GoodPractice For Treatment Planning

IAEA Training Material on Radiation Protection in Radiotherapy
Radiation Protection in Radiotherapy
Part 10
Good Practice including Radiation Protection in EBT

Lecture 3: Radiotherapy Treatment Planning
In BSS Treatment Planning is part of Clinical Dosimetry
BSS appendix II.20. Registrants and licensees shall ensure that the following items be determined and documented:
... (b) for each patient treated with external beam radiotherapy equipment, the maximum and minimum absorbed doses to the planning target volume together with the absorbed dose to a relevant point such as the centre of the planning target volume, plus the dose to other relevant points selected by the medical practitioner prescribing the treatment;
Radiation Protection in Radiotherapy Part 10, lecture 3: Radiotherapy treatment planning 2
and BSS appendix II.21
In radiotherapeutic treatments, registrants and licensees shall ensure, within the ranges achievable by good clinical practice and optimized functioning of equipment, that:
(a) the prescribed absorbed dose at the prescribed beam quality be delivered to the planning target volume; and (b) doses to other tissues and organs be minimized.
Part 10, lecture 3: Radiotherapy treatment planning
Treatment planning is the task to make sure a prescription is put into practice in an optimized way
Prescription Planning Treatment
Objectives

Understand the general principles of radiotherapy treatment planning Appreciate different dose calculation algorithms Understand the need for testing the treatment plan against a set of measurements Be able to apply the concepts of optimization of medical exposure throughout the treatment planning process Appreciate the need for quality assurance in radiotherapy treatment planning
Contents of the lecture

A. Radiotherapy treatment planning concepts B. Computerized treatment planning C. Treatment Planning commissioning and QA
The need to understand treatment planning

IAEA Safety Report Series 17 Lessons learned from accidental exposures in radiotherapy (Vienna 2000): About 1/3 of problems directly related to treatment planning! May affect individual patient or cohort of patients
A. Basic Radiotherapy Treatment Planning Concepts

i. Planning process overview ii. Patient data required for planning iii. Machine data required for planning iv. Basic dose calculation
i. Planning process overview

Combine machine parameters and individual patient data to customize and optimize treatment Requires machine data, input of patient data, calculation algorithm Produces output of data in a form which can be used for treatment (the treatment plan) Patient information Treatment unit data
Planning Treatment plan

ii. Patient information required
Radiotherapy is a localized treatment of cancer - one needs to know not only the dose but also the accurate volume where it has been delivered to. This applies to tumour as well as normal structures - the irradiation of the latter can cause intolerable complications. Again, both volume and dose are important.
12
One needs to know

Target location Target volume and shape Secondary targets - potential tumour spread Location of critical structures Volume and shape of critical structures Radiobiology of structures
It all comes down to the correct dose to the correct volume
Dose Volume Histograms are a way to summarize this information
Dose Volume Histograms

120 100
Volume (%)
Comparison of three different treatment techniques (red, blue and green) in terms of dose to the target and a critical structure
80 60 40 20 0 0 20 40 60 80
Dose (Gy)
Critical organ
Target dose
15
The ideal DVH
Tumour:
Critical organ
volume 100%
High dose to all Homogenous dose

volume 100%
Low dose to most of the structure
dose
Radiation Protection in Radiotherapy Part 10, lecture 3: Radiotherapy treatment planning
dose
16
Need to keep in mind

Always a 3D problem Different organs may respond differently to different dose patterns. Question: Is a bit of dose to all the organ better than a high dose to a small part of the organ?
18
Organ types
Serial organs - e.g. spinal cord

High dose region
Parallel organ - e.g. lung
High dose region
Parallel organ
Serial organ
What difference in response would you expect?

Part 10, lecture 3: Radiotherapy treatment planning 19
In practice not always that clear cut

ICRU report 62 Need to understand anatomy and physiology A clinical decision
20
In many organs, dose and volume effects are linked - e.g.

Boersma* et al., classified the following (Dose,Volume) regions to be regions of high risk for developing rectal bleeding:
Dose (Gy) >65 >70 >75 Rectal volume(%) 40 30 5
*Int.
J. Radiat. Oncol. Biol. Phys., 1998; 41:84-92.

In EBT practice
Need to know
where to direct beam to, and how large the beam must be and how it should be shaped
22
Target design and reference images
In radiotherapy practice the target is localized using diagnostic tools:

Diagnostic procedures - palpation, X Ray, ultrasound Diagnostic procedures - MRI, PET, SPECT Diagnostic procedures - CT scan, simulator radiograph
23
BSS appendix II.18.
Therapeutic exposure: Registrants and licensees shall ensure that:

(a) exposure of normal tissue during radiotherapy be kept as low as reasonably achievable consistent with delivering the required dose to the planning target volume, and organ shielding be used when feasible and appropriate ...
24
Optimization of protection
One part of the optimization of radiotherapy Strategies:
Employ shielding where possible Use best available radiation quality Ensure that plan is actually followed in practice = verification
25
Selection of treatment approach

Requires training and experience May differ from patient to patient Requires good diagnostic tools Requires accurate spatial information May require information obtained from different modalities
26
Minimum patient data required for external beam planning

Target location Patient outline
27
Diagnostic tools which could be used for patient data acquisition

Ruler, calipers, many homemade jigs CT scanner, MRI, PET scanner, US, Simulator including laser system, optical distance indicator (ODI) Many functions of the simulator are also available on treatment units as an alternative - simulator needs the same QA! (compare part 15)
28
Simulator
Diagnostic X Ray tube Radiation beam defining system
Rotating gantry
Simulator couch
Nucletron/Oldelft
Image intensifier and X Ray film holder

29
Radiotherapy simulator
Obtain images and mark beam entry points on the patient
30
Patient marking
Marks on shell
Create relation between patient coordinates and beam coordinates
Tattoos
Skin markers
31
Beam placement and shaping

DRR with conformal shielding
simulator film with block
41
Tools for optimization of the radiotherapy approach
Choice of radiation quality Entry point Number of beams Field size Blocks Wedges Compensators
Optimization approaches
beam
beam
Choice of best beam angle

patient
target target patient
wedge
target
Use of a beam modifier

patient
43
Beam number and weighting

beam
Beam 1
100% 50%
50%
target patient
Beam 2
patient
40% 30% 10%
20%
A note on weighting of beams

Different approaches are possible: 1. Weighting of beams as to how much they contribute to the dose at the target 2. Weighting of beams as to how much dose is incident on the patient
25% 25% 30% 40% 25% 10%
These are NOT the same
20% 25%
45
Use of wedges
Wedged pair Three field techniques
Isodose lines
patient
patient
Typical isodose lines


Entry point Field size Blocks Wedges Compensators
a two-dimensional approach?
47

Entry point Field size Blocks Wedges Compensators
Multiple beams Dynamic delivery Non-coplanar Dose compensation (IMRT) not just missing tissue Biological planning
This is actually a 3D approach

Target Localization

Diagnostic procedures - palpation, X Ray, ultrasound Diagnostic procedures - MRI, PET, SPECT Diagnostic procedures - CT scan, simulator radiograph
Allows the creation of Reference Images for Treatment Verification: Simulator Film, Digitally Reconstructed Radiograph
49
Simulator image
During verification session the treatment is set-up on the simulator exactly like it would be on the treatment unit. A verification film is taken in treatment geometry
50
Simulator Film

Field defining wires
Shows relevant anatomy Indicates field placement and size Indicates shielding Can be used as reference image for treatment verification
51
iii. Machine data requirements for treatment planning

Beam description (quality, energy) Beam geometry (isocentre, gantry, table) Field definition (source collimator distance, applicators, collimators, blocks, MLC) Physical beam modifiers (wedges, compensator) Dynamic beam modifiers (dynamic wedge, arcs, MLC IMRT) Normalization of dose
Machine data required for planning
Depends on

complexity of treatment approaches resources available for data acquisition
May be from published data or can be acquired MUST be verified...
57
Quick Question:
Who is responsible for the preparation of beam data for the planning process in your center?
Acquisition of machine data
from vendor or publications (e.g. BJR 17 and 25) - this requires verification!!! Done by physicist Some dosimetric equipment must be available (water phantom, ion chambers, film, phantoms,) Documentation essential
59
Machine data availability
Hardcopy (isodose charts, output factor tables, wedge factors,) - for emergencies and computer break downs Treatment planning computer (as above or beam model) - as standard planning data Independent checking device (e.g. MU checks) - should be a completely independent set of data
60
Machine data availability

Hardcopy (isodose charts, output factor tables, wedge factors,) Treatment planning computer (as above or beam model) Independent checking device (eg. mu checks)
61
Machine data summary
Need to include all beams and options (internal consistency, conventions, collision protection, physical limitations) Data can be made available for planning in installments as required Some data may be required for individual patients only (e.g. special treatments) Only make available data which is verified
62
Quick Question:
What data is available for physical wedges in your center?
iv. Basic dose calculation
Once one has the target volume, the beam orientation and shape one has to calculate how long a beam must be on (60-Co or kV X Ray units) or how many monitor units must be given (linear accelerator) to deliver the desired dose at the target.
64
Normalization
Specifies what absolute dose should be given to a relative dose value in a treatment plan - e.g. deliver 2Gy per fraction to the 90% isodose Often the reason for misunderstanding Should follow recommendation of international bodies (compare e.g. ICRU reports 39, 50, 58 and 62)
Components of dose calculation for a single beam

Calibration method - what is the reference condition? Dose variation with depth and field size - covered in percentage depth dose or TPR/TMR data Off axis ratio - if the normalization point is not on central axis
Variation of percentage depth dose with field size

120 FS 5 FS 10 FS 20 FS 30 FS 40 100
80
60
40
10MV photons
20 0 0 5 10 15 20 25 30
67
Variation of percentage depth dose with FSD
68
Dose calculation
Scatter corrections for field size changes with blocking Attenuation factors for wedges and trays

difference between physical and dynamic wedges the thicker the wedge, the higher the attenuation at central axis
70
From single to multiple beams
Mainly an issue for megavoltage photons where we have significant contribution of dose to the target from many beams
1
3
60 Gy
4
Beam weighting must be factored in !!!

GoodPractice For Treatment Planning

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IAEA Training Material on Radiation Protection in Radiotherapy

Radiation Protection in Radiotherapy

Good Practice including Radiation Protection in EBT

In BSS Treatment Planning is part of Clinical Dosimetry

and BSS appendix II.21

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

Contents of the lecture

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

The need to understand treatment planning

Radiation Protection in Radiotherapy Part 10, lecture 3: Radiotherapy treatment planning 7

A. Basic Radiotherapy Treatment Planning Concepts

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

i. Planning process overview

Planning Treatment plan

ii. Patient information required

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

One needs to know

Radiation Protection in Radiotherapy Part 10, lecture 3: Radiotherapy treatment planning 13

It all comes down to the correct dose to the correct volume

Dose Volume Histograms are a way to summarize this information

Dose Volume Histograms

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

The ideal DVH

High dose to all Homogenous dose

Low dose to most of the structure

Need to keep in mind

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

Serial organs - e.g. spinal cord

Parallel organ - e.g. lung

High dose region

What difference in response would you expect?

Radiation Protection in Radiotherapy

In practice not always that clear cut

ICRU report 62 Need to understand anatomy and physiology A clinical decision

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

In many organs, dose and volume effects are linked - e.g.

J. Radiat. Oncol. Biol. Phys., 1998; 41:84-92.

Radiation Protection in Radiotherapy

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

Target design and reference images

In radiotherapy practice the target is localized using diagnostic tools:

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

BSS appendix II.18.

Therapeutic exposure: Registrants and licensees shall ensure that:

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

Selection of treatment approach

Radiation Protection in Radiotherapy

Part 10, lecture 3: Radiotherapy treatment planning

Minimum patient data required for external beam planning