1

Isocenter shifts in treatment planning and clinical implications

Yasmin Ahmed, BS, R.T. (R)(MR), Stephanie Damiani, BS, Yijian Cao, PhD, Abolghassem
Jamshidi, PhD, Nishele Lenards, MS, CMD, R.T. (R)(T), FAAMD, Ashley Hunzeker, MS, CMD
ABSTRACT
In radiation oncology, the isocenter placement for each patient is crucial during the
planning phase. It is important because it allows radiation beams to deliver dose at the center of
the tumor, maximizing dose to the target volume while minimizing dose to normal tissues. Often
during treatment planning, a shifted isocenter is created. For every patient treatment, the process
of shifting the isocenter to the appropriate location is implemented. Therefore, isocenter shifts
yield longer patient set-up time, thus reducing productivity. In addition, errors may occur
because of the additional steps noted in the treatment plan. The aim of this study is to reduce
future set-up time and errors by determining when shifted isocenters are necessary.
The population size consisted of 340 patients treated on 4 machines. Data was collected
retrospectively over 8 weeks to determine how and why these shifts occurred and were
categorized according to treatment site and treatment type. Data was then reduced to a sample
size that focused on lung and pelvis patients. Results indicated that the shifts occurred due to
necessary and unnecessary means. The final analysis demonstrated that an average of 53% of
planned isocenter shifts were avoidable. The cases that were deemed necessary had more than a
5% difference in planning target volume (PTV) coverage and/or organs at risk (OR) doses when
compared to the original plan. Careful planning at the CT simulator and a detailed review of CT
images when the simulation is performed is important to reduce any complications that can
emerge in the next stages of treatment. A qualitative survey was also distributed to 11 radiation
therapists regarding isocenter shifts. The clinical impact of isocenter shifts such as issues of
patient safety, treatment efficiency, and quality of treatment planning is discussed in detail. In
addition, more studies must be conducted in order to conclude theories regarding shifted
isocenters in radiation oncology.
Key Words: Shifted isocenter, isocenter, treatment planning.

Introduction
The first step in the delivery of radiation therapy requires the patient to undergo a CT
simulation. The steps involved during the CT simulation involve positioning and marking the
patient, as they would be during the actual treatment. During the CT simulation, external fiducial
markers are placed on the patients skin and tattoos are made at the location of these markers.
These marks represent the marked isocenter once the images are sent to the treatment planning
system (TPS). However, these marks may or may not be at an ideal location. If they are not, a
shift from the marked isocenter is necessary. Hence, patients with a shift must be repositioned
before their treatment is delivered. When this occurs, there are additional steps that need to be
taken. Depending on the treatment site, some shifted isocenters may take longer to set-up
properly than others. Patients are first set-up based on the external marks made during the CT
simulation and are moved on the treatment table in three dimensions to where the desired
location is, based on the instructions given in the plan.
Isocenter shifts are strongly related to different treatment sites. Multiple disease locations,
limitations of each machine, and treatment plan quality aid in why shifts occur. In addition, shape
changes and tumor size contribute to isocenter shifts.1 Furthermore, if there is an isocenter shift,
this means that treatment time will increase due to patient set-up. This includes gantry rotations,
couch shifts, and time spent on repositioning the patient if there are multiple isocenters. It is also
important to note that total treatment includes patient changing time and time the patient enters
and exits the treatment room. Less time during set-up leads to higher efficiency, decreased
amount of patient discomfort, and improved accuracy because there is reduced risk for patient
movement.2
In order to reduce errors, the direction of a shift must be well thought-out if an isocenter
shift is necessary. For example, a left-right isocenter shift has fewer set-up errors compared to a
cranio-caudal or anterior/posterior isocenter shift for prostate cases.3 Set-up error refers to any
incongruity among the real treatment position of the patient and the intended planned position. A
gross error is a large mistake which may have detrimental effects, such as the tumor volume
receiving less than prescribed dose or OR receiving greater than maximum constraints outlined.
One of the many causes of gross error includes setting up the patient at an incorrect isocenter
position.4 The risk for this type of error may heighten when a shifted isocenter technique is

applied. Conversely, other times shifts may not be necessary and this is demonstrated by reevaluating the treatment plans without applying the isocenter shifts for lung and pelvis.
Incidents related to isocenter shift of a treatment plan in regards to daily practice are high
when comparing other contributing factors. Shifts are however sometimes necessary. For
instance, multiple sites, work around of machine limitations, and optimized dosimetry may be
valid reasons for shifted isocenters. However, other times shifts are not necessary and this is
tested by re-evaluating the treatment plans without applying the isocenter shifts for lung and
pelvis cases. Unnecessary isocenter shifts on a daily basis yield longer times for therapists to setup the patient and verify the shift every treatment. This affects the throughput of patient flow.
In this study, there were 6 intensity modulated radiation therapy (IMRT) lung cases and 9
IMRT pelvis cases. Intensity modulated radiation therapy has many benefits compared to 3D
conformal radiotherapy (3D-CRT). Intensity modulated radiation therapy allows maximum dose
to be delivered directly to the tumor while minimizing dose to OR surrounding the tumor. Since
IMRT employs a modulated method to regulate beam intensity, stricter QA procedures are
required as compared to 3D-CRT.5
Methods and Materials
This mixed methods study included quantitative retrospective data analysis of 340
patients and a qualitative survey of radiation therapists. The quantitative data was dissected to
examine lung and pelvis patients further. Within the context of radiation oncology workflow,
isocenter shifts were employed for different reasons. When the patient arrived for the simulation
CT, the radiation oncologist usually was not present with the radiation therapist. For this reason,
the simulation radiation therapist chooses the placement of external marks. The simulation
radiation therapist chooses the location based on the particular treatment site, as well as their
knowledge and experience. Many times, the placement of this marked isocenter is not feasible
for planning purposes. Therefore, another location is created and referred to as the shifted
isocenter. The radiation therapists shift to this new location from the marked isocenter on a daily
basis for many patients.

Patients
Combined data collected over 8 weeks consisted of 340 patients from 4 different linear
accelerators. Of these 340 patients, an average of 51% had isocenter shifts. The patient data was
then categorized according to site category and plan type. To examine the data further, each site
category consisted of a subset of different tumor sites. For the purpose of this study, 2 tumor site
categories were investigated further: lung and pelvis. These specific anatomical sites were
chosen due to the large amount of patients being treated to these anatomical regions. Of the 340
patients, there were a total of 17 lung cases and 27 pelvis cases. Of the lung cases, 6 patients did
not have a shifted isocenter and in regard to the pelvis cases, 17 patients did not have a shifted
isocenter. Taking this into consideration, 11 lung patients and 10 pelvis patients were examined
in detail to determine whether or not the shifted isocenter was necessary. Figures 1 and 2
demonstrate the measured shift for each patient. The data shows the absolute value of the sum of
shifts per patient in all directions. For the lung patients, the measurement of the shifts range
between 0 cm and 12 cm. For the pelvis patients the shifts range from 0 cm to 11 cm.
Plan Comparisons
The final treatment plan for each case was re-opened in the respective planning system
and was re-calculated using the original marked isocenter for all beams. The generated plan data
was analyzed to outline the statistics of the original plan with the shifted isocenter and the new
plan with the marked isocenter. A side-by-side comparison was done for each case comparing the
maximum dose received by the PTV, the minimum dose (Dmin) received by the PTV, and what
dose 90 percent of the PTV volume received. Up to 3 OR were also chosen for each case to
compare the maximum and mean dose received by these organs. Some of the OR chosen for lung
were the spinal cord, heart, and esophagus. Some of the OR chosen for the pelvis were the
femoral head, bladder, and rectum. This was done because it is not only important to evaluate
PTV coverage for the comparison. The dose that the OR receive is also important when
evaluating treatment plans. These organs were chosen to include the OR that were taken into
consideration when the patient was treated.

Results
Based on the dose comparison between isocenters, the percent change was calculated for
each case. The cases that were deemed necessary had more than a 5% difference in PTV and/or
OR doses when compared to the original plan. Out of 11 lung cases, 6 were IMRT and 5 were
3D-CRT. Of the IMRT plans, only 1 was deemed necessary regarding the creation of a shifted
isocenter. Of the 3D-CRT plans, 4 shifted isocenters were deemed necessary. In total, 45% of the
lung cases with shifted isocenter were deemed necessary. The pelvis studies consisted of 9 IMRT
and 1 3D-CRT case. Five IMRT cases were deemed necessary based on the percent change
between plans and 1 3D-CRT was deemed necessary. In total, 60% of the pelvis cases with
shifted isocenters were necessary. These results suggested that about 53% of the lung and pelvis
patients combined did not need a shifted isocenter.
In addition, a qualitative survey that consisted of 5 questions was distributed to 11
radiation therapists regarding isocenter shifts (Table 1). The printed survey was distributed to the
radiation therapists and answers were anonymous. The questions included time spent on patients
that had isocenter shifts, daily errors, simulation procedures, etc. The results indicated variation
in responses between radiation therapists. Factors affecting responses such as experience,
training, and other influencing factors could not be determined as demographic questions were
not included on the survey.
Discussion
The reason a shifted isocenter is created has several explanations that include subjective
and objective reasons. For example, each individual planner with ranging experience levels has a
different view on whether or not a shift is needed and how to plan in general. These factors
require more in-depth research and additional studies need to be conducted in order to investigate
this topic further. During the isocenter shift process, it is important to verify each step during
radiation delivery. The purpose of this verification is to ensure that the radiotherapy is delivered
within treatment plan guidelines and geometric accuracy is maintained. In order to reduce gross
errors, personnel should abide by departmental guidelines to include:

Management team that includes radiation oncologists, medical dosimetrists, medical

physicists, and administrators to verify and construct department rules regarding process
and responsibilities.

Providing staff with refresher courses for training/competency.

Follow department protocol at all times. If deviation is requested/required, consult with

supervisor.
Have independent checks put in place during each phase of the radiation therapy

department workflow as deemed necessary.4

Physics verification should be implemented post first treatment to avoid/correct errors.

In addition to personnel responsibilities, another recommended procedure to reduce errors is to

have the radiation oncologist present during the patients simulation CT for more accurate
isocenter placement. The most important detail to note is that it is imperative that all oncology
staff be reminded to always follow department policy regarding procedures for all their decisionmaking processes. When in doubt in regards to patient care, the radiation therapist should be
encouraged to always consult another radiation therapist, medical dosimetrist, medical physicist,
or radiation oncologist as deemed appropriate, in order to reduce errors in treatment delivery.
Conclusion
Setting up the patient accurately is one of the most important steps in the delivery of
radiation therapy. This study showed that creating a shifted isocenter was not always necessary in
order to achieve a desirable outcome in treatment planning. A small number of patients were
selected for evaluation of 2 anatomical sites, which included the lung and pelvis. The results of
the study found that about 53% of the lung and pelvis patients combined did not need a shifted
isocenter. Of the cases that did not need a shifted isocenter, PTV coverage and OR constraints
were within a 5% difference. Evaluation of the plans showed that without the isocenter shift,
these plans still yielded a desirable dose distribution. A limitation to this study however is that
medical dosimetrists were not interviewed in order to determine the reasoning why a shifted
isocenter was employed initially. Also, the data related to errors having occurred due to shifted
isocenters was not evaluated. More in-depth research and analysis is required to evaluate the
limitations of this study. Multiple anatomical sites and a larger patient population should also be
studied to determine if shifted isocenters were in fact necessary.

References

1. Wang L, Hayes S, Paskalev K, et al. Dosimetric comparison of stereotactic body radiotherapy

using 4D CT and multiphase CT images for treatment planning of lung cancer: evaluation of
the impact on daily dose coverage. Radiother Oncol. 2009;91(3):314-324.
http://dx.doi.org/10.1016/j.radonc.2008.11.018
2. Meyers P, Stathakis S, Gutierrez AN, et al. Dosimetric comparison of craniospinal axis
irradiation (CSI) treatments using helical tomotherapy, smartarc, and 3D conventional
radiation therapy. Int J Med Phys Clin Eng Radiat Oncol. 2013;2(1):30-38.
http://dx.doi.org/10.4236/ijmpcero.2013.21005
3. Stemminger S, Kunz G, Brown D, et al. Influence of isocenter shift on dose distribution in
prostate cancer patients. Strahlentherapie und Onkologie. 2006;182(suppl 1):179.
4. The Royal College of Radiologists, Society and College of Radiographers, Institute of
Physics and Engineering in Medicine. On Target - Ensuring Geometric Accuracy in
Radiotherapy. London: The Royal College of Radiologists.
https://www.ipem.ac.uk/Portals/0/Images/On%20target%20ensuring%20geometric
%20accuracy%20in%20radiotherapy.pdf. Published November 2008. Accessed November 6,
2013.
5. Shin D, Yoon M, Park SY, et al. Isocenter optimal matching shift algorithm to verify the dose
distribution in intensity-modulated radiation therapy through the stochastic property. J
Korean Phys Soc. 2007;51(5):1792-1797. http://dx.doi.org/10.3938/jkps.51.1792

Figures

12

10

7.5

6.5
5

5
4

Figure 1. This figure shows the total size of lung isocenter shifts in each direction in centimeters
for every patient.

11
10
9

8.5

5
4

4
2.55
2

Figure 2. This figure shows the total size of pelvis isocenter shifts in each direction in
centimeters for every patient.

10

10

Tables
Table 1. Survey results of radiation therapists regarding isocenter shifts.
Question

Yes

When a patient has a shift, is it more 4

difficult to reproduce set-up?
Would it be helpful for the radiation 6
oncologist to be present at the time
of CT simulation?
Would it be helpful to reduce daily
4
Set-up error if the shifted isocenter is
remarked/tattooed during virtual
simulation?
Are there always at least 2 therapists 3
present to verify correct positioning?
How much extra time does it take to
position a patient with a shifted
isocenter?

No

Same <5 min. Within 10 min.

>10 min.

7
3

8
6