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Peter Hirschi
DOS 523 Treatment Planning
February 27, 2015
1) SM (set-up margin) vs. 2) Internal Margins (IM)
In order to better understand set-up margin and internal margin a quick over view of how
volumes and margins were initially defined and how they have changed and evolved to what they
are today will be covered.
In 1979, the International Commission on Radiation Units and Measurements (ICRU) published
a report that defined the dose specification for reporting external beam therapy with photons and
electrons. Figure 1 shows the three classifications created, which includes: Irradiated Volume,
Treated Volume, and Target Volume.

Figure 1
In 1993, the ICRU published report 50 which better defined the target volume by breaking it into
3 parts shown in figure 2.

Figure 2

The 3 new classifications are defined as:

Gross Tumor Volume (GTV): Gross palpable or visible/demonstrable extent and location of
malignant growth.
Clinical Target Volume (CTV): An anatomical concept. Tissue volume that contains a GTV
and/or subclinical microscopic malignant disease that needs to be eliminated. This volume has to
be treated adequately in order to achieve the aim of therapy: cure or palliation.
Planning Target Volume (PTV): A geometrical concept. Defined to select appropriate beam sizes
and beam arrangements, taking into consideration the net effect of all the possible geometrical
variations and inaccuracies, in order to ensure that the prescribed dose is actually absorbed in the
CTV. Its size and shape depend on the CTV, but also includes any other factors that need to be
accounted for in order to ensure the CTV receives the proper dose, i.e. patient movement, linear
accelerator variations. 1
In 1999, ICRU report 62 was published which added the Internal Target Volume (ITV): Volume
encompassing the CTV and IM. (ITV = CTV + IM) Shown in figure 3.

Figure 3
ICRU also introduced classifications for the Internal Margin (IM) and set-up margin (SM).
The IM is the variation in size, shape, and position of the CTV relative to anatomic reference
points. The IM accounts for physiological changes to the CTV, like the filling of bladder for
prostate treatments. The CTV can change if the bladder is smaller or larger from day to day.

Another example of IM is lung tumor motion during respiration. A good example of IM being
accounted for is lung tumors done with a 4DCT scan. When a lung tumor is scanned with 4DCT,
a maximum intensity projection (MIP) can be created from the scan. A MIP shows the motion of
a tumor by tracking the motion of the higher density of the tumor within the lower density of the
lung.
Figure 4 shows two images. Image A shows a free breathing scan that shows the majority of the
tumor being in an inferior location. Image B shows a MIP that was created on the same lung
tumor. The MIP shows that the lung is moving superior to inferior. The red contour in Image B is
the ITV which includes the internal margin (IM) because the MIP shows exactly where the
physiological movement is taking place.

Figure 4
The orange line around the ITV is the PTV. The PTV accounts for setup error and penumbra.
When a physician says, put a .8 cm margin on an ITV or CTV, that margin accounts for setup
error. Accounting for setup error is also referred to as setup margin (SM). SM not only
includes the patients setup but also any other equipment factors like mechanical variations of the
linear accelerator.
Setup Margin can be broken into two categories. 1. Inter-Fraction: the variations from the
setting the patient up for treatments each day. Each day the therapist (no matter how skilled) sets
up a patient, there will be some variation in the patients position. This slight variation must be

accounted for. 2. Intra-fraction: this includes variations that occur after the therapist leave and the
patient is on the table. An example of this is when patients are tense while being positioned, after
the therapist leave the room some patients tend to relax more the longer theyre on the table, this
slight movement causes variation in the setup and also needs to be accounted for. Internal organs
may move slightly while the patient is being treated as well.

In conclusion, the Internal Margin and Setup Margin are

important concepts for accurate planning and treating. The
internal margin is added to the CTV to create the ITV.
While the setup margin (setup errors and machine
inaccuracies) is added to the ITV in order to create the
PTV.

At my clinical site the setup margin and internal margin are never mentioned by name. The
physician usually just tells the dosimetrist how much of a PTV margin to put on a treatment
volume. An easy way to remember is internal margin happens inside the patient. While setup
margin accounts for everything outside of the patient, like linear accelerator variations and daily
setup differences done by therapist. So if its a factor that doesnt occur in the patient then it falls
under setup margin. I found an insightful power point that talks about margins in radiation
therapy, which can be found at www.aapm.org/meetings/amos2/pdf/35-9817-23186884.pdf A concise explanation can also be found in Principles and Practice of Radiation

Therapy. 3rd ed. By Washington and Leaver on page 540.

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References:
1. Prescribing, recording, and reporting electron beam therapy: contents. J ICRU.
2004;4(1):5-9. DOI.

10.1093/jicru/ndh003 accessed February 17,2015

Figures 1-3, www.aapm.org/meetings/amos2/pdf/35-9817-23186-884.pdf accesssed

February 17, 2015
Figure 4, http://www.jthoracdis.com/article/view/2119/html accessed February 19,
2015