Radiotherapy Planning
(Isodose Distributions)

Aim:-

1. Understanding the meaning of isodose curves, and the factors

affecting the distribution of dose with depth.
2. Practicing how to plan for treating a target region with multiple
radiationfields.
3. Performing correction to isodose distribution charts to account for patient
contour irregularities.
4. Calculation of the expected dose distribution at the target volume and nearby
tissues.

Theory:

An “isodose curve” is a line

passing through points of equal dose. An
“isodose chart” for a given beam
consists of a family of isodose curves
usually drawn at equal increments of
dose, representing the variation in dose as
a function of depth and transverse
distance from the central axis (see
figure1, for a typical isodose chart).
Among the parameters that affect the
isodose curves are the beam quality,
source size, field size, and the source to
skin distance (SSD). “Percentage depth
dose” is the percentage of the absorbed
dose at any depth “d”, D (d), to the
absorbed dose at a fixed reference depth
“do”, D (do) along the central axis of the
beam where “do” is usually the depth
taking the maximum dose (100%) and is
called maximum build up depth (figure-
2),
Figure-1

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Percentage depth dose (P) = {D (d) / D (do)} x 100

Figure-2

For ortho-voltage (about 400 kVp) and low energy x-rays, the reference depth
(at which maximum build up occurs) is usually the surface (do = 0). For higher
energies, the maximum build up is below the surface of the patient. This is called skin
sparing effect, where the patient's skin is saved from burning.
A number of parameters affect the central axis depth dose distribution as follows:-

1. Beam quality (or energy)

The percentage depth dose increases with beam energy. Higher
energy beams have greater penetrating power and thus deliver a
higher percentage depth dose.

2. Depth
The percentage depth dose decreases with depth beyond the depth of
maximum dose. However, there is an initial build-up of dose which becomes
more and more pronounced as the energy is increased. The region between the
surface and the point of maximum dose is called the dose build-up region. The
dose build-up effect of the higher energy beams gives rise to what is clinically
known as the skin-sparing effect.

3. Field size
Percentage depth dose increases with increasing the field size.

4. Source-to-surface distance (SSD)

Photon fluence emitted by a point source of radiation varies inversely as a
square of the distance from the source (figure 3). The source dimensions become
unimportant in relation to the variation of photon fluence with distance at SSD
about 80 cm. Of course, the inverse square law dependence of dose rate assumes

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that we are dealing with a primary beam without scatter. In a given clinical
situation, collimation or other scattering materials in the beam may cause
deviation from the inverse square law. So, the percent depth dose increases with
SSD because of the effects of the inverse square law.

Figure-3

Combination of Radiation Fields

Treatment by a single photon beam is seldom used except in some cases in

which the tumour is superficial. Whereas single fields of superficial X-rays are
routinely used for treating skin cancers, which are confined to a depth of a few
millimetres. For the treatment of most tumours, however a combination of two or
more beams is required for an acceptable distribution of dose within the tumour and
the surrounding normal tissues. Reduction of dose to sub-cutaneous tissue and normal
tissue surrounding the tumour can be achieved by using a combination of three or
more fields. In figure 4, we can see a schematic diagram showing examples of
multiple fields. Figure 4A, shows two opposing pairs at right angles, figure 4B, shows
two opposing pairs at 120oC, and figure 4C shows three fields, one anterior and two
posterior.

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Figure-4

1. Parallel opposed fields

The simplest combination of two fields is a pair of fields directed along the
same axis from opposite sides of the treatment volume. The advantages of the
parallel opposed fields are the simplicity and reproducibility of setup,
homogeneous dose to the tumour, and less chances of geometrical miss, given
that the field size is large enough to provide adequate lateral coverage of the
tumour volume. A disadvantage is the excessive dose to normal tissues and
critical organs above and below the tumour.

2. Multiple fields
One of the most important objectives of treatment planning is to deliver the
maximum dose to the tumour and minimum dose to the surrounding tissues. In
addition, dose uniformity within the tumour volume and sparing critical
organs are important considerations in judging a plan. To achieve these goals,
we should do the following:

a. Use fields of appropriate size,

b. Increase the number of fields,
c. Select appropriate beam directions,
d. Adjust beam weights,
e. Use appropriate beam energy,
f. Use beam modifiers, such as wedge filters and compensators.

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Correction of Contour Irregularities

The basic dose distribution data are obtained under standard conditions, which
include homogeneous unit density phantom, perpendicular beam incidence, and flat
surface. During treatment, however, the beam may be obliquely incident with respect
to the surface and in addition, the surface may be curved or irregular in shape. Under
such conditions, the standard dose distributions cannot be applied without proper
modifications or corrections. Contour corrections may be avoided by using a bolus or
a compensator but under some circumstances it is permissible to determine the actual
dose distribution by calculation. We can correct for the contour irregularities by three
methods:

1. Effective SSD method

2. Tissue-air ratio method
3. Isodoseshift method

The first two methods are useful for making individual point dose calculations. In this
experiment, we will focus only on the third method.

Isodose shift method

For manual treatment planning, it is convenient to correct the entire isodose chart
for contour irregularities. This can be done by an empirical method, known as the
isodose shift method. Suppose that S - S in figure 5,is the patient contour drawn
on a transparent paper, and S`- S` is a flat surface line passing through the point of
intersection of the central axis with the contour. This method can be summarized
as follows;

1. From the line S`-S` draw vertical grid lines, parallel to the central axis and
spaced about 1 cm apart, to cover the full field width.

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2. Place the standard isodose chart underneath this paper and align the central
line of the chart with that of the grid.

3. Mark the percentage depth dose values on the central axis.

Figure-5

4. For each grid line, slide the isodose chart up or down, depending on whet-
her there is tissue excess or deficit along that line, by an amount k x h,
where “k” is a factor less than 1.

N.B. Factor “k” depends on the radiation quality (as shown in the table-1), field
size, depth of interest, and SSD.

5. Mark the isodose values at points of intersection of the given grid line and the
shifted isodose curves.

6. After all the isodose positions along all the grid lines have been marked,
newisodose curves are drawn by joining the marked points having the
sameisodose values.

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N.B: In case of tissue excess, the shift is upward k x h, where h is the distance between
S`-S` and the contour S-S. In case of air-gap, the shift
is downward – (k x h`), where h` is the distance between S`-S` and S-S.

Table-1
Important Definitions

Target volume
This is the volume which needs to be irradiated to a specified absorbed dose.

Maximum target dose

It is the highest dose inside the target area.

Minimum target dose

It is the lowest absorbed dose in the target area.

Hot spot
It is an area outside the target volume, which receives a higher dose than the
specified target dose.

Procedure:-

1. Plot the contour of the patient.

2. Draw the standard isodose chart.

3. Correct the isodose chart for contour irregularities (considering air-gaps and
excess tissue) by using the “isodose shift method”.

4. Collect all these points and make a treatment plan.

References:

F. M. Khan 1994 (2nd edition). The Physics of Radiation Therapy. pp. 226 – 314

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