The physicians at our facility at Virginia Commonwealth University (VCU) prescribe 100% of

the isodose line to cover 95% of the PTV. Some acceptable deviations from this, however, are
used in our clinic. For example, it is acceptable for 98% or 99% of the prescription dose to cover
95% of the PTV.
From my experience and while interacting with other dosimetrists, I have come to understand
that the treatment method used also affects our acceptance criteria. For example, treating with
3DCRT parallel opposed pair (POP) fields, especially with emergency cases, makes our doctors
more lenient with the coverage criteria. In these cases, 98% or 99% coverage is acceptable.
At VCU, the normalization mode is to 100% of the body maximum dose. For 3DCRT, IMRT,
and VMAT, the maximum hotspot accepted in our clinic is 110%. We define the hotspot to be at
a 3cc volume. Our physicians prefer that the hotspot lies within the GTV or the PTV. However,
this may not always be achievable, especially with POP fields. If a critical organ intercepts with
the PTV, it is advisable not to have the hotspot within that critical structure, even if it is still in
the PTV. It is also preferable to have the hotspot in the center of the GTV/PTV, as there is less
chance that when the patient moves, this hotspot moves to a nearby critical organ.

The physicians at our facility at Virginia Commonwealth University (VCU) prescribe 100% of
the isodose line to cover 95% of the PTV. Some acceptable deviations from this, however, are
used in our clinic. For example, it is acceptable for 98% or 99% of the prescription dose to cover
95% of the PTV.

From my observation, I have not yet seen a case where the hotspot is allowed to be higher than
110%. If the dosimetrist is not able to achieve the desirable hotspot, then the dosimetrist usually
has a conversation with the physician to discuss changing the treatment planning technique, or a
hotspot > 110% maybe acceptable on a case-by-case basis.