planning based on two orthogonal films, surrogate points are used for
critical structures (2).
● The dose point for the bladder is defined as the posterior surface of a
Foley catheter balloon filled with 7 cc of contrast.

● The dose point for the rectum is defined 0.5 cm from the vaginal wall
directly posterior to the center of the ring or midpoint of the ovoids.
HDR Planning
■ Physician will delineate a target volume (a CTV) and critical structure con-
tours for planning.
■ Catheter is reconstructed on the CT for each channel in the applicator, typi-
cally starting at the tip end of the applicator.
■ The catheter should be reconstructed sufficiently beyond the area to be
treated.
■ The length of each catheter must be defined for the planning system to
properly index the channel position.
■ Source dwell position are activated, spaced 5 to 10 mm apart depending on
the type of applicator used.
■ The location of the first dwell position in relation to the tip end of the cath-
eter is determined when commissioning the HDR afterloader and applica-
tors by autoradiograph.
■ The treatment plan is typically normalized to a set of points.
● These points will receive on average 100% of the prescribed dose.
● The dwell times for all active positions remain equal after normalization.
■ The plan can also be optimized. Optimization adjusts the dwell times such
that the dose at each normalization point is closer to 100% of the prescribed
dose, with the average dose among all points still equal to the prescribed
dose. Specific examples follow.
Example: Vaginal Cuff Brachytherapy

■ The vaginal cuff applicator is used to treat postoperative endometrial cancer.
■ Stage 1 patients receive brachytherapy only.
■ Postoperative patients with stage 2 disease and beyond, typically only
receive an HDR boost following external beam radiation therapy (EBRT)
if there are positive margins, cervical stromal invasion, or lower uterine
involvement.
■ Prescription: 21 Gy in 3 fractions (7 Gy per fraction) for HDR only, or
12 Gy in 2 fractions (6 Gy per fraction) for HDR boost after EBRT dose
of 45 Gy. The combined dose from EBRT and brachytherapy results in
an equivalent dose in 2 Gy fractions (EQD2) of 60 Gy at 5 mm depth.
The EQD2 represents dose delivered in 2 Gy fractions that is biologically
equivalent to the total dose delivered from the primary and boost radia-
tion. Treatments are typically delivered once a week.
■ A vaginal cylinder applicator is placed in the vagina for CT simulation and
treatment.
● Patient is positioned in the lithotomy position.
● Patient does not require sedation or anesthesia.
● The largest size cylinder (diameters range from 20 to 35 mm) that fits for
specific patient anatomy should be used to reduce the air gap between
the cylinder and vaginal wall. The applicator must be in contact with the
vaginal mucosa in order to obtain an effective dose distribution.
● Cylinders can be single or multi-channel.
● The cylinder is secured in place using an external clamping platform.
■ The CTV is defined as the volume surrounding the cylinder to a depth of 5 mm.
● CTV contour is created by expanding the cylinder contour by 5 mm and
subtracting the cylinder volume from this expansion volume.

● The length of the treatment area is the upper 4 to 5 cm of the vagina to
avoid excess vaginal morbidity as the majority of recurrences are crani-

ally located.
■ Target dose points (based on GEC-ESTRO)
● Prescription point at 5 mm from the applicator surface at the mid-point of
the active source length should receive the prescription dose.

● Additional points at 5 mm from the applicator surface along the active
length should also receive 100% of the prescribed dose.

● The central apical point of the volume should receive greater than 90%
of the prescribed dose.

■ OARs: bladder, rectum, sigmoid colon, and small bowel.
■ Single channel cylinder treatment planning
● The catheter is reconstructed from the tip end of the cylinder down the
center of the channel as visualized on the planning CT. The image should
be windowed and leveled in order to correctly identify the end of the
cylinder channel. Begin the catheter reconstruction at the proper distance
from the end as previously determined by autoradiograph.
● Activate dwell positions every 5 mm starting from the tip end of the cath-
eter, giving nine active dwell positions if treatment length is 4 cm and 11

active points for a 5 cm treatment length.
● Define a set of catheter points at a depth of 5 mm from the surface of
the cylinder perpendicular to each active dwell position (Figure 10.12).

● Normalize and then optimize the dose to these catheter points, the result-
ing dose distribution is given in Figure 10.13.

■ Multi-channel cylinder treatment planning
● The multi-channel cylinder has seven to nine channels depending on
diameter (2.5, 3.0, 3.5 cm).

● Catheters in the peripheral channels can be reconstructed manually by
visualizing radio-opaque markers on the planning CT. Similar to the

single channel cylinder, the catheter reconstruction should begin at the
proper distance from the end as previously determined by autoradiograph.
● Catheters can be reconstructed using applicator modeling. This method
requires contouring the CTV, bladder, and rectum. The cylinder should
first be aligned such that the central marker is along the y-axis and the
perineal bar groove aligns to the z-axis. There are four anchor points on
the cylinder and three points should be defined to perform the applicator
modeling. Point A is located at 12 o’clock, 15 to 21 mm (depending on
200%
100%
50%
25%
FIGURE 10.12 Catheter points (blue crosses) placed at a depth of 5 mm from

the cylinder surface. The dwell times have been normalized and optimized to
these points.
cylinder diameter) from the tip end; point B is at 8 o’clock, about 5 cm

from the tip; and point C at 4 o’clock, another 1 cm lower from point B.
● To spare OARs, inverse planning simulated annealing (IPSA) is used.
The planning objectives should include at least 95% dose coverage to the
CTV and no more than 0.1 cc of the bladder and rectum receiving 100%
of the prescription dose.
Small Bowel
Bladder
CTV
200%
100%
Rectum 50%
25%
FIGURE 10.13 Axial (left) and sagittal (right) views of an example dose
distribution for vaginal cuff brachytherapy using a single channel cylinder.
Example: Tandem and Ring for Cervical Cancer
■ Prescription: 25 to 30 Gy in five fractions (5–6 Gy per fraction) delivered
one to two times per week. For patients receiving 30 Gy from brachytherapy
and 45 Gy EBRT, the total equivalent dose in 2 Gy fractions (EQD2) is
84.3 Gy.
■ A tandem and ring applicator is placed in the uterus and cervix for CT
simulation and treatment.
■ Patient can be anesthetized for placement, simulation, and treatment.
■ The length and angle of the tandem is chosen based on measured length and
curvature of the uterus.
■ The largest ring (if multiple sizes are available) that fits into the fornices
should be used to provide optimal dose delivery to the tumor and spare
normal tissues.
■ A Smit sleeve may be placed into the cervical os during first applicator
insertion to facilitate tandem insertion at subsequent treatments.
■ Tandem and ring placement are verified with CT before each fraction.
■ The CTV is contoured by the physician.
■ If an MRI simulation was performed, targets should include a high-risk
CTV (HR-CTV), defined as the area of gross residual disease and an inter-
mediate-risk CTV (IR-CTV), the HR-CTV plus an additional margin rang-
ing from 5 to 15 mm.
■ Target dose volumes (GEC-ESTRO)
● The IR-CTV should receive a dose of more than 60 Gy EQD2 for EBRT
and HDR brachytherapy combined.

● The optimal dose to HR-CTV remains undefined but commonly is
assumed to be the same as the total dose to point A (defined below)

with a target coverage goal of D90 equal to 100% of the prescription
dose.
■ OARs: bladder, rectum, sigmoid colon, and small bowel
● Bladder dose to 2 cm3 less than 90 Gy EQD2 combined EBRT and HDR
brachytherapy.
● Rectum dose to 2 cm3 less than 75 Gy EQD2 combined EBRT and HDR
brachytherapy.
● Sigmoid colon dose to 2 cm3 less than 75 Gy EQD2 combined EBRT and
HDR brachytherapy.
● International Commission on Radiation Units and Measurements
(ICRU) bladder and rectum points should be limited to less than 3.7 Gy
per fraction.
■ Tandem and ring treatment planning
● The image should be windowed and leveled in order to visualize the
catheter positions.
200%
100%
50%
25%
Point A (R) Point A (L)
FIGURE 10.14 Axial (top), coronal (bottom left), and sagittal (bottom right)
views of an example dose distribution from a tandem and ring applicator. Dose
is normalized to Point A.
● The extra coordinate system (ECS) or similar planning system can ori-
ent the 3D image view such that the ring is visualized in one plane,
perpendicular to the position of the tandem in the other two planes
(Figure 10.14).
● Reconstruction of each catheter should begin at the proper distance from
the end of the channel as previously determined by autoradiograph.
● Six dwell positions are activated in the ring, three positions spaced 5 mm
apart on each lateral side of the tandem centered at the mid-plane. This
avoids dose to the nearby rectum and bladder.
● Dwell positions are activated for the entire length of the tandem spaced
5 to 10 mm apart. The number of dwell positions in the tandem should
be approximately equal to that in the ring (3). For short tandem lengths
(i.e., 4 cm), dwell positions are activated every 5 mm. For longer tan-
dem lengths (i.e., 6–8 cm), dwell positions should be spaced every
10 mm.
● Point A is placed 2 cm superior to the cervical os, and 2 cm lateral (left
and right), along the coronal plane perpendicular to the intrauterine tan-
dem. The plan is normalized to these points and no optimization of the
dwell times is performed; see Figure 10.15.
200%
100%
50%
25%
FIGURE 10.15 Patient points (blue crosses) placed at a depth of 2 cm from the
center of the tandem. The dwell times have been normalized and optimized to
these points.
● After normalizing the plan to point A, coverage to the HR-CTV and IR-
CTV can be modified using graphical optimization. Weighting of dwell
times can be adjusted by manually dragging isodose lines to cover the
HR-CTV and IR-CTV with the desired dose.
Example: Tandem and Ring for Uterine Cancer

■ The tandem and ring applicator is used to treat medically inoperable uterine
(corpus uteri) cancer when the uterus is intact.
■ Stage 1 patients receive brachytherapy only to the entire uterus and upper
third of the vagina.
■ Patients stage 2 and beyond with high risk factors and/or nodal involvement,
receive an HDR boost after completion of EBRT.
■ Prescription: 30 to 42 Gy in five to six fractions (commonly 36 Gy in six
fractions) for HDR alone, or 16 to 17 Gy in two fractions (8–8.5 Gy per
fraction) for HDR boost after EBRT of 45 Gy with each HDR fraction
delivered weekly.
■ A tandem and ring applicator is placed in the uterus and cervix for CT
simulation and treatment as described for tandem and ring treatment of
cervical cancer.
■ A dual channel “Y” tandem (Rotte Y) applicator may be used for better posi-
tion reproducibility and improved target coverage for patients with large
uterine width.
■ The whole uterus is the CTV, as contoured by the physician.
■ If an MRI simulation was performed with applicator in place, a GTV can
be visualized and defined.
■ Target dose volumes (GEC-ESTRO)
● The overall aim is to treat the GTV (macroscopic disease) to at least
80 Gy EQD2 from the combination of EBRT and HDR.

● The whole uterus should receive a dose of 60 Gy EQD2 and the upper
vagina should be treated to 45 to 50 Gy EQD2.

■ OARs: bladder, rectum, sigmoid colon, and small bowel
■ Tandem and ring treatment planning
● For uterine cancer, dwells are only activated in the tandem catheter.
● Reconstruction of the tandem catheter should begin at the proper distance
from the end of the channel as previously determined by autoradiograph.

● Dwell positions are activated for the entire length of the tandem spaced
5 mm apart.
● Define a set of patient points at a depth of 2 cm perpendicular to the tandem
axis for each active dwell position for plan normalization (Figure 10.15).
● The dwell times should be optimized to the same set of patient points used
for normalization, resulting in the dose distribution shown in Figure 10.16.
CTV (uterus)
200%
100%
50%
25%
FIGURE 10.16 Axial (top), coronal (left), and sagittal (right) views of an
example dose distribution from an HDR boost to an intact uterus loading the
tandem only.
CTV, clinical target volume; HDR, high dose rate.
Example: Interstitial Implant
■ Used to treat large gynecological tumors or disease with lower vaginal
involvement and lateral extension where intra-cavitary applicators are
insufficient.
■ Prescription: 20 to 30 Gy in five fractions (4–6 Gy per fraction) delivered
without removal of the template until total dose delivered. Treated twice
daily, separated by at least 6 hours.
■ A Syed gynecological interstitial template is sutured in place in the operat-
ing room.
● Patient is placed under general anesthesia and epidural.
● The template consists of transperineal needles that are inserted directly
into the tissue to be treated. The depth of insertion is determined from

previous imaging.
● The insertion of the needles is performed using laparoscopic or fluoro-
scopic image guidance to avoid bowel perforation.

● The template can be used independently or in conjunction with a tandem
intra-cavitary applicator to deliver radiation to the tumor.

● Each needle length is measured for input into the planning system for
proper channel position indexing.

■ The CTV is contoured by the physician.
■ OARs: bladder, rectum, sigmoid colon, and small bowel.
■ Template treatment planning
● Needle reconstruction is performed starting from the connector end (nee-
dles are typically labeled from the 12 o’clock position of the interior ring
of the template going clockwise); see Figure 10.17.
● If a tandem applicator is also inserted into the uterus, this catheter is
labeled to correspond with the required index on the afterloader.

● Dwell positions are activated every 5 mm within the CTV.
● The prescription dose can be normalized to a set of dose points that out-
line the surface of the CTV, and dose point optimization can then be
applied. Further graphical optimization of CTV coverage by visually
adjusting the isodose lines may be necessary.
● Alternatively, prescription dose can be normalized to a 5 mm box
around the implant based on the highest dose on each box surface.
Graphical optimization can then be used to refine CTV coverage
(Figure 10.18).
FIGURE 10.17 Axial (top left), coronal (top right), sagittal (bottom left), and
3D (bottom right) views of catheter reconstruction for an interstitial implant
used as a vaginal cuff boost for uterine cancer.
Bladder
CTV
200%
100%
Rectum
50%
25%
FIGURE 10.18 Axial (top), coronal (left), and sagittal (right) views of an
example dose distribution for an interstitial implant after graphical optimization
of dose to the CTV.
REFERENCES
1. Gerbaulet A, Potter R, Mazeron JJ, et al. eds. The GEC-ESTRO Handbook
of Brachytherapy. Brussels, Belgium: European SocieTy for Radiotherapy &
Oncology; 2002.
2. Chassagne D, Dutreix A, Almond P, et al. ICRU Report No. 38: Dose and
Volume Specification for Reporting Intracavitary Therapy in Gynecology.
Bethesda, MD: International Commission on Radiation Units and Measure-
ments; 1985.
3. Halperin EC, Brady LW, Perez CA, Wazer DE. Perez & Brady’s Principles
and Practice of Radiation Oncology. Philadelphia, PA: Lippincott Williams
& Wilkins; 2013.
11 LYMPHOMA
Bingqi Guo, Cory Hymes, Sheen Cherian,

Hodgkin’s and Non-Hodgkin’s Lymphoma ................................................ 227

Total Skin Electron Irradiation ................................................................... 230
Total Body Irradiation ................................................................................. 231
Reference .................................................................................................... 234
HODGKIN’S AND NON-HODGKIN’S LYMPHOMA

■ Clinical application
● Radiation therapy as monotherapy, or as an adjunct to chemotherapy to
treat Hodgkin’s and non-Hodgkin’s lymphoma

■ Patient setup and immobilization
● Depending on the disease location, simulation and setup options vary.
● For head and neck areas, either a three- or five-point mask is used. The
patient is supine, the head and shoulders in neutral position, and arms by
his or her side or fingers interlocked on the abdomen. Three alignment
markers are placed outside the mask.
● For treatments involving areas inferior to the head and neck region, the
patients should be in the supine position with arms above head. Three
alignment marks are placed on patient skin for repositioning.
● Active breathing coordinator (ABC) may be used for respiratory motion
management while treating mediastinal or abdominal lymphoma, at the

discretion of the treating physician.
■ Treatment planning
● Dose specification
■ Dose prescription varys from 24 Gy to 50 Gy, in 1.8 to 2 Gy per frac-
tion, depending on the type and stage of lymphoma and the use of
chemotherapy.
● Extended field radiation therapy (EFRT)
■ Most commonly used in the past; rarely used nowadays.

■ Irradiating multiple involved and uninvolved lymph nodal groups
using mantle, para-aortic, inverted “Y” fields or a combination of
the three for the total nodal irradiation as shown in Figures 10.1 and
10.2 of sisterbook Handbook of Treatment Planning in Radiation
Oncology (1).
■ Mantle field borders: superiorly entends to the inferior portion of man-
dible including mastoid tip. The lateral borders split the humeral head
in half to ensure the adequate dose coverage in the axilla. The inferior
border extends to the eleventh thoracic vertebrae.
■ A laryngeal block may be placed if it does not block the involved
regions. The lung blocks are added laterally but not to block the hilar
nodes. Additional blocks may be added during treatment to protect
other organs at risk (OARs; such as kidneys) if needed.
■ Inverted Y Borders: The superior border is in the T10–T11 inter-
space. The lateral border is defined by allowing appropriate dosi-

metric coverage to the lymph nodes as well as the whole spleen.
The inferior border is in the L4–L5 to cover the para-aortic nodal
chain. Pelvic/inguinal lymph node involvement may further extend
the border inferiorly to 5 cm below the lesser trochanter. Additional
shielding is typically required to protect genitalia/reproductive
organs.
■ Typical OARs are the spinal cord, heart, lungs, kidneys, liver, bowel,
stomach, and femoral heads. It should also be noted that total nodal
irradiation exposes a lot of bone marrow.
■ The most common beam arrangement is anterior posterior/posterior
anterior (AP/PA).
■ In the total nodal irradiation, a gap calculation/junction change may be
needed to avoid the gross hotspots on the spinal cord.

● Involved/regional field radiation therapy (IFRT)
■ Irradiating only the involved lymph node site(s), commonly used
nowadays.
■ Most common involved field nodal regions are neck, mediastinum,
axilla, spleen, and para-aortic and inguinal lymph nodes.

■ 3D conformal or IMRT (intensity modulated radiation therapy)/VMAT
(volumetric modulated arc therapy) planning technique are ultized

for IFRT. Beam arrangement and beam energy selection vary by the
location of the disease and the near by critical structures. Figure 11.1
shows the beam setup and isodose lines (IDLs) for a lymphoma patient
treated to the stomach.
■ For dose constraints of planning, refer to the chapter for each specific
site: Chapters 5 and 7.

11: Lymphoma ■ 229
FIGURE 11.1 Beam setup and isodose distributions for a lymphoma patient
treated to the stomach.
■ For tumors in the thorax and abdomen, breathing control techniques

such as breath-hold and respiratory gating may be used to reduce the
inter- and intra-fractional motion and/or reduce the dose to critical
structures.
● Involved site radiation therapy (ISRT)
■ Following adequate induction systemic therapy if a complete
response or a good partial response is obtained, ISRT should be

considered.
■ The post-chemo gross tumor volume (GTV), if present, is con-
toured. The pre-chemo GTV is then reconstructed on the simulation

CT taking care to include the post-chemo GTV. Normal structures
that were univolved are then excluded from this volume and then
renamed as post-chemo clinical target volume (CTV). The post-
chemo CTV is then volumetrically expanded into a planning target
volume (PTV).
■ The final PTV could be planned using three dimensional conformal
radiation therapy (3DCRT) or IMRT techniques with daily image
guidance.
TOTAL SKIN ELECTRON IRRADIATION

● For definitive treatment of cutaneous T-cell lymphoma, also called myco-
sis fungoides.
■ Patient setup
● Patient in standing position at extended distance from isocenter, typically
3.5 meters or more.

● Six treatment positions: anterior-posterior, right anterior oblique, left
anterior oblique, posterior-anterior, right posterior oblique, and left pos-

terior oblique to ensure complete skin coverage. Refer to Figure 10.6 of
sisterbook Handbook of Treatment Planning in Radiation Oncology for
illustration of the six treatment positions (1).
● A platform may be used to raise patient up from the floor to reduce scatter
from the floor. Support device may be needed to ensure patient safety and
correct positioning in a standing position.
■ Treatment planning
■ Total dose of 36 Gy is prescribed to the skin surface. Treatment
delivered over 9 weeks, 1 Gy per day (treat anterior-posterior, right

posterior oblique, and left posterior oblique beams on day 1 and poste-
rior-anterior, right anterior oblique, and left anterior oblique beams on
day 2, 2-day cycle), 4 days per week, with a 1-week break after week 4.
● Treatment techniques
■ Six dual-field irradiation technique: for each of the six patient posi-
tions, two beams angled ~20° up/down are used to improve dose
homogeneity at surface. Figure 11.2 shows the beam setup.
■ Use electron beams with energy 4 to 10 MeV. No electron cone.
Collimator jaw opens to maximum positions. Mean electron energy at

patient treatment plane around 3 to 7 MeV. When combining the dose
from all six dual-field oblique beams, depth of maximum dose moves
to surface and 50% IDL lies at depth of 5 to 15 mm.
■ Dose rate at least 0.25 Gy/minute at maximal dose point is required
to shorten treatment time, 1 Gy/minute or higher is desirable.

Usually a special high dose rate mode is used for total skin electron
irradiation.
■ Dose uniformity within 10% at the treatment planes is expected.
Treatment plane
~ 20 degree
~ 20 degree
FIGURE 11.2 Illustration of dual-field technique for total skin irradiation.
■ Average X-ray background lower or around 1% of prescription dose is

desirable, higher than 4% is considered unacceptable.
■ Use nail and eye blocks for all or part of the treatment fractions to
reduce dose to these areas.
■ Soles of the feet, scalp, inframammary, pannicular, perianal, buttocks/
thighs, inner thighs, and perineal skin regions may be under-dosed.
Electron boost to these areas may be considered.
■ In vivo dosimetry recommended for quality assurance, small mea-
surement devices such as Thermo-Luminescent Dosimeter (TLD)
and Optically Stimulated Luminescent Dosimeter (OSLD) may be
used. TLDs (or OSLDs) are placed on the patient skin at regions of
interest including the head, arm, breast, umbilicus, femur, and ankle.
Measured dose is expected to be within 10% of the prescribed dose.
TOTAL BODY IRRADIATION

● Used on its own, or as an adjunct to chemotherapy as part of a myeloab-
lative regimen, to condition the host prior to receiving a hematopoietic

transplantation.
■ Patient setup
● AP/PA technique
■ Patient in a standing position. Midline of the patient (in AP/PA direc-
tion) at an extended distance from the isocenter, usually 4 to 6 meters.

Additional lasers may be installed in the treatment room to set up
patients at this distance.
● Opposed lateral technique
■ Patient seated on the couch with back support, arms follow the body
contour and shadow the lungs. Midline of the patient (in lateral direc-
tion) at an extended distance from the isocenter, usually 4 to 6 meters.
Additional lasers may be installed in the treatment room to set up
patients at this distance.
■ Small children can lay down on the couch for opposed lateral technique.
● Patient support system
■ Due to fatigue of the patient, additional support device may be needed
to ensure patient remains in the same position during treatment. Figure

11.3 shows a total body irradiation (TBI) stand for AP/PA technique.
■ Treatment Planning
■ No standard dose prescription. Varying from 2 Gy in 1 fx to 12 Gy in
6 to 8 fx.
■ Dose prescribed to the whole body. Prescription point is placed at
patient midline of the thickest part of the body, usually the umbilicus.
■ Keep a low dose rate of 5 to 10 cGy/min at patient midline. A typical
dose rate set at machine console is 200 MU/min.

■ Dose uniformity within 10% of prescribed is expected.
● Treatment techniques
■ AP/PA technique. Irradiate antero-posteriorly by parallel opposed
fields.
■ Opposed laterals technique. Use left and right lateral opposing fields.
■ 6 to 15 MV photon beams may be used, depending on patient thickness.
■ Collimators open to the maximum positions and rotated 45° to cover
the entire body.

■ A Beam spoiler made of a 1 to 2 cm thick acrylic and placed ~10 cm in
front of the patient may be used to achieve a 90% or higher surface dose.
■ Body thickness varies along the patient axis, especially for the lateral
technique. Tissue compensator may be used to improve dose unifor-

mity. Thickness of the body along the beam path is measured at the
level of head, neck, chest, umbilicus, hip, and legs. Compensators of
various thicknesses are made for different body parts and mounted
close to the patient.
FIGURE 11.3 A custom TEST/TBI stand with hand holders and straps to help
hold patient in the same position.
TEST/TBI, total electron skin therapy/total body irradiation.
■ Lung blocks may be used to reduce lung dose to fraction of the pre-
scription dose, usually <8 Gy. Lung blocks are mostly used for AP/PA
technique. They are usually made of Cerrobend with thickness of one
half value layer of the energy used. Shape of the lung block is delin-
eated from the AP/PA films. Chest wall may be boosted with electrons
if lung blocks are used.
■ In-vivo dosimetry recommended for quality assurance, small mea-
surement devices such as TLD and OSLD may be used.

● IMRT for TBI
■ Helical Tomotherapy has been used to treat children and young adults
for TBI. The patient is supine on the treatment table. Dose is delivered
continuously as the table moves the entire patient body across the iso-
center plane in one or two treatment sessions.
■ VMAT has also been used for TBI. The patient lays on a stationary
table beneath the gantry at an extended distance (e.g., 2 meters). The
head-to-toe direction is perpendicular to the gantry axis. Dose is deliv-
ered by two partial arcs covering the entire body. Patient is supine for
one arc and prone for the other.
■ IMRT for TBI require CT scan of the entire body, which usually means
two CT scans combined into one.
■ Planning target volume (PTV) is defined as the entire body. Inverse
planning is used to achieve uniform dose in the PTV and reduce the
dose to the lungs to fraction of the prescribed dose.
■ IMRT allows the patient to stay in a comfortable position during deliv-
ery and setup using image guided radiation therapy (IGRT). It has the
potential to improve dose homogeneity in the target and lung sparing.
The downside is increased complexity and longer planning time.
REFERENCE
1. Videtic GM, Woody NM. Handbook of Treatment Planning in Radiation On-
cology. 2nd ed. New York, NY: Demos Medical; 2015.
12 SOFT TISSUE SARCOMA
Kyle Verdecchia, Lama Muhieddine Mossolly, Matt Kolar,

Eric Murray, Lanea Keller, and Chirag Shah
Simulation ................................................................................................... 235

Abdomen/Thorax/Pelvis ........................................................................ 236
Extremities............................................................................................... 236
Bolus ........................................................................................................ 236
Treatment Planning .................................................................................... 236
Image Registration and Localization..................................................... 236
Preoperative Versus Postoperative Radiotherapy ................................ 238
Planning Goals and Critical Structure Objectives ................................ 238
EBRT Treatment Techniques .................................................................. 239
Treatment Planning: Preoperative Radiotherapy Examples ................... 241
Abdomen ................................................................................................. 241
Thigh ........................................................................................................ 241
Treatment Planning: Postoperative Radiotherapy Examples.................. 243
Chest Wall/Abdomen Wall ...................................................................... 243
Thorax ...................................................................................................... 243
Calf (Left) ................................................................................................. 245
Lower Limb .............................................................................................. 246
Dual-Isocenter IMRT/VMAT .................................................................... 248
Extended SSD ......................................................................................... 251
Treatment Planning: Brachytherapy Examples ........................................ 251
References .................................................................................................. 254
SIMULATION
■ A CT with 3 mm slices is acquired in the treatment position.
■ Oral/IV contrast can be considered to better define target and organs at risk
(OARs) based on treatment site.
■ Contrast is particularly useful for retroperitoneal sarcomas or cases where
lymph node irradiation is being considered.
■ Isocenter is placed in the center of the treatment volume during simulation.
Abdomen/Thorax/Pelvis
■ Immobilization devices such as alpha cradle casts, arm boards, knee sad-
dles, thigh stirrups, or vacuum bags are used to ensure consistency in setup
during treatment.
■ Patient position is supine or prone, dictated by location of disease and adja-
cent OARs.
■ 4D CT can be employed to account for motion of abdominal or thoracic/
chest wall soft tissue sarcomas.
■ Deep inspirational breath-hold or gating can be employed during radio-
therapy to limit margins required to account for breathing motion.
■ Arms are positioned on chest for pelvis or lower abdomen diseases and
above the head for chest and upper abdomen tumors.
Extremities
■ Immobilization devices such as polyurethane foam molds, body fix, alpha
cradle casts, or vacuum bags are used to ensure consistency in setup during
treatment.
■ Mobile normal tissue should be moved away from targets at the time of
setup. For example, simulate the patient with the treated leg straight and the
untreated leg “frog-legged” (Figure 12.1) to create separation between legs,
limiting dose to the untreated leg and allowing for effective fusion of the MRI.
■ Patient position can be supine or prone, depending on target location, and
head or feet first; the latter is most common for lower extremities. A gen-
eral rule-of-thumb is an isocenter placement below the greater trochanter
requires the patient to be feet first (reversed).
Bolus
■ Bolus is added over any postoperative surgical scars during simulation or
during treatment planning, typically 5 to 10 mm.
■ Surgical scars and drain sites should be wired for bolus to aid visualization
during treatment planning (Figure 12.2).
TREATMENT PLANNING
Image Registration and Localization
■ To assist the physician with target delineation, diagnostic scans, such as
CT, MRI, and PET, are fused to the region of interest with the planning CT.
12: Soft Tissue Sarcoma ■ 237
FIGURE 12.1 Coronal slice illustrating the untreated left leg “frog-legged.” The
green contour illustrates the PTV in the treated right leg.
■ MRI simulation may be acquired for better target and OAR delineation.
■ Daily cone beam CT (CBCT) can be considered for localization depending
on the clinical scenario.
● Preoperative cases can be aligned to tumor.
● Postoperative cases can be aligned to bony anatomy initially and then
soft-tissue.
Wires for
Bolus
FIGURE 12.2 Wires are placed during simulation to highlight scars requiring
bolus.
Preoperative Versus Postoperative Radiotherapy
■ Preoperative and postoperative external beam radiation therapy (EBRT)
are both used and clinical presentation may favor one strategy over another.
■ Brachytherapy can be also used either exclusively or as a boost with EBRT
that is delivered in the preoperative or postoperative setting.
Planning Goals and Critical Structure Objectives

■ Target volumes are provided by the physician with a list of planning objectives.
■ Preoperative volumes
● Use MRI to help delineate volume (sequence is dependent on histology).
● RTOG 0630 provides image guided radiation therapy (IGRT)-based
volumes (1).
■ Postoperative volumes
● Traditionally include volume to 50 Gy with cone down but this will be
dependent on clinical scenario.

■ Retroperitoneal volumes
● Preliminary consensus volume guidelines are provided by Baldini et al.
(2,3).
■ Target goals
● >95% of the PTV to be covered by 100% of the prescribed dose.
● 95% of the prescribed dose to cover >99% of the PTV.
● Aim for a maximum point dose in the PTV <107% of the prescribed dose.
■ Dose constraints are extracted from in-house scorecards, QUANTEC (quan-

titative analyses of normal tissue effects in the clinic), and RTOG 0630 (4).
■ Abdomen/pelvis (adapted from QUANTEC and in-house scorecards,
unless noted otherwise)
● Liver: V
30 Gy ≤30%, Dmean <28 Gy
● Kidneys: V
18 Gy ≤50%
● Whole kidneys: V
15 Gy ≤40%
● Bladder: V ≤35%, Dmax ≤60 Gy
45 Gy
● Rectum: V
40 Gy ≤60%, Dmax ≤55 Gy
● Stomach: D
100% ≤45 Gy
● Small bowel: V
45 Gy ≤30%, Dmax ≤55 Gy
● Large bowel: V
45 Gy ≤50%
● Femoral heads: V
30 Gy ≤15%, V60 Gy ≤5% (adapted from RTOG 0630)
● Spinal cord: V
40 Gy ≤10%, Dmax ≤45 Gy
■ Thorax (adapted from QUANTEC and in-house scorecards)
● Whole lung (combined right and left lungs): V
20 Gy ≤20%, Dmean
<17.5 Gy, and V5 Gy ≤65%
● Ipsilateral lung: V
20 Gy ≤35%, Dmean <20 Gy
● Esophagus: Dmean <34 Gy and V
50 Gy ≤40%
● Heart: V30 Gy ≤50%, V40 Gy ≤35%
● Spinal cord: V40 Gy ≤10%, Dmax ≤45 Gy
■ Extremities (adapted from RTOG 0630)
● Bone/joints: V
50 Gy ≤50%
● Genitalia: Dmean ≤8 Gy and V
3 Gy ≤50%
● Normal skin (defined as outer 5 mm of body surface): V
20 Gy ≤50% (lon-
3
gitudinally), V70 Gy ≤10 cm , and Dmax ≤76 Gy
EBRT Treatment Techniques

■ Techniques to treat soft tissue sarcomas with EBRT include:
● 3D conformal radiation therapy (3D-CRT)—static beams
■ Typically, two to four fields are required.
■ Forward planning.
■ Dose conformality and OAR sparing is achieved by dose shaping
techniques, such as field blocking, field-in-field, or wedges (virtual or

physical).
● Intensity modulated radiation therapy (IMRT)
■ Number of beams range from four to nine.
■ Dose conformality and OAR sparing increases with the number of
beams at the cost of increased treatment delivery time.

■ Caution is required to ensure gantry clearance for complex setups.
■ Number of segments for direct aperture optimization techniques
also vary but start with five to seven segments per beam and increase
depending on the ability to meet optimization goals.
● Volumetric modulated arc therapy (VMAT)
■ Typically, two to four full or partial dynamic arcs are required depend-
ing on the complexity and laterality of the target volume.

■ Full arcs are often used for central tumor locations.
■ Partial arcs are used for lateral tumor locations in order to limit low
dose spread, reduce dose to critical structures, and for arc clearance.
■ Reduced treatment delivery time, better dose conformality, and lower
exposure to OARs as compared to IMRT techniques (5,6).

■ Optimization of IMRT/VMAT
● Define prescription dose and fractionation.
● Add beams and define energy, gantry, and collimator angles.
● 6 MV for superficial tumor or small extremity lesions, 10 to 15 MV for
deep tumors.
● Gantry angles that irradiate through untreated tissue (i.e., contralateral
leg) should be avoided.

● Define IMRT/VMAT objectives for target, OARs, and planning struc-
tures (e.g., rings).

● Examples of planning rings include normal tissue rings of 1 cm
(NTR1cm) and 3 cm (NTR3cm), which are created by subtracting a
PTV expanded by 1 cm and 3 cm, respectively, from the external contour.
For this example, the planning objectives for NTR1cm and NTR3cm
would be maximum doses of 50% and 30%–35% of the prescription
dose, respectively.
● IMRT plan parameters
■ Type of optimization (e.g., IMRT).
■ Jaw settings (see Table 12.1 for example).
■ Number of segments (five to seven segments per field).
■ Minimum segment area (≥4 cm2).
■ Minimum number of leaf pairs per segment (≥6).
■ Minimum segment MU (≥3 MU).
■ Minimum segment area and minimum number of leaf pairs per seg-
ment depend on the treatment volume size. For large target volumes,
the segment area and number of leaf pairs are increased to avoid highly
modulated segments.
● VMAT plan parameters
■ A nonzero collimator angle is advised. The collimator of each arc is
set to a nonzero angle to prevent dose banding (via leakage through

the multi-leaf collimator [MLC]) and provides additional degrees of
freedom to the optimizer. Typically, the collimator angles chosen are
±10°. The start and stop rotational angles of the gantry are adjusted to
reduce dose to critical structures near the target.
■ To avoid confusion, the gantry angles of full VMAT arcs do not start
at 180°, but rather 182° or 178° for clockwise and counterclockwise

rotational directions, respectively; the rotational direction is at the
discretion of the planner.
TABLE 12.1 Collimator and Jaw Parameters for VMAT Beam Setup. Lock
the Jaw Settings as the Maximum Field Size Before Optimization
Gantry Angle (°) Collimating Jaws (cm)
Collimator
VMAT Arc Start End Angle (°) X1 X2 Y1 Y2
Proximal_1 350 176 10 14.5 14.5 19.99 19.99

Proximal_2 176 350 350 14.5 14.5 19.99 19.99
Distal_3 352 178 350 14.5 14.5 19.99 19.99
Distal_4 178 352 10 14.5 14.5 19.99 19.99
TREATMENT PLANNING: PREOPERATIVE RADIOTHERAPY EXAMPLES
Abdomen
■ Patient position: supine with arms across chest.
■ Prescription: 50 Gy in 25 fractions.
■ Treatment plan
● VMAT delivered by four 6 MV partial arcs between 182° and 32° for a
right-sided tumor. The number of partial arcs may vary (suggested num-
ber of partial arcs is between two to four) depending on target conformal-
ity and dose sparing of OARs; additional arcs may facilitate treatment
plan improvement.
● Each set of partial arcs are offset by 2° giving the plan optimizer addi-
tional degrees of freedom. A set consists of two arcs that travel the same
number of rotational degrees; however, one arc rotates clockwise, and the
other arc rotates counterclockwise.
● The four partial arcs in sequence travel from 182° to 32°, 32° to 182°,
184° to 34°, and 34° to 184°.

■ For non-central targets, partial arcs are used to limit low dose spread, to reduce
dose to critical structures, and for arc clearance. For example, in Figure 12.3,
the gantry stops at 32° to avoid unnecessary dose to the bowel on the left side
of the abdomen.
■ Higher energy (>10 MV) is considered for thicker patients (>25 cm).
■ OARs: kidneys, liver, bladder, small and large bowel, femoral heads, and
spinal cord.
Thigh
■ Patient position: supine and feet first.
■ CT fused with MRI to delineate target and critical structures.
53.5, 50.0, 45.0, 25.0 Gy
FIGURE 12.3 A preoperative abdominal soft tissue sarcoma treatment plan

(illustrated in sequence: axial, sagittal, and coronal slices). Green represents
the PTV.
53.5, 50.0, 45.0, 25.0 Gy
FIGURE 12.4 A treatment plan for soft tissue sarcoma of the right thigh
(illustrated in sequence: axial, sagittal, and coronal slices. Green represents the
PTV.
■ Prescription: 50 Gy in 25 daily fractions.

■ Treatment plan (Figure 12.4): Two 6 MV VMAT arcs between 174° to 322°
were chosen to minimize dose to OARs and for arc clearance. An offset of
2° increases the degrees of freedom for the planning optimizer, as described
previously.
■ OARs (Table 12.2): external genitalia, femur, and normal skin.
■ It is strongly advised to tape male external genitalia in the direction opposite
of the target for medial leg sarcomas at simulation and during treatment
(Figure 12.4) if not in target volume.
■ A clam shell during treatment can be considered.
■ CBCT for daily localization.
TABLE 12.2 Treatment Planning Goals for a Extremity Soft Tissue

Sarcoma
Dose Dose*
GTV Min DVH (%) 5000 99% 4990.1 99.9% Met

CTV Min DVH (%) 5000 98% 4307.6 98.1% Met
PTV Min DVH (%) 5000 95% 4332.5 95.9% Met
Genitals Mean Dose 800 – 590.0 – Met
Femur right Max DVH (%) 2000 50% 2316.6 2.1% Met
PTV, planning treatment volume.
TREATMENT PLANNING: POSTOPERATIVE RADIOTHERAPY EXAMPLES
Chest Wall/Abdomen Wall
■ Can be treated with postoperative EBRT due to superficial target and lack
of OARs.
■ Deeper targets in abdomen/retroperitoneal sarcomas should be considered
for preoperative radiotherapy.
■ Patient position: supine with arms across chest or above head.
■ Prescription: 50 Gy in 25 fractions to a larger volume followed by a
cone down or boost of 10–20 Gy (60–70 Gy total) depending on margin
status.
■ Treatment plan (Figure 12.5): VMAT for both initial and cone down
treatments. Two 6 MV partial arcs, 320° to 120° (clockwise and counter-
clockwise).
■ For non-central targets, partial arcs are used to limit low dose spread to
reduce dose to critical structures and for arc clearance.
■ Bolus of 5 mm is added on the postoperative scar to increase surface dose.
■ At simulation, contrast was given to highlight the bowel for accurate OAR
contouring; for planning, the density of the contrast is overridden to tissue
equivalent density (1 g/cm3).
■ OARs (Table 12.3): kidneys, bladder, and bowel.
Thorax
■ Patient position: supine with arms above head.
■ For posterior targets, prone position may reduce dose anteriorly.
Furthermore, prone eases placement of bolus, if required.
70.6, 66.0, 50.0, 45.0, 33.0 Gy
FIGURE 12.5 A postoperative abdominal soft tissue sarcoma treatment plan

(illustrated in sequence: axial, sagittal, and coronal slices). Green and blue
represent the low dose PTV and high dose PTV, respectively.
TABLE 12.3 Treatment Planning Goals for a Abdominal/Retroperitoneal
Sarcoma
Dose Dose*
PTV_5000 Min DVH 5000 95% 4142.2 99.2% Met
(%)
CTV_5000 Min DVH 5000 98% 4677.0 99.8% Met
(%)
PTV_6600 Min DVH 6000 95% 5327.4 95.6% Met
(%)
CTV_6600 Min DVH 6000 98% 5801.3 98.1% Met
(%)
Small Bowel Max DVH 5500 0.03 cm3 5474.4 0.00 cm3 Met
(cm3)
Small Bowel Max DVH 4500 30% 5474.4 2.3% Met
(%)
Bladder Max DVH 6000 0.03 cm3 5242.0 0.00 cm3 Met
(cm3)
Bladder Max DVH 4500 35% 5242.0 0.2% Met
(%)
Rectum Max DVH 5500 0.03 cm3 1794.4 0.00 cm3 Met
(cm3)
Rectum Max DVH 4000 60% 1794.4 0.0% Met
(%)
Femur Left Max DVH 5000 0.03 cm3 159.3 0.00 cm3 Met
(cm3)
Femur Left Max DVH 4000 25% 159.3 0.0% Met
(%)
Spinal Cord Max DVH 4500 0.03 cm3 987.0 0.00 cm3 Met
(cm3)
Spinal Cord Max DVH 4000 10% 987.0 0.0% Met
(%)
Kidney Left Max DVH 1800 50% 1010.8 0.0% Met
(%)
Kidney Right Max DVH 1800 50% 921.8 0.0% Met
(%)
Kidney Max DVH 1500 40% 1010.8 0.0% Met
Whole (%)
CTV, clinical target volume; DVH, dose volume histogram; PTV, planning treatment volume.
64.2, 60.0, 45.0, 30.0 Gy
FIGURE 12.6 A thoracic soft tissue sarcoma treatment plan (illustrated in

sequence: axial, sagittal, and coronal slices). Green represents the PTV.
■ Depending on the location of the target a 4D CT may be acquired to delin-

eate the maximum extent of the respiratory motion in all directions.
■ Treatment plan (Figure 12.6): Eight 10 MV static step-and-shoot IMRT
fields between gantry angles of 200° and 160° were used with avoidance
of parallel-opposed fields in efforts to prevent hot spots due to overlapping
entrance and exit doses.
■ OARs: right/left lung, heart, spinal cord and esophagus.
Calf (Left)
■ Patient position: prone and feet first.
■ Bolus placed over surgical bed.
■ For superficial targets, fields may require the addition of bolus, which can
be done by wrapping a folded wet towel around the leg (equivalent to 5 mm
thickness) to increase surface dose at the scar. When using wet towel as
bolus, you should always verify delivered dose with in vivo dosimetry.
■ During treatment planning, a density override to tissue (1 g/cm3) is required
to approximate radiation attenuation due to bolus placed during planning. The
density override on the planning CT is expected to reproduce bolus placement
during treatment but is not required when bolus is placed at simulation.
■ Treatment plan (Figures 12.7 and 12.8): mixed energy (five 6 MV and one
10 MV) IMRT step-and-shoot coplanar radiation fields between 210° and
320° (counterclockwise). Mixed energies are strategically used to improve
coverage to the PTV while sparing normal tissue, such as bone.
■ OAR: tibia dose constraint objective is V30 Gy ≤50%. Sparing of a skin strip
for lymphatic drainage is achieved by meeting the goal of Dmax <20 Gy,
with a hard constraint of Dmax <30 Gy.
FIGURE 12.7 Beam arrangement for an IMRT treatment plan for soft tissue
sarcoma in the left calf. Gantry angles of 210°, 320°, 0°, 40°, 120°, and 152°
are shown by light blue, red, blue, yellow, pink, and green, respectively.
IMRT, intensity modulated radiation therapy.
Lower Limb
■ Patient position: supine and feet first.
■ For long target volumes, either extended source-to-skin (patient) distance
(SSD) or two-isocenters may be required.
64.2, 60.0, 45.0, 30.0 Gy
FIGURE 12.8 A treatment plan for a soft tissue sarcoma in the left calf
(illustrated in sequence: axial, sagittal, and coronal slices). Green represents the
PTV.
FIGURE 12.9 An axial slice of beam arrangement for the proximal isocenter
of a dual-isocenter treatment plan. The blue and purple beams are AP/PA with
beam energies of 6 MV and 15 MV and wedges, respectively. The yellow beam
represents the lateral field.
■ Prescription: 50 Gy in 25 daily fractions followed by a cone down of

10 Gy.
■ OAR: bone, normal skin, and external genitalia.
■ Treatment plan (Figure 12.9): five mixed energy beams (four 6 MV and one
15 MV) were delivered by a dual-isocenter plan.
● Distal isocenter: two 6 MV energy beams delivered by a segmented
AP/PA (0° and 180°) technique. Segments were used to minimize hot
spots.
● Proximal isocenter (Figure 12.9): two beams, 6 MV (AP) and 15 MV
(PA) were modified with 30° and 35° wedges, respectively. A third lateral
6 MV beam is delivered by a segmented field.
● The cone down was created by taking the original beams and shrinking
to cover the high-risk area (green PTV in Figures 12.10 and 12.11).
■ In Figure 12.9, the anatomy on the left (feet first simulation) is not imaged
entirely. It is important for the treatment planner to identify such scenarios
to ensure no beams irradiate through the missing tissue.
■ Since the tumor is relatively deep, a gap of ~1 cm at the skin surface sepa-
rates adjacent beams for the dual-isocenters, Figure 12.10.
Distance = 1.0 +/– 0.1 cm
FIGURE 12.10 A sagittal slice showing the junction site of matched adjacent
fields for a dual-isocenter sarcoma. The adjacent beams are separated by a
gap of ~1 cm at the skin surface due to the relatively deep target. The blue and
green contours represent the original and cone down PTVs, respectively.
■ The junction location (Figure 12.10) is varied by 1 cm twice (half-way

through large volume course and when starting cone down) during the treat-
ment course to smear the junction point.
■ The full plan is presented in Figure 12.11.
Dual-Isocenter IMRT/VMAT
■ If the tumor volume exceeds the maximum field size, an IMRT/VMAT plan
with a dual-isocenter is the preferred treatment technique, particularly when
a multi-field plan is required.
■ While either IMRT or VMAT techniques may be used, VMAT reduces treat-
ment time. VMAT will be used here as an example.
■ The arcs are setup with the y-axis parallel to the long side of the target as
illustrated in Figure 12.12. This enables the motion of the MLCs to be per-
pendicular to the target and maximizes field length.
■ Angling the collimator for a VMAT arc prevents dose banding (Figure 12.12).
70.6
66.0
50.0
45.0
33.0
Gy
(A) (B)
(E)
(C) (D)
FIGURE 12.11 Composite dual-isocenter (distal and proximal isocenters

shown by blue and red crosshairs, respectively) treatment plan of leg sarcoma
illustrating the total dose delivered to the plan and cone down PTVs shown
by the blue and green contours, respectively. The top images represent the
axial (A) and coronal (B) slices of the distal isocenter and the bottom images
represent the axial (C) and coronal (D) slices of the proximal isocenter;
(E) shows a sagittal slice, which contains both isocenters.
■ Before plan optimization, the maximum field size for the y-axis (<20 cm
per jaw) and the x-axis (14.5 cm per jaw for modern Varian accelerators)
may need to be locked to the maximum allowed jaw settings before opti-
mization depending on the planning system (Table 12.1). This prevents
the optimizer from widening the field beyond the physical limit of the
accelerator.
■ Strategic placement of each isocenter is required. Considerations should
include:
● Location of critical structures.
● Field size limitations.
● Type of MLC being utilized.
● Gantry rotation clearance to avoid collisions.
● Range of motion of the treatment couch (Figure 12.13).
■ Limitations in the range of motion of the treatment table exist; a maximum

separation of 20 cm between two isocenters (Diso) is highly recommended
PTV
Avoidance
Isocenter
FIGURE 12.12 Proximal isocenter in dual isocenter plan prior to

optimization. The green, red, and blue represent the PTV, avoidance and
isocenter, respectively. The collimator angle is 350° and the MLC positions
are included.
MLC, multi-leaf collimator; PTV, planning treatment volume.
to ensure the patient does not collide into the gantry while shifting
isocenters.
■ From the edge of the target, inferiorly and superiorly, a 2 cm extension of
the field is suggested. This reduces the maximum target length, superiorly
to the proximal isocenter and inferiorly to the distal isocenter, to 18 cm (i.e.,
a maximum jaw size of 20 cm is assumed but accounting for this recom-
mended 2 cm extension past the target edge reduces the maximum target
size to 18 cm both superiorly and inferiorly).
■ At the junction, a 2 cm overlap of adjacent arcs is suggested.
■ Also, at the junction, if possible, the isocenters should be strategically
placed such that MLCs that overlap from adjacent fields are offset (i.e.,
overlapping MLCs are interleaved by half the width of an MLC).
■ The planner should consider utilizing the smallest defined MLCs avail-
able (i.e., MLC widths of 2.5 mm or 5 mm) in the junction or near criti-
cal organs. This is illustrated in Figure 12.12, where the red avoidance
OAR is located within the small MLCs due to thoughtful isocenter
placement.
GANTRY
18 cm Diso 18 cm Dtissue Dcouch

100 cm
TARGET
COUCH
FIGURE 12.13 The range of motion of a Varian TrueBeam couch for a

dual-isocenter treatment. The distance between the gantry isocenter and the
surface of the gantry is 100 cm for a Varian TrueBeam. The red Xs show the
two isocenter locations in the patient with a separation defined by Diso. The
maximum distances that are located between the target and the gantry for
normal tissue, Dtissue (assuming normal tissue ends at the couch edge), and for
couch-to-gantry separation, Dcouch, are presented.
Extended SSD
■ For tumors that exceed the maximum field size, an extended SSD technique
can be used to treat the entire tumor volume.
■ The extended SSD technique should be used for 3D fields (not IMRT or
VMAT) and usually use no more than two to three beams.
■ Large SSDs (>120 cm) are not recommended due to unknown distribution
of dose. Extrapolating data beyond 120 cm SSD is not accurate due to
increases in the width of the penumbra (7).
TREATMENT PLANNING: BRACHYTHERAPY EXAMPLES

■ Lower limb (recurrent soft tissue sarcoma) treated with high-dose rate
(HDR) brachytherapy.
■ Preoperative imaging is used (Figure 12.14) to help assist with preopera-
tive GTV location.
■ The planning CT is fused to preoperative PET/CT and/or MRI.
● Fuse the preoperative CT component of the PET/CT acquisition to the
postoperative primary CT image.

● Fuse the preoperative MR images (T1-weighted and T2-weighted
depending on histology) to the postoperative primary CT image.

(A) (B)
FIGURE 12.14 (A) PET/CT preoperative. Blue = MRI GTV, Green = PET GTV.
(B) Preoperative MRI (STIR sequence). Blue = MRI GTV, Green = PET GTV.
GTV, gross tumor volume; STIR, short T1 inversion recovery.
■ Naghavi et al. provide well-summarized guidelines that should be used

when treating soft tissue sarcomas with brachytherapy (8).
■ Brachytherapy catheters are placed at an interval of 0.5 to 1.0 cm in the
tumor bed plus a margin of 1 to 2 cm during surgery (1).
■ Catheters are reconstructed on the treatment planning CT.
■ Dwell positions are placed inside the contoured target.
■ Dose distribution can be optimized by graphical optimization.
■ Treatment plan (Figure 12.15).
● Hypofractionated prescription dose of 33.6 Gy delivered in eight frac-
tions, twice a day, with at least 6 hours between fractions.

● 11 catheters were required.
D(TG43)% D(TG43)%
200% 200%
150% 150%
100% 100%
75% 75%
50% 50%
(A) (B)
D(TG43)%
Volume
200% [%]
Tumor Bed
90.00
150% 80.00
DVH Values
PD 420.0000 cGy
100% 70.00 NPD 379.4008 cGy
60.00
75% 50.00
D(TG43)
40.00
50% 30.00
20.00
10.00
0.00 100.00 200.00 300.00 400.00 500.00 600.00 700.00 800.00 900.00 1000.00 1100.00 1200.00 1300.00 1400.00 1500.00 1600.00 Dose [cG
NPD PD
ROI Dose [%] Dose [cGy] Volume [%] Volume [ccm]
tumor bed 100.00 420.00 95.06 22.79
tumor bed 150.00 630.00 49.32 11.83
tumor bed 200.00 840.00 21.95 5.26
(C)
(D)
FIGURE 12.15 HDR Brachytherapy Treatment Plan for recurrent soft tissue sarcoma of the arm. Cyan is the tumor bed.
HDR, high-dose rate.
REFERENCES
1. Wang D, Kirsch DG, Okuno SH, et al. RTOG 0630: A Phase II Trial of Image
Guided Preoperative Radiotherapy for Primary Soft Tissue Sarcomas of the
Extremity. Philadelphia, PA: Radiation Therapy Oncology Group; 2012.
2. Baldini EH, Abrams RA, Bosch W, et al. Retroperitoneal sarcoma target vol-
ume and organ at risk contour delineation agreement among NRG sarcoma
radiation oncologists. Int J Radiat Oncol Biol Phys. 2015;92(5):1053–1059.
doi:10.1016/j.ijrobp.2015.04.039
3. Baldini EH, Wang D, Haas RLM, et al. Treatment guidelines for preoperative
radiation therapy for retroperitoneal sarcoma: preliminary consensus of an in-
ternational expert panel. Int J Radiat Oncol Biol Phys. 2015;92(3):602–612.
doi:10.1016/j.ijrobp.2015.02.013
4. Bentzen SM, Constine LS, Deasy JO, et al. Quantitative analyses of normal tis-
sue effects in the clinic (QUANTEC): an introduction to the scientific issues. Int
J Radiat Oncol Biol Phys. 2010;76(3):S3–S9. doi:10.1016/j.ijrobp.2009.09.040
5. Oliver M, Ansbacher W, Beckham WA. Comparing planning time, delivery
time and plan quality for IMRT, RapidArc and tomotherapy. J Appl Clin Med
Phys. 2009;10(4):117–131. doi:10.1120/jacmp.v10i4.3068
6. Pasler M, Wirtz H, Lutterbach J. Impact of gantry rotation time on plan
quality and dosimetric verification—volumetric modulated arc therapy
(VMAT) vs. intensity modulated radiotherapy (IMRT). Strahlenther Onkol.
2011;187(12):812–819. doi:10.1007/s00066-011-2263-1
7. McDermott P, Orton C. Chapter 10: central axis dose distribution. In: The Phys-
ics and Technology of Radiation Therapy. Madison, Wisconsin: Medical Phys-
ics Publishing; 2007:10-1–10-24.
8. Naghavi AO, Fernandez DC, Mesko N, et al. American Brachytherapy Society
consensus statement for soft tissue sarcoma brachytherapy. Brachytherapy.
2017;16(3):466–489. doi:10.1016/j.brachy.2017.02.004
13 PEDIATRIC CANCER
Nicky Vassil, Andrew Godley, Mihir Naik,

and Erin Murphy
Patient Setup and Immobilization ............................................................. 255

Planning of Pediatric Cases ....................................................................... 257
Wilms’ Tumor and Whole Abdomen ........................................................... 259
Ewing’s Sarcoma ........................................................................................ 261
Rhabdomyosarcoma .................................................................................. 261
Retinoblastoma .......................................................................................... 262
Craniopharyngioma .................................................................................... 262
Craniospinal Irradiation (CSI) of Embryonal Tumors ............................... 263
Total Body Irradiation (TBI) ........................................................................ 266
References .................................................................................................. 268
PATIENT SETUP AND IMMOBILIZATION

■ Much consideration and discussion should take place between physicians
(including anesthesia team members), dosimetry, physics, and therapists
before a patient is brought into the simulator and scheduled on a treat-
ment machine. One should try to anticipate factors such as how the patient
will be immobilized, target and organ at risk dose goals, and beam angles.
Whenever possible, patient’s care should be referred to a high-volume pedi-
atric oncology center, and clinical trial enrollment should be considered.
■ Patients should be in a tolerable, reproducible position. Since pediatric
malignancies involve a spectrum of ages, patient comprehension, and cog-
nitive ability, it is important to establish whether a patient can hold still and
maintain position without anesthesia prior to simulation.
■ Anesthesia techniques include conscious sedation, deep sedation, or general
anesthesia. Important factors to consider when using anesthesia include:
● Prone position may not be viable if patient is under anesthesia.
● Coordination of schedules between the anesthesia team and simulator or
treatment machine for simulation and daily treatment respectively.

● The treatment room must be able to accommodate anesthesia equip-
ment, with sufficient clearance for movement of the gantry and table,
specifically considering table kicks and gantry rotation for cone beam
CT (CBCT) or other image guidance.
● Patients under anesthesia are often very limp, so immobilization should
be maximized to limit movement.

● Cameras need to be able to see the patient and anesthesia monitors and
equipment. Anesthesia monitors may have a second display at the treat-

ment console.
● Masks may need to be cut to allow access to the airway and use of nasal
cannula.
● Ensure IV access for anesthesia is not prevented by the immobilization
devices.
● Beam arrangement (e.g., table rotations) may need to account for loca-
tion of anesthesia equipment.

■ Patient position should be reproducible and allow for the best placement of
beams or arcs to minimize normal tissue dose.
■ Options for patient immobilization
● Full body molds or bags (e.g., vacuum bags); see Figure 13.1.
● Partial vacuum bags can also be used, either waist down or pelvis up or
small mold to immobilize extremities, as in Figure 13.2.

● A custom mask and head holder is shown in Figure 13.3.
● Feet should be banded.
● Safety straps are important for patients that may move involuntarily or
are heavily sedated and have a possibility of putting themselves in danger

or changing treatment position; see Figure 13.4.
FIGURE 13.1 A full body vacuum bag. Actual bag is that for an adult, folded in
half.
13: Pediatric Cancer ■ 257
FIGURE 13.2 A partial vacuum bag to immobilize the leg.
PLANNING OF PEDIATRIC CASES

■ The treatment time for a pediatric patient is an important factor. If a patient
is sedated, treatment time may be less important. If a pediatric patient is not
sedated and is voluntarily holding still during treatment, a prolonged treat-
ment time should be avoided.
■ Pediatric patients are at higher risk for long term toxicities so care should
be taken to minimize dose to normal tissues.
FIGURE 13.3 A custom thermoplastic mask to immobilize head with a cutout

for nasal cannula.
FIGURE 13.4 A safety strap is put on during simulation. The same fabric and
Velcro strap will be used at treatment to prevent involuntary movement during
treatment.
■ Energies of 15 MV and higher should be avoided due to the potential for

increased carcinogenic effects of neutron contamination in high energy beams.
■ Treatment can affect the growth of developing organs, particularly growth
plates in the bone. The entire vertebral body must be included in the axial
dimension and also the entire length of each vertebra to avoid asymmetric
growth resulting in scoliosis-like effects. Treating other growth plates sym-
metrically may also avoid issues such as joint dysfunction.
■ Motion management techniques
● 4D CT is used if significant target motion is anticipated, for example,
lung and abdominal targets near the diaphragm. The use of 4D CT will
however increase radiation exposure to the patient; therefore a smaller
view should be considered.
● Care should be taken to not place the 4D monitoring device, for example,
pressure sensing belt, in the anticipated treatment field.

● Breathing restriction devices exist, for example, abdominal compres-
sion belt or paddle, or active breath control system (for age-appropriate

patients). These may be used if target excursion is greater than 1 cm or to
displace normal tissue from target tissues.
■ Planning techniques
● 3D techniques have the advantage of less integral dose to the patient but
there is increasing use of intensity modulated radiation therapy (IMRT)

and proton therapy for young patients.
● 3D conformal plans are typically quicker to deliver than volumetric mod-
ulated arc therapy (VMAT) and IMRT.

● Proton therapy is another technique to allow highly conformal therapy
via the Bragg peak effect, which causes no exit dose for the beam.
■ Image guidance
● The physician will determine if daily image guidance is needed (e.g.,
CBCT). More frequent imaging guidance improves the precision of tar-

geting but increases the dose to normal tissues. Risk and benefit must be
carefully balanced.
● IMRT or field-in-field 3D plans are particularly helpful when the plan-
ning target volume (PTV) is close to critical structures (e.g., spinal cord)
and PTV margins are small.
● If using daily imaging, the imaging dose could be included in the patient’s
cumulative dose. If CBCT is used, consider using a small collimator set-

ting to reduce the imaging dose and scatter, and block areas of concern.
The frequency of imaging can also be reduced if including daily imaging
dose exceeds acceptable limits.
■ Target definitions
● gross tumor volume (GTV) – gross disease (typically primary tumor,
metastatic sites and/or involved lymph nodes based on biopsy, imaging

or physical exam).
● clinical target volume (CTV) – expansion for microscopic tumor exten-
sion beyond GTV; often limited by physical barriers to tumor spread, for
example, dura limiting glioma spread.
● internal target volume (ITV) – motion of target based on 4D CT; gener-
ated by contouring on a maximal intensity projection of the 4D CT, or

manual or automated propagation of target on each phase of the 4D CT.
WILMS’ TUMOR AND WHOLE ABDOMEN

■ Patients are typically positioned supine with arms above head. Arms may
be akimbo if treating lung.
■ 4D CT is used to assess both abdominal and respiratory motion for an ITV.
■ Wilms’ tumor is very radiosensitive. Typical doses range from 10.8 to
19.8 Gy, determined by the attending physician; dose varies by treatment
location, patient age, clinical scenario, and disease biology.
■ Specific attention should be paid to avoid contralateral (remaining) kidney
when possible.
■ For whole lung irradiation (WLI), fields are typically arranged anterior
posterior/posterior anterior (AP/PA) with 1 cm PTV margin added around
entire pleural surface and accounting for respiratory motion.
■ For flank irradiation (typically tumor/kidney and regional lymph nodes),
AP/PA field arrangement is used with the medial field border extending to
include the entire vertebral body (to minimize late effects of asymmetric
bone growth).
■ For large field size (i.e., whole abdominal irradiation [WAI]/WLI), 1.5 Gy
per fraction is often used. For WAI, fields are typically AP/PA with superior
border 1 cm above the diaphragm, and inferior border at the bottom of the
obturator foramen (blocking femoral heads), and lateral border 1 cm beyond
the lateral abdominal walls. 3D conformal radiation therapy (3D-CRT) or
IMRT may be used to boost any gross residual disease.
■ When treating whole lung and whole abdomen together (WLI and WAI),
simultaneous or sequential treatments to these regions are considered; if
WLI is delayed, it is okay to overlap the previous field to give margin for
motion management.
■ Conventional Cerrobend blocks affixed to the accelerator’s accessory tray
may be needed to reduce kidney dose for the whole abdomen irradiation
(Figure 13.5).
■ Dose limits to normal organs are typically referenced from the current
Children’s Oncology Group (COG) protocols. Organs at risk typically
include:
● Small bowel (maximum point dose 45 Gy).
● Spinal cord (maximum point dose 45 Gy).
● Mean dose to lung (18 Gy if <50% of lungs treated, 15 Gy if >50% lungs
treated)
FIGURE 13.5 A whole abdomen field with kidneys shown in blue and
Cerrobend island blocks in orange.
● Mean dose to kidneys (if WAI dose >10.5 Gy, then shield the normal
kidney to <14.4 Gy).
● Mean dose to the whole liver less than 23.4 Gy or 50% of the liver
volume received less than 30.6 Gy.
EWING’S SARCOMA
■ Treatment of Ewing’s sarcoma involves chemotherapy and local therapies
(surgery, definitive, adjuvant, or neoadjuvant radiation therapy, and in some
cases stereotactic body radiation therapy [SBRT] for metastases).
■ As a primary treatment, timing of radiation must be carefully coordinated
with chemotherapy.
■ Rigid immobilization (e.g., custom plastic mask) may be used for head and
neck locations and vacuum bags for extremities.
■ Target volumes and dose
● Initial CTV (GTV plus 1 to 1.5 cm margin) is often treated to 45 Gy,
followed by a field reduction to 55.8 Gy (doses up to 64.8 Gy have been

used on phase II trials for tumors >8 cm in size); preoperative doses are
often reduced to 36 to 45 Gy with 2 cm CTV margin.
● Treatment of metastatic disease may involve whole or hemi-lung irra-
diation and follow treatment planning principles listed earlier (section

on “Wilms’”), with current Children’s Oncology Group (COG) dosing
based on age.
■ Planning
● Highly conformal techniques, that is, IMRT, are preferred for head and
neck locations and if near sensitive critical structures (e.g., spinal cord).
● 3D-conformal techniques are often used for extremities.
● Daily imaging is typically used when planning with small PTV margins
and when treating near sensitive critical structures (e.g., spinal cord, head
and neck structures).
● For male patients, testicular shielding may be needed (e.g., if an expected
dose to testes exceeds 2.5 Gy). Ovarian transposition for female patients
may be considered as well.
RHABDOMYOSARCOMA
■ This disease can affect a variety of body sites. Treatment indications are
based on disease histology, disease stage, and risk group.
■ Immobilization
● For head and neck locations, patients are immobilized in a thermoplastic
mask in a supine position with neck extended and shoulders lowered.

Intravenous contrast can be helpful for delineating vascular anatomy for
treatment planning purposes and is often given if not contraindicated.
● For extremities, patient is typically immobilized with a vacuum bag with
anticipated sparing of skin strip (preferably medial strip) to reduce the
risk of long-term lymphedema.
● Co-registration with diagnostic studies (e.g., CT, PET, MRI) is criti-
cally important to delineating gross disease (GTV; primary and involved

lymph nodes). CTV and PTV expansions vary by site and protocol.
● Typical dosing is in the range of 36 to 50.4 Gy (depending on stage group
and histology).
■ Planning
● Same principles apply as in Ewing’s sarcoma section.
RETINOBLASTOMA
■ Plaque brachytherapy and external beam radiation therapy (EBRT) tech-
niques (photon or proton) are used based on institutional experience.
■ Plaque brachytherapy is typically limited to patients with a solitary focus of
disease up to 16 mm in axial dimension, 3 mm from the optic disk or fovea,
and <10 mm thick and for salvage after EBRT.
■ A variety of isotopes have been used (e.g., 60Co, 125I, 192Ir).
■ Applicator plaques are typically made of gold and sizes and shapes are
selected based on target size and location.
■ Source location is modeled to achieve 40 to 45 Gy to the tumor apex deliv-
ered over 48 to 96 hours for 125I (23 to 30 Gy after chemotherapy).
■ Under general anesthesia, the conjunctiva is opened and tumor located
using transillumination or ultrasound and the plaque is sutured to this loca-
tion. Lead shielding is placed in front of the eye.
■ When EBRT is required, conformal radiation therapy, IMRT, and proton
beam radiation therapy should be considered.
CRANIOPHARYNGIOMA
■ Radiation therapy is typically used after subtotal resection.
■ Patients are positioned supine and immobilized with a custom plastic mask.
● Co-registration with postoperative MRI (T1 with contrast) is used for
defining gross disease (GTV; primary and involved lymph nodes). CTV
and PTV expansions vary by site and protocol. Typical margins are 5 mm
for CTV and 3 mm for PTV. Larger expansions may be needed for CTV
(e.g., 1 to 2 cm) if weekly MRI is not available (see next).
● Typical dosing is in the range of 54 Gy at 1.8 Gy per fraction.
■ Given the proximity to critical structures, IMRT or VMAT is preferred.

■ CBCT for daily image guidance is recommended.
■ Weekly MRI should be considered if using a small CTV expansion. The
cystic component of the tumor may expand beyond the target volume dur-
ing radiotherapy.
CRANIOSPINAL IRRADIATION (CSI) OF EMBRYONAL TUMORS

■ CSI is most commonly used in the treatment of embryonal tumors (includ-
ing medulloblastoma, atypical teratoid rhabdoid tumor [ATRT], and primi-
tive neuroectodermal tumor [PNET]).
■ Prone position may not be possible if the patient requires general anesthesia.
Furthermore, some patients may have discomfort lying prone if they have
a newly placed port.
■ Simulation is one of the most critical components of CSI as you must
ensure that the patient will have a reproducible setup for daily treatment.
Reproducibility is of vital importance for CSI due to the use of field
matching.
■ Given that most patients are treated postoperatively, it is important to make
sure there is minimal discomfort during the simulation process at the loca-
tion of the surgical incision.
■ Prone setup advantages
● Ability to see alignment of spine.
● Allows direct visualization of field junctions.
■ Prone setup disadvantages

● Does not allow for easy intubation with anesthesia.
● May be uncomfortable and difficult to reproduce.
■ Supine advantages
● More comfortable and easily reproduced.
● Allows for intubation.
● Spine flattens out, making cord dose more uniform.
■ Supine disadvantages
● Inability to visualize bony landmarks for setup confirmation.
● No direct visualization of field junctions.
■ Patient setup for CSI.

● Extend the neck and pull shoulders down.
● Tilt chin up and position head in a comfortable and fitted head holder
and mask. A mask that covers down past the shoulders can signifi-
cantly help increase the amount the shoulders are pushed down. This
is important to maximize the amount of distance you have to use for
junction changes.
● Head holder should be positioned to minimize curvature of cervical spine
and skin folds.

● Spine should be as straight as possible, however, if patient seems to con-
sistently set up with curvature it is more important to be reproducible than
straight, the plan can account for the curvature.
● A straight spine is important to maximize the amount of distance you
have to use for junction changes.

■ 3D conformal CSI planning
● Physician contours target structures (GTV, CTV, PTV) and organs at risk
(e.g., ovaries, optic structures, brainstem, cochlea, mandible, oral cavity).

● Co-registration with lumbosacral spine MRI (sagittal sequence) can aid
in determining the inferior aspect of the cauda equina and sacral nerve
root delineation (axial sequences).
● Fields are lateral for cranial fields and PA for spine fields.
● The inferior border of the lateral cranial fields must be superior enough
to avoid the shoulders.

● A match and junction changing of the cranial and superior PA fields is
necessary.
● A single PA field is preferable, but often field size limitations do not allow
this, thus a superior and an inferior PA field is often required to cover the
length of the spine.
● The PA spine fields are typically treated source-to-skin (patient) distance
(SSD) technique, as this allows for easier setup, and slightly larger fields.
● When the PA spine field(s) are being created, care must be taken with the
isocenter placement to allow for opening the superior field for junction
changes (Figure 13.6).
● The superior spine and cranial isocenters are located in the center of the
fields. The inferior spine isocenter is at the inferior edge of the field as it
is half-beam blocked.
● The spine field isocenters are located on the surface of the patient (100
SSD), this necessitates a calculation point (CP) just anterior to the spinal
cord.
● Table and collimator rotations for the cranial field are used to remove
divergence of the cranial field into the superior spinal field.

● The superior PA should have the lowest possible superior border to allow
superiorly directed junction changes and avoid divergence anteriorly

through the mandible.
● The inferior border of the inferior PA field should cover the thecal sac,
minimizing sacroiliac joint and ovarian tissue when feasible. A half-beam

block may be used to limit divergence inferiorly to pelvic tissue if the
field size permits.
● Field segments may be used to improve dose homogeneity.
● The lateral borders of the PA fields should cover the transverse spinous
processes.
BRAIN ISO
SUP SPINE CP
SUP SPINE ISO
INF SPINE CP
INF SPINE ISO
FIGURE 13.6 The locations of the isocenters of the cranial (brain, red) fields,
the superior spine field (green), and inferior spine field (aqua). The spine
fields are treated SSD, necessitating a calculation point (CP) for each field at
treatment depth.
SSD, source-to-skin (patient) distance.
■ Junction changes
● Due to divergence of adjacent spinal fields and cranial fields, hot or cold
spots arise, depending on the gap between the fields, and the depth within
the patient.
● Junction changes are required at the match point of the cranial fields and
the superior aspect of the superior PA field to avoid high dose to spinal
cord and soft tissues of the neck.
● To alleviate these inhomogeneities, the position of the junction should
be moved every 9 Gy.

● The junction should be moved between 3 to 10 mm (junction between
the superior and inferior spine fields can even be increased up to 2 cm to
help feather dose in the lumbar spine).
● Often three isocenters are used (cranial and two spinal) and these should
have the same lateral position.

● The span of junction change is determined by looking at
■ The maximum inferior field size allowable for the cranial field as lim-
ited by shoulders.
■ The maximum superior field size of the superior PA field as limited by
exit through the mandible.

● Junction changes can be performed in either a superior or inferior direc-
tion but it can reduce errors and make planning and checking the chart
easier if done in a consistent direction.
● An example plan with four sets of fields is given in Figure 13.7. The
resulting dose distribution is displayed in Figure 13.8.

■ VMAT for CSI improves homogeneity of plans (1).
■ TomoTherapy also can improve homogeneity (2).
■ Proton therapy can also be considered for CSI.
TOTAL BODY IRRADIATION (TBI)

■ Most pediatric patients are treated with standing AP/PA fields as described
in Chapter 11.
FIGURE 13.7 A coronal (A) and sagittal (B) views of the cranial and spinal
fields. The four sets of field borders can be seen. Note that the cranial
collimator angle changes to match each spinal field.
45 Gy
36 Gy
FIGURE 13.8 The 36 Gy prescription isodose line covers the craniospinal

region. There is anterior deviation of the isodose line at the borders of the
spinal fields, and also a hot spot (45 Gy) in the lumbar region, but no high dose
in the cord.
■ Younger patients can be treated lying on the floor; see Figure 13.9.
■ A typical accelerator target would be 200 to 250 cm from the floor. This
would allow a 110 to 140 cm field to be treated, assuming a maximum field
size at isocenter of 40 cm, and a collimator rotation of 45°.
■ The patient can be frog legged to decrease the field size needed.
■ A special stand should be created to:
● Hold the patient comfortably.
● Support a plastic spoiler, used to increase surface dose.
● Be raised off the ground to allow a film or imager to be placed under the
patient.
■ Lung blocks are placed on the spoiler. An image is taken with the treatment
beam to align the lung blocks.
■ The closer distance of the patient to the accelerator will require a lower
dose rate to be used to achieve and effective dose rate at the patient below
10 cGy/minute.
FIGURE 13.9 A pediatric patient set up for treating TBI. Lung shields can be
seen resting on the plastic beam spoiler. The stand sits slightly off the ground,
allowing a sheet of film to be placed under it for imaging the lung block
position.
TBI, total body irradiation.
REFERENCES
1. Lee YK, Brooks CJ, Bedford JL, et al. Development and evaluation of multiple
isocentric volumetric modulated arc therapy technique for craniospinal axis
radiotherapy planning. Int J of Radiat Oncol Biol Phys. 2012;82(2):1006–1012.
doi:10.1016/j.ijrobp.2010.12.033.
2. Parker W, Brodeur M, Roberge D, Freeman C. Standard and nonstandard cra-
niospinal radiotherapy using helical TomoTherapy. Int J Radiat Oncol Biol
Phys. 2010;77:926–931. doi:10.1016/j.ijrobp.2009.09.020.
14 PALLIATIVE TREATMENT
Peng Qi, Kristan Pechatsko, Saju Rajan, and John H. Suh
Spine Stereotactic Body Radiation Therapy (SBRT) ................................ 270

Simulation ............................................................................................... 270
Target and OAR Delineation ................................................................... 270
Planning ................................................................................................... 270
Hippocampal-Sparing Whole Brain Radiotherapy.................................... 273
Simulation ............................................................................................... 273
Target and OAR Delineation ................................................................... 273
Planning ................................................................................................... 273
Whole Brain Radiation Therapy (WBRT) ................................................... 274
Simulation ............................................................................................... 274
Planning ................................................................................................... 274
Spine Metastases ....................................................................................... 276
Simulation ............................................................................................... 276
Planning ................................................................................................... 278
Bone Metastases ........................................................................................ 282
Simulation ............................................................................................... 282
Malignant Pulmonary Obstruction ............................................................ 285
Simulation ............................................................................................... 285
Planning ................................................................................................... 285
Other Malignant Obstructions and Bleeding............................................ 288
Soft Tissue Metastases .............................................................................. 289
Simulation ............................................................................................... 289
Planning .................................................................................................. 289
References .................................................................................................. 292
SPINE STEREOTACTIC BODY RADIATION THERAPY (SBRT)
Simulation
■ The patient should be simulated supine in a comfortable and consistently
reproducible position.
■ A five-point reinforced thermoplastic mask (see Chapter 3) is used for the
treatment of cervical and upper thoracic lesions.
■ A custom vacuum bag is used for treating lesions inferior to the T4 vertebra
(see Chapter 3).
■ A slice thickness of 1.5 mm in planning CT is used to facilitate target and
organs at risk (OAR) delineation.
■ The treatment isocenter is placed at the center of the diseased vertebral body.
Target and OAR Delineation

■ The target and OAR volumes are defined based on the guidelines outlined
in RTOG 0631 (1).
■ Image fusion
● Fusion between the simulation CT and high-resolution MRI (gadolinium
enhanced T1- and T2-weighted images) is required.

● The MRI may not be usable in the presence of excessive hardware from
spine surgery, in which case fusion between the simulation CT and a CT

myelogram is recommended.
■ Target definition
● Vertebral body metastasis: includes the involved vertebral body, both
left and right pedicles, and all gross disease including epidural and/or
paraspinal components.
● Posterior element only metastasis: involved spinous process and laminae.
● Metastasis involving pedicle: target volume is at physician discretion to
include whole vertebral body and posterior elements or a smaller volume.

● No margin for planning target volume (PTV).
■ OARs
● Spinal cord: a partial spinal cord volume is delineated 5 to 6 mm superior
and inferior to the target volume.

● Other OARs (e.g., esophagus or kidneys) should be contoured if they are
close to the target volume.
Planning
■ A linac equipped with multi-leaf collimator (MLC) leaf width less than
5 mm is preferred.
■ Beam energy
● 6 or 10 MV photons.
14: Palliative Treatment ■ 271
● Flattening filter free (FFF) beams are preferred because of their higher
dose rates. This reduces treatment time, as patients are frequently in pain.
■ Beam arrangement depends on target shape and position relative to the
spinal cord.
● Coplanar beams.
● Typically, nine posterior and posterior oblique intensity modulated radi-
ation therapy (IMRT) beams (e.g., 181°, 205°, 230°, 255°, 280°, 80°,
105°, 130°, and 155°) or two full (182°–178° and 178°–182°) volumetric
modulated arc therapy (VMAT) arcs.
● Any non-zero collimator angles.
■ Prescription
● 16 Gy or 18 Gy in one fraction. Fractionated regimens (e.g., 30 Gy in four
fractions) are also used for retreatment.

● The plan is prescribed to the periphery of the target so that at least 90%
of the target volume is covered by the prescription dose.

● The plan is normalized to the dose at the isocenter.
■ Planning goals
● Target: V
100% >90% and Dmin as large as possible (prefer >14 Gy).
● Partial spinal cord: D
0.03cc <14.0 Gy and V10 Gy <10.0%
● Partial nerve or cauda equina: D
0.03cc <16.0 Gy and V12 Gy <10.0%
● Esophagus: D
0.03cc <15.4 Gy and V11.8 Gy <5 cc
● Combined kidney: V
4 Gy <50%
■ Optimization
● To deliver maximally achievable dose to target periphery.
● Typical initial planning objectives are listed in Table 14.1.
■ Comparison of a VMAT and a step and shoot (SS) IMRT plan, created with
same optimization goals; see Figures 14.1 and 14.2.
TABLE 14.1 Treatment Planning Objectives for Spine SBRT

Structure Type Dose Volume (%) Weight
Target Min Dose 16–18 50% 5

Max Dose 11–13 1–3
Cord Max DVH 8–10 8% 1–3
Nerve Max Dose 13–15 1–3
Max DVH 10–12 8%
Dose limiting ring* Max Dose 16–18 1–3
Max DVH 13–14 10%–15% 1–3
*The structure is a 2 cm ring directly expanded from the target.
DVH, dose volume histogram; SBRT, stereotactic body radiation therapy.
VMAT SS-IMRT
18.0, 10.0, 5.0, 2.5 Gy
FIGURE 14.1 Isodose distributions in a VMAT (left) and SS-IMRT spine plan.
The spinal lesion (T12) is in solid blue and the spinal cord in solid green.
SS-IMRT, step and shoot intensity modulated radiation therapy; VMAT, volumetric
modulated arc therapy.
● Typically, treatment planning goals can be achieved with both VMAT

and SS-IMRT plans.
● The VMAT plan overall is more conformal than the SS-IMRT plan.
● The intermediate and low dose distributions can differ greatly between
the approaches.
100
90
80
70
Volume (%)
SS-IMRT
60
VMAT
50
SPINAL_CORD
40
TUMOR T12
30
20
10
0
0 5 10 15 20
Dose (Gy)
FIGURE 14.2 Comparing DVHs of a VMAT and SS-IMRT spine plans.

DVHs, dose volume histograms; SS-IMRT, step and shoot intensity modulated radiation
therapy; VMAT, volumetric modulated arc therapy.
HIPPOCAMPAL-SPARING WHOLE BRAIN RADIOTHERAPY
Simulation
■ The patient should be simulated in supine position. Devices such as couch
pads, custom molded head pads, and knee bolsters can be used in an effort
to make the patient comfortable.
■ A three-point thermoplastic mask is used to immobilize the patient.
■ A slice thickness of 1 to 1.5 mm in planning CT is used.
■ The treatment isocenter is placed at midline of the brain.
Target and OAR Delineation

■ The target volumes and OARs are defined based on the guidelines outlined
in RTOG 0933/NRG-CC001 (2,3) and NRG-CC003 (4).
■ Image fusion: MRI scans (1.5 mm slice axial T2-weighted and T1-weighted
gadolinium enhanced MP-RAGE sequences) are fused with the simulation
CT.
■ Targets: the PTV is created as the CTV (whole brain down to C1 or C2)
subtracting the hippocampal avoidance region which is a 5 mm uniform
expansion of the contoured hippocampus.
■ The hippocampus is contoured bilaterally on the MRI. The hippocampal
avoidance regions are generated by three-dimensionally expanding the hip-
pocampal contours by 5 mm.
■ Other OARs include lenses, eyes, optic nerves, and chiasm.
Planning
■ A linac equipped with MLC leaf width less than 5 mm is required.
■ Beam energy: 6 MV photons.
■ Beam arrangement
● Non-coplanar VMAT arcs: two full arcs (182°–178° and 178°–182°) and
a half arc (2°–178°) with 90° couch kick

● Any non-zero collimator angles
■ Prescription
● 25 Gy (NRG-CC003) or 30 Gy (NRG-CC001) in 10 fractions.
● The plan is prescribed to the periphery of the PTV so that at least 95% of
the PTV is covered by the prescription dose.

● The plan is normalized to the dose at the isocenter.
■ Planning goals (per protocol)

● PTV: V
100% >95%, D2% <32.5 Gy or 37.5 Gy, and D98% >21 Gy or 25 Gy
● Hippocampus: D
100% <9 Gy and Dmax <16 Gy
● Optic Nerve: D
0.03cc <30 Gy
● Chiasm: D0.03cc <37.5 Gy
■ Optimization
● Typical initial planning objectives are given in Table 14.2.
● The resulting isodose distributions and dose volume histograms (DVHs)
are shown in Figure 14.3A and B.
WHOLE BRAIN RADIATION THERAPY (WBRT)

Simulation
■ The patient should be simulated in supine position. Devices such as couch
pads, custom molded head pads, and knee bolsters can be used in an effort
to make the patient comfortable.
■ A three-point thermoplastic mask is used.
■ A slice thickness of 3 mm in planning CT is used.
■ The treatment isocenter is placed at midline of the brain.
Planning
■ The field setup and block shapes are determined by the physician.
■ WBRT fields (beam angles at 90° and 270°) use a collimator angle, a small
eye block, a spine block, and have flash around the skull; see Figure 14.4.
■ The German helmet fields have a zero collimator angle, use larger blocks
covering the eyes, face, and neck, use a 5° gantry tilt (beam angles at 85° and
275°), and allow flash around the skull; see Figure 14.5. Treat to C1 or C2.
■ Typical fractionation schemes are 30 Gy in 10 fractions or 20 Gy in 5 frac-
tions, and 25 Gy in 10 fractions is for prophylactic treatment.
TABLE 14.2 Treatment Planning Objectives for Hippocampal Sparing

WBRT
Structure Type Dose Volume (%) Weight
PTV Uniform Dose Rx 5

Min DVH Rx 100 5
Max Dose <105% Rx 1–3
Hippocampus Max Dose 12 1–3
Optic Nerve Max Dose 5 1–3
Chiasm Max Dose 24 1–3
Lens Max dose 5 1–3
Note: Rx is the prescription dose.
DVH, dose volume histogram; PTV, planning target volume; WBRT, whole brain
radiation therapy.
31.25, 30.0, 15.0 Gy

(A)
100
90
80
CHIASM
70 CTV_2500
Volume (%)
GLOBE_L
60
GLOBE_R
50 HIPPOCAMPI
LENS_L
40 LENS_R
OPTIC_NRV_L
30 OPTIC_NRV_R
PTV_2500
20
10
0
0 5 10 15 20 25 30
Dose (Gy)
(B)
FIGURE 14.3 Isodose distributions (A) and DVH (B) of a VMAT plan for an
NRG-CC003 hippocampal sparing WBRT.
DVH, dose volume histogram; PTV, planning target volume; WBRT, whole brain
radiation therapy; VMAT, volumetric modulated arc therapy.
■ Traditionally these plans are normalized to the isocenter with 100% of pre-
scription dose (Figure 14.6). Plans can also be prescribed to a lower isodose
line to allow for improved coverage of the brain.
■ Segments can be used to decrease hotspots (e.g., forehead, eye, and scalp)
while maintaining coverage to the brain and cribriform plate (Figure 14.7).
■ Traditionally, plans were accepted that did not fully cover the brain with the
prescription isodose line.
■ Using segments can keep the maximum dose to the lenses to less than
8 Gy while covering the brain with the prescribed dose. Pay close atten-
tion anteriorly to the temporal lobes and the cribriform plate to ensure
dose coverage.
FIGURE 14.4 A lateral field shape for WBRT with a gantry angle of 270°.
WBRT, whole brain radiation therapy.
SPINE METASTASES
Simulation
■ The patient should be simulated supine in a comfortable and consistently
reproducible position. Prone position is an option for posterior anterior
(PA)-only field.
FIGURE 14.5 A German helmet field shape with a gantry angle of 275°.
31.5, 30.0, 28.5, 27.0, 24.0, 15.0 Gy
FIGURE 14.6 A traditional isodose distribution for a WBRT case.

WBRT, whole brain radiation therapy.
■ A five-point reinforced thermoplastic mask is used for the treatment of

cervical and upper thoracic lesions at and superior to the T4 vertebra.
■ A slice thickness of 3 mm in planning CT is used. Radio-opaque markers
can be placed prior to image acquisition to clinically define areas that are
symptomatic with radiographic lesions.
■ The treatment isocenter is placed at the center of the diseased vertebral
body.
Beam 275° Seg 2 Beam 275° Seg 3 Beam 85° Seg 2

(A)
31.5, 30.0, 28.5, 27.0, 15.0 Gy

(B)
FIGURE 14.7 (A) Segments for 275° and 85° beams to reduce dose at the
forehead and scalp and the resulting isodose distributions (B).
■ Consider additional modifications based on the potential beam angles being
considered (e.g., chin up, shoulders down for treatment of cervical spine).
Planning
■ Typically, 6 or 10 MV photons are used for cervical spines; 6 to 18 MV for
thoracic spines; 10 to 18 MV for lumbar spines.
■ Cervical spines
● Opposed lateral beams are used; dose to the mouth through the oral cav-
ity/jaw and the face should be minimized (Figure 14.8).

● Opposed laterals with non-zero table angle can be used to minimize the
dose to the shoulders (Figure 14.9).

● Anterior posterior/posterior anterior (AP/PA) or PA-only beam (Figure
14.10) can be used if the superior/inferior field length is short and not
exiting into the chin. Kicking the table to 270° or 90° and using a gantry
angle can also be an option if treating PA or AP/PA beams.
● Lastly, using opposed split beams (or half-beams) laterally to treat the
superior portion, and a posterior beam (half beam) for the inferior por-
tion can also provide adequate dose coverage to the cervical spine while
avoiding the mouth and shoulders (Figure 14.11).
Beam 270° with wedge Beam 90° with wedge

(A)
31.5, 30.0, 28.5, 27.0, 15.0 Gy

(B)
FIGURE 14.8 (A) A cervical spine case treated with two lateral fields with
wedges, and the resulting isodose distribution (B).
Beam 280° with wedge

and 10° couch kick Beam 90° with wedge
(A)
31.5, 30.0, 28.5, 27.0, 15.0 Gy

(B)
FIGURE 14.9 (A) A cervical spine plan with non-zero table angle to avoid the
shoulders and the resulting dose distributions (B).
Beam 180°
(A)
Distance = 6.0 cm
Isocent
31.5, 30.0, 28.5, 27.0, 15.0 Gy

(B)
FIGURE 14.10 (A) A short cervical spine field treated with a PA beam and the
resulting dose distributions (B). The depth of prescription point is at 6.0 cm.
Beam 270° Beam 90° Beam 180°

(A)
33.0, 30.0, 28.5, 27.0, 15.0 Gy

(B)
FIGURE 14.11 (A) Two opposed lateral half beams and a PA spine beam with a
shared isocenter and the resulting dose distributions (B).
■ Thoracic spine
● Wedges and segments can be used for plans in this region.
● Posterior beam only: Treatments are typically delivered at 100 cm
source-to-skin (patient) distance (SSD) to allow for a simplified patient

setup. With this technique the spinal cord receives the full prescription
dose, while the vertebral bodies receive 90% of the prescription dose
(Figure 14.12).
● AP/PA: Adjust the weight on the PA beam to 60% to 80% to provide full
coverage of the gross tumor volume (GTV; Figure 14.13).

● Posterior oblique fields can also be used.
■ Lumbar spine
● AP/PA technique: Adjust the relative weighting and/or energy of the AP
and PA beams to cover the anterior vertebral bodies with 100% of pre-
scription dose.
● Segments can be added if necessary to reduce hot spots. Figure 14.14
shows a lumbar spine case treated AP/PA using a segment in the PA field
to reduce dose where the spine is closer to the posterior surface.
● A wedge in the superior-inferior direction on the PA field can be used
instead of segments to reduce the hot spot.

Beam 180° with wedge

(A)
Distance = 7.0 cm
33.0, 30.0, 27.0, 24.0, 15.0 Gy

(B)
FIGURE 14.12 (A) A posterior beam to treat the thoracic spine lesion and the
resultant dose distributions (B). The prescription point is at depth of 7.0 cm.
Beam 0° Beam 180°

(A)
33.0, 30.0, 27.0, 24.0, 15.0 Gy

(B)
FIGURE 14.13 (A) A thoracic spine lesion is treated with AP/PA beams and the
resultant dose distributions (B).
Beam 180° Seg 1 Beam 180° Seg 2 Beam 0°

(A)
22.0, 20.0, 19.0, 18.0, 10.0 Gy

(B)
FIGURE 14.14 (A) The lumbar spine is being treated AP/PA beams with a
segment in the PA field to reduce the hot spot superiorly and the resultant dose
distributions (B).
● A three-beam arrangement using an anterior beam and two posterior

oblique beams at 210° and 150° beam angles with wedges weighted
appropriately can be used to reduce the dose to the abdomen (Figure
14.15).
BONE METASTASES
Simulation
■ The patient is simulated in the supine head-first position for areas superior
to the mid-femur. Treating areas inferior to the mid-femur will likely require
the patient to be set up feet first in order to prevent collision of the patient’s
head with the gantry.
■ Devices such as couch pads, custom molded pads, masks, vacuum bags, and
knee bolsters can be used in an effort to make the patient comfortable and
the setup more reproducible (see Chapter 3).
■ Radio-opaque markers can be placed prior to image acquisition to clinically
defined areas that are symptomatic with radiographic lesions.
Beam 0° Beam 210° with wedge Beam 150° with wedge
(A)
22.0, 20.0, 18.0, 16.0, 10.0 Gy

(B)
FIGURE 14.15 (A) The lumbar spine is being treated with one anterior field and
two wedged posterior oblique fields and resultant dose distributions (B).
■ Often patients are in a considerable amount of pain; therefore the field

arrangements are few and simple in order to plan and deliver treatment
quickly. The area being treated will dictate the type of field arrangement
and energy needed.
■ Prescription is determined by the physician and include: 30 Gy in 10 frac-
tions; 20 Gy in 5 fractions; 8 Gy in 1 fraction.
■ Field arrangement options
● AP/PA weighted to a calculation point, and segments can be used to
reduce hot spots (Figure 14.16).

● Tangents or oblique fields are used to treat areas near the surface of the
patient. Adjusting the field weighting, and adding wedges or segments is

needed to provide a uniform dose distribution (Figure 14.17).
● For large treatments such as whole femurs, an extended SSD must be
used to increase the maximum field length (a typical of 40 cm field length

at 100 cm distance). The field size increases linearly with distance, so at
110 cm, the field size will be 40 × 110/100 = 44 cm. Segments can be used
to reduce dose in narrower areas, as seen in Figure 14.18.
Beam 0° Set 1 Beam 0° Set 2 Beam 180°

(A)
22.0, 20.0, 19.0, 18.0, 10.0 Gy

(B)
FIGURE 14.16 A pelvic bone metastasis case treated with AP/PA fields (A) and
resultant dose distributions (B). The AP field is weighted 56% and PA 44%, due
to the location of the calculation point.
Beam 35° Seg 2 Beam 35° Seg 1 Beam 220° with wedge
(A)
31.5, 30.0, 27.0, 24.0, 15.0 Gy

(B)
FIGURE 14.17 (A) A chest wall tumor is being treated with two oblique fields
with a wedge in the posterior oblique beam. The anterior oblique also has a
segment to further homogenize the dose. (B) The resultant dose distributions.
22.0, 20.0, 19.0, 16.0, 10.0 Gy
FIGURE 14.18 The whole femur is treated with segments (left) and without
segments (right). The use of segments reduces the high dose near the knee
(left).
● In addition to oblique beam configurations, simple AP/PA field

arrangements can be used. Again it is important to account for
changes in the patient’s separation or surface contour with wedges or
segments to achieve a uniform dose distribution. Figure 14.19B shows
a dramatic high dose region when wedges are omitted, as seen in
Figure 14.19C.
MALIGNANT PULMONARY OBSTRUCTION

Simulation
■ Patient arms above their head. Arms at the sides are acceptable if using an
AP/PA beam arrangement for treatment.
■ For patients having difficulty lying flat, use an inclined device that is suit-
able to treat through with the posterior beam.
Planning
■ 6 or 10 MV photons.
■ Wedges and segments can be used.
■ Prescription is determined by the physician, including: 30 Gy in 10 frac-
tions; 20 Gy in 5 fractions; 17 Gy in 2 fractions; 8 Gy in 1 fraction.
■ Field arrangement options
● With AP/PA, adjust the prescription isodose line while dose is normal-
ized to the calculation point to provide adequate dose coverage to the

GTV (Figure 14.20).
Beam 0° with wedge Beam 180° with wedge

(A)
31.5, 30.0, 27.0, 24.0, 15.0 Gy

(B)
31.5, 30.0, 27.0, 24.0, 15.0 Gy

(C)
FIGURE 14.19 A shoulder metastasis is treated with AP/PA fields (A). The
isodose distribution without wedges (B) and with wedges (C) shows improved
dose uniformity with wedges.
● A lung obstruction case in the right chest is shown in Figure 14.21 using
AP/PA fields with a wedge, where the GTV received 95% of the prescrip-
tion dose of 8 Gy. Using the wedge in AP field compensates for different
thickness at the apex of lung.
● Figure 14.22 compares a lung obstruction case in the left chest with seg-
ments to reduce hot spots (left) and without segments (right).
● More complicated field arrangements to further conform the dose include
slightly oblique fields with a total of three or four fields, although this
will increase the total treatment time. More information on these setups
is described in Chapter 7.
Beam 0° Beam 180°

(A)
22.0, 20.0, 19.0, 18.0, 10.0 Gy

(B)
FIGURE 14.20 A left chest obstruction case is treated with AP/PA fields (A)
and resulting dose distributions (B) with a prescription dose of 20 Gy.
Beam 0° with wedge Beam 180°
(A)
8.8, 8.0, 7.84, 7.6, 4.0 Gy

(B)
FIGURE 14.21 (A) A lung obstruction case in the right chest is treated with AP/
PA fields, with a wedge in the AP field. (B) The resultant dose distributions.
With segments No segments

33.0, 30.0, 29.4, 27.0, 15.0 Gy
FIGURE 14.22 A lung obstruction in a left chest case is treated with segments
(left) to reduce hot spots, compared to without segments (right).
OTHER MALIGNANT OBSTRUCTIONS AND BLEEDING

■ AP/PA is the most common setup for patients that have an obstruction or
bleeding; see an esophageal case in Figure 14.23. Other palliative treatment
scenarios include a stomach case in Figure 14.24, a gynecological case in
Figure 14.25, and a bladder case in Figure 14.26.
Beam 0° Beam 180°

(A)
22.0, 20.0, 19.0, 18.0, 10.0 Gy

(B)
FIGURE 14.23 (A) An esophagus case is treated with AP/PA fields and (B) the
resultant dose distributions.

with wedge with wedge with wedge
(A)
8.8, 8.0, 7.6, 7.0, 4.0 Gy

(B)
8.8, 8.0, 7.6, 7.0, 4.0 Gy

(C)
FIGURE 14.24 A stomach malignancy case is treated with three wedged fields.
Beam arrangement in (A), and isodose distributions in (B) and (C).
SOFT TISSUE METASTASES

Simulation
■ Patient is simulated in the supine head or feet-first position depending on
location of the treatment target.
■ Immobilization devices such as couch pads, custom molded pads, masks,
vacuum bags, and knee bolsters can be used in an effort to make the patient
comfortable and the setup more reproducible.
Planning
■ 6 to 10 MV photons or electrons.
■ Field arrangements are determined by the location and size of the lesion.
Figure 14.27 shows a left inguinal area being treated using a three-field
arrangement with wedges and a segment.

(A)
37.8, 36.0, 34.2, 32.4, 18.0 Gy

(B)
FIGURE 14.25 A gynecological tumor is treated with three-field arrangement.

(A) Beam shapes for the three fields and isodose distributions (B).
Beam 0° Beam 180°

with wedge
Beam 270° Beam 90°

(A)
37.8, 36.0, 34.2, 32.4, 28.8, 18.0 Gy

(B)
FIGURE 14.26 A bladder tumor is treated with a four-field box technique. (A)
Beam shapes for the four fields and isodose distributions (B).
Beam 0° Beam 180° Seg 1 Beam 180° Seg 2 Beam 90°

with wedge with wedge
(A)
31.5, 30.0, 28.5, 27.0, 15.0, 9.0 Gy

(B)
FIGURE 14.27 (A) A left inguinal area is being treated using a three-field
arrangement with wedges and a segment and dose distributions (B).
■ A wedged pair arrangement is shown in Figure 14.28 to treat a right neck

case.
■ Bolus is used when coverage is required at or near the surface.
Beam 320° Beam 210°

with wedge with wedge
(A)
8.8, 8.0, 7.6 7.2, 4.0 Gy

(B)
FIGURE 14.28 A right neck is treated using a wedged pair field arrangement
(A) and dose distributions (B).
REFERENCES
1. Radiation Therapy Oncology Group. A phase II/III study of image-guided ra-
diosurgery/SBRT for localized spine metastasis. https://www.nrgoncology.org/
Clinical-Trials/Protocol-Table
2. NRG Oncology. Memantine hydrochloride and whole-brain radiotherapy
with or without hippocampal avoidance in reducing neurocognitive decline
in patients with brain metastases. https://clinicaltrials.gov/ct2/show/study/
NCT02360215
3. Gondi V, Pugh SL, Tome WA, et al. Preservation of memory with conformal
avoidance of the hippocampal neural stem-cell compartment during whole-brain
radiotherapy for brain metastases (RTOG 0933): a phase II multi-institutional
trial. J Clin Oncol. 2014;32(34):3810–3816. doi:10.1200/JCO.2014.57.2909.
4. NRG Oncology. Whole-brain radiation therapy with or without hippocampal
avoidance in treating patients with limited stage or extensive stage small cell
lung cancer. https://clinicaltrials.gov/ct2/show/NCT02635009.
ABBREVIATIONS
3D-CRT Three dimensional conformal radiation therapy

ABC Active breathing coordinator
AIP Average intensity projection
AP Anterior posterior
ASU Anterior set up
ATRT atypical teratoid rhabdoid tumor
BEV Beam’s eye view
CBCT Cone beam computed tomography
cc Cubic centimeter (cm3)
CCF Cleveland Clinic Foundation
COG Children’s oncology group
CP calculation point
CSI Craniospinal irradiation
CT Computed tomography
CTV Clinical target volume
DIBH Deep inspiration breath hold
Dmax Depth of maximum dose deposition
DMPO direct machine parameter optimization
DRR Digitally reconstructed radiograph
DVH Dose volume histogram
EBRT External beam radiation therapy
ECS Extra coordinate system
EFRT Extended field radiation therapy
EGD Esophagogastro-duodenoscopy
EQD2 Equivalent dose in 2 Gy fractions
EUD Equivalent uniform dose
EUS Endoscopic ultrasound
FFF Flattening filter free
FIF Field in field
FLAIR Fluid attenuation inversion recovery
GK Gamma Knife
GTV Gross tumor volume
Gy cGy Gray, centi-gray
HD High dose
HDR High dose rate
HN Head and neck
294 ■ Abbreviations
HR-CTV high-risk CTV
ICRU International commission on radiation units and
measurements
IDL Isodose line
IEC Internation electrotechnical commission
IFRT Involved field radiation therapy
IGRT Image guided radiation therapy
IM Internal mammary
IMRT Intensity modulated radiation therapy
IPSA Inverse planning simulated annealing
IR-CTV Intermediate-risk CTV
ISO Iso-center
ISRT Involved site radiation therapy
ITV Internal target volume
IV Intravenous
KBP Knowleadge-based planning
kV kilo-voltage
LD Low dose
LDR Low dose rate
Linac Linear accelerator
MCO Multi-criteria optimization
MIP maximum intensity projection
MLC Multi-leaf collimator
MTV Metabolic target volume
MRI Magnetic resonance imaging
MU Monitor units
MV Megavoltage
NCCN National Comprehensive Cancer Network
NRG NRG Oncology
OAR Organs at risk
OSLD Optically stimulated luminescent dosimeter
PA Posterior anterior
PAB Posterior axillary boost
PBT Proximal bronchial tree
PCI Paddick conformity index
PET Positron emission tomography
PNET Primitive neuroectodermal tumor
PRV (PRV3 PRV5) Planning organ at risk volume (3 or 5 mm expansion)
PTV Planning target volume
PTV-HD/HD-PTV High dose planning target volume
PTV-LD/LD-PTV Low dose planning target volume
Abbreviations ■ 295
QUANTEC Quantitative analyses of normal tissue effects in the
clinic
ROI Region of interest
RT Radiation therapy
RTOG Radiation Therapy Oncology Group
SAD Source-to-axis (isocenter)
SBRT Stereotactic body radiation therapy
SCV Supraclavicular
SIB Simultaneous integrated boost
SRS Stereotactic radiosurgery
SSD Source-to-skin (patient) distance
SS-IMRT Step and shoot IMRT
STIR Short T1 inversion recovery
TBI Total body irradiation
TEST Total electron skin therapy
TLD Thermo-luminescent dosimeter
TRUS Transrectal ultrasound
VMAT Volumetric modulated arc therapy
WAI Whole abdominal irradiation
WBRT Whole brain radiation therapy
WLI Whole lung irradiation
WPRT Whole pelvis radiation therapy
INDEX
abdomen IMRT/VMAT planning principles,

pediatric cancer, 259–261 39–41
preoperative radiotherapy, 241 linear accelerator-based stereotactic
simulation, 236 radiosurgery, 47–50
abdominal compression, 29 planning objectives and evaluation,
abutting electron fields, 119–121 41–42
alpha cradle device, 27 simulation and immobilization, 37–38
anal cancer simultaneous integrated boost, 45
planning technique, 158–160 3D conformal planning, 39
setup and immobilization, 158 treatment plan goals, 42–47
aquaplast bolus, 27–28 cervical cancer
auto-planning process, 15–17 tandem and ring, HDR brachytherapy,
220–222
bite block, 27–28 whole pelvis radiation therapy,
bladder cancer 210–211
planning objectives, 190 chest wall, postoperative radiotherapy,
setup and immobilization, 187–189 243
target volumes and OARs, 189 Hodgkin’s lymphoma, 227
treatment planning, 190–193 non-Hodgkin’s lymphoma, 227
body masks, 26 total body irradiation, 231
bolus total skin electron irradiation, 230
soft tissues sarcoma, 236 clinical target volume (CTV)
bolus material, 27 expansions, 38
bone metastases, 282–285 clinical treatment planning, 1
brachytherapy conformal arc plan, 5
high dose rate, 216–226 conventional 3D plan, 11
low dose rate, 183–187 conventional fractionated prostate
soft tissue sarcoma, 251–253 organs at risk, 166
vaginal cuff, 217–219 planning objectives, 166–168
breast cancer setup and immobilization, 166
IMRT and VMAT, 123–125 target volumes, 166
opposed tangents, 104–114 treatment planning, 168–172
regional nodal irradiation, 114–123 cost function, 12
simulation, 103–104 craniopharyngioma, 262–263
breathing management, 29–30 craniospinal irradiation, embryonal
tumors, 263–267
central nervous system critical structure objectives
Gamma Knife stereotactic high dose rate (HDR) brachytherapy,
radiosurgery, 47–50 216
298 ■ Index
critical structure objectives (cont.) stereotactic body radiation therapy,
soft tissue sarcoma, 238–239 150–154
whole pelvis radiation therapy, 203 rectal cancer, 154–158
CTV expansion. See clinical target gating, 29–30
volume expansions generic cost function, 12
custom head pads, 27 genitourinary cancer
bladder cancer, 187–193
direct aperture optimization, 9 prostate cancer
dual-isocenter IMRT/VMAT, conventional fractionated, 166–172
248–250 low dose rate (LDR) brachytherapy,
dynamic conformal arc plan, 5, 7 183–187
dynamic delivery, 10 stereotactic body radiation therapy,
172–182
embryonal tumors, craniospinal testis treatment, 193–199
irradiation, 263–267 gradient index, 51
endometrial cancer, WPRT, 207–210 gradient search algorithm, 12
esophageal cancer, 144–147 gradient-based optimizer, 12
Ewing’s sarcoma, 261 gross tumor volume (GTV), 38
anal cancer, 158–160 GTV. See gross tumor volume
esophageal cancer, 144–147 gynecologic cancer
pancreas fractionated, 147–150 high dose rate (HDR) brachytherapy,
rectal cancer, 154–158 216–226
soft tissue sarcoma, 239–240 whole pelvis radiation therapy,
201–215
field-in-field, 7
five-point mask, 25–26 HDR brachytherapy. See high dose rate
forward planning, 9 brachytherapy
4D-CT, 30 head and neck cancer treatment planning
base of tongue, 76
Gamma Knife cases involved with pacemaker, 102
general principles of, 51 connective tissue of head, face, and
inverse planning, 53 neck, 85–86
planning goals, 51–52 ethmoidal sinus, 95–102
prescription, 53 general planning principles, 57–65
shot placing strategy, 52–53 glottis, 70–78
stereotactic localization, 52 nasal cavity, 80–81
stereotactic radiosurgery, 47–50 right tonsil, 90–95
gastrointestinal radiotherapy simulation, 55–57
anal cancer, 158–160 specific case planning, 65–70
esophageal cancer, 144–147 tonsil, 86–89
liver stereotactic body radiation high dose rate (HDR) brachytherapy. See
therapy, 160–163 also brachytherapy
pancreas cancer critical structure objectives, 216
fractionated external beam interstitial implant, 224–226
radiation therapy, 147–150 planning, 216–217
Index ■ 299
planning targets and goals, 216 IMRT. See intensity modulated radiation
simulation and localization, 216 therapy
tandem and ring, cervical cancer, integrated boost method, 9
220–222 intensity modulated planning, 204–207
uterine cancer, tandem and ring for, intensity modulated radiation therapy
222–223 (IMRT)
vaginal cuff brachytherapy, 217–219 in breast cancer, 124–125
hippocampal-sparing whole brain delivery method, 10
radiotherapy dual-isocenter, 248–250
planning process, 273–274 manually iterative, staged, 14–15
simulation, 273 planning principles, 39–41
target and OAR delineation, 273 thoracic cancer, 135–138
Hodgkin’s lymphoma treatment plan, 5
clinical application, 227 internal mammary node irradiation,
setup and immobilization, 227 118
treatment planning, 227–230 internal target volume (ITV), 31
inverse planning
image acquisition, thoracic cancer, advanced tools, 15
128–129 auto-planning process, 15–17
immobilization basics principles of, 11–14
anal cancer, 158 definition of treatment plan, 9
bladder cancer, 187–189 knowledge-based planning, 17–18
central nervous system, 37–38 multi-criteria optimization, 18–20
conventional fractionated prostate, planning objectives, 12–14
166 planning tools, 20–21
esophageal cancer, 144–147 inverse planning optimization, 9
Hodgkin’s lymphoma, 227 ITV. See internal target volume
liver stereotactic body radiation
therapy, 160 KBP. See knowledge-based planning
low dose rate (LDR) brachytherapy, knowledge-based planning (KBP),
183 17–18
non-Hodgkin’s lymphoma, 227
pancreas- fractionated, 147 LDR brachytherapy. See low dose rate
pancreas stereotactic body radiation brachytherapy
therapy, 150–151 linear accelerator-based stereotactic
pediatric cancer, 255–256 radiosurgery, 47–50
prostate stereotactic body radiation liver stereotactic body radiation therapy
therapy, 172–175 motion management techniques,
rectal cancer, 154–155 160–161
reusable devices, 23–25 setup and immobilization, 160
simulation and, 37–38 planning technique, 161–163
single use devices, 25–27 localization
special devices, 27–28 high dose rate (HDR) brachytherapy,
testis cancer, 193–195 216
thoracic cancer, 127–128 soft tissue sarcoma, 236–237
300 ■ Index
localization (cont.) setup and immobilization, 227
thoracic cancer, 129 treatment planning, 227–230
whole pelvis radiation therapy, normalization point, 7
201–202
low dose rate (LDR) brachytherapy. See OARs. See organs at risk
also brachytherapy open field, 7
patient setup and immobilization, 183 open-face mask, 25
planning objectives, 184 optimal plan components, 11–12
target volumes and OARs, 184 optimizer, 12
treatment planning, 184–187 organs at risk (OARs), 38
lower limb, postoperative radiotherapy, bladder cancer, 189
246–248 conventional fractionated prostate,
lymphoma 166
Hodgkin’s and non-Hodgkin’s hippocampal-sparing whole brain
lymphoma, 227–230 radiotherapy, 273
total body irradiation, 231–234 low dose rate (LDR) brachytherapy,
total skin electron irradiation, 230–231 184
prostate stereotactic body radiation
malignant pulmonary obstruction therapy, 175–176
bleeding and other, 288–289 spine stereotactic body radiation
planning process, 285–288 therapy, 270
simulation, 285 testis treatment, 195
mathematic cost function, 12
MCO. See multi-criteria optimization PAB. See posterior axillary boost
motion management Paddick conformity index (PCI), 51
breast cancer, 104 palliative treatment
compression, 29 bone metastases, 282–285
4D-CT, 30 hippocampal-sparing whole brain
gating and breathing management, radiotherapy, 273–274
29–30 malignant pulmonary obstruction,
internal target volume, 31 285–289
liver stereotactic body radiation soft tissue metastases, 289–291
therapy, 160–161 spine metastases, 276–282
pancreas fractionated treatment, spine stereotactic body radiation
147–148 therapy, 270–272
pancreas stereotactic body radiation whole brain radiation therapy,
therapy, 151 274–276
thoracic cancer, 128 pancreas fractionated treatment
mouthpiece, 27 motion management techniques,
multi-criteria optimization (MCO), 147–148
18–20 planning technique, 148–150
setup and immobilization, 147
non-convex cost, 12–13 target delineation, 148
non-Hodgkin’s lymphoma pancreas stereotactic body radiation
clinical application, 227 therapy
Index ■ 301
motion management techniques, 151 planning margin, 5
planning technique, 151–154 planning objectives, 12–14
setup and immobilization, 150–151 bladder cancer, 190
patient marking, 32 conventional fractionated prostate,
patient setup 166–168
anal cancer, 158 low dose rate (LDR) brachytherapy,
bladder cancer, 187–189 184
conventional fractionated prostate, 166 prostate stereotactic body radiation
esophageal cancer, 144 therapy, 176–177
Hodgkin’s lymphoma, 227 planning process
liver stereotactic body radiation hippocampal-sparing whole brain
therapy, 160 radiotherapy, 273–274
low dose rate (LDR) brachytherapy, malignant pulmonary obstruction,
183 285–288
non-Hodgkin’s lymphoma, 227 soft tissue metastases, 289–291
overview of, 28 spine metastases, 278–282
pancreas fractionated treatment, 147 spine stereotactic body radiation
pancreas stereotactic body radiation therapy, 270–272
therapy, 150–151 whole brain radiation therapy,
pediatric cancer, 255–256 274–276
prostate stereotactic body radiation planning target volume (PTV)
therapy, 172–175 definition of, 5
rectal cancer, 154–155 expansions, 38
testis cancer, 193–195 planning technique
total body irradiation, 232 anal cancer, 158–160
total skin electron irradiation, 230 esophageal cancer, 144–147
patient simulation liver stereotactic body radiation
high dose rate (HDR) brachytherapy, therapy, 161–163
216 pancreas fractionated treatment,
whole pelvis radiation therapy, 201–202 148–150
PCI. See Paddick conformity index pancreas stereotactic body radiation
pediatric cancer therapy, 151–154
craniopharyngioma, 262–263 rectal cancer, 155–158
craniospinal irradiation, embryonal point-based normalization, 7
tumors, 263–267 posterior axillary boost (PAB), 116
Ewing’s sarcoma, 261 prescription, 7
planning of cases, 257–259 prone belly board, 23–24
retinoblastoma, 262 prone breast system, 23–24
rhabdomyosarcoma, 261–262 prostate stereotactic body radiation
setup and immobilization, 255–256 therapy
total body irradiation, 267–268 planning objectives, 176–177
Wilms’ tumor and whole abdomen, setup and immobilization, 172–175
259–261 target volumes and OARs, 175–176
pelvis, simulation in soft tissue sarcoma, treatment planning, 177–182
236 PTV. See planning target volume
302 ■ Index
quality assurance and charting, 32–34 immobilization, 37–38
malignant pulmonary obstruction, 285
Radiation Therapy Oncology Group soft tissue metastases, 289
(RTOG), 51 soft tissue sarcoma, 235–236
rectal cancer spine metastases, 276–278
planning technique, 155–158 spine stereotactic body radiation
setup and immobilization, 154–155 therapy, 270
regional nodal irradiation virtual, 31–32
abutting electron fields, 119–121 whole brain radiation therapy, 274
composite plan evaluation, 116, 118 simultaneous integrated boost (SIB)
internal mammary node irradiation, central nervous system, 45
118 single use devices, 25–27
mono-isocentric technique with half- sliding window, 10
beam block, 114 soft tissue metastases
opposed tangent beams, 116 planning process, 289–291
partially wide tangents, 118 simulation, 289
plan evaluation, 123 soft tissue sarcoma
posterior axillary boost, 116 brachytherapy, 251–253
SCV beam, 115–116 EBRT treatment techniques, 239–240
two-isocenter technique, 115 image registration and localization,
re-irradiation 236–237
Head and Neck Cancer right tonsil, planning goals and critical structure
90–95 objectives, 238–239
Head and Neck Cancer tonsil, 86–89 postoperative radiotherapy, 238,
retinoblastoma, 262 243–251
reusable devices, 23–25 preoperative radiotherapy, 238,
rhabdomyosarcoma, 261–262 241–242
RTOG. See Radiation Therapy Oncology simulation, 235–236
Group source-to-axis distance (SAD), 2
RTOG homogeneity ratio, 51 source-to-skin distance (SSD), 2, 251
spine metastases
SAD. See source-to-axis distance planning process, 278–282
SBRT. See stereotactic body radiation simulation, 276–278
therapy spine stereotactic body radiation therapy
scan acquisition, 31–32 planning process, 270–272
selectivity ratio, 51 simulation, 270
sequential boost method, 9 target and OAR delineation, 270
SIB. See simultaneous integrated boost SSD. See source-to-skin distance
simulation step-and-shoot, 10
bone metastases, 282–285 stereotactic body radiation therapy
breast cancer, 103–104 (SBRT)
central nervous system, 37–38 liver, 160–163
head and neck planning, 55–57 pancreas, 150–154
hippocampal-sparing whole brain spine, 270–272
radiotherapy, 273 thoracic cancer, 138–141
Index ■ 303
superflab type of bolus, 27 three-point mask, 25–26
supine thoracic immobilization, 23–24 thoracic cancer, 129–130
total body irradiation (TBI)
target coverage ratio, 51 clinical application, 231
target volumes patient setup, 232
bladder treatment, 189 pediatric cancer, 267–268
conventional fractionated prostate, treatment planning, 232–234
166 total skin electron irradiation
low dose rate (LDR) brachytherapy, clinical application, 230
184 patient setup, 230
prostate stereotactic body radiation treatment planning, 230–231
therapy, 175–176 treatment planning
testis treatment, 195 bladder treatment, 190–193
TBI. See total body irradiation clinical, 1
technical treatment planning, 1 conventional fractionated prostate,
template 168–172
for head and neck, 35 Hodgkin’s lymphoma, 227–230
for partial or whole brain, 34 low dose rate (LDR) brachytherapy,
for thorax, 34–35 184–187
testis cancer non-Hodgkin’s lymphoma,
setup and immobilization, 193–195 227–230
target volumes and OARs, 195 preparation of, 2
thermoplastic masks, 25 prostate stereotactic body radiation
thigh, preoperative radiotherapy, therapy, 177–182
241–242 SSD vs. SAD, 2
thoracic cancer technical, 1
beam energy, 129–130 total body irradiation, 232–234
image acquisition, 128–129 total skin electron irradiation,
immobilization, 127–128 230–231
IMRT and VMAT, 135–138 2D plan, 5
localization, 129
motion management, 128 uterine cancer, tandem and ring
SBRT treatment planning, 138–141 treatment, 222–223
3D conformal planning
central nervous system, 39 vaginal cancer, WPRT, 213–215
whole pelvis radiation therapy, vaginal cuff brachytherapy, 217–219
203–204 virtual simulation, 31–32
3D planning VMAT. See volumetric modulated arc
conventional, 11 therapy
definition, 5 volume-based normalization, 7
testis treatment, 195–199 volumetric modulated arc therapy
thoracic cancer, 130–135 (VMAT)
3D treatment planning, 130–135 in breast cancer, 124–125
postoperative radiotherapy, 243–245 delivery method, 10
simulation, 236 dual-isocenter, 248–250
304 ■ Index
volumetric modulated arc therapy whole pelvis radiation therapy (WPRT)
(VMAT) (cont.) cervical cancer, 210–211
planning principles, 39–41 critical structure objectives, 203
thoracic cancer, 135–138 endometrial cancer, 207–210
vulvar cancer, WPRT, 211–213 intensity modulated planning, 204–207
planning targets and goals, 202–203
WBRT. See whole brain radiation simulation and localization, 201–202
therapy 3D conformal planning, 203–204
wedged field, 7 vaginal cancer, 213–215
weight factor, 12 vulvar cancer, 211–213
whole brain radiation therapy (WBRT) Wilms’ tumor, 259–261
planning process, 274–276 WPRT. See whole pelvis radiation
simulation, 274 therapy

Strategies For Radiation Therapy Treatment Planning

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STRATEGIES FOR RADIATION THERAPY TREATMENT PLANNING

Ping Xia, PhD Andrew Godley, PhD

Chirag Shah, MD Gregory M. M. Videtic, MD, CM, FRCPC

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Copyright © 2019 Springer Publishing Company.

Demos Medical Publishing is an imprint of Springer Publishing Company, LLC.

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Names: Xia, Ping, editor. | Godley, Andrew, editor. |

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1. Overview of External Beam Treatment Planning Principles 1

2. Inverse Planning and Advanced Treatment Planning Tools 11

3. Overview of Simulation and Verification 23

4. Central Nervous System 37

5. Head and Neck Planning 55

6. Breast Cancer 103

7. Thoracic Cancer 127

8. Gastrointestinal Radiotherapy 143

9. Genitourinary Cancer 165

11. Lymphoma 227

12. Soft Tissue Sarcoma 235

13. Pediatric Cancer 255

14. Palliative Treatment 269

Sudha Amarnath, MD, Staff Physician, Department of Radiation

Jennifer Archambeau, CMD, Dosimetrist, Department of Radiation

Ehsan H. Balagamwala, MD, Staff Physician, Department of Radiation

Salim Balik, PhD, Staff Physicist, Department of Radiation Oncology,

Carol Belfi, CMD, Dosimetrist, Department of Radiation Oncology,

Henry Blair, MD, Staff Physician, Department of Radiation Oncology,

Joycelin Canavan, MD, Staff Physician, Department of Radiation

Sheen Cherian, MD, Staff Physician, Department of Radiation Oncology,

Taoran Cui, PhD, Physics Resident, Department of Radiation Oncology,

Jeremy Donaghue, MS, Staff Physicist, Department of Radiation

Andrew Dorfmeyer, CMD, Dosimetrist, Department of Radiation

George Engeler, MD, Staff Physician, Department of Radiation Oncology,

Andrew Godley, PhD, Staff Physicist, Department of Radiation Oncology,

John Greskovich, MD, Staff Physician, Department of Radiation Oncology,

Cory Hymes, CMD, Dosimetrist, Department of Radiation Oncology,

Nikhil Joshi, Staff Physician, Department of Radiation Oncology, Taussig

Lanea Keller, MD, Staff Physician, Department of Radiation Oncology,

Matt Kolar, MS, Staff Physicist, Department of Radiation Oncology,

Susan Kost, PhD, Staff Physicist, Department of Radiation Oncology,

Shlomo Koyfman, MD, Staff Physician, Department of Radiation

Elaine Kunka, CMD, Dosimetrist, Department of Radiation Oncology,

Daesung Lee, MD, Staff Physician, Department of Radiation Oncology,

Anthony Magnelli, MS, Staff Physicist, Department of Radiation

Anthony Mastroianni, MD, Staff Physician, Department of Radiation

Omar Mian, MD, PhD, Staff Physician, Department of Radiation

Lama Muhieddine Mossolly, MS, Staff Physicist, Department of Radiation

Erin Murphy, MD, Staff Physician, Department of Radiation Oncology,

Eric Murray, CMD, Dosimetrist, Department of Radiation Oncology,

Mihir Naik, DO, Staff Physician, Department of Radiation Oncology,

Kristan Pechatsko, BAR.T. (R)(T) CMD, Dosimetrist, Department of

John Potter, CMD, Dosimetrist, Department of Radiation Oncology,

Peng Qi, PhD, Staff Physicist, Department of Radiation Oncology, Taussig

Saju Rajan, MD, Staff Physician, Department of Radiation Oncology,

Michelle Sands, PhD, Physics Resident, Department of Radiation

Chirag Shah, MD, Staff Physician, Department of Radiation Oncology,

Eva Suarez, MD, Staff Physician, Department of Radiation Oncology,

John H. Suh, MD, Staff Physician, Department of Radiation Oncology,

Radoslaw Szwedowski, CMD, Dosimetrist, Department of Radiation