Chapter 10
TREATMENT PLANNING
RUSSELL J. HAMILTON, PHD, MARTIN E. LACHAINE, PHD, BENJAMIN ARMBRUSTER, BS
Treatment planning is an integral component of intensi-
ty-modulated radiation therapy (IMRT). As discussed in
Chapter 2, “Physics of IMRT,” there are a number of opti-
mization algorithms for IMRT, including gradient descent,
simulated annealing, iterative algebraic reconstruction,
and linear optimization. Each of these algorithms requires
a unique set of parameters to specify the target and nor-
mal tissue goals. Some of these parameters include the min-
imum or maximum dose, mean organ dose, and individual
dose-volume histograms (DVHs). Likewise, there are many
ways to adjust the relative importance of these parameters
to create a cost function. The large number of permuta-
tions available by combining an algorithm with a partic-
ular choice of optimization parameters and a cost function
has led to the emergence of a number of treatment plan-
ning systems, each with its own characteristics.
The aim of this chapter is to discuss the practical aspects
of IMRT planning that are applicable to all treatment plan-
ning systems, including the selection of beam energy and
orientation, planning techniques, and plan evaluation. A
brief description of commercially available planning sys-
tems is provided. Lastly, a methodology is proposed to sys-
tematically investigate the characteristics of one’s own
planning system.
Beam Energy Selection
Once the tumor and organs at risk (OAR) are contoured,
for nontomotherapy delivery techniques, the treatment
planner must make a decision on the number, energy, and
directions of treatment beams. It is common practice to
select a fixed set of five, seven, or nine equally spaced, nonop-
posing coplanar beams—the class solution approach. A
larger number of beams (eg, nine vs five) may produce a
more conformal plan, at the expense of treatment time and
complexity. Pirzkall and colleagues showed that for deep-
seated targets, the dose to both planning target volume
(PTV) and OAR does not depend significantly on the num-
ber of beams and/or energy.1 Instead, the main difference
149
occurs in regions far from the PTV. In these regions, the
dose is significantly increased for both a smaller number of
beams and for lower energy. They also demonstrated that
for nine beams or more, the energy dependence far from
the PTV was negligible. Therefore, for a five-field plan, one
may want to consider using higher-energy beams, such as
15 MV, but if one prefers to use nine fields, then a 6 MV
beam could be used with the same results.
When selecting appropriate beam energies, other effects
need to be considered.2 Followill and colleagues postu-
lated that there is an increased risk of secondary malig-
nancies in patients treated with beam energies of > 10 MV
owing to a higher neutron dose.3 However, the degree of
neutron production depends on the specific IMRT plan
parameters, including the number of segments and mon-
itor units (MUs). Moreover, the importance of consider-
ing secondary malignancies from IMRT treatments for any
energy beam has been raised, especially for pediatric cases,
for which IMRT may offer better dose conformity than
conventional planning.4–6 These aspects require further
investigation and scrutiny.
Beam Orientation Selection
It is well known from rotational radiation therapy and
stereotactic radiosurgery that the dose falloff outside the
PTV is not as sharp as the penumbra of a single photon
beam. The reason is that the dose gradient in the penum-
bra may be as high as 20%/mm, whereas photon attenua-
tion is on the order of 2 to 3%/cm. This is also true in IMRT
planning when a large number of fields are used. The dose
gradient away from the PTV for a nine-field IMRT plan is
less steep than is achieved with a well-designed static field
(conventional) plan. The advantage of more fields, and
IMRT in general, lies in the ability to better conform the
high-dose region to the shape of the target. If a high gra-
dient is required at a certain critical interface, then careful
selection of beam angles is important. This phenomenon
can sometimes be observed when comparing the DVH of
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IMRT plans to three-dimensional conventional plans. The
DVH of an IMRT plan is often better in the high-dose region
owing to the high degree of dose conformity, whereas the
conventional plan is often better in the low-dose region
because the field placement is usually arranged specifical-
ly to cause a sharp dose falloff near a critical structure.
It is common in IMRT to use standard sets of coplanar
beams. Although this is convenient, it does not always yield
the best results. Price and colleagues studied the use of non-
coplanar beam orientations for prostate IMRT.7 In a typ-
ical plan, they demonstrated that the use of noncoplanar
fields resulted in a 15 to 25% decrease in dose to the hottest
portion of the rectum compared with coplanar field arrange-
ments. Furthermore, a seven-field noncoplanar IMRT tech-
nique produced increased bladder sparing compared with
standard field arrangements.
The optimal selection of coplanar beam arrangements
has been intensely investigated, and a number of meth-
ods have emerged.8–11 Beam orientation optimizers use a
variety of parameters and cost functions, spanning a range
similar to the overall problem of IMRT dose optimization.
Rowbottom and colleagues developed an optimization algo-
rithm that finds the best beam arrangement for a small
number of fields and was designed to avoid orientations
that pass through OAR with low radiation tolerance.11 Das
and colleagues used an unconstrained objective function
based on equivalent uniform dose in combination with
DVH constraints of critical OAR.8 In a series of articles and
in Chapter 2, combinations of several different parameter
sets and cost functions were shown to be effective in select-
ing optimal beam orientations.10,12,13 One method that
combined prior geometric and dosimetric knowledge was
FIGURE 10-1. Illustration of the dosimetric
effect of beam angle selection. (A) Rendering
of a tumor located near the optic nerve and
chiasm. (B) The best intensity-modulated radi-
ation therapy (IMRT) plan generated using a
coplanar beam arrangement. (C) Conventional
plan using noncoplanar beams. (D) An IMRT
plan using the noncoplanar beams from C. (To
view a color version of this image, please refer
to the CD-ROM).
shown to be computationally efficient and hence is promis-
ing for eventual clinical implementation.13 Most of the
methods employed for coplanar beam orientation opti-
mization have also been demonstrated to work for opti-
mization of noncoplanar beams as well.
Because commercial IMRT planning systems do not offer
beam orientation optimization, important practical ques-
tions remain. In particular, when should noncoplanar beams
be used, and how are their directions selected? Noncoplanar
beams should be considered when the path to the PTV for
most coplanar beam orientations intersects critical organs.
In these cases, constructing a three-dimensional conventional
plan provides valuable insight into beam angle selection and
also sets a standard for a potential IMRT plan to beat. Figure
10-1A shows an example of a tumor located near the optic
apparatus. The best IMRT plan obtained using coplanar beams
is shown in Figure 10-1B. This plan was deemed unaccept-
able owing to the significant amount of intermediate-dose
spread into the left optic nerve. With conventional three-
dimensional planning, the best approach would be to use
noncoplanar beams.Although the dose distribution produced
with a noncoplanar conventional plan does not provide ade-
quate coverage owing to the OAR constraints (Figure 10-1C),
it does provide a useful set of beams to be used for IMRT
planning. The optimal IMRT plan was determined using the
same beam directions as the noncoplanar conventional plan
(Figure 10-1D). The target is fully covered, a sharp dose gra-
dient anterior to the PTV spared the left optic nerve, and the
volume of intermediate dose was small. These features were
improvements on the three-dimensional conventional plan
and were achieved by using the same angles determined by
an experienced conventional planner.
 Treatment Planning / 151

Planning Techniques consisting of the PTV inside the rectum to reduce hot spots
near the prostate-rectum interface. Two planning struc-
Once the energies and beam orientations are selected, the
tures, post1 and post2, were defined for this purpose in the
planner must define objectives and/or constraints for the
IMRT prostate example illustrated in Figure 10-2. Post 1
optimizer. Depending on the planning system, this could
is the volume of rectum that is not in the PTV but is in the
consist of dose-volume objectives, weights describing the
collar. Post 2 is the volume of rectum that is not in the PTV
importance of each objective, minimum and maximum
or in the collar. Separate dose-volume constraints were
target dose values, mean organ doses, or maximum OAR
placed on these structures during the optimization process.
dose values. The problem is that although these directives
can satisfy appropriate PTV coverage or keep sensitive struc-
tures to certain dose levels, it is difficult to ensure adequate Selection Criteria
dose falloff outside the PTV. In this case, the optimizer will
A major difference between conventional and IMRT plan-
not pay too much attention to the relatively small volume
ning is that in the former, the planner is continually eval-
of this tissue directly surrounding the PTV unless speci-
uating the quality of a plan during its construction, whereas
fied in the constraints. One common solution to this prob-
in the latter, control of the optimization process is governed
lem is the use of a strategically drawn “planning structure”
by a computer algorithm attempting to minimize a cost
surrounding the PTV. Dose objectives lower than the PTV
function. The implication of this difference is that for IMRT,
can be imposed on such a structure to guide the optimiz-
the planner must encode all of the desired components of
er in producing a sharper falloff. For planning systems that
a treatment plan into a few numbers that are used as input
permit structures to have “holes,” a simple doughnut shape
for the planning system. Furthermore, this must be done
around the contour will suffice. Otherwise, this may be
such that the value of the cost function computed by the
accomplished with either a horseshoe-shaped planning
IMRT planning system is lower for preferred plans.
structure or by expanding the PTV by a known margin.
The available parameters are planning system depen-
For the latter option, any dose objective on the planning
dent, as are the effects of weighting and priority factors.
structure must account for the dose objective of the PTV
The actual cost function is often a “black box” to the plan-
because the PTV is inside the structure, making an appro-
ner. Furthermore, only a limited amount of information is
priate selection of constraints difficult.
encapsulated in the planning parameters, and the system
If dose-volume objectives are available in the planning
may ignore an obvious deficit in a plan because it was not
system, one solution is to allow a fraction, f = VPTV/Vstruct,
assigned a cost. Conventional experience and intuition are
of the planning structure to be greater or equal to the pre-
scription dose, whereas the objective dose is lowered for
the rest of the planning structure (VPTV and Vstruct are
the PTV and planning structure volumes, respectively).
This technique was employed for increasing the dose gra-
dient for the prostate cancer IMRT plan shown in Figure
10-2. The planning structure, labeled collar, was introduced
around the PTV and a dose constraint was placed on it,
improving the gradient in the anterior and lateral direc-
tions where the PTV is surrounded by unspecified normal
tissue.
In addition to ensuring dose falloff outside the PTV,
planning structures can serve a variety of purposes, for
instance, to reduce hot spots in a certain region of the PTV
(eg, the urethra for a prostate cancer case) or to eliminate
high-dose regions appearing far from the PTV or other
critical structures. Another common use of planning struc-
tures is in overlap regions, such as when the PTV overlaps
the rectum in a prostate IMRT plan. In such a case, instead
FIGURE 10-2. Illustration of the use of “planning structures.” The gross
of setting conflicting objectives and constraints on each of
tumor volume (GTV) and planning target volume (PTV) are shown in yel-
the overlapping structures and having the optimizer decide
low and magenta, respectively. The PTV is expanded to produce a struc-
on a tradeoff, the planner can create a planning structure ture, denoted as “collar” (gray), which is used to conform the dose to
consisting of the rectum minus the PTV, possibly with a the shape of the PTV. Other planning structures include Post 1 and Post
margin between to allow for the dose gradient. This makes 2 (both gray), which are used to improve the dose gradient though the
selection of appropriate goals and constraints manageable. rectum (red). (To view a color version of this image, please refer to the
It may also be useful to define another planning structure CD-ROM).
152 / Intensity-Modulated Radiation Therapy
not easily transferred to IMRT planning. The phrase “a pic-
ture is worth a thousand words” aptly captures the distinc-
tion. The influence of the topology of the dose distribution,
including locations of hot and cold spots, on the expected
treatment outcome is easily appreciated and evaluated when
a skilled dosimetrist reviews a plan. However, IMRT plan-
ning systems cannot see the big picture because they are lost
in the details of the cost function. Therefore, the planner is
forced to explore the solution space for various input para-
meters that will result in a desirable plan. The planner must
make quantitative decisions that are neither intuitive nor
knowledge based. For example, one may need to commu-
nicate to the planning system the relative importance of keep-
ing the mean kidney dose to < 20 Gy versus the maximum
cord dose to < 45 Gy. This is precisely why, when begin-
ning a new IMRT program or when moving to a new treat-
ment site, the initial time investment is large and why taking
advantage of workshops focusing on a particular IMRT plan-
ning and delivery systems is warranted.
It is also essential to establish IMRT planning goals and
selection criteria for each treatment site that are indepen-
dent of the hardware and software. These goals may be
obtained by reviewing the treatment records of patients
treated with three-dimensional conventional radiation ther-
apy at an individual center. There are now established pro-
tocols (Radiation Therapy Oncology Group [RTOG]
H-0022 and 0225) and peer-reviewed articles on IMRT that
may also provide starting points for establishing goals.
These goals may include the maximum acceptable dose
delivered to an organ and the fraction (or absolute volume)
of that organ receiving a particular dose. The goals must
also include values for the PTV, clinical target volume, and
gross tumor volume.
Establishing general plan selection criteria that are uni-
versally applicable is difficult, even for a single treatment
site. This is because the medical history of patients often has
a significant impact on their care. However, site-specific
guidelines are useful to structure the planning process.
Developing criteria is relatively straightforward for sites with
a limited number of planning goals. In the treatment of
prostate cancer, for example, the planning goals may involve
the percentage of the PTV receiving the prescription dose,
the maximum rectal dose, the volume of bladder receiving
a certain dose, and the magnitude of any hot spots outside
these structures. Thus, ranking the importance of these goals
may be enumerated in a few statements. For complex regions,
such as the head and neck, the number of organs is increased
and different dose-volume relationships are involved, so
that enumerating all possibilities is not productive a priori
because it is not known what is achievable by the planning
system. In these cases, although the specification of only a
few key criteria may be possible, it is still useful.
To meet the often stringent dosimetric goals and con-
straints imposed by the user, the optimizer may use field
segments, which are either very small in aperture area or
have a very low number of MUs. This may create discrep-
ancies between doses planned and actually delivered. Some
planning systems have the ability to set minimum values
for these parameters. The appropriate values vary depend-
ing on the linear accelerator used; therefore, accelerator-
specific values should be determined experimentally.
Another issue that takes even more importance when plan-
ning IMRT is the review of the isodose lines of a candidate
plan. In three-dimensional conventional planning, the high-
dose volume is confined to the geometric intersection of
the beams. In IMRT, the strong variation of fluence across
fields can create unexpected volumes of high dose far out-
side the general area of beam intersections. For this reason,
it is advisable to carefully examine the dose distribution on
every slice of the planning scan. One instance in which the
generation of unexpected hot spots can become of particu-
lar importance is when part of the PTV is very superficial.
Forcing the optimizer to completely cover the PTV will like-
ly produce extremely heavily weighted segments. In this sit-
uation, regions near the surface (< 5 mm depth) may receive
a high dose. However, many dose calculation algorithms are
not reliable at shallow depths. If PTV coverage is truly indi-
cated, a better solution may be to apply a bolus.
Finally, based on the selection criteria, an IMRT plan
should be better than a conventional plan before it is used.
The comparison must be made using identical volume def-
initions for all structures. For example, it is not permissi-
ble to use tighter margins between the clinical target volume
and the PTV for IMRT planning than are used in conven-
tional planning, unless the immobilization and localiza-
tion process is different between the two. Thus, a
conventional plan should be constructed for each case,
unless experience clearly dictates that IMRT is warranted.
Commercial Planning Systems
Listed below is a brief description of the commercially avail-
able IMRT planning systems as provided by the individual
manufacturers. A summary of these planning systems is
also provided in Table 10-1.
BrainLAB
BrainLAB (Heimstetten, Germany) IMRT is a component
of the BrainSCAN treatment planning system (Figure 10-
3). Planning begins after the user has defined all of the tar-
gets and relevant OAR. The planning goals are entered in
the form of dose-volume constraints (ie, DVHs) for the
PTVs and OAR. Other user-defined options include a vari-
able calculation grid size, selection between dynamic or
static delivery, resolution of the IMRT fluence map, opti-
mization of the tongue-and-groove effect, and relative
importance weighting between at-risk organs. In addition,
normal tissue around the PTV can be easily defined as an
OAR for which a constraint can be set. This will reduce the
high-dose areas around the PTV.
 Treatment Planning / 153

TABLE 10-1. Intensity-Modulated Radiation Therapy Planning Systems

Company (Web Site) Product Input Parameters Dose Calculation Optimization Plan Evaluation Unique Features
BrainLAB BrainSCAN DVH constraints Pencil beam algorithm Dynamically Isodose distributions, 4 plans calculated
(www.brainlab.com) penalized likelihood DVHs simultaneously
CMS Inc. XiO IMRT Dose, dose-volume Pencil beam algorithm Conjugate gradient Isodose distributions, Ability to generate
(www.cmsrtp.com) constraints DVHs; review MLC compensator files
segments
Elekta Inc. PrecisePlan DVH objectives Modified Clarkson Cimmino algorithm Isodose distributions, Delivery optimized
(www.elekta.com) and priorities algorithm DVHs; review of with automatic
beams, segments segment ordering
North American Scientific, CORVUS DVH constraints, Pencil beam or Monte Gradient, discrete Isodose distributions, Ability to modify
NOMOS Radiation Oncology tissue types Carlo algorithm and continuous DVHs isodose distribution
Division annealing interactively
(www.nasmedical.com)
Philips Medical Systems Pinnacle-PRO Minimum and Collapsed cone Sequential quadratic Isodose distributions, Includes biologic
(www.medical.philips.com) maximum doses, convolution programming for DVHs optimization
penalties superposition nonlinear problems
Prowess Inc. Panther DVH constraints, Convolution, Simulated annealing Isodose distributions, Can produce intensity-
(www.prowess.com) DAO IMRT number of superposition DVHs modulated fields
apertures/beam using jaws only
RAHD Oncology Products 3-D/Pro, DVHs, penalty Multikernel pencil Gradient algorithm Isodose distributions, Leaf sequencing
(www.rahd.com) KonRad factors beam algorithm DVHs incorporated into
inverse planning
Siemens Medical Solutions KonRad Dose-volume Multikernel pencil Gradient algorithm Isodose distributions, IMRT-specific report
(www.siemens.com/oncology) constraints and beam algorithm DVHs, plan statistics feature
limits
TomoTherapy, Inc. Hi-ART DVHs, user- Convolution, Iterative least Isodose distributions, CT acquired at time
(www.tomotherapy.com) defined treatment superposition squares DVHs of treatment and
variables daily plan modification
Varian Medical Systems Eclipse DVH constraints Pencil beam Gradient Isodose distributions, Interactive planning
(www.varian.com) convolution optimization DVHs

Adapted from Palacio M. IMRT treatment planning systems. Adv Imaging Oncol Admin 2004;14(4):56–9.
CT = computed tomography; DVH = dose-volume histogram; MLC = multileaf collimators.

FIGURE 10-3. The BrainSCAN treatment

planning environment. (To view a color ver-
sion of this image, please refer to the CD-
ROM). Courtesy of Franz Gum, BrainLAB.
154 / Intensity-Modulated Radiation Therapy
BrainSCAN’s optimization algorithm is known as the
dynamically penalized likelihood (DPL) estimator. The DPL
evolved from the well-known maximum likelihood esti-
mator with dynamically changing penalization terms. Based
on statistical estimation theory, the minimization of errors
between desired and delivered doses is equivalent to a least
squares minimization, except that the DPL yields only non-
negative beamlets and does not get trapped in local mini-
ma of the cost function (ie, it always converges to an optimal
solution). Through this algorithm, beam delivery condi-
tions imposed by the MLC and avoidance of hot spots in
normal tissues are optimized inside the inversion loop.
The BrainSCAN pencil beam (PB) algorithm is based on
the assumption that the photon scatter is implicit to the
beam data measurements and does not vary significantly
with the depth in a medium. The algorithm is a further
development of the work of Mohan and colleagues.14 The
incident beam is divided into many small beamlets, for which
an individual radiologic path length correction is performed
to take tissue inhomogeneities into account. These polyen-
ergetic PB kernels are transformed to momentum space by
fast Fourier transformation (FFT) for a two-dimensional
convolution with the fluence distribution of the beam.
The BrainSCAN leaf-sequencing algorithm is based
on the algorithm published by Bortfeld and colleagues.15
Dynamic multileaf collimator (MLC) IMRT has been imple-
mented as an extension of the published algorithm. This
implementation additionally accounts for the MLC trans-
mission and minimizes the leakage between opposing and
neighboring leaves. The dosimetric problem associated with
the tongue-and-groove design of the MLC is also addressed,
and the synchronization is achieved without increased
beam-on time.
BrainSCAN’s IMRT system provides the automatic and
simultaneous calculation of four different plans for imme-
diate plan comparison. This allows the clinician to be able
to choose the best plan for the particular patient without
time-consuming recalculations should the plan not suit all
requirements. The four plans differ by having a different
importance weighting of PTV and OAR constraints. Plan
evaluation tools include isodose distributions overlaid on
computed tomography (CT) slices and DVHs.
Computerized Medical Systems Inc.
Computerized Medical Systems (CMS) Inc.’s (St. Louis, MO)
XiO is a three-dimensional treatment planning system that
incorporates modern dose calculation algorithms with an
intuitive user interface driven by icons and “drop-down”
menus. XiO can be used for a variety of planning tasks, rang-
ing from simple point dose calculations to three-dimen-
sional conformal and complex IMRT plans (Figure 10-4).
In XiO IMRT, which uses a conjugate gradient opti-
mizer, the cost function is composed of the sum of objec-
tive functions. Each objective function, or simply
“objective,” is an anatomy-specific function that establishes
dose goals (eg, the PTV should receive at least 60 Gy and
no more than 66 Gy, and the spinal cord should receive no
more than 45 Gy) or dose-volume goals (eg, no more than
40% of the liver should receive more than 50 Gy). IMRT
dose constraints are entered either through a spreadsheet
or an interactive graph. Minimum, maximum, and goal
dose constraints can be entered for target volumes.
Maximum, dose-volume, and dose-threshold constraints
can be entered for OAR. Importance weights and penalty
powers can be specified for each dose minimum, maxi-
mum, and volume constraint.
FIGURE 10-4. The XiO IMRT planning inter-
face. (To view a color version of this image,
please refer to the CD-ROM). Courtesy of
Therese Munger, CMS Inc.

Beamlet doses are calculated using a variation on the
PB algorithm. The total energy released per unit mass
(TERMA) is computed as is normally done for convolu-
tion-based algorithms. This TERMA is then convolved with
a simple two-dimensional analytic formula shown to pro-
duce self-consistent PB profiles.16 These “fast” PBs are then
corrected so that they yield the same summed result as the
original, unmodulated field dose calculation. Dose is cal-
culated using a very accurate fast Fourier transformation,
superposition, or fast superposition algorithm (user select-
ed). Therefore, the XiO PB calculation has the favorable
property that it reproduces the characteristics of its base
photon calculation. Existing dose (eg, when using IMRT
for a boost to a three-dimensional conventional plan) may
also be accounted for during the optimization process (the
user controls this), and the original beams are unaffected
by the optimizer. Tradeoffs between optimization speed
and plan accuracy are made by specifying the resolution of
the optimization grid, the scatter extents of the beamlets,
and the size of the beamlets.
The resulting intensity maps can be displayed, edited,
made discrete, and exported. Changes in the optimized
intensity map, either through manual editing or dis-
cretization, are reflected in the updated isodose distribu-
tion. Optimized intensity maps can be automatically
extended to account for tissue swelling and respiratory
motion (useful for breast or head and neck IMRT plans).
The user can control the minimum size of MLC segments
and the number of intensity levels onto which the intensi-
ty map is discretized prior to segmentation. At the end of
FIGURE 10-5. Example of aperture opti-
mization using the PrecisePLAN system. (To
view a color version of this image, please
refer to the CD-ROM). Courtesy of Timothy
Prosser, Elekta Inc.
Treatment Planning / 155
the final dose calculation, the user has the option of send-
ing the beams (with the actual segments) back to the opti-
mizer to fine-tune the beam weights.
Plan evaluation tools offer the ability to compare the
optimized dose with the final dose; view, print, and edit
intensity and fluence maps; and review MLC segments (with
the ability to delete unwanted segments and view and print
the leaf positions of any or all segments), as well as a plan
summary, which includes the beam setup, dose calculation
parameters, IMRT prescription, and MU information. MLC
segments are sent to the record and verify system via
DICOM (Digital Imaging and Communication in
Medicine). Milling machine files can also be generated
for compensating filters.
Elekta Inc.
Elekta Inc.’s (Norcross, GA) PrecisePLAN uses an aperture-
based inverse planning method for IMRT optimization that
incorporates human intuition into the planning process
(Figure 10-5). This technique is a natural extension to exist-
ing three-dimensional conformal practices and yields a rel-
atively small number of beam segments. The user specifies
DVH objectives and priorities for the PTV and normal tis-
sues. The apertures are then created in two phases. In the
initial phase, the system automatically creates geometric
segments using user-directed preferences for structure inclu-
sion or exclusion. After running the optimizer (Cimmino
algorithm), a second set of segments is created that targets
residual low-dose regions. The optimizer is run again, after
which more dose-based apertures can be drawn if desired.
156 / Intensity-Modulated Radiation Therapy
The collimator is free to rotate between segments so that
the MLC leaves may optimally conform to the requested
MLC shape in either phase of segment creation.
IMRT is an extension of existing practice, and many
daily cases may be non-IMRT; some patients may have part
IMRT, part non-IMRT. Often a patient’s treatment may
start with a three-dimensional conformal plan, and then a
boost plan will be done using IMRT. For patient safety and
convenience, these are maintained as a single composite
plan within PrecisePLAN. With the “fraction groups” fea-
ture, such a composite plan can be easily calculated, and
the dose contribution associated with each treatment phase
is maintained independently. The optimizer considers the
dose to previously irradiated structures together with boost
plan constraints as it calculates the composite plan. Fraction
groups enable beams to be grouped together for different
phases of treatment, such as initial treatment and boost.
Having these fraction groups available enables composite
plans using IMRT to be quickly and easily created.
During optimization, the planner is able to interact with
the optimizer, view intermediate results, make adjustments
when necessary, and observe the DVH approach dose objec-
tives. Optimization continues until the rate of change drops
beneath the threshold or a fixed number of iterations is
reached. It may, however, be stopped at any time if a lack
of progress indicates that the input segments need to be
improved or the objectives reconsidered. The optimizer
retains all progress and, once changes are made, resumes
calculating where it paused. Dose is calculated using a mod-
ified Clarkson integration algorithm. Plan evaluation tools
include image review of the beams or segments using dig-
itally reconstructed radiographs, DVH comparison, and
simultaneous, multiple-plane isodose evaluation.
North American Scientific (NOMOS)
North American Scientific, NOMOS Radiation Oncology
Division (Cranberry Township, PA) pioneered IMRT with
the introduction of the CORVUS inverse treatment plan-
ning system in 1994. Originally, CORVUS was used as part
of the PEACOCK system, NOMOS’s tomotherapy plan-
ning and delivery system. Shortly thereafter, CORVUS added
capability to plan IMRT treatments using conventional sta-
tic and dynamic multileaf collimation (Figure 10-6).
In the CORVUS planning system, the user prescribes
objectives that are presented as a cumulative DVH. For each
target, the user specifies the minimum and maximum allow-
able dose, the goal dose, and a percentage of the volume
that the user will tolerate receiving less than the goal dose.
For each OAR, the user specifies the maximum allowable
dose, the limit dose, and a percentage of the volume that
the user will tolerate receiving more than the limit dose.
Also, for each OAR, the user specifies a minimum dose,
below which the organ receives no detrimental damage.
The user also specifies the tissue type of each target or
OAR. The type selected influences the objective function
parameters that will be used for evaluating the fitness of
the planned dose distribution. In the case of targets,
CORVUS provides for specialized target types intended for
intensity-modulated radiosurgery, highly uniform dose
distributions (homogeneous), targets that surround other
targets (surround), targets that should be ignored (refer-
ence), and standard targets (basic). In the case of OAR,
CORVUS provides for specialized tissue types intended for
parallel organs (BU), critical organs (critical), organs that
should be ignored (reference), organs that are expendable
to meet the target objective (expendable), and standard
OAR (basic).
FIGURE 10-6. Modification of the 70% iso-
dose line using ActiveRx in the CORVUS plan-
ning system. The user adjusts the 70% isodose
line extending into normal tissue by “drag-
ging” the dose toward the PTV. The fluence
maps are automatically modified in this
process. (To view a color version of this image,
please refer to the CD-ROM). Courtesy of
Robert Hill, North American Scientific,
NOMOS Radiation Oncology Division.

CORVUS supports multiple optimization algorithms,
which can be selected by the user. A gradient algorithm can
be employed, which produces smoother intensity distrib-
utions that require fewer MUs and segments but produces
a less conformal dose distribution. A discrete annealing
algorithm is also available, which results in slightly more
complex plans than gradient algorithms but with improved
dose conformity. Lastly, the system supports a continu-
ous annealing algorithm, which produces highly confor-
mal and complex treatment plans.
The user may specify a tradeoff between delivery com-
plexity and dose conformity using a number of controls
and methods. For example, the FAST IMRT delivery con-
trol includes a term in the objective function that causes
plans with higher delivery complexities to be penalized
when compared with plans with lower delivery complexi-
ties. In the case of tomotherapy treatments, FAST IMRT
allows the user to control the number of MUs used in the
plan. For static or dynamic multileaf collimation, FAST
IMRT allows the user to reduce the segment count as low
as one segment per beam, should that be desired.
CORVUS uses advanced PB dose calculation software
specially designed to improve dosimetric agreement over
the range of field sizes used in IMRT treatments. In addi-
tion, CORVUS has integrated support for PEREGRINE,
North American Scientific’s Monte Carlo–based dose cal-
culation system. PEREGRINE can be used as a replace-
ment for the CORVUS PB dose calculation software or
as a quality assurance tool to verify that the dose distrib-
ution calculated by CORVUS is correct.
After the plan is optimized, leaf sequencing commences.
CORVUS includes several leaf sequencing algorithms, each
specifically tuned to maximize the quality of the plan for
each delivery system. Leaf sequencing includes corrections
for the tongue-and-groove effect, differences between the
light and radiation field, and partial transmission through
MLC leaves, to create a treatment plan that matches the opti-
mized intensity distribution to the maximal possible extent.
A number of plan evaluation tools are available, includ-
ing two- and three-dimensional isodose displays, DVHs,
statistical outputs, digitally reconstructed radiographs, and
treatment plan summaries. At this point, the user must
decide if the plan is acceptable as is or if changes are required.
If changes are required, CORVUS includes ActiveRx, which
allows real-time modification of the optimized treatment
plan by sculpting or dragging isodose lines, erasing hot or
cold spots, dragging DVHs, or constraining minimum or
maximum doses to targets or OAR. ActiveRx uses advanced
plan sampling and optimization techniques to provide treat-
ment plan optimization to modify the plan based on a user
request in just a few seconds and immediately provides feed-
back to the user by automatically updating dose distribu-
tions, statistics, and cumulative DVHs.
After arriving at an acceptable treatment plan, CORVUS
allows the user to specify one or more systems to which
Treatment Planning / 157
plan information can be transferred, including record and
verify systems, various delivery systems, and image-guided
therapy systems, such as North American Scientific’s BAT
(B-mode acquisition and targeting) system. The transport
mechanism may use a DICOM network transfer, a vari-
ety of other network protocols, or a floppy disk as direct-
ed by the user.
Philips Medical Systems
The Pinnacle3 treatment planning system from Philips
Medical Systems (Andover, MA) provides integrated three-
dimensional planning, CT simulation, and IMRT inverse
planning (Figure 10-7). Inverse planning is performed using
the P3IMRT software module developed in partnership
with RaySearch Laboratories AB in Stockholm, Sweden.
For targets, the clinical objectives for an optimized plan
are expressed in terms of minimum dose, maximum dose,
minimum dose to a given volume, maximum dose to a
given volume, and uniform dose. For OAR, any combina-
tion of maximum dose and maximum dose to a given vol-
ume may be used. A weight or penalty factor is assigned to
each objective to reflect its importance in the overall treat-
ment objective. P3IMRT also allows for the use of con-
straints (objectives that must not be violated) during
optimization. Any dose-based objective can be specified as
a constraint except the uniform dose objective, but a uni-
formity constraint can be used to force the dose within the
volume to vary by less than a specified percentage. A bio-
logic optimization and review module adds the ability to
combine generalized equivalent uniform dose objectives
with dose-based objectives and constraints.
The optimization algorithm divides the beam’s eye view
of the targets for each beam into a series of finite-sized
beamlets. The corresponding weights of the beamlets are
optimized to produce a fluence or intensity map for each
beam. During optimization, the Delta Pixel Beam dose
computation is used to determine the dose from the inten-
sity-modulated beam.17 The quality of the plan is scored
based on the predefined treatment goals to achieve a bal-
ance between adequate target coverage and sparing OAR.
In addition to intensity modulation optimization, beam
weight and segment weight optimization are also available.
The P3IMRT optimization engine uses NPSOL, a sequen-
tial quadratic programming algorithm for solving gener-
al nonlinear optimization problems.18,19 The generated
fluence map is a transmission filter expressed as the rela-
tive intensity between the intensity-modulated beam and
the open beam exiting the treatment head. Each fluence
map is discretized over a grid (typically 5 mm resolution).
The weight of the corresponding beam elements (pixels)
constitutes the optimization variables.
Pinnacle3 uses a collapsed cone convolution superposi-
tion (CCCS) computation to determine the dose distrib-
ution from external photon beams. The CCCS dose model
is a true three-dimensional dose computation that intrin-
158 / Intensity-Modulated Radiation Therapy
FIGURE 10-7. A treatment plan produced using the P3IMRT planning system. (To view a
color version of this image, please refer to the CD-ROM). Courtesy of Todd McNutt, Philips
Radiation Oncology Systems.
sically handles the effects of patient heterogeneities on both
primary and secondary scattered radiation. This compu-
tation method is inherently able to account for dose dis-
tributions in areas in which electronic equilibrium is
perturbed, such as tissue-air interfaces and tissue-bone
interfaces. Because IMRT requires both fast and accurate
dose calculation, a hybrid dose calculation of the CCCS
and a finite PB technique, Delta Pixel Beam, are used to
maintain CCCS accuracy while providing speed for IMRT
optimization.
P3IMRT allows for both step-and-shoot and sliding win-
dow conversions. A direct machine parameter optimization
module provides the ability to directly optimize MLC leaf
positions and segment weights during the optimization
process. This offers the potential to produce step-and-shoot
plans with a minimum number of segments and total MUs.
Pinnacle3 offers a number of plan evaluation tools, includ-
ing DVHs for single or multiple plans, side-by-side isodose
comparison between competing plans, tumor control prob-
abilities, and normal tissue complication probabilities.
Prowess Inc.
Prowess, Inc. (Chico, CA), in cooperation with the University
of Maryland, has developed direct aperture optimization
and incorporated the technology into its two Prowess
Panther IMRT treatment planning products (Figure 10-8).
One product, DAO IMRT, uses an MLC, whereas the other,
Jaws-Only IMRT, requires only the jaws of the linear accel-
erator to shape the beams.
The user prespecifies the number of apertures to deliv-
er from each beam direction. Input parameters include DVH
constraints for target volumes, critical volumes, the num-
ber of beams, the number of apertures per beam, and the
prescribed dose. The physical limitations of the MLC are
also taken into account during the optimization process, so
the constraints are machine specific rather than generic.
Using a simulated annealing algorithm, a technique is used
that simultaneously optimizes the leaf positions and weights
of the apertures rather than the relative weights of the PBs.
Leaf sequencing is eliminated, and the resulting plans have
significantly fewer segments. The objective function can be
in the form of a dose, DVHs, or a biologic function.
DAO IMRT uses a convolution and superposition dose
calculation engine that takes into account the effects of
radiation scattered from surrounding tissue and provides
results reasonably close to those of Monte Carlo calcula-
tions, in much less time. Plan evaluation tools include iso-
dose overlays and DVHs.
RAHD Oncology Products
RAHD Oncology Products (St. Louis, MO) has integrated
the KonRad inverse calculation engine into the RAHD 3D/Pro
 Treatment Planning / 159

FIGURE 10-8. The Prowess DAO IMRT planning system. (To view a color version of this image, please
refer to the CD-ROM). Courtesy of Brian Horvath, Prowess Inc.

FIGURE 10-9. The 3-D/Pro treatment planning system. (To view a color version of this image, please
refer to the CD-ROM). Courtesy of Mark Russell, RAHD Oncology Products.
160 / Intensity-Modulated Radiation Therapy
conformal planning system desktop (Figure 10-9). Using the
RAHD 3D/Pro virtual simulation tools, targets, structures,
and regions of interest are created for either forward, con-
formal, or inverse planning. Plans can be developed with
either approach using a common virtual patient. Once the
dose is calculated, it can be evaluated, combined in a com-
posite plan, or compared with other plans for analysis of the
best solution. Many valuable variations are available from
within this spectrum of tools. Inverse planning integrated
with progressive three-dimensional conformal planning
allows complicated problems to be evaluated using both a
three-dimensional conformal plan and an IMRT plan. The
planner can select between these plans or combine them.
The use of a slider-bar weighting tool dynamically assigns
a relative dose value to a prescription point and is variable
by individual beam or by group. In both cases, when adjust-
ing the weight of one beam or group, the remaining beams
are adjusted proportionally to maintain the prescription
dose at the prescription point. The dose for any beam or
group can be locked, allowing the weighting parameters
to be proportionally distributed to the unlocked beams.
The efficient use of forward-planning IMRT requires
simplified MLC beam design. Beam shapes for target vol-
umes can be automatically defined with user-selected mar-
gins applied dynamically while adjusting the geometry of
the setup. Importing dose volumes from three-dimensional
radiation therapy or IMRT conformal plans allows field
shaping around dose volumes to boost cold spots or block
hot spots, improving the dose uniformity by use of mul-
tiple segments. Exporting plans to any of the record and
verification systems automates the communication of plan
delivery parameters to the linear accelerator.
Siemens Medical Solutions
Siemens Medical Solutions (Malvern, PA) uses the KonRad
(MRC Systems GmbH, Heidelberg, Germany) inverse plan-
ning software for IMRT planning (Figure 10-10). By means
of dose-volume constraints and/or absolute dose limits for
overdosage of OAR and for underdosage and overdosage
of the tumor, the oncologist provides the objectives of the
optimization (gradient algorithm). Penalty factors allow
for an additional ranking of these dose limits and can there-
fore incorporate their clinical importance. Parallel organs
may be modeled using dose-volume constraints by assign-
ing higher-tolerance doses to volume fractions of the organ
if a higher dose to the tumor can be achieved. However,
serial organs may be better modeled using restrictive max-
imum dose constraints. As its inverse planning algorithm,
the system uses the weighted quadratic difference of pre-
scribed and calculated dose distributions, which is the most
common type of dose-based objective function.
Dose is calculated using the multikernel PB algorithm
and full three-dimensional ray-tracing. Inhomogeneity cor-
rections are included as part of the planning system. The
leaf sequencer is used to convert an optimized fluence into
a deliverable sequence of MLC segments. It takes into
account machine limitations and constraints, such as the
transmission through the primary and secondary colli-
mators or through the rounded leaf-ends of some MLC.
KonRad’s sequencer can create deliverable fluences for both
FIGURE 10-10. The Siemens IMRT planning
system. DHV = dose-volume histogram. (To
view a color version of this image, please
refer to the CD-ROM). Courtesy of Sandi Lotter,
Siemens Medical Solutions.
 Treatment Planning / 161

static or dynamic MLC modes. In addition, KonRad pro- Once the beamlets are calculated, each optimization iter-
vides the user with intensity filtering features, which can ation takes approximately 4 seconds to calculate using
significantly improve the deliverability of optimized flu- full convolution or the superposition dose, which compares
ences. Plans are evaluated using side-by-side comparisons the results with the prescribed dose. This algorithm pro-
of dose distribution and DVHs. Additionally, plans are sum- vides accurate results in the presence of inhomogeneities,
marized in tabular form to compare statistical quantities. high gradient regions, and electronic nonequilibrium sit-
uations. Optimization is an interactive process through
TomoTherapy Inc.
TomoTherapy (Madison, WI) is a unique delivery system
that combines the capabilities of a helical CT scanner with
those of a linear accelerator. Unlike linear accelator–based
IMRT planning, there are no beam angles to define. Rather,
the optimizer relies on the user to define the prescription
based on regions of interests, which are divided into two
categories: tumor and region at risk. If two structures are
overlapping, the user may choose which structure the shared
voxels belong to for optimization. The user also selects
which of the contoured structures are to be used for opti-
mization (Figure 10-11).
The helical delivery is emulated by calculating 51 pro-
jections per rotation. The planning process is typically
accomplished in two phases: a relatively passive phase, in
which the beamlets are precalculated, and an interactive
optimization phase, in which the final plan is rapidly devel-
oped. The number of beamlets used in any particular case
depends on a number of user-defined parameters. It may
vary from approximately 4,500 beamlets for a prostate
IMRT plan to over 100,000 beamlets for a craniospinal plan.
The TomoTherapy planning system uses an inverse treat-
ment planning process based on iterative least squares min-
imization of an objective function. The optimization is driven
by several user-defined parameters. The pitch determines
the amount of beam overlap, at the machine isocenter,
between gantry rotations. It is defined as the distance trav-
eled by the couch during one complete rotation, divided by
the field width. Pitch settings of less than 1 will provide more
overlap between the rotations to allow for uniformity in the
dose distribution. The fan beam width of the beam is defined
in CT terms. It is the superior or inferior dimension of the
fan beam (range 10–50 mm). The modulation factor deter-
mines the range of intensity values that are allowed in the
optimized plan. The modulation factor is calculated from
the leaf sinogram and is defined as the greatest leaf intensi-
ty, divided by the average intensity for all nonzero leaves. The
importance factor indicates the relative weight of the select-
ed structure compared with other structures (tumor and
region at risk) included in the optimization plan. Relative
importance applies to meeting the goals of the minimum
and maximum doses for the selected structure (as well as the
DVH dose for regions at risk) and is rated on an arbitrary
scale. Lastly, the prescription is defined as the dose (Gy) to
be delivered to a percentage of the tumor volume. Minimum FIGURE 10-11. A head and neck intensity-modulated radiation thera-
and maximum doses are defined by the user with the appro- py plan produced by the Hi-ART planning system. (To view a color ver-
priate “penalties” to the structure, along with a dose or vol- sion of this image, please refer to the CD-ROM). Courtesy of Sam Jeswani,
ume penalty for regions at risk. TomoTherapy Inc.
162 / Intensity-Modulated Radiation Therapy
which the user may modify the outcome of the plan. Plans
are evaluated using a variety of tools, including isodose
lines and clouds, as well as DVHs.
On the day of treatment, a megavoltage CT scan
(TomoImage) of the region of interest is acquired. This
image set is then aligned to the reference (planning) CT
scan. Based on the difference in position between the two
scans, the dose distribution can be adjusted to take into
account the daily patient position.
Varian Medical Systems
Varian Medical Systems’ (Palo Alto, CA) Eclipse treatment
planning system has a full complement of capabilities that
support photon, electron, and proton therapy (Figure 10-12).
Eclipse employs interactive IMRT planning. The user speci-
fies planning constraints in the form of DVHs, and IMRT
plans are generated using a gradient optimization algorithm.
The user is able to observe the progress of optimization and
to modify dose objectives in real time, while the plan is opti-
mized. This capability guarantees that desired results are
achieved quickly and shortens the IMRT learning curve. Eclipse’s
interactive planning gives users the ability to make clinical
tradeoffs as the plan evolves, thereby allowing the planner to
create the best plan for each patient. Eclipse is part of Varian’s
SmartBeam IMRT solution and supports both high-resolu-
tion dynamic IMRT and segmental IMRT of any resolution.
Eclipse uses a PB convolution for photon dose calcula-
tions. Beam data configuration requires depth-dose data,
beam profiles, and output factors. Blocks, MLC, enhanced
dynamic wedges, motorized wedges, and virtual wedges are
fully supported in Eclipse.
Plan evaluation in Eclipse allows the user to customize
the display of the dose distributions in both two- and three-
dimensional views. Isodose lines or colorwash can be used
to view dose distributions. Users can create and modify
FIGURE 10-12. A computed tomography–positron emission tomogra-
phy image dataset used to create an intensity-modulated radiation ther-
apy plan in Eclipse. (To view a color version of this image, please refer
to the CD-ROM). Courtesy of L. Scott Johnson, Varian Medical Systems.
templates that store isodose line values and colors. Hard
copy reports include beam’s eye view plots, isodose plots,
flexible plan reports, and numerous other plan evalua-
tion plots. Electronic plan approval in Eclipse is password
protected. Approved plans cannot be modified.
Planning Methodology
Most IMRT planning systems provide a general description
of their dose optimization algorithm. However, the cost
function is often not specified, and the planner is given lit-
tle or no guidance on how varying a single input parame-
ter will affect the overall quality of a treatment plan. This
type of knowledge can be gained only through trial and
error. A systematic approach used in many clinics involves
beginning with a single dose constraint (such as the PTV
dose) and adding constraints one by one until an accept-
able plan is achieved. This approach provides valuable insight
into the cost function and the complex interplay between
input parameters. Once a set of input parameters is deter-
mined, the class solution approach can be employed where-
by the same input parameters are used for a given disease
site (ie, prostate), and minor “tweaking” of these parame-
ters is performed for each individual patient. Our system-
atic approach is illustrated in the next section using our
research software to illustrate the type of results encoun-
tered.20 Although the results are specific to our planning
system, the approach can be generalized to any system.
Prostate Case Example
In this section, a prostate case is used to illustrate the thought
process used in producing a clinically acceptable IMRT
plan. After obtaining a CT scan, the prostate, seminal vesi-
cles, bladder, rectum, and femoral heads were outlined. In
this example, the prostate is the gross tumor volume, and
a 1 cm expansion is used to generate the PTV. Starting with
an anterior beam and proceeding clockwise, nine beams
spaced 40º apart, all with a beamlet size of 0.5 cm, are used
to generate each plan.
Iteration 1
The initial goal is to deliver a uniform dose to the PTV. The
minimum PTV dose is set equal to the prescription dose,
and heterogeneity is minimized. The resulting maximum
PTV dose is within 1% of the prescription dose, but there
is no normal tissue sparing (Figure 10-13A).
Iteration 2
The PTV dose constraints are relaxed. An additional goal
of minimizing the maximum dose to the rectum outside
the PTV (rectum dose − PTV dose) is added. The opti-
mization met the planning goals in the PTV, and the max-
imum dose in the rectum outside the PTV is 59% of the
prescription dose; however, an unanticipated result is
obtained (Figure 10-13B).
 Treatment Planning / 163

FIGURE 10-13. (A–I), Prostate treatment plans using constraints as

defined in the text. Isodose contours include 30% (dark blue), 50% (light
blue), 80% (yellow), 100% (red), and 115% (dark red) of the prescrip-
tion dose. GTV = gross tumor volume; PTV = planning target volume. (To
view a color version of this image, please refer to the CD-ROM).
164 / Intensity-Modulated Radiation Therapy
Iteration 3
Instead of minimizing the maximum rectum dose (as
above), a constraint is added to minimize the mean rec-
tum − PTV dose. In this plan, the PTV goals were achieved,
and the mean rectum − PTV dose is 15% of the prescrip-
tion dose. The isodoses conform to the posterior edge of
the PTV, but unacceptable hot regions and streaks remain
(Figure 10-13C). Note that doses in unconstrained tis-
sues are high because they are not penalized in the cost
function.
Iteration 4
In addition to the previous constraints, an upper bound of
25% of the prescription dose is set for the femoral heads. In
this case, the PTV and femoral goals are achieved, and the
mean rectum − PTV dose is 30% of the prescription dose.
The isodoses conform to the posterior edge of the PTV, but
unacceptable hot streaks remain, and there is no significant
improvement in the overall plan quality (Figure 10-13D).
Iteration 5
Building on the previous iteration, an upper bound of 33%
of the prescription dose is placed on the mean rectum −
PTV dose, and the mean bladder dose is minimized. The
plan is significantly improved. PTV, rectal, and femur goals
are achieved, and the mean bladder dose is 54% of the pre-
scription dose. Only a few hot spots remain (Figure 10-
13E). The only remaining volume to place constraints on
is tissue within the external contour (skin).
Iteration 6
Small modifications are made on previous input parame-
ters. In particular, upper bounds of 37.5%, 50%, and 71%
of the prescription dose are set for the femurs, mean rec-
tum − PTV dose, and mean bladder dose, respectively. In
addition, the mean external dose is minimized (excluding
all other structures). All goals are achieved, and the mean
external dose is 17% of the prescription dose. However,
several hot spots remain (Figure 10-13F).
Iteration 7
In the last iteration, pixels near the edge of the PTV are
penalized by the external goal. Thus, a collar is added to
the PTV, permitting the exclusion of this region from con-
sideration in the minimization. The collar is 6 pixels wide
(5.625 mm). The mean external dose to be minimized
now represents the volume enclosed by the external con-
tour, excluding the PTV + collar and all other structures.
The goals are achieved, and the mean external dose is 17%
of the prescription dose (Figure 10-13G). The most strik-
ing feature of the dose distribution is the hot spot in the
bladder.
Iteration 8
The mean external dose is relaxed and set to an upper bound
of 26% of the prescription dose. The mean bladder dose is
added as a parameter to be minimized. In this example, the
goals are achieved, and the mean bladder dose is 37% of
the prescription dose (Figure 10-13H). A few regions of
medium dose persist.
Iteration 9
An upper bound of the external dose is set to 80% of the
prescription dose. All other parameters remain the same.
All goals are achieved, and the mean bladder dose is 39%
of the prescription dose (Figure 10-13I). The plan is now
acceptable. Further improvement may be possible by low-
ering the doses of the constraint upper bounds.
Summary
Many options are available for IMRT planning. The selec-
tion of a particular planning system is limited by the IMRT
delivery hardware. However, there are still several choices
for most hardware platforms. Rather than converging to
a smaller number, it appears that the number of options
will further increase once beam orientation becomes part
of the optimization engine. Thus, IMRT treatment plan
optimization will become more automated, requiring care-
ful scrutiny of the influence of the optimization parame-
ters on the final result.
This chapter has presented several important planning
considerations for IMRT. Consensus positions have also
provided such a description for the entire IMRT process.21,22
These works are useful because they provide a framework
for comparison of the wide variety of methods that are
available in practice. For detailed guidance on IMRT plan-
ning specific to a particular hardware or software config-
uration, it is becoming essential to attend workshops and
participate in user groups. The topics discussed in this chap-
ter will inevitably confront the clinician. Although the res-
olution of the issues will depend on the particular IMRT
software, careful consideration of them is expected to lead
to better patient care.
Acknowledgments
The authors and editors acknowledge the contributions of
Franz Gum (BrainLAB), Robert Hill (North American
Scientific, NOMOS Radiation Oncology Division), Brian
Horvath (Prowess Inc.), Sam Jeswani (TomoTherapy Inc.),
L. Scott Johnson (Varian Medical Systems), Sandi Lotter
(Siemens Medical Solutions), Todd McNutt (Philips Medical
Systems), Therese Munger (CMS Inc.), Timothy Prosser
(Elekta Inc.), and Mark Russell (RAHD Oncology Products).

References
1. Pirzkall A, Carol MP, Pickett B, et al. The effect of beam energy
and number of fields on photon-based IMRT for deep-
seated targets. Int J Radiat Oncol Biol Phys 2002;53:434–42.
2. Schneider U, Lomax A, Lombriser N. Comparative treatment
planning using secondary cancer mortality calculations.
Phys Med Biol 2001;17:97–9.
3. Followill D, Geis P, Boyer A. Estimates of whole-body dose
equivalent produced by beam intensity modulated conformal
therapy. Int J Radiat Oncol Biol Phys 1997;38:667–72.
4. Verellen D, Vanhavere F. Risk assessment of radiation-induced
malignancies based on whole-body equivalent dose
estimates for IMRT treatment in the head and neck region.
Radiother Oncol 1999;53:199–203.
5. Glatstein E. Intensity-modulated radiation therapy: the inverse, the
converse, and the perverse. Semin Radiat Oncol 2002;12:272–81.
6. Hall EJ, Wu CS. Radiation-induced second cancers: the
impact of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys
2003;56:83–8.
7. Price RA, Hanks GE, McNeeley SW, et al. Advantages of using
noncoplanar vs. axial beam arrangements when treating
prostate cancer with intensity-modulated radiation therapy
and the step-and-shoot delivery method. Int J Radiat Oncol
Biol Phys 2002;53:236–43.
8. Das S, Cullip T, Tracton G, et al. Beam orientation selection for
intensity-modulated radiation therapy based on target
equivalent uniform dose maximization. Int J Radiat Oncol
Biol Phys 2003;55:215–24.
9. Djajaputra D, Wu Q, Wu Y, et al. Algorithm and performance
of a clinical IMRT beam-angle optimization system. Phys
Med Biol 2003;48:3191–212.
10. Pugachev A, Xing L. Incorporating prior knowledge into beam
orientation optimization in IMRT. Int J Radiat Oncol Biol
Phys 2002;54:1565–74.
11. Rowbottom CG, Nutting CM, Webb S. Beam-orientation
optimization of intensity-modulated radiotherapy:
clinical application to parotid gland tumours. Radiother
Treatment Planning / 165
Oncol 2001;59:169–77.
12. Pugachev A, Xing L. Computer-assisted selection of coplanar
beam orientations in intensity-modulated radiation therapy.
Phys Med Biol 2001;46:2467–76.
13. Pugachev AB, Boyer AL, Xing L. Beam orientation optimization
in intensity-modulated radiation treatment planning. Med
Phys 2000;27:1238–45.
14. Mohan R, Chui C, Lidofsky L. Differential pencil beam dose
computation model for photons. Med Phys 1986;13:64–73.
15. Bortfeld T, Boyer AL, Schlegel W, Kahler DL, Waldron TJ.
Realization and verification of three-dimensional conformal
radiotherapy with modulated fields. Int J Radiat Oncol Biol
Phys. 1994;30:899-908.
16. Alber ML. A concept for the optimization of radiotherapy
[thesis].Tübingen (Germany): University of Tübingen; 2001.
17. McNutt T. Dose calculations: collapsed cone convolution
superposition and Delta Pixel Beam. Pinnacle3. 2002. White
Paper No. 4535 983 02474.
18. Löf J. Development of a general framework for optimization
of radiation therapy [thesis]. Stockholm: Stockholm
University; 2000.
19. Gill PE, Murray W, Saunders MA, et al. User’s guide for NPSOL:
a Fortran package for nonlinear programming. 1992. Report
No.: Systems Operation Lab (SOL) 86-2.
20. Ar mbr uster B, Lachaine ME, Hamilton RJ, et al. LP
formulations for optimizing radiation treatment strategies.
In: Institute of Industrial Engineering (IIE) 2004 Annual
Conference Proceedings (in press).
21. Ezzell GA, Galvin JM, Low D, et al. Guidance document on
delivery, treatment planning, and clinical implementation of
IMRT: report of the IMRT Subcommittee of the AAPM
Radiation Therapy Committee. Med Phys 2003;30:2089–115.
22. Intensity Modulated Radiation Therapy Collaborative Working
Group. Intensity-modulated radiotherapy: current status
and issues of interest. Int J Radiat Oncol Biol Phys
2001;51:880–914.