ICRU 83

Prescribing, Recording, and

Reporting Photon-Beam
Intensity-Modulated
Radiation Therapy
2010
 ICRU 83

 The present report is based on concepts

and definitions previously introduced
in ICRU Reports 50 and 62.

 This provides the information

necessary to standardize techniques and
procedures and to harmonize the
prescribing, recording and reporting of
IMRT.
 Why we need this report??

 By the evolution of modern

technologies conformity of
radio therapy techniques has
increased

 It necessitate extreme care

in volume delineation , dose
prescription and recording
 ICRU83
• IMRT has large number of degree of freedom
and it use variable intensity beam lets

• Manual comparisons of all possible intensity

patterns are not practical

• Thus some evaluation tools have to be used

such as DVH
 ICRU 83

• In this report the use of DVHs in

prescribing, recording and reporting is
emphasized
• The dose-volume histogram ( DVH ) has
become a critical tool to evaluate complex
3D absorbed-dose distributions, and its use
is even more important for IMRT.
 ICRU 83
• It is recommended that the dose-volume specifications be
used for reporting the treatment plan.

• DV : The absorbed dose that covers a specified fractional

volume V ( For example, D95% is the absorbed dose that
covers 95% of the volume).
 ICRU83

• The report recommends that the median absorbed

dose, specified by D50%, should be reported, instead
of previously defined dose at the ICRU reference point
Dref.

• D50% – is the absorbed dose received by 50% of the

volume, is often a good choice for a representative
absorbed-dose value for the PTV.
 ICRU 83

• The dose-volume metric D100%would be

commonly called the minimum absorbed dose.

• The minimum absorbed dose might not be

accurately determined because it is often located
in a high-gradient region at the edge of the PTV,
making it highly sensitive to the resolution of the
calculation.
 ICRU 83

• Therefore, reporting of D100% is not recommended because the

PTV cannot be determined with sufficient accuracy .
• Reporting of minimum absorbed dose should be replaced by
the better determined near-minimum absorbed dose, D98% ,
also designed Dnear-min.
• Other dose-volumes values, such as D95%, may also be
reported but should not replace the reporting of D98%.
 ICRU 83

In previous ICRU Reports, it was recommended to report the “

maximum absorbed dose “.

In the ICRU83 Report, is recommended the near-maximum

absorbed dose, D2% , as a replacement for the “ maximum
absorbed dose “

It is recommended that D2% also be reported as it is simple to

obtain and will add to consistency of reporting.
 ICRU 83 Prescribing and Reporting

Historically, the ICRU ( 1993, 1999, 2004

and 2007 ) identified three levels of
prescribing and reporting:
 - Level 1
 - Level 2
 - Level 3
 • Is considered the minimum standard
ICRU 83 – P & R Level 1 required in all centers, a standard
below which radiotherapy should not
be performed
ns: • Level 1 is sufficient for treatments
atio ards
v l 1 e
e m sta an nd nd d and implies that knowledge of
e
▪ L recommum ribing absorbed doses on the central beam
ini resc .
m p ng axis is known and that simple two-
for orti
rep dimensional ( 2D ) absorbed-dose
distributions at the central axis are
available.
 • Level 2 prescribing and reporting
ICRU 83 – P & R Level 2 implies that the treatments are
performed using computational
dosimetry and 3D imaging. At this
n s: level, it is assumed that all volumes of
atio
e nd t
m -ar
interest are defined using CT or MR
m e
reco of-th and the 3D dose distributions are
e l 2 e-
v at
Le R st es. available and include heterogeneity
u
P & hniq
tec corrections.
ICRU 83 – P & R Level 2 cont..

• It is expected that dose-volume histograms ( DVH´s) for

all volumes of interest are routinely computed.
• It is also assumed that a complete QA program is in place
to ensure that the prescribed treatment is accurately
delivered.
ICRU 83 – P & R Level 3

n s: • Reporting at Level 3 includes the

tio
a
e nd d- development of new techniques and
m m -an g.
co rch tin
e 3
e
r sea por
l l re re • approaches for which reporting
v
Le ona en t
ti m criteria are not yet established .
op elop
dev • Examples include the use of concepts
such as tumor-control-probability ( TCP
) normal tissue complication
probability ( NTCP ),
TCP and NTCP
 TCP is then interpreted as the
probability of tumor clonogens
not surviving anywhere in the
tumor.

 TCP follows a sigmoid curve

from zero control at some low
absorbed dose to certain local
control at high absorbed doses
 MATHEMATICAL FORMULA

TCP = e-(SF × N) NTCP=

1/1+(D50\D)k

The main aim of radiation SF=survival fraction

therapy is to maximize the k = slope of dose–
response curve
TCP and minimize NTCP D = total dose
D50 = tolerance dose
 ICRU 83 – Homogeneity & Conformity
Dose homogeneity
Homogeneiy index is defined as, characterizes the
uniformity of the absorbed-

HI = D2%-D98%
dose
distribution within the

D50%
target .

Dose-volume reporting
- D50% (Dmedian), Dose received by 50% of PTV
- D98% : Dose received by 98% volume of PTV
- D2% : Dose received by 2% volume of PTV
 CONFORMITY AND CONFORMITY INDEX

CI=TV/PTV
It can be employed when the PTV is fully enclosed by Dose conformity
the Treated Volume. characterizes the degree to
wich the high-dose region
It can be used as a part of the optimization procedure. conforms to the target
volume, usually the PTV.
Dose conformity characterizes the degree to which the
high-dose region conforms to the target volume,
usually the PTV.
Examples of low and high dose homogeneity and dose conformity.
 ICRU VOLUMES

• Delineation of volumes is an obligatory step in the

planning process

• several volumes related to both tumor and normal

tissues have been defined for use in the treatment-
planning and reporting processes.
DEFINED VOLUMES ARE
Gross tumor volume or GTV
 Clinical target volume or CTV
 Planning target volume or PTV
 Organ at risk or OAR
 Planning organ-at-risk volume
or PRV
 Internal target volume or ITV
 Treated volume or TV
 Remaining volume at risk or
RVR
 Gross tumor volume (GTV)
• The GTV is the gross demonstrable extent and
location of the tumor.
• The GTV may consist of
• primary tumor (primary tumor GTV or GTV-T),
• metastatic regional node(s) (nodal GTV or GTV-
N),
• distant metastasis (metastatic GTV, or GTV-M)
• In case of post-operative irradiation there is no GTV
to define, and only a CTV needs to be delineated
• An adequate absorbed dose must be delivered to
the whole GTV to obtain local tumor control.
 CLINICAL TARGET VOLUME
The CTV is a volume of tissue that contains a
demonstrable GTV and/or subclinical malignant
disease with a certain probability of occurrence
considered relevant for therapy

typically a probability of occult disease higher

than from 5 % to 10 % is assumed to require
treatment

The delineation of the CTV is currently based

on clinical experience
 INTERNAL TARGET VOLUME
ITV was defined as the CTV plus a
margin taking into account
uncertainties in size, shape, and
position of the CTV within the
patient. Such a margin was called
the internal margin

It was first introduced in ICRU62

 PLANNING TARGET VOLUME
The PTV is a geometrical concept introduced
for treatment planning and evaluation. It is
the recommended tool to shape absorbed-
dose distributions to ensure that the
prescribed dose is actually absorbed in the
CTV .

The delineation of the PTV utilizes

knowledge of the presence and impact of
uncertainties and variations in both the
tumor location and machine parameters
 PTV cont..
To ensure accurate reporting of absorbed dose to the PTV in cases for which the
PTV encroaches or overlaps another PTV, OAR, or PRV, it is now recommended
that the delineation of the primary PTV margins should not be compromised

in such cases subdivision of the PTV into regions with different prescribed
absorbed doses (so-called PTV-sub volumes, PTVSV) may be used

The dose reporting should, however, be done for the whole PTV
Pictorial representation
 ORGAN AT RISK
The OAR or critical normal structures are tissues that if irradiated could suffer
significant morbidity and thus might influence the treatment planning and the
absorbed-dose prescription

They may be divided into 3 classes :

Class I : Radiation lesions are fatal or result in severe morbidity.

Class II : Radiation lesions result in mild to moderate morbidity.
Class III : Radiation lesions are mild, transient, and reversible, or result
in no significant morbidity.
 PLANNING ORGAN AT RISK VOLUME (PRV)
This is a volume which gives into consideration the movement of
the Organs at Risk during the treatment.

An integrated margin must be added to the Organ at Risk to

compensate for the variations and uncertainties, using the same
principle as PTV and is known as the Planning Organ at Risk volume
( PRV ).

A PTV and PRV may occasionally overlap.

 TREATED VOLUME

It is a volume enclosed by isodose surface, selected and specified by

the radiation oncologist as being appropriate to achieve the purpose
of treatment .

It may closely match to the PTV or may be larger than the PTV.

If, however, it is smaller than the PTV, then the probability of tumor
control is reduced and the treatment plan has to be re-evaluated or
the aim of the therapy has to be reconsidered
 REMAINING VOLUME AT RISK (RVR)

Ideally when delineating the OAR, especially for

IMRT, all normal tissues that could potentially be
irradiated should be outlined.

The imaged volume within the patient, excluding

any delineated OAR
and the CTV(s), should be identified as the RVR
 Conclusion

ICRU 83 is the recent update published on

prescribing recording and reporting
The aim of this report is to standardize and
harmonize all these process
It is very important to follow these
recommendations to achieve the aim of radiotherapy
This report is being followed since 2010 by most of
the institutions