THE ICRU SYSTEM OF DOSE AND

DOSE REPORTING
ICRU Report 38 Dose and Volume
Specifications for Reporting
Intracavitary Therapy in
Gynecology

The ICRU System

n

Recommends that reference points like

Point A not be used because, such points
are located in a region where the dose
gradient is high and any inaccuracy in the
determination of distance results in large
uncertainties in the absorbed doses
evaluated at these points.

The ICRU System

n

Recommends that doses be reported in

terms of, total reference air kerma,
description of a reference volume, and
calculated values of dose to specific normal
tissue reference points within the treatment
volume.
Recommends a system of dose specification
that relates the dose distribution to a target
volume.

Definition of Target Volume for Only

Intracavitary Treatment
The Target Volume is
defined anatomically, and
contains those tissues that
are to be treated to a
specific dose according to a
specified time-dose pattern.
The target volume should
include the demonstrated
tumor and any presumed or
microscopic disease.

Tumor Volume

From ICRU. Dose and volume specification for reporting intracavitary therapy In gynecology. ICRU
reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and Measures, 1985.

Data for Reporting Intracavitary

Therapy--ICRU
Therapy
n
n
n
n
n

Description of the Technique

Total reference air kerma
Description of the reference volume
Absorbed dose at reference points
Time-dose pattern

DESCRIPTION OF THE TECHNIQUE

Description of the Technique

n

n
n

Described in terms of the radionuclide,

source strength, shape and filtration.
The applicator type.
The source arrangement.

TOTAL REFERENCE AIR KERMA

Total Reference Air Kerma

n

The total air kerma at 1 meter from the

implant.
Is equal to the air kerma strength times the
duration (in hours) of the implant.
Is analogous to mgRaeq-hr, which is the
total implanted activity times the number of
hours of the implant.

Total Reference Air Kerma

n

TRAK = total mgRaeq x hours (duration of

implant) x 8.25 (gamma for Ra-226) x
0.876 (cGy /R) = uGy m2.

DESCRIPTION OF THE
REFERENCE VOLUME

Definition of Target and Treatment

Volumes for Only Intracavitary Treatment
Target Volume
Treatment Volume

Tumor
Volume

Reference Volume is the

volume of the isodose surface
that just surrounds the
Target Volume.

From ICRU. Dose and volume specification for reporting intracavitary therapy In gynecology. ICRU
reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and Measures, 1985.

Definition of Target and Treatment

Volumes for Combined Intracavitary and
External Beam Treatment
Target Volume
of EBRT

Treatment Volume of
Intracavitary Treatment
Target Volume of
Intracavitary
Treatment

Treatment
Volume of EBRT

Tumor Volume

From ICRU. Dose and volume specification for reporting intracavitary therapy In gynecology. ICRU
reoprt no. 38 Bethesda, MD: International Commission on Radiation Unit s and Measures, 1985.

Description of the Reference Volume

n

The value of the isodose surface

prescription, based on the Paris experience,
is set at 60 Gy.
This prescription isodose value is
determined by the following two factors:

Description of the Reference Volume

n

1. The dose contribution from the external

beam treatment.
The contribution of the EBRT is subtracted
from the 60 Gy total dose, then a relevant
isodose surface from the intracavitary plan
is divided by the duration of the insertion.

Description of the Reference Volume

n
n
n
n

Example:
EBRT total dose = 40 Gy whole pelvis
60 Gy - 40 Gy = 20 Gy
20 Gy is the total dose to be delivered from
brachytherapy.
Thus 20 Gy / x hr = y cGy/hr isodose
surface.

Description of the Reference Volume

n

2. And the intracavitary portion of the

treatment in dimensions of height, width,
and thickness of the pear-shaped reference
volume.

Description of the Reference Volume

n

The dimensions of height, width, and

thickness of the pear-shaped reference
volume can be measured from the oblique
frontal and oblique sagittal planes.
The reference volume is approximated by
the equation ( dh x dw x dt ) cm3.

Determination of the Reference

Volume
Oblique Frontal Plane

Oblique Sagittal Plane

Pear-shaped
reference volume

Pear-shaped
reference volume

height

d
thickness

d width
From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRU report no. 38.
Bethesda, MD: International Commission on Radiation Units and Measures, 1985.

Description of the Reference Volume

n

Thus the determination of the reference

isodose volume is predominantly based
upon implant duration and external beam.

ABSORBED DOSE AT REFERENCE

POINTS

Absorbed Dose at Reference Points

n
n
n
n

Bladder Point
Rectal Point
Lymphatic Trapezoid of Fletcher
Pelvic Wall Points

Bladder Point
n

The bladder point is localized by using a

Foley catheter, with the balloon filled with
7 cc of a radiopaque fluid.
The catheter is then pulled downwards to
bring the balloon against the urethra.

Localization of Bladder and Rectal Points

from ICRU Report No. 38
balloon with 7 cc
of contrast

bladder reference point

on LAT film
tandem sources

vaginal sources
vaginal posterior
wall
0.5 cm from most posterior aspect of
system/packing
rectal reference point

From ICRU. Dose and volume specification for reporting therapy in gynecology.
ICRU report no. 38. Bethesda, MD: International Radiation Units and Measures, 1985.

Location of ICRU-38 Bladder Point

Y axis

On the Lateral film the

bladder point is obtained
X axis

on a line drawn
anteroposteriorly through
the center of the balloon
at the posterior surface.

center

Foley balloon
with 7 cc of
contrast

Location of ICRUICRU-38 Bladder Point

On the AP film the

bladder point is marked
at the center of the
balloon.
Foley balloon with
7 cc of contrast

Center of
foley
balloon

Location of ICRU-38 Rectal Point

Y axis

X axis

5 mm

Midpoint of activity
in the ovoids

On the Lateral film the

rectal point is located
on a line drawn from
the midpoint of the
activity in the ovoids ,
5 mm behind the
posterior vaginal wall.
The use of radiopaque
gauze for the vaginal
packing aids in the
visualization of the
posterior vaginal wall.

packing

Location of ICRUICRU-38 Rectal Point

Lower end of the

intrauterine source

The rectal point is

identified at the
midpoint of the activity
of the sources in the
ovoids or at the lower
end of the intrauterine
source.

Midpoint of the
activity in the ovoids

LYMPHATIC TRAPEZOID OF
FLETCHER

Lymphatic Trapezoid of Fletcher

n

n
n
n

Points corresponding to the following

nodes:
Mid-external iliac lymph nodes
Low common iliac nodes
Low paraortic nodes

10

Lymphatic Trapezoid of Fletcher

R. Para

2 cm
L4

L4
L. Para

1/2

L5

L5
L. Com

R. Com
S1S2

1/2
R. Ext

S1S2
1/2

L. Ext
6 cm

Symphysis

1/2

Symphysis
From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRU
report no. 38. Bethesda, MD: International Commission on Radiation Units and Measures, 1985.

PELVIC WALL POINTS

Pelvic Wall Points

n

On the AP film the pelvic wall points are

located at the intersection of a horizontal
tangent to the superior aspect of the
acetabulum and a vertical line touching the
medial aspect of the acetabulum.

11

Pelvic Wall Points

n

On the Lateral film these points are marked

as the highest mid-distance points of the
right and left acetabulums.
These points are selected to estimate dose to
the distal parts of the parametrium and the
obturator lymph nodes.

Definition of Pelvic Wall Points

Dose to distal parts of the parametrium and the obturator nodes.
Intersection of the superior aspect and the
medial aspect of the acetabulum

Rt. Pelvic wall

Highest middistance points of

the right and left acetabulum

Lt. Pelvic wall

AP Film

LAT Film

From ICRU. Dose and volume specification for reporting intracavitary therapy in gynecology. ICRY
report no. 38. Bethesda, MD: International Commission on Radiation Units and Measures, 1985>.

TIME--DOSE PATTERN
TIME

12

Time--Dose Pattern
Time
n

The duration and time sequence of the

implant relative to the external beam
treatment should be included.
Example: One 42 hour intracavitary implant
one week after EBRT completed.

CRITICISM OF ICRU REPORT 38

CRITICISM OF ICRU REPORT 38

Two pear-shaped
reference volumes

dheight
Region of
underdosage

By using ICRU dimensions of

maximum width, height, and
thickness for the evaluation of an
intracavitary system, regions of
underdosage may not be
recognized. However if the entire
surface of the intracavitary is
evaluated, regions of underdosage
can be recognized and addressed.

dwidth

13

The ICRU System

n

The ICRU is currently reexamining its

recommendations of dose specification and
is expected to issue a new report.

14