RADIATION THERAPY TREATMENT PLANNING
RT 312: RADIATION THERAPY | 2025 - 2026
Instructor: Ma’am Jhe Ann Gorada
Treatment planning is the critical link between the clinical intention and the practical delivery of radiation therapy. It
ensures that a prescription is put into practice in an optimized way, considering patient circumstances and available
resources.
PLANNING PROCESS OVERVIEW
CUES NOTES
Treatment Planning Treatment planning combines machine parameters and individual patient data to
customize and optimize treatment.
Requires: machine data, patient data input, and a calculation algorithm.
Produces: An output of data in the form of a treatment plan.
The goal is to optimize treatment for each patient using the available treatment
choices at a particular center. This involves integrating individual patient information
(e.g., anatomical outlines, disease site and size) with data for the treatment units.
PATIENT INFORMATION REQUIRED
CUES NOTES
● Radiotherapy is a localized cancer treatment, so precise knowledge of the
dose and accurate volume of delivery is essential for both tumors and normal
structures. Irradiation of normal structures can lead to intolerable
complications, making both volume and dose critical.
● The volume is a very important issue in predicting the Normal Tissue
Complication Probability (NTCP).
One Needs To Know 1) Target location.
2) Target volume and shape.
3) Secondary targets (potential tumor spread).
4) Location of critical structures.
5) Volume and shape of critical structures.
6) Radiobiology of structures.
Target Delineation The International Committee on Radiation Units and Measurements (ICRU)
provides guidelines for defining target volumes and reference points for dose
calculation.
GTV (Gross Tumor Volume)
➔ The volume containing the visible or clinically detectable tumor (e.g., on
examination or imaging). This is the smallest volume and may not be present
in every plan (e.g., adjuvant radiotherapy after tumor excision).
CTV (Clinical Target Volume)
➔ The volume is determined to require radiation treatment. It includes the GTV
plus areas of clinical risk (e.g., potentially involved lymph nodes or
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microscopic involvement around the GTV). The CTV should be included in
every plan.
ITV (Internal Target Volume)
➔ Includes a margin to account for physiological patient movements that
cannot be controlled during treatment (e.g., gut movement, heart beating,
respiration). This margin is the Internal Margin (IM). The ITV is a newer
concept that aims to separate internal patient factors from external factors.
Methods to reduce internal movements (e.g., respiratory gating) can
substantially reduce the ITV.
PTV (Planning Target Volume)
➔ An expansion from ITV to account for external treatment inaccuracies. This
distance is the External Margin (EM), which can vary by department and
treatment site (e.g., for body, for head and neck). Improving external
factors can reduce this margin and allow for smaller PTV expansions.
OAR (Organs At Risk)
➔ Volumes placed on organs that are susceptible to radiation damage. OARs
place constraints on beam arrangement and dose, as they have different
radiation tolerances.
The ultimate goal is to deliver the correct dose to the correct volume.
Dose Volume Histograms ➔ Are a way to summarize dose distribution information and describe the
(DVHS) desired dose distribution.
Ideal DVH aims for:
Tumor: High and homogeneous dose to all parts.
Critical organ: Low dose to most of the structure.
Need To Keep In Mind ● Always a 3D problem.
● Different organs may respond differently to different dose patterns.
● A key question is whether a small dose to all of an organ is better than a high
dose to a small part of an organ
TARGET DESIGN AND REFERENCE IMAGES
CUES NOTES
Target localization in radiotherapy practice uses various diagnostic tools:
Diagnostic procedures:
1) Palpation
2) X-ray
3) Ultrasound
4) MRI
5) PET
6) SPECT
7) CT scan
8) simulator radiograph.
Selection of ➔ Requires training and experience.
Treatment Approach ➔ May differ from patient to patient.
➔ Requires good diagnostic tools and accurate spatial information.
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➔ May require information from different modalities (e.g., palpation, biopsy,
multiple imaging types).
Diagnostic Tools ● CT scanner, MRI, PET scanner, US.
For Patient Data
Acquisition Simulator: Includes laser system, optical distance indicator (ODI). Many simulator
functions are also available on treatment units, but simulators require the same QA.
ROLE OF SIMULATION
A simulator is often used twice in the radiotherapy process:
I. Patient data acquisition: Target localization, contours, outlines.
II. Verification: To ensure the plan can be practically implemented. Acquisition
of reference images for verification. Simulators can be replaced by other
diagnostic equipment or virtual simulation.
Virtual Simulation
● All aspects of simulator work are performed on a 3D data set of the
patient.
● Requires high-quality 3D CT data of the patient in the treatment
position.
● Verification can be performed using Digitally Reconstructed
Radiographs (DRRs).
● Virtual simulation can be more cost-effective than a physical
simulator if a patient's CT scan is available.
This advanced virtual simulation involves a patient undergoing a CT scan,
with the clinician identifying the target while the patient is still on the couch.
The target localization information is then fed back to a movable laser
system, which indicates the center of the target on the patient, allowing for
in-situ marking and beam positioning.
Patient Marking
● Creates a relation between patient coordinates and beam
coordinates.
● Methods: Marks on shell, tattoos, skin markers.
● Marks must be easily visible, durable, and regularly redrawn if
deletable.
Digital Reconstructed ➔ a 2D image generated from a 3D CT dataset, simulating a conventional
Radiograph (DRR) radiograph. They are used for field definition and conformal shielding in
treatment planning.
Blocks
● are crucial for beam shaping and avoiding irradiation of normal
tissues. Clinicians use them to shield specific areas within a
rectangular radiation field.
● Generally, a higher number of beams allows for greater sparing of
individual tissues, as the tumor is the focus of all beams.
Beam weighting
● is a vital tool, often assigning higher weighting to beams closest to
the target.
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Wedges
● are beam modifiers that modify the radiation beam to achieve a
more homogeneous dose distribution within the target volume,
compensating for body curvature and tissue heterogeneities.
Simulator Film
● A simulator image is taken during a 'verification session' where the
treatment is set up on the simulator exactly as it would be on the
treatment unit. A verification film is taken in 'treatment' geometry.
a) Shows relevant anatomy.
b) Indicates field placement and size.
c) Indicates shielding.
d) Can be used as a reference image for treatment verification.
MACHINE DATA REQUIREMENTS FOR TREATMENT PLANNING
Machine data is crucial for accurate treatment planning and must be comprehensive and verified.
CUES NOTES
Key Data Elements 1) Beam description: Quality and energy.
2) Beam geometry: Isocenter, gantry, table positions.
3) Field definition: Source collimator distance, applicators, collimators, blocks,
MLC.
4) Physical beam modifiers: Wedges, compensators.
5) Dynamic beam modifiers: Dynamic wedge, arcs, MLC IMRT.
6) Normalization of dose
This data depends on the complexity of treatment approaches and available
resources for data acquisition. It can be from published data or acquired in-house,
but MUST be verified.
Machine Data ● Hardcopy: Isodose charts, output factor tables, wedge factors (for
Availability emergencies).
● Treatment planning computer: Standard planning data or beam models.
● Independent checking device: For example, MU checks with a completely
independent set of data.
Machine data should be kept in duplicate and preferably in different formats. It must
be dated, verified regularly, and its source (including the responsible person) must be
documented.
Machine Data Summary
➢ Must include all beams and options.
➢ Account for internal consistency, conventions, collision protection,
and physical limitations.
➢ Data can be made available in installments as needed.
➢ Some data may be required only for individual special treatments.
➢ Only verified data should be made available.
When multiple beams are used to treat the same volume, beam
weighting must be factored in. A common approach for correct
normalization is to ensure the weighting of all beams together equals
1.
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Compensators ➔ Modulate the photon fluence in different parts of the beam (a 2D map, unlike
the 1D wedge).
● Physical compensators: Lead sheets, brass blocks, customized
milling.
● Intensity modulation: Multiple static fields, arcs, dynamic MLC.
Intensity Modulation (IMRT)
➢ Allows for the optimization of dose distribution.
➢ Aims to make the dose in the target homogeneous and minimize
dose outside the target.
➢ Achieved using a Multi-Leaf Collimator (MLC), which can alter the
field shape either step-by-step or dynamically during dose delivery.
Basic Dose Calculation ➔ Once the target volume, beam orientation, and shape are defined, the next
step is to calculate the required beam-on time (for 60Co or X-ray units) or
monitor units (MUs) (for linear accelerators) to deliver the desired dose to the
target.
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