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PRINCIPLES OF ISODOSE PLANNING
RT-311: RADIATION THERAPY
DANIELE CLYDE P. CACHA, RRT

College of Radiologic Technology
COLLEGE OF RADIOLOGIC TECHNOLOGY
Calayan Educational Foundation, Inc.

Radiation Oncology Team
A. Radiation Oncologist
• Doctor of medicine specializing in use of ionizing radiation in the treatment of

disease.
• Makes most of the decision regarding the cancer patient’s treatment.
• Prescribes the quantity of radiation and determines the anatomic regions to be
treated.

B. Medical Physicist
• Responsible for calibration and maintenance of the radiation-producing equipment.

• Advises the physician about dosage calculations and complex treatment techniques.
C. Medical Dosimetrist
• Responsible for computing the dose and planning the dose delivery for treatment.

D. Radiation Therapist
• Responsible for obtaining radiographs or CT scans that localize the area to be

treated, administering the treatments, keeping accurate records of the dose
delivered each day, and monitoring the patient’s physical well-being.
• Executing the radiation treatment.

Terminologies
Cancer – malignant tumor that expands locally by invasion and systematically by

metastasis.
Neoplasia – new growth. Abnormal proliferation that is uncontrollable.
Neoplasm – abnormal growth of tissue which is palpable.
Metastasis – spread of cancer from primary tumor to sites elsewhere in the body.

Remission – stage or period of absence of cancer. (5 years)
A. Complete remission – all signs and symptoms of cancer are gone
B. Partial remission – the malignant tumor shrunk, but does not disappear

Recurrence - return of cancer after treatment and after a period of time (remission) during
which the cancer cannot be detected.
A. Local – reappears at the original site
B. Regional – returns at the vicinity near the previous tumor
C. Distant – located at areas farther from the previous tumor
Second primary cancer – patient is diagnosed with new cancer that is completely unrelated
with the previous cancer.

Three Major Subtypes of Cancer
1. Carcinoma – originating from epithelial tissue
2. Sarcoma – originating from connective tissue
3. Lymphoma – involves blood forming tissue


Cancer Risk Factors
1. External
• Exposure to chemicals
• Viruses
• Ionizing radiation
2. Internal
• Hormones
• Genetic mutation
• Disorders of the immune system

General Cancer Signs and Symptoms
1. Unexpected weight loss – unexplained weight loss (about 10 lbs)

2. Fever – reduced resistance to infection
3. Fatigue – chronic blood loss
4. Pain – due to abnormal growth
5. Skin changes – change in color
6. Non-healing sore
7. Change in bowel/bladder function

Classification of Tumor
1. Grading – testing the aggressiveness or virulence of cancer cell
2. Staging – determine the extensiveness of the tumor

• Surgical staging
• Pathological staging
• Clinical staging

TNM SYSTEM
CLASSIFICATION DESCRIPTION OF TUMOR
STAGE 0,
Occult lesion; no evidence clinically
T0N0M0
STAGE I, Small lesion confined to organ of origin with no evidence of

T1N0M0 vascular or lymphatic spread or metastasis
STAGE II, Tumor of less than 5cm. invading surrounding tissue and first-
T2N1M0 station lymph nodes but no evidence of metastasis
Extensive lesion greater than 5cm. with fixation to deeper
STAGE III, T3N2M0 structure and with bone and lymph invasion but no evidence
of metastasis
STAGE IV, T4N3M1 More extensive lesion than above or with distant metastasis
T – size of tumor N – spread of cancer (in nodes) M - metastasis


Methods of Radiotherapy Planning
1. Source to surface distance (SSD) – the distance from the source to the surface of
the patient is kept constant for all beams.
2. Source to axis distance (SAD) – the centre of the target volume is placed at the
machine isocentre.

Tumor Localization Simulation
STEP 1. PATIENT IMMOBILIZATION
STEP 2. TUMOR TARGET VOLUME CENTER (ISOCENTRIC DEFINITION)
STEP 3. COMPUTE PLANNING AND TREATMENT DELIVERY
STEP 4. PLANNING IMPORTANT TREATMENT ACTION VERIFICATION


Patient Treatment Position and Immobilization Devices
Depending on the patient treatment position or the precision required for

beam delivery, patients may or may not require an external immobilization device for
their treatment.
Immobilization devices have two fundamental roles:
1. To immobilize the patient during treatment

2. To provide a reliable means of reproducing the patient’s position from simulation
to treatment, and from one treatment to another.

Immobilization Devices
1. Thermoplastic mask (head) – made up of thermoplastic. When heated and placed

on patient, molds in shape.
2. Alpha cradle (head & extremities) – made of 2 chemicals that can be mixed
together to form a styro-like material that may take shape of the patient.
3. Breast board – is used for selected patients with significant chest wall angulation to
make the anterior chest wall horizontal.
Thermoplastic mask Alpha cradle Breast board


Tumor Target Volume Center
The first step of radiation therapy involves determining the volume of tissue
that needs to be encompassed within the radiation field.
This is done with a simulator, which is a diagnostic quality x-ray machine that
has the same geometric and physical characteristics as a treatment unit.
A conventional treatment simulator has the capability to reproduce most treatment

geometries available on radiotherapy treatment units. Simulators use a diagnostic X ray
tube and fluoroscopic system to image the patient

During simulation, the radiation oncologist uses the patient‘s radiographic
images or the CT or MRI scan to determine the tumor's precise location and to design
a treatment volume, or area.
The treatment volume often includes the tumor plus a small margin, the
draining lymphatic that are at risk for involvement, and a rim of normal tissue to
account for patient movement.
Volume definition is a prerequisite for meaningful 3-D treatment planning and

for accurate dose reporting.

The following volumes have been defined as principal volumes related to 3-D
treatment planning:
1. Gross tumour volume (GTV)

2. Clinical target volume (CTV)
3. Internal target volume (ITV)
4. Planning target volume (PTV)

Gross tumour volume
The Gross Tumour Volume (GTV) is the gross palpable or visible/demonstrable

extent and location of malignant growth.
The GTV is usually based on information obtained from a combination of

imaging modalities (computed tomography (CT), magnetic resonance imaging (MRI),
ultrasound, etc.), diagnostic modalities (pathology and histological reports, etc.) and
clinical examination.

Clinical target volume
The clinical target volume (CTV) is the tissue volume that contains a
demonstrable GTV and/or sub-clinical microscopic malignant disease, which has to be
eliminated. This volume thus has to be treated adequately in order to achieve the aim
of therapy, cure or palliation.
The CTV often includes the area directly surrounding the GTV, which may
contain microscopic disease and other areas considered to be at risk and requiring
treatment (e.g. positive lymph nodes).

Internal target volume
The ITV consists of the CTV plus an internal margin. The internal margin is
designed to take into account the variations in the size and position of the CTV
relative to the patient’s reference frame (usually defined by the bony anatomy); that
is, variations due to organ motions such as breathing and bladder or rectal contents.

Planning target volume
The planning target volume (PTV) is a geometrical concept, and it is defined to

select appropriate beam arrangements, taking into consideration the net effect of all
possible geometrical variations, in order to ensure that the prescribed dose is actually
absorbed in the CTV.
The PTV includes the internal target margin and an additional margin for set-
up uncertainties, machine tolerances and intra-treatment variations.
Graphical representation of the volumes of interest

Contours of GTV, CTV, PTV and organs at risk (bladder and rectum) have been drawn
on this CT slice for a prostate treatment plan.

Using fluoroscopy, the radiation therapist determines the field dimensions
(length and width) and depth of isocenter as specified by the radiation oncologist.
The treatment field outline and positioning marks are placed on the patient'
skin surface.
A radiographic image is then taken of all treatment fields to facilitate

treatment planning, block fabrication, and document the anatomic region to be
treated.
The radiation therapist places skin marks on the patient's skin surface for
alignment of the radiation beam during treatment
Multileaf Collimator
Lateral radiograph demonstrating contrast in the

AP pelvic radiograph demonstrating contrast in the
rectum and bladder and their relationship to the
bladder and its relationship to the prostate gland.
prostate gland

Procedure of Isodose Planning
• Single port
• Double port
• Cross fire technique
• Quadratic (box technique)
• Perpendicular
• Rotational
• tangential

Clinical Method Treatment
• Protraction technique
• Fractionation technique
• Split dose
• Pallative vs. Curative
• Pre-operative technique
• Post-operative technique
• Brachytherapy vs. Teletherapy

Fractionation – discovered by Claude Regaud & Henri Coutard.
• Fractionated dose – radiation dose delivered at the same dose in equal portions at
regular intervals
• Protracted dose – dose of radiation that is delivered continuously but at a lower
dose rate. Total duration of the treatment (number of days between the 1st and last
session)
1.8 – 2 Gy/day, 5 days a week – fractionation schedule for adults


HYPERFRACTIONATION/CONCOMITANT BOOST REGIMEN
- two times a day
CONTINUOUS HYPERFRACTIONATION ACCELERATED RADIOTHERAPY
- three times a day


Treatment
Factors for treatment
1. Tumor type
2. Tumor location
3. Stage
4. General health of patient
On completion of the planning stage, including simulation and dosimetry,

patient treatment can begin.
The radiation therapist positions the patient and aligns the skin marks
according to what was recorded in the treatment chart at the time of simulation.
Accuracy and attention to detail are critical for precise administration of the
radiation to the patient.

Precision in positioning the machine, accurate placement of cerrobend blocks
or wedges, and the implementation of any change in a patient's treatment plan are
critical for ensuring optimum treatment.
Failure to do any of these may result in an overdose to normal tissue, causing

long term side effects, or underexposure of the tumor, reducing the patient's chance
for cure.
Verification images, called port films or images, are taken on a weekly basis to
ensure accuracy and consistent application of the radiation treatment.

Radiation Therapist Responsibilities
• Interpreting the radiation oncologist's prescription
• Calculating the correct monitor units or timer setting
• To achieve a desired dose of radiation for each treatment field
• Recording the daily administration of the radiation and the cumulative dose to date
• monitoring the patient's physical and emotional well-being


Causes of Failure in Radiation Therapy
1. ERROR OF JUDGEMENT
• wrong diagnosis – wrong treatment
• failure to detect metastasis before exposing the patient to radical treatment for the primary tumor
2. ERROR OF OMISSION
• failure to give adequate level of dosage
3. ERROR OF COMMISSION
• habitual use of poor technique in time will be reflected in lower cure rate than might have been expected
• error in dose calculation
• badly positioned x-ray applicators which can lead to the so called “geographic miss” with an inevitable
result of failure to control growth.

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Evolve.

PRINCIPLES OF ISODOSE PLANNING

RT-311: RADIATION THERAPY

DANIELE CLYDE P. CACHA, RRT

PRINCIPLES OF ISODOSE PLANNING

• Doctor of medicine specializing in use of ionizing radiation in the treatment of

PRINCIPLES OF ISODOSE PLANNING

• Responsible for calibration and maintenance of the radiation-producing equipment.

PRINCIPLES OF ISODOSE PLANNING

• Responsible for obtaining radiographs or CT scans that localize the area to be

PRINCIPLES OF ISODOSE PLANNING

Cancer – malignant tumor that expands locally by invasion and systematically by

Neoplasia – new growth. Abnormal proliferation that is uncontrollable.

Neoplasm – abnormal growth of tissue which is palpable.

PRINCIPLES OF ISODOSE PLANNING

A. Complete remission – all signs and symptoms of cancer are gone

PRINCIPLES OF ISODOSE PLANNING

A. Local – reappears at the original site

B. Regional – returns at the vicinity near the previous tumor

C. Distant – located at areas farther from the previous tumor

PRINCIPLES OF ISODOSE PLANNING

1. Carcinoma – originating from epithelial tissue

2. Sarcoma – originating from connective tissue

3. Lymphoma – involves blood forming tissue

PRINCIPLES OF ISODOSE PLANNING

PRINCIPLES OF ISODOSE PLANNING

1. Unexpected weight loss – unexplained weight loss (about 10 lbs)

PRINCIPLES OF ISODOSE PLANNING

1. Grading – testing the aggressiveness or virulence of cancer cell

2. Staging – determine the extensiveness of the tumor

PRINCIPLES OF ISODOSE PLANNING

STAGE I, Small lesion confined to organ of origin with no evidence of

T – size of tumor N – spread of cancer (in nodes) M - metastasis

PRINCIPLES OF ISODOSE PLANNING

PRINCIPLES OF ISODOSE PLANNING

STEP 1. PATIENT IMMOBILIZATION

STEP 2. TUMOR TARGET VOLUME CENTER (ISOCENTRIC DEFINITION)

STEP 3. COMPUTE PLANNING AND TREATMENT DELIVERY

STEP 4. PLANNING IMPORTANT TREATMENT ACTION VERIFICATION

PRINCIPLES OF ISODOSE PLANNING

Depending on the patient treatment position or the precision required for

Immobilization devices have two fundamental roles:

1. To immobilize the patient during treatment

PRINCIPLES OF ISODOSE PLANNING

1. Thermoplastic mask (head) – made up of thermoplastic. When heated and placed

PRINCIPLES OF ISODOSE PLANNING

Thermoplastic mask Alpha cradle Breast board

PRINCIPLES OF ISODOSE PLANNING

PRINCIPLES OF ISODOSE PLANNING

A conventional treatment simulator has the capability to reproduce most treatment

PRINCIPLES OF ISODOSE PLANNING

Volume definition is a prerequisite for meaningful 3-D treatment planning and

PRINCIPLES OF ISODOSE PLANNING

1. Gross tumour volume (GTV)

PRINCIPLES OF ISODOSE PLANNING

The Gross Tumour Volume (GTV) is the gross palpable or visible/demonstrable

The GTV is usually based on information obtained from a combination of

PRINCIPLES OF ISODOSE PLANNING

PRINCIPLES OF ISODOSE PLANNING

PRINCIPLES OF ISODOSE PLANNING

The planning target volume (PTV) is a geometrical concept, and it is defined to

PRINCIPLES OF ISODOSE PLANNING

Graphical representation of the volumes of interest