\OL. 114, No.

TUMOR LOCALIZATION, DOSIMETRY, SIMULATION

AND TREATMENT PROCEDURES IN RADIO-
THERAPY: THE ISOCENTRIC TECHNIQUE*
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

By ANGELA GARDNER, B.SC., M. A. BAGSHAW, M.D., VERA PAGE, B.SC., and

C. J. KARZMARK, PH.D.
STANFORD, CALIFORNIA

M ANY modern megavoltage radiother- particular unit. The isocenter is located at

apy units are gantry mounted in a fixed point in space which is illustrated
order to take advantage of isocentric treat- in Figure I for the 6 MeV. Clinac-6 accel-
ment methods)’9’6 For an isocentric treat- eraton.
ment, the patient is positioned with the Isocentnic methods facilitate dosimetry
tumor center coincident with the center of preplanning, since patient dimensions have
rotation or
of the isocenter
unit. The only a small effect on the isodose contours
source-tumor-distance (STD) is constant near the isocenter. The normalization dose
for all fields and the source-skin-distance at the isocenter and field weightings can be
( SSD) is variable. The source-tumor-dis- quickly established once the skin-isocen ter
tance is equal to the source-axis-distance
( SAD) or sounce-isocenter-distance for the * Varian Model \77O.

SIDE
LIGHTS

RAY SOURCE ,-

FIG. I. Location of the isocenter for 6 MeV. Varian Accelerator. The isocenter is defined by the horizontal
( gantry) axis of rotation of the treatment unit and the central axis of the radiation beam. Note that side
lights are used to locate the isocenter.

C From the Department of Radiology, 5tanford University School of Medicine, Stanford, California.
This work has been supported by Research Grant CA-o5838 from the National Cancer Institute, N.I.H.

I 63
 I 64 A. Gardner, NI. A. Bagshaw, V. Page and C. j. Karzmark JANUARY, 1972

depths are known. Ireatment iniplementa- treatment unit itselfbecomes a pin and arc.
tion i5 expedited by use of a treatment Alignment for treatment is achieved by
simulator which provides tumor localiza- positioning the patient with the beam di-
tion in a manner which promotes eflcient rected vertically downward and centering
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

and accurate setting_up of the patient on on the tumor; then, using the cross-lines
the treatment unit itself. The major differ- projected by the side lights, raising the
ence between the simulator and the acceler- couch until the tumor center is coincident
aton is the employment of the diagnostic with the isocenten, and finally rotating the
roentgen-ra\’ source instead of a 6 MV. gantry to the appropriate angular positions
therapeutic source. for treatment (Fig. 2). Errors in angular
Isocentnic procedures can be used with a settings are less significant than with con-
number of treatment field geometries. ventional techniques as the beam is always
However, there is only a slight advantage directed at the tumor and a serious ana-
in using isocentric techniques to treat tomic miss is unlikely. However. the most
through parallel opposing fields at this elaborate treatment is ineffective if the
energy. This is because a block of tissue initial tumor localization is inaccurate or if
from one entrant surface
other to the
is ir- the daily set_up is not reproducible. The
radi ated nearly homogeneouslytherefore, ; effective use of an isocentric method of
the localization problem is two dimensional radiotherapy therefore involves: (i) identi-
and the depth of the tumor is unimportant. fication of the tumor volume; (2) develop-
For multiple field and rotation therapy, ment of a treatment plan; and () trans-
however, the depth of the tumor is critical, lation ofthis plan into a reproducible treat-
tumor localization is three dimensional, and ment set-up. The following description out-
accurate beam direction is essential. In lines the isocentnic treatment technique as
these circumstances, isocen tn c methods developed at Stanford for use with the 6
give optimum precision with speed of set- MeV. Clinac.6 Two standard forms, the
up. The pin and arc,1#{176}
which was devised to Physical Report Form (Fig. the 3) and
improve the accuracy ofbearn direction for Daily Therapy Record’2 help implement
non-isocen tric beam uni ts, is u nnecessary the method. Similar methods could be de-
when treating isocentricalk because the veloped for any isocentrically mounted unit
or for a non-isocentnic beam unit, such as
the 4.8 MeV. Stanfoid medical linear ac-
celerator17 which is used with a rotating
treatment chair.

TUMOR LOCALIZATION AND TREATMENT

SIMULATION

The aim of these procedures is to define

the tumor volume and to select the point
within this volume which will be positioned
at the isocenter during treatment for the
best dose distribution. To accomplish this,
/
/ a speci ally constructed treatment simulator
/
unit is employed. We have found it ex-
- X5Ainmor4s pedient to employ a special-purpose diag-
nostic roentgen-ray treatment simulator*
11G. 2. Set-up for treatment showing accelerator
vertical for patient positioning and angled for which duplicates the Clinac-6 treatment
patient treatment. The side lights and lateral skin unit, including patient support assembly,
marks are used to establish the vertical positioi
of the patient. * Constructed by and in collaboration with Varian Associates.
 Voi. 114, No. i Tumor Localization I 6#{231}

PHYSICAL REPORT 1055

PatIent: PhysicIan: Accclertor:

LOCATION OF ISOCEN1ER
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

Date Speclflcation Longltudlnsl Transverse I Sagqk - (fP)

Reference Point (N) ?iPLh:.N.., /hbi:o:,T:rt.

;Lt. Tumor Point (T) O#{225}ovL. 4 &#{243}ov... q .

SPECIFICATION OF TREATIWNT FIFIDS

Date ield FIeld . .

DescrIption Angulatuons Wedge THICK edge

7/i: L kAt :b;#’9Ld AP Itb0_

-.-
- t*_r_ R X7o 1L 4itb’

-i--- L t&i. J. . Llt.Iaii’A.L O#{176} LL 41’AiBY

I
-__

DOSE CALCULATION
-t
Date qare
d I Sd 0 D.
I9 So. Field R.,d/RdI #{149} 0id ‘

T1Lk L. ‘1- ....L iz JL. Ao M &3 21o.

.. ,j . .l 9. ilb.
--- : . 2f 27t .L& 2.?9 ac 3a

COMMENTS :
‘ee
/$.t. )4,
/
.2d)4y F,j4.j ,

S I gn : _t-.

11G. 3. Example Physical Report Form as completed after treatment

planning for the plan illustrated in Figure o ib.

in general appearance and in considerable sette with the film plane perpendicular to
mechanical but not structural detail (Fig. the central
axis of the roentgen-ray beam
4). All motions and positional limits of the and 135 cm. from the target.
simulator including couch correspond to The steps involved in the tumor localiza-
those of the Clinac-6. The field light projec- flon procedure follow:
tion system and collimators provide a light (a) A provisional reference point (R), es-
field and diagnostic radiation beam which timated from clinical data to be near the
accurately simulate the Clinac-6. Two side tumor center, is specified within the patient
and I ceiling lights project cross-lines in- and defined with respect to the nearest
tersecting in quadrature at the isocenter. standard external landmark; e.g., the public
They are extremely useful in localization ramus or the suprasternal notch.
procedures and are provided in both the (b) Anteropostenior and lateral orthog-
simulator and treatment rooms. A retract- onal roentgenognams are exposed on the
able cassette holder is attached to the simu- simulator with lead markers projected over
lator gantry which, when extended, rigidly the reference point (R) positioned at the
supports a i4X 17 inch roentgen-ray cas- isocen ter.
 I 66 .A. Gardner, \I. A. Bagshaw, V. Page and C. J. Karzmark JANUARY, 1972
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

11G. 4. Simulator \vith film cassette holder extended. The lateral film
marker is shown attached to the couch.

( c) The treatment area is outlined on hence the reference point (R) on the films
1)0th roen tgenograms, the dimensions de- (Fig. 4). A magnification factor of 1.35 (for
termined and centers marked. structures which are in the plane of the iso-
The reference point (R) may be any center) is standard for all films. The SF1)
arbitrary point; however, it is routinely is always i#{231}cm. and the SAl) is ioo cm.
defined as being situated i I cm. above the (l’ig. 6).
couch at the estimated transverse and Ion-
gitudinal position of the tumor center. The
estimated tumor position is defined by the
radiotherapist from all available clinical
and roentgenographic data. The location of
this point’in thepatient is indicated by three
skin marks, one on the upper surface yen-
tically above and one on each lateral sun-
face at the same horizontal level (Fig. c).
The transverse, longitudinal and sagittal
coordinates of the reference point (R) are
measured from the nearest external land-
mark and recorded on the Physical Report
Form under reference point (R) as illus-
trated in Figure 3. The orthogonal roent-
genognams are exposed on the simulator
with the reference point (R) at the iso-
center and the 14X 17 inch film clamped in XS/cin marks

the extendible cassette holder. Fixed film l”ic. . Location of reference point (R) with respect
markers are attached to the couch to in- to the patient coordinate axes, skin marks and
dicate the position of the isocenter and anatomical landmarks.
 \OL. 114, No. lUlflor Localization 167

lated on the films and the cross section of

I35 cm
the patient are acquired by a technician.
ISOCENTER
5cm A/IOO cm After placing the skin marks that relate to
the provisional treatment center, the ref-
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

erence point (R), the patient may be dis-

missed. The radiotherapist and the dosime-
trist then have a permanent record of all
)icm
data necessary to formulate the treatment
plan and may execute this plan at their
LATERAL convenience. The localization session does
FILM 3cm
LATERAL FILM
not require the physician in attendance ex-
MAPtEP ‘-‘---AP FILM MARD’EP
cept to stipulate the anatomic coordinates
of the reference point (R). This procedure
-AP FILM
facilitates orderly scheduling and decreases
11G. 6. Geometry for exposing localization extemporaneous demands upon the radio-
films on simulator therapist.
Although the anteropostenior/lateral
The boundaries of the treatment region roentgenographic procedures outlined are
( i.e., tumor plus margins and likely avenues particularly relevant to the isocentnic tech-
of extension) are outlined on each localiza- nique, other procedures are important. For
tion film4 (Fig. 7 and 8). These data are example, the simulator is especialk useful
then transferred to the patient’s cross sec- in setting-up patients for tangential breast
tional diagram and an appropriate treat- radiotherapy using two opposing tangential
ment planned as described below. and one direct anterior field. Here, diag-
At the conclusion of the tumor localiza- nostic treatment-field films are effectively
tion procedure, the patient leaves the de-
partment with three skin marks defining
the provisional reference point (R) as
specified on the Physical Report Form.
After planning, the center of the treatment
region is relocated according to the treat-
ment plan. The skin marks will be read-
justed to coincide with this point, now de-
fined as the tumor point (T), which is then
positioned at the isocenter for treatment.
The ernplo-ment of a simulator for lo-
calization procedures such as described has
general usefulness. Provided the patient is
positioned in a similar wa\; e.g., lying
supine, the localization information can be
used for patient set_up and treatment on a
therapy unit other than that simulated.
\\Th’tt is important is that tumor location
and size are established relative to external
skin marks and a bony landmark. When
this can he done by roentgenographic tech-
niques, the use of orthogonal films has
m any adv au tages over fluoroscopv . A
11G. 7. Lateral localization roentgenogram illustrat-
nearby 90 second film processor expedites ing a bladder tumor and treatment area, reference
the procedure. The pertinent data accumu- point (R) and tumor point (T).
 .A. Gardner, NI. A. Bagshaw, V. Page and C. j. Karzrnark JANUARY, 1972
!#{149}T #{149}--r--

struction, the lateral film is positioned on a

- . ‘-;r vertical illuminator and the anteropos-
tenor film on a horizontal illuminator. The
film marker crosses are positioned coin-
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

$,

cident with the crosses on the illuminators

which identify the orthogonally projected
isocenter points. The patient’s contour
drawing is positioned n a vertical metal
plate which serves as a drawing board. The
lower edge of the plate represents the level
of the couch top. The anteroposterior and
....- .- Trn,eisE #{163}ad1

lateral central beam axes are indicated by

the vertical and horizontal yellow tapes SO
r
that the isocenter is located at the intersec-
l’i;. 8. Anteroposterior localization tion of these tapes. Strings attached to
men tgenograrn. pointers on each illuminator represent
roentgen rays from the target so that an-

used for tumor localization, treatment- atomic points can be located by positioning
field verification and treatment simulation. the pointers appropriately on each film and
finding the intersection ofthe strings within
‘I’REATMENI’ PLANNING AND DOSIMETRY the cross section. Three dimensional recon-
The steps involved in these procedures struction can be carried out by stacking
are: multiple cross sections.
After outlining the treatment region and
(a) patien t measurements and contours
other anatomic structures on the patient’s
are obtained
cross section drawing (Fig. 10), suitable
( 1)) anatorn ic i ii form ation is transferred
field arrangements and weightings are de-
to the contour
vised which maximize tumor dose homo-
(c) a suital)le treatnient plan is devised
geneitv while minimizing the irradiation of
( d) a dose calculation is performed
sensitive structures. For neoplasms situated
\Vithout moving the patient after ex- centrally, the most homogeneous tumor
posing the localization roentgenograms. a dose is usually achieved if equal isocenter
transverse contour is obtained and drawn doses are given b\- each field. However, for
on paper specif\-ing the locations ofthe skin an asymmetric tumor this requires giving
marks. Distances between the skin marks relatively more radiation through distant
are verified by direct caliper measurements. fields (Fig. i ). Dose distributions nor-
If the patient’s dimensions vary consider- malized to ioo per cent at the isocenter are
ably over the length of the proposed treat- obtained either manually using universal
men t region, then additional measurements isodose curves and the concepts described
and contours are obtained at other levels. elsewhere2”7”’5 or by computer. The op-
The position and dimensions of the tu- timum treatment plan is determined from
mor together with other anatomical regions these dose distributions and appropriate
ofinterest are transferred into the patient’s data; i.e., field orientations, sizes, and
contour from the roentgenograms by using weightings are recorded on the form under
the special cross section reconstruction Lie- Specification of Treatment Fields (Fig. 3).
vice (Fig. 9). The geometry of this device The final dose distribution determines the
exactly duplicates that of the simulator and location of the isocenter point for treatment
perm its full-scale two-dim ensi on al recon- and the corresponding cootdinates arere-
struction ofthe anatomic details within the corded by the dosimetnist under tumor
patient’s contour (Fig. io). For the recon- point (T) on the Physical Report Form. In
 Vot.. 114, No. I Tumor Localization I 69

Simulated focal spot

Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

Taut strings representing X rags

Vertical beam axis

Lateral radiograph

I.
I ‘1

Lateral beam axis :T’’p :J

Reference point

A P radiograph 1Adjustable pointers

;,. .: . #{149}

A I
FIG. 9. Contour projection device with films and patient contour drawing in position. Note the
similarity of its geometric arrangement to that shown in Figure 6.

most cases this point falls at the center of isocenten-depths (d) and then entered on
the treatment region (Fig. 3). the Physical Report Form (Fig. 3). A sim-
To deliver the prescribed tumor dose ac- ilar expression using tissue-air-ratios could
cording to the treatment plan, it is neces- be used to determine treatment times for a
sary to calculate the daily isocenter dose. cobalt 6o unit. Presumably other paname-
For example in Figure I ib, if the therapy ters such as the modified tissue-phantom
prescription specified a tumor point (T) ratio (MTPR),’5 the tissue-maximum ratio8
dose to the ioo pen cent level as 6,ooo rads (TMR) or the tissue-output ratiofl (TOR)
to be delivered in 6 weeks, treating times could be used in the calculations.
pen week, then the daily isocenter dose is The peak central axis dose (i.e., applied
200 nads. The monitor settings (M) re- dose or Dm) and the peak off-axis dose with
quired to deliver this isocenter dose (DId) wedges (Dmv) are estimated for each field
for each field are calculated as follows: either (i) from isocenter doses using uni-
vensal isodose curves or (ii) from monitor
D,d settings using standard calibration data
.11=:: __ -

TPR X C1 x II’ and inverse square law. Finally, a treat-

ment cycle is devised to satisfy the condi-
The values of tissue-ph an tom-ratio tions of the treatment plan. Ideally, one
(TPR),11’2 calibration factor (C1) and would prefer to complete the treatment
wedge factor (II’) are obtained from graphs cycle each day. However, when the treat-
for the appropriate field sizes and skin- ment schedule is saturated, time can be
 I 70 A. Gardner, M. A. Bagshaw, V. Page and C. J. Karzmark JANUARY , 1972

cated at the isocenter using the current

skin marks. The accelerator is rotated to
the appropriate position for each treatment
field and exposures given according to the
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

specified treatment cycle and monitor set-

tings on the Physical Report Form.

SUMMARY

The use of a treatment simulator in tu-

X-SA, tNi-x.i
mon localization for the isocentnic treat-
FIG. 00. Patient contour with treatment ment technique is described.
region and anatomical structures. The localization procedure usually in-
volves obtaining anteroposterior and lat-
conserved by extending the cycle over 2 eral orthogonal roentgenograms having a
or 3 days thus reducing the total num- constant magnification factor. The treat-
ben of daily set-ups. When such considena- ment region is drawn onto both roentgeno-
tions dictate this compromise, cane should grams and transferred to the patient’s
be exercised to select fields for each daily cross section by using a special reconstruc.-
treatment whose sum closely approximates flon device.
a homogeneous daily tumor dose. Further- For tumor localization the patient is
more, 400 rads peak dose (Dm or Dmw) positioned with a specified, but provisional,
should never be exceeded per field per day reference point (R) located at the isocenter
in order to prevent later development of
#1 d8cn,
subcutaneous fibrosis. In the example il-
8n8 5./j
lustrated in Figures 3 and JIb, a 2 day
cycle was used giving 200 rads isocenten
dose from the anterior field the first day
and ioo rads isocenten dose from each r
8:8
wedYeI( ? _____ 7\ :ge

lateral on the second day. /dI8cm

TREATMENT

After the treatment plan has been calcu-

lated and the patient returns for therapy, a. ecuaIIy weighted cieIds

the original reference point (R) skin marks 0I

are relocated, when necessary, to conre-

spond with the surface projection of the
tumor point (T) which is used to position
them correctly for treatment. If the marks wj c1_ v:ge
have been lost, the patient is re-marked ac-
cording to the previously recorded ana-
tomical data. Port films are exposed either
with the accelerator or the simulator to couch
confirm the tumor point (T) location and b. 3 unequall9 weighted fields

field size. Ifthe tumor point (T) is relocated FIG. I 1. Compound isodose distribution for an ante-
at any time, the appropriate displacement nor 8X8 cm. field and 2 lateral 8X8 cm. wedged
with the date is entered on the Physical fields for (a) equal weighting and (1’) unequal
weighting (6 MV., 100 cm. STD, isocentric tech-
Report Form and the skin marks adjusted
nique). S=weighting factor; i.e., fraction of total
correspondingly. isocenter dose from a particular field. Field size
For treatment, the patient is positioned is specified at ioo cm. STD = source-tumor-dis-
with the confirmed tumor point (T) lo- tance.
 VOL. 114, No. Tumor Localization 71

of the simulator. This reference point (R) 3. Du SALT, L. A. Simplified method of treatment

is specified within the patient by 3 skin planning. Radiology, 1959, 73, 85-94.
4. FARMER, F. T., FOWLER, J. F., and HAGGITH,
marks, and recorded on the roentgenograms J. W. Megavoltage treatment planning and
by marker crosses relative to standard ana- use of xeroradiography. Brit. 7. Radiol., 1963,
Downloaded from ajronline.org by 185.175.252.178 on 09/29/23 from IP address 185.175.252.178. Copyright ARRS. For personal use only; all rights reserved

tomic structures and drawn on the patient 36, 426-435.

contour drawing. 5. GooDwIN, P. N. Use of concept of tissue-air
ratios with linear accelerators. urn. ii.
A suitable treatment plan is devised and
Physicists in Med. Quart. Bull., 0970, 4, 23.
this determines the position of the tumor
6. HAIMSON, J., and KARZMARK, C. J. New design
point (T) which is located coincident with 6 MeV linear accelerator system for super-
the isocenter of the accelerator during voltage radiotherapy. Brit. 7. Radiol., 1963,

treatment. The tumor point (T) may differ 36, 650-659.

7. HEGEWAL, H. Zur einheitlichen Dosisberechnung
from the original reference point (R). The
bei harter and ultraharter Strahlung. Radio-
anatomic coordinates of the tumor point
biol. et Radioterapia, 1966, 4, 457-465.
(T) are recorded and used to establish the 8. HOLT, J. G., LAUGHLIN, J. S., and MORONEY, J.
final skin marks for positioning the patient P. Extension of concept of tissue-air-ratios
for each therapeutic session. (TAR) to high-energy x-ray beams. Radiology,
1970, 90, 437-446.
The pre-set dosimetry parameters are
9. HOWARD-FLANDERs, P., and NEWBERY, G. R.
calculated by the dosimetnist following the
Gantry type of mounting for high voltage x-
development of the treatment plan thus ray therapy equipment. Brit. 7. Radiol., 1950,
limiting the treatment technician’s ne- 23, 355-357.
sponsibility to adjusting the patient’s posi- 10. JOHNS, H. E., and MACKEY, J. A. Collimating
tion, beam angulation and field size, at- device for cobalt 6o teletherapy units. 7. Fac.
Radiologists, 1954,5, 239-247.
taching such accessories as wedge filters,
I I. KARZMARK, C. J., DEUBERT, A., and LOEVINGER,
and setting the precalculated values. R. Tissue-phantom-ratios aid to treatment
planning. Brit. :7. Radiol., 1965,38, 158.
C. J. Karzmark, Ph.D.
Department of Radiology 12. KARZMARK, C. J., DUEBERT, A., LOEvINGER, R.,
Stanford University Medical Center and STEED, P. R. Notation and formulae for
Stanford, California 94305
dose specification and calculations in radio-
therapy. Brit. 7. Radiol., 1966, 39, 476-478.
We would like to acknowledge the help 13. MACDONALD, J. C. Simplified techniques in
and encouragement of the radiotherapy employment of rotational cobalt 6o beam
therapy unit. AM. J. ROENTGENOL., RAD.
staff, particularly Dr. H. S. Kaplan. We
THERAPY & NUCLEAR MED., 1961,86,730-736.
are indebted to Peter Huisman for devising 04. PFALZNER, P. M. Precalculated dose distribu-
and fabricating the reprojection apparatus tions in cobalt 6o fixed field and rotation
and extendible film cassette holder. We also therapy. Ada radiol., 1962,58, 205-225.

would like to thank Patricia Steed for help- 15. SAUNDERS, J. E., PRICE, R. H., and HORSLEY,
R. J. Central axis depth doses for constant
ful comments.
source-tumor distance. Brit. 7. Radiol., 1968,
4’, 464-467.
REFERENCES
16. SMITH, I. H., FEI-I-ERLY, J. C. M., and Loi-r, J.
I. BRAESTRUP, C. B., and MOONEY, R. T. Physical S. Cobalt-6o Teletherapy. Paul B. Hoeber,
aspects of rotating telecobalt equipment. Inc., New York, 1964.
Radiology, 1955, 64, 17-27. 17. WEISSBLUTH, M., KARZMARK, C. J., and STEELE,
2. BUCHAN, R. C. Stationary field treatment plan- R. E. Stanford medical linear accelerator: II
fling at fixed source-tumor distance. Brit. 7. installation and physical measurements.
Radiol., 0968, 4!, 692-695. Radiology, 1959, 72, 242-253.