Chapter 11
PLAN EVALUATION
TODD PAWLICKI, PHD, QUYNH-THU LE, MD, CHRISTOPHER KING, MD, PHD
Intensity-modulated radiation therapy (IMRT) represents
a novel approach to the planning and delivery of radiation
therapy. Physicians and physicists implementing IMRT are
thus faced with learning a number of new approaches and
techniques, for example, target delineation and quality assur-
ance. These issues have received considerable attention in
the literature and are discussed in other chapters in this text.
One aspect of IMRT, however, that has received sur-
prisingly little attention is plan evaluation. A common mis-
conception regarding IMRT is that the treatment planning
computer generates the optimal plan, which is then used for
treatment. In reality, the computer generates a number of
optimized plans based on specified input parameters. The
physician and physicist must evaluate these various plans
and select the best one to be used in treatment. In some cases,
however, all of the plans may be rejected and the optimiza-
tion process repeated with modified input parameters.
The purpose of this chapter is to provide an overview
of the plan evaluation process from a clinical viewpoint.
More theoretic considerations, such as biologic modeling
of tissue structures, tumor control and tissue complica-
tion probabilities, decision making by artificial neural net-
works, or any of the many other score functions or figures
of merit, are beyond the scope of this chapter and are not
discussed. Instead, attention is focused on the various plan
evaluation tools provided by the major inverse planning
systems, such as cumulative dose-volume histograms
(DVHs), two-dimensional dose distribution display, three-
dimensional dose distribution display, and structure min-
imum, maximum, and mean dose values. In addition, the
impact of various aspects of IMRT planning (eg, patient
selection, target delineation, beam selection, field match-
ing) on plan evaluation is also discussed.
IMRT Treatment Planning
A major clinical indication for IMRT is the need to conform
a high dose to the target while keeping adjacent normal tis-
sues within tolerance. This section is devoted to discussing
166
the goals of IMRT planning and how those goals may differ
from conventional three-dimensional conformal radiation
therapy (3DCRT) treatment planning. Users of IMRT expect
something different from that provided by 3DCRT tech-
niques, namely, better target coverage and/or better normal
tissue sparing. Effective and efficient IMRT plan evaluation
is based, in part, on those expectations and differences. The
advantages and disadvantages of IMRT in comparison with
3DCRT and some guidelines to determine the optimal patient
and tumor characteristics for IMRT are outlined below.
Is IMRT Always Better than 3DCRT?
Whether IMRT is better than 3DCRT depends, in part, on
the treatment goals. With IMRT, there are larger volumes
of normal tissues receiving low doses, increased monitor
units needed for delivery, and verification port film require-
ments. These can result in an increase in patient expo-
sure from head leakage, neutron production, and scatter.1–3
This may increase the risk of secondary malignancies in
long-term survivors4 and the probability of pneumonitis
in thoracic cancer patients, in whom large volumes of the
lungs may receive moderate radiation doses. IMRT also
requires significant patient cooperation and more precise
immobilization than 3DCRT. However, these drawbacks
may be considered acceptable if a more conformal dose
distribution is achieved with IMRT.
Target and Normal Tissue Contouring
Tissue contouring impacts plan evaluation. Targets must
be drawn carefully, and a marginal miss is a concern in IMRT.
It is important to contour not only the gross tumor volume
(GTV) but also the clinical target volume (CTV), which
includes tissues at risk of microscopic disease involvement.
Surrounding normal tissues should also be identified for
treatment avoidance. It is best to use the International
Commission on Radiation Units and Measurements (ICRU)
Report 505 or the more current ICRU Report 626 definitions
and available anatomic atlases or publications to facilitate
the accuracy and consistency of contouring.7–9 Accurate vol-

ume delineation will result in optimal IMRT planning and
lower the risk of geographic misses.
In situations in which target volumes overlap with nor-
mal tissue structures, a priority must be assigned to these
overlapping structures, and clinical consideration must be
taken into account for these priorities. It is our practice to
assign a higher priority to the GTV than surrounding nor-
mal tissues and a higher priority to critical neural tissues
(ie, optic chiasm, brainstem, and spinal cord) than the adja-
cent planning target volume (PTV). When it is difficult to
achieve a good IMRT plan, an apparently easy solution is
to modify the target to conform to the isodose lines.
However, such maneuvers limit the efficacy of IMRT and
may result in increased risk of treatment failure. It is prefer-
able to loosen the dose constraints and accept increased
heterogeneity within the target.
Normal tissue contouring must also be performed care-
fully. One should avoid contouring the skin as part of the
CTV, unless it is explicitly involved. Inclusion of the skin can
lead to an unacceptably high skin dose, especially when
immobilization materials act as a bolus.10 Lastly, it is impor-
tant to define not only what are truly GTV and CTV but also
a physically realistic target for the optimization algorithm.
Figure 11-1 illustrates a case in which the target was drawn
FIGURE 11-1. (A) Example of a carelessly drawn target volume that is
outside the patient’s skin. This can limit the quality of the intensity-
modulated radiation therapy plan by requiring that the dose be deliv-
ered to the surrounding air. (B) A better approach is to draw the target
volume carefully and add bolus to increase the dose to the skin. (To view
a color version of this image, please refer to the CD-ROM).
Plan Evaluation / 167
outside the skin. It is better to draw the target inside the skin
and use a bolus to increase the skin dose if necessary.
IMRT versus 3DCRT Treatment Plans
In general, IMRT allows for smaller margins and is better for
concave-shaped targets. In addition, IMRT planning is less
dependent on beam energy than 3DCRT.11 The best IMRT
plan may require beam directions that are counterintuitive.
For example, a beam direction directly through a critical struc-
ture may result in the best plan, whereas with conventional
planning techniques, beams rarely enter through a critical
structure that is not in or directly adjacent to the treatment
volume. Guided by appropriate dose-volume constraints,
optimization algorithms can limit the dose within parts of
the beam, avoiding overdosage of a critical structure.
Figure 11-2 illustrates such a situation for an IMRT prostate
cone-down plan. Figure 11-2A shows an axial computed
tomography (CT) slice through the prostate for a six-field
FIGURE 11-2. Two intensity-modulated radiation therapy (IMRT) plans
for a 24.0 Gy prostate boost that demonstrates nonstandard beam direc-
tions in IMRT planning. The isodose curves are 24.8 Gy (dark blue), 24.0
Gy (purple), 22.7 Gy (red), 16.8 Gy (yellow), 12.0 Gy (green), and 7.2 Gy
(cyan). (A) Six-field IMRT plan avoiding the rectum. The maximum dose in
this plan is 25.7 Gy. (B) Five-field IMRT plan with a posterior – anterior
beam directly through the rectum. The maximum dose in this plan is 25.3
Gy. (To view a color version of this image, please refer to the CD-ROM).
168 / Intensity-Modulated Radiation Therapy
IMRT plan with beam directions of left posterior oblique (one),
left anterior oblique (two), right anterior oblique (two), and
right posterior oblique (one). Figure 11-2B shows the corre-
sponding CT slice for a five-field plan with beam orienta-
tions as left posterior oblique (one), left anterior oblique (one),
right anterior oblique (one), and right posterior oblique (one)
and a direct posterior – anterior (one) beam through the rec-
tum. The plans are similar, but the five-field plan has slightly
more homogeneous dose coverage of the prostate and small-
er hot spots. The minimum dose to the prostate for the five-
field plan is 2.0% higher than that produced by the six-field
plan. Moreover, the maximum dose to the prostate for the five-
field plan is 1.6% lower than that for the six-field plan. The
maximum dose to the rectum is only slightly different between
the two plans (< 1%). The improvement of the five-field plan
over the six-field plan is marginal, but this case demonstrates
that counterintuitive beams play a role in IMRT planning. In
addition, fewer beams imply a more efficient delivery. Thus,
treatment time is a criterion to judge the quality of an IMRT
plan. It is easier for patients to hold still in the treatment posi-
tion for short treatment times.Furthermore,long delivery times
may have a negative effect on tumor control.12
Another issue one must address is field abutment. For
example, with head and neck IMRT, the question arises
regarding how to treat the supraclavicular lymph nodes.
The physician and planner must decide if these nodes are
to be included in the IMRT fields or within a conventional
anterior field. Unlike conventional approaches in which the
dose at the field edge is sharp and easily identified, the dose
at IMRT field edges is often jagged and not well delineated.
Figure 11-3 demonstrates the different cases for a conven-
tionally planned supraclavicular field and an IMRT planned
target in the head. It is best to avoid matching IMRT treat-
ment fields to one another or IMRT fields with conventional
fields because it can be difficult to achieve a homogeneous
dose at the junction. A consistent policy should be estab-
lished in situations in which field matching is used.
Approaches for optimal field junctioning have been pub-
lished.13,14 Readers are strongly encouraged to evaluate these
approaches in detail to identify a method that best fits with
their clinical scenario and treatment planning system.
An additional consideration is the spatial differences
between 3DCRT and IMRT dose distributions, as highlighted
in Figure 11-4. 3DCRT dose distributions are very intuitive
and predictable compared with IMRT dose distributions. In
3DCRT, the physician and planner know what to expect in
terms of dose gradients at field boundaries, regions of high
dose and their location, and the low-dose volume. In con-
trast, IMRT dose distributions have somewhat randomly
located hot and cold spots. The conformity of an IMRT dose
distribution comes at the expense of spreading a low dose
to a larger volume of the patient. Notice that in Figure 11-4,
even though the treatment volume is much larger for the
3DCRT plan, the low-dose region in the IMRT plan covers
an area similar to that of the 3DCRT plan. It is important to
remember that in IMRT planning, it is very difficult to adjust
an isodose line by a few millimeters to avoid a critical struc-
ture or increase target coverage. IMRT is not like 3DCRT, in
which one can change a block edge by a finite amount and
subsequently shift an isodose curve by a similar amount.
One should not try to force IMRT to “behave” like 3DCRT.
IMRT is a completely different treatment technique. To reap
the benefits of IMRT, one must also accept its limitations.
The following sections elaborate on these points.
Other Considerations
Another issue that should be considered is that IMRT plan-
ning is a time-consuming process with extensive quality
assurance procedures. It takes time to generate a good IMRT
plan, more so than with 3DCRT. It thus may not be opti-
mal to use IMRT in situations that require rapid plan gen-
eration, for example, in patients requiring emergency
FIGURE 11-3. A picture of a conventionally
planned supraclavicular field and an intensity-
modulated radiation therapy (IMRT) plan in
which the two plans were abutted for treat-
ment. The green isodose line in the IMRT plan
(upper right) is the 50% isodose line. The sup-
raclavicular field (upper left and bottom pan-
els) is matched at 3 mm inferior to the 50%
isodose line in the IMRT plan. This gap sig-
nificantly reduces the chance for unwanted
hot spots at the match line, but this approach
should not be used where positive nodes exist
in the neck. A = anterior view. S = superior
view. (To view a color version of this image,
please refer to the CD-ROM).
 Plan Evaluation / 169

FIGURE 11-4. This figure demonstrates the

differences between three-dimensional con-
formal radiation therapy (3DCRT) and intensity-
modulated radiation therapy (IMRT) dose
distributions. The 3DCRT plan was treated to
20 Gy, and IMRT was used to treat the clini-
cal target volume plus the margin for anoth-
er 28 Gy. The isodose bands (± 2%) shown
are 100%, 90%, 80%, 70%, and 50% of the
prescription dose (the IMRT plan also shows
the 30% isoband). (To view a color version of
this image, please refer to the CD-ROM).

treatment or with rapidly growing tumors. One option is
to start with 3DCRT for a few fractions to allow time for
generating and implementing the IMRT plan. Judicious use
of this option is warranted. One must remember that, at
present, an IMRT plan requires 1 to 4 hours of physics and
dosimetry time to prepare for treatment and perform the
necessary quality assurance procedures. Furthermore, it is
best to use this option only if your IMRT planning system
allows for optimization on the 3DCRT dose distribution
that was already delivered to the patient. This will reduce
the concern of overlapping hot spots in the two plans.
As previously mentioned, ease of treatment delivery (eg,
coplanar vs noncoplanar beams) and delivery time (eg, num-
ber of beam and/or segments) are also important. The best
IMRT plan is not optimal if it takes too long to deliver. The
duration of treatment depends on the delivery method and
the vendor to some extent, and these must be considered in
the planning process. Beam directions are also important
because it is not ideal to treat through immobilization devices
that attenuate the beam. There are also cases in which 3DCRT
seems to be the best choice, but, after consideration, IMRT is
the better treatment option. Figure 11-5 shows a 3DCRT plan

FIGURE 11-5. Three-dimensional conformal

radiation therapy plan for a superficial target.
The plan consisted of four fields: three pho-
ton fields and one abutting electron field with
1 cm of bolus. Note that not all fields are
shown in the upper panel. The isodose curves
are 60 Gy (magenta), 50 Gy (yellow), 45 Gy
(purple), and 25 Gy (cyan). The maximum dose
in the plan is 71.5 Gy. (To view a color ver-
sion of this image, please refer to the CD-
ROM).
170 / Intensity-Modulated Radiation Therapy
for a case in which the patient was unable to lie flat. The patient
was immobilized in a thermoplastic mask on an incline board.
The best 3DCRT plan shown in Figure 11-5 consists of com-
bined photon and electron beams. Bolus was also used to
increase the surface dose. Because the patient tolerated immo-
bilization well, an IMRT plan was attempted. Figure 11-6 shows
the resultant six-field IMRT plan that can be delivered in
one treatment time slot. With the 3DCRT plan in Figure 11-
5, therapists would have to enter the treatment room to apply
the electron applicator for the electron fields, and there would
also be the uncertain dosimetry issues of abutting electron
and photon fields. The IMRT plan obviates these concerns.
It has been shown that dose calculation plays a role in
the extent of optimization.15,16 The accuracy of beamlet
dose distributions impacts IMRT plan optimization, and
one will get a better optimized plan when accurate dose
calculation models are used. Also, because IMRT plans can
FIGURE 11-6. Six-field intensity-modulated radiation therapy plan for
a superficial target with 1 cm of bolus to treat the same target as shown
in Figure 11-5. The isodose curves are 55 Gy (blue), 50 Gy (purple), 45 Gy
(yellow), 35 Gy (green), and 15 Gy (cyan). The maximum dose in the plan
is 61.7 Gy. R = right view. L = Left view. A = anterior view. P = posteri-
or view. (To view a color version of this image, please refer to the CD-
ROM).
have nonstandard beam directions, clinical experience based
on uncorrected 3DCRT treatments with conventional beam
directions may not translate to IMRT. Although the issues
related to dose calculation are usually transparent to the
IMRT user, it is recommended that heterogeneity correc-
tions are used for IMRT planning,17 especially in head and
neck or thoracic tumors. Organ motion and setup uncer-
tainty are important considerations when treating with
IMRT.18–26 In contrast to 3DCRT, an IMRT field consists
of many subfields, and each subfield treats only part of the
target at any give time. There can be significant dosimet-
ric problems if the patient or target moves during delivery
of the IMRT treatment. For patients with tumors that move
owing to respiration, IMRT should be attempted only with
some method to account for intrafraction motion, such as
active breathing control, respiratory gating, four-dimen-
sional tumor tracking, or a breath-holding technique.
Optimal Candidates for IMRT Treatment
IMRT candidates are patients with immobilizable tumors
that are often irregularly shaped and located adjacent to
critical structures, whose functions may be compromised
by standard radiation treatment or dose escalation. Ideal
IMRT patients should also be cooperative and can with-
stand prolonged immobilization without excessive dis-
comfort or pain during treatment. Morbidly obese patients
with poor immobilization, agitated patients, or those with
resting tremors are not ideal candidates for IMRT. Some
claustrophobic patients are also poor candidates for IMRT
for head and neck cancers unless they receive adequate seda-
tion during treatment. In general, an uncomfortable patient
makes a poor IMRT candidate.
Aspects of IMRT Plan Evaluation
Before embarking on generating an IMRT plan, issues that
should be considered and communicated with the IMRT
planning systems are definitions of the target and avoid-
ance structures, definition of the objectives and constraints
for optimization (ie, what is the exact treatment plan), and
dose prescriptions (simultaneous integrated boost vs
sequential cone-down plans).
IMRT plan evaluation is a compromising process, requir-
ing considerable time and attention. One cannot ask for an
impossible goal such as zero dose to the critical tissue adja-
cent to the target volume. One has to define the problem
sufficiently as to what is absolutely necessary and what can
be compromised, a process similar to that with 3DCRT
planning. One has to understand that the IMRT product
may not be exactly as desired but may be adequate for the
treatment purpose. In some situations, a comparison
between an IMRT and a 3DCRT plan may be necessary to
identify the best approach. However, overuse of compari-
son plans is strongly discouraged because it can signifi-
cantly tax physics and dosimetric resources.
 Plan Evaluation / 171

Target Coverage this constraint may need to be relaxed if more conformity is

As previously mentioned, in IMRT plans, there are rou-
tinely regions of high dose (hot spots) and regions of low
dose (cold spots). Hot spots are volumes of tissues that
receive doses greater than the prescribed dose, and cold
spots are those that receive doses less than the prescribed
dose. Important issues to consider for these hot and cold
spots are magnitude, volume, and location. At present, there
is no accepted consensus regarding the magnitude and the
volumes for these spots for most tumor types. In head and
neck cancer, we recommend the Radiation Therapy
Oncology Group (RTOG) H-0222 trial guidelines, name-
ly, that 95% of the PTV should be covered by the prescribed
isodose line. The hot spots (defined in this study as regions
receiving a dose > 110% of the prescribed dose) should
cover < 20% of the PTV and < 1% of tissues outside the
PTV. Such spots should be within the CTV (ideally with-
in the GTV), not in the overlapping normal tissues. Similar
constraints can be used for IMRT of tumors located else-
where. For example, investigators from the University of
Chicago limit 15% or less of the PTV volume to receive the
dose at the 110% level and 1% or less to receive the dose at
the 115% level for gynecologic patients undergoing
intensity-modulated pelvic irradiation.27
RTOG H-0222 defines cold spots as regions within the
PTV receiving doses < 93% of the prescribed dose. The total
volume of cold spots should be < 1% of the PTV; however,
desired. The location of cold spots is important. They should
not be located within the GTV and ideally should be at the
periphery of the PTV, as far from the GTV as possible.
It is also worth noting that it is easier to get a good con-
formal treatment plan on smaller target volumes than on
larger ones.28 In our experience, one can achieve a better
IMRT plan with a simultaneous integrated boost than with
a sequential cone-down approach.
Target coverage in IMRT treatment plans is different than
in 3DCRT. Some hallmark aspects of an IMRT dose distri-
bution distinguish it from conventional approaches. First,
IMRT isodose curves are wavier than in 3DCRT (see Figure
11-4). Second, target coverage is more heterogeneous. Thus,
one can also expect a more pronounced shoulder and usu-
ally a small high-dose tail associated with the DVH of the
PTV. These high- and low-dose regions must be accounted
for in the evaluation of the treatment plans because they
may affect toxicity and tumor control probability.
A simple case will demonstrate these points. Figure 11-7
shows a 3DCRT plan, and Figure 11-8 shows a correspond-
ing IMRT plan for partial breast irradiation. The conformal
nature of the IMRT plan comes at the expense of dose het-
erogeneity within the target. The prescription dose for these
plans was 34 Gy. Note that the IMRT plan has hot spots with-
in or near the target of 112%, whereas the 3DCRT has a max-
imum hot spot in the patient of only 107%. An evaluation of

FIGURE 11-7. A conformal partial breast

treatment plan consisting of tangential pho-
ton beams with an en face electron beam.
One centimeter of bolus is used. The isodose
curves are 34 Gy (yellow), 30 Gy (purple), 20
Gy (cyan), 10 Gy (white), and 5 Gy (blue). The
maximum dose in this plan is 36.4 Gy. (To view
a color version of this image, please refer to
the CD-ROM).

FIGURE 11-8. A seven-field noncoplanar

intensity-modulated radiation therapy partial
breast treatment plan. One centimeter of bolus
is used. The isodose curves are 38 Gy (orange),
34 Gy (yellow), 30 Gy (purple), 20 Gy (cyan),
10 Gy (white), and 5 Gy (blue). The maximum
dose in this plan is 39.5 Gy. (To view a color
version of this image, please refer to the CD-
ROM).
172 / Intensity-Modulated Radiation Therapy

the DVHs in Figure 11-9 shows this information. What is
clear from the DVHs is that there is an underdosage of the
PTV in the IMRT plan compared with 3DCRT. Both the hot
spots and the cold spots must be investigated on a slice-by-
slice basis to determine whether they are acceptable. This is
almost always a clinical decision that must be made by the
physician. Difficult decisions are routinely required concerning
the balance between target coverage and critical structure
sparing.29 Figure 11-10 demonstrates this for a case in which
100.0
80.0 PTV_3D
PTV_IMRT_3D
LT_Lung_3D
Volume (%)
the CTV may be slightly underdosed to spare the critical
structure. Such compromises are common because IMRT
is not ideal for every case that cannot be adequately treat-
ed with 3DCRT.
An important principle regarding target coverage in
IMRT is the trade-off between conformity and dose het-
erogeneity. Requirements for increased conformity will
result in decreased dose uniformity. If the priority is con-
formity, one must accept increased inhomogeneity and vice
versa. In addition, dose uniformity can also be affected by
increased target concavity and decreased beam number.
These considerations should be taken into account during
evaluation of target coverage. It is absolutely critical to eval-
uate IMRT plans slice by slice on the planning computer
because one has little control of the location of hot or cold

60.0 LT_Lung_IMRT3D spots. For our slice-by-slice plan evaluation, we typically

normalize the plan to the maximum dose in the plan. We
40.0 then evaluate the following isodose lines: the prescribed
doses for the GTV and CTV, 5% less than the prescribed
20.0 doses for the GTV and CTV, and 95%, 90%, 50%, and 30%
of the maximum dose in the plan. Detailed evaluation of
0.0
isodose coverage allows for accurate determination of plan
0.0 500.0 1,000.0 1,500.0 2,000.0 2,500.0 3,000.0 3,500.0 4,000.0 conformity and location of the hot and cold spots.
Dose (cGy)
Normal Tissue Sparing
FIGURE 11-9. Dose-volume histograms for the treatment plans in
Figures 11-7 and 11-8. IMRT = intensity-modulated radiation therapy;
Unfortunately, there are few data regarding partial organ
PTV = planning target volume. tolerance at present; therefore, most guidelines for normal
tissue tolerances are based on previously published whole
organ data. Table 11-1 shows a partial list of the dose lim-
its that have been published regarding whole and partial
organ tolerance with radiation alone. We generally follow
these dose limits for both IMRT and 3DCRT planning.
Lowering these limits by 10% when concurrent chemother-
apy is used may be appropriate. In cases of the mandible
or larynx in which the mean dose may be as important as
the maximum dose, we also restrict the mean dose to less
than 35 to 45 Gy for the mandible and less than 25 to 30
Gy for the larynx. These constraints are not “set in stone”
and may be relaxed or tightened on a case-by-case basis.
On occasion, an IMRT plan may produce a maximal point
dose that exceeds the so-called tolerance of a critical struc-
ture. It is important to review the DVH to determine how
much of the critical structure actually receives doses exceed-
ing the specified limit. In many cases, it may correlate to only
a few voxels and thus may be acceptable. However, this deci-
sion should be individualized based on other clinical con-
siderations, such as prior treatments (radiation or surgery),
comorbidities, and the use of concurrent chemotherapy. A
rule of thumb is that < 5% of the contoured normal struc-
ture should receive doses exceeding the limits. For the brain
FIGURE 11-10. This figure demonstrates the trade-off between target
and spinal cord in which the entire structure is often not delin-
coverage and critical structure (optic chiasm) sparing. The isodose lines eated, the volume in cubic centimeters is more important,
are 66 Gy (orange), 60 Gy (red), 50 Gy (yellow), 40 Gy (green), 30 Gy (light and we usually require that < 1 cc of contoured volumes
blue), and 20 Gy (blue). (To view a color version of this image, please receives doses exceeding the limits. If there is concern about
refer to the CD-ROM). exceeding dose tolerance for adjacent critical structures based
 Plan Evaluation / 173

TABLE 11-1. Dose Limits Related to Whole Organ and Partial Organ Tolerance with Radiation Alone
Tissue Maximal Dose*, Gy Mean Dose, Gy Other Volume Doses, Gy Reference

Brain 60 30
Brainstem 54 30
Optic chiasm/nerves 54 30
Retina 45 30
Lens 12 30
Parotid gland 70 26 31
Larynx 70 ≤ 25†
Mandible 65 ≤ 35–45†
Spinal cord 45 30
Lung 20 V20 < 35% radiation therapy alone; V20 < 20% with chemotherapy 32
Esophagus V45 < 30% 33
Small bowel 50 30
Rectum V50 < 66% 34
Bladder V47 < 53% 35

*Maximal dose limits should be decreased by 10% when concurrent chemotherapy is used.
†Additional dose specifications used at Stanford University for head and neck cancer intensity-modulated radiation therapy.

on maximum doses, one should also evaluate the isodose lines
that correspond to or are within a couple of percentage points
of this maximum dose to determine the volume and location
of critical structures that receive a higher dose than previ-
ously constrained. A situation such as this is shown in Figure
11-11. If the maximum spinal cord dose is constrained at
45 Gy and the plan showed the maximal achievable dose of
46 Gy, one should also look at the 46 Gy isodose line to deter-
mine the location and volume of the cord covered within
these isodose lines and whether it is clinically acceptable.
What are achievable normal structure doses with pre-
sent-day IMRT planning systems? This is a seminal ques-
tion in IMRT planning. Tables 11-2 and 11-3 give some
of our results for achievable dosimetry. Table 11-2 presents
our data for localized prostate treatment, and Table 11-3
presents our data for head and neck treatment. The results
shown are an average of 10 cases per site. The minimum
dose and maximum dose for all 10 cases are given in brack-
ets. Although the dose to structures in IMRT depends
strongly on each specific case, these data give an indication

FIGURE 11-11. A case showing high dose

near the spinal cord (C4–C5). The maximum
dose to the spinal cord as tabulated in the
plan statistics is 46.4 Gy. The isodose lines
are 58.4 Gy (dark blue), 50.4 Gy (purple), 45.0
Gy (red), 35.0 Gy (green), 25.0 Gy (cyan), 30.0
Gy (light blue), and 20.0 Gy (blue). The mag-
nitude of setup uncertainty associated with
immobilization and the amount of spinal cord
receiving > 45.0 Gy must both be considered
when determining if this plan is acceptable
for treatment. (To view a color version of this
image, please refer to the CD-ROM).

TABLE 11-2. Achievable Dose Levels for Structures in Prostate Intensity-Modulated Radiation Therapy
Structure Volume, cc Dose at 100% Volume, Gy Mean Dose, Gy Dose at 1% Volume, Gy
Prostate 80.4 ± 1.3 (78.7, 82.7) 70.8 ± 1.0 (69.4, 72.9) 75.3 ± 0.4 (74.9, 76.1) 79.0 ± 0.8 (77.8, 80.3)

Structure Name Volume, cc Dose at 25% Volume, Gy Dose at 5% Volume, Gy Maximum Dose, Gy
Rectum 67.5 ± 28.1 (41.3, 122.8) 57.3 ± 2.2 (55.1, 61.0) 71.6 ± 1.4 (69.2, 73.3) 77.4 ± 1.7 (75.2, 80.0)

Listed are the mean values for 10 cases and the standard deviations. Minimum and maximum doses for each structure are in brackets. For the 10 cases, the average
maximum value in the dose distribution is 80.4 Gy ± 1.3 Gy (78.7 Gy, 82.7 Gy).
174 / Intensity-Modulated Radiation Therapy

TABLE 11-3. Dose Statistics for Head and Neck Intensity-Modulated Radiation Therapy
Structure Volume, cc Minimum Dose, Gy Mean Dose, Gy Maximum Dose, Gy

Gross tumor volume 82.4 ± 49.1 (20.2, 195.8) 54.2 ± 11.8 (24.3, 63.6) 70.6 ± 0.8 (69.9, 72.4) 78.4 ± 2.6 (74.6, 82.5)
Nodes 423.3 ± 163.9 (258.2, 710.3) 26.0 ± 7.2 (14.0, 35.7) 62.0 ± 2.3 (56.1, 64.3) 77.8 ± 2.2 (74.2, 80.5)
Spinal cord* 17.7 ± 5.4 (7.1, 24.1) 1.6 ± 2.3 (0.4, 7.8) 19.2 ± 4.7 (11.6, 26.6) 34.3 ± 7.7 (13.9, 40.5)
Brainstem* 27.4 ± 3.1 (22.5, 33.3) 7.3 ± 5.5 (1.9, 16.7) 22.1 ± 8.4 (6.5, 33.0) 39.9 ± 7.0 (26.8, 48.9)
Ipsilateral parotid gland 22.0 ± 10.6 (10.9, 42.5) 15.4 ± 9.2 (7.1, 35.7) 34.7 ± 13.0 (18.0, 61.1) 61.2 ± 8.2 (45.0, 74.5)
Contralateral parotid gland 25.4 ± 10.2 (10.5, 47.1) 8.8 ± 2.6 (3.4, 12.3) 21.6 ± 4.9 (13.3, 27.9) 49.5 ± 8.4 (31.4, 56.9)
Mandible 66.6 ± 16.7 (40.8, 85.6) 11.8 ± 5.7 (3.8, 20.2) 43.3 ± 3.3 (39.4, 49.9) 66.7 ± 5.1 (58.0, 73.5)
Larynx 9.8 ± 6.3 (3.7, 23.4) 9.9 ± 6.6 (2.9, 24.7) 18.2 ± 9.4 (7.5, 40.7) 42.1 ± 11.4 (30.9, 68.0)

These are the mean values for 10 cases and the standard deviations. Minimum and maximum doses are in the brackets. On average, the maximum value in the dose
distribution is 79.3 Gy ± 2.6 Gy (75.0 Gy, 82.5 Gy).
*The maximum dose to the spinal cord and brainstem is given as the maximum dose to 1 cc of that tissue. The difference between the maximum dose to 1 cc of
tissue and the maximum dose as reported by the dose distribution statistics (ie, the single voxel dose value) is 10.6% for the spinal cord (38.4 Gy ± 8.3 Gy [16.1 Gy,
45.0 Gy]) and 13.4% for the brainstem (46.1 Gy ± 7.4 Gy [31.8 Gy, 55.5 Gy]).

of what is achievable. These cases were planned on the
CORVUS inverse planning system, version 4.0 (North
American Scientific, NOMOS Radiation Oncology Division,
Cranberry Township, PA), with 1 × 1 cm2 beamlets and
segmented with 10 intensity levels for step-and-shoot IMRT
delivery on a Varian C-series linear accelerator (Varian
Medical Systems, Palo Alto, CA).
On occasion, hot spots can be found in normal tissue
outside the target tissues. Figure 11-12 shows a head and
FIGURE 11-12. Axial slice showing a hot spot in normal tissue and a
region of low dose through the brainstem. The isodose curves shown
in this figure are 63.0 Gy (dark blue), 60.2 Gy (purple), 55.0 Gy (orange),
45.0 Gy (light green), 35.0 Gy (green), and 25.0 Gy (light blue). (To view
a color version of this image, please refer to the CD-ROM).
neck IMRT treatment that covers the tumor adequately but
deposits a hot spot (63 Gy) in the contralateral uninvolved
side. In addition, the 25 Gy isodose line streaks across the
skull base through the brainstem to the opposite side. This
would not be seen in 3DCRT treatment planning but is
typical in IMRT owing to unconventional beam arrange-
ments used to improve dose conformity. The hot spot in
normal tissue and low-dose streaks can be modified by the
use of a “tuning structure.” Figure 11-13A shows the addi-
tion of such a structure to reduce unwanted dose outside
the target volume, as shown in Figure 11-13B. No change
was made in the beam directions. This is a useful tool to
modify the IMRT dose distribution specifically when one
desires the same beam directions to avoid physical con-
straints (eg, not wanting to direct a beam through part of
the treatment couch or immobilization device). The hot
spots and low dose in Figure 11-13 are reduced at the
expense of increased heterogeneity within the target (see
Figure 11-13B). In summary, the beam directions in 3DCRT
are very important in achieving a conformal target dose
and adequate normal tissue sparing. However, with IMRT,
the beam directions are not as critical. Other tools are used
in IMRT planning to achieve planning goals, such as dose-
volume constraints and tuning structures.
New IMRT users or experienced users on a new system
need to be aware of unexpected consequences when plan-
ning IMRT. For example, a CyberKnife (Accuray Inc,
Sunnyvale, CA) treatment plan generated to treat the prostate
in Figure 11-14 results in streaking doses over the right femoral
head. This appeared with identical dose constraints on the
left and right femoral heads. This anomaly was due to unfore-
seen limitations in the optimization algorithm that have since
been corrected. Figure 11-14 highlights the point that IMRT
planning is significantly different from 3DCRT planning. An
IMRT plan can have unexpected results in the dose distrib-
ution, and each plan should be considered carefully.
DVHs provide a global view of whether the plan meets
the specified goals and constraints. One can extract data on
the underdosed volumes for the GTV, CTV, and PTV and
 Plan Evaluation / 175

FIGURE 11-13. This figure shows the effect

of a tuning structure in improving the dose
distribution. (A) The plan (see Figure 11-12)
was optimized without a tuning structure and,
(B) the plan was optimized with a tuning struc-
ture (yellow). The isodose curves shown in
this figure are 63 Gy (dark blue), 60.2 Gy (pur-
ple), 55 Gy (orange), 45 Gy (light green), 35 Gy
(green), and 25 Gy (light blue). (To view a color
version of this image, please refer to the CD-
ROM).

FIGURE 11-14. A CyberKnife treatment plan

showing the dose distribution in the coronal
plane (left) and the individual beams (right).
(To view a color version of this image, please
refer to the CD-ROM).

the overdose volumes for each normal structure. In gener-
al, we evaluate the DVH to ensure that at least 95% of the
target receives the prescribed dose. In addition, the DVH
provides data on mean and partial volume doses, which can
be used to determine partial volume tolerances in the future.
Another method to evaluate a treatment plan is to use a
three-dimensional dose display. This type of display com-
plements the DVHs by showing where hot or cold spots
exist relative to other tissues. Figure 11-15 illustrates a three-
dimensional display for a head and neck IMRT plan, show-
ing the location of hot spots outside the target. Although
this type of display provides qualitative information only,
it gives a huge amount of information quickly and may assist
in rapidly evaluating multiple plan iterations.
Final Comments on IMRT Planning
The goal of treatment planning is to maximize the thera-
peutic ratio. This may be difficult to achieve in real life. The
planner must understand what the physician will accept as
a dose limit to critical structures and, at the same time,
must attempt to achieve those limits within the constraints
of the prescription dose for the target. Often, when plan-
ning IMRT, the physician and planner will unnecessarily
go in circles, without a satisfactory solution, because nei-
ther party knows what can be achieved. Hopefully, what to
expect from IMRT has been demonstrated in this chap-
ter. The remaining burden falls on treating physicians to
determine exactly what they will accept in terms of target
coverage and normal tissue sparing. It is essential to be real-
istic in the expectations of IMRT. Unfortunately, IMRT
cannot produce miracles because its dose distributions are
bound by physical principles. It is also essential to be pre-
pared to accept some of the dose to critical structures (but
keeping them below tolerance) to obtain more conformal
target coverage than with 3DCRT. In many cases, a small
volume of the critical structures will receive more of the
dose than it would with 3DCRT, but the IMRT plan will
show better dose conformity. If this trade-off is unaccept-
able, then IMRT may not be the best treatment techique.
176 / Intensity-Modulated Radiation Therapy

The development of IMRT plans usually takes several iter-

ations. Even for experienced IMRT users, the physician and
planner do not always know a priori the quality of plan that
can be achieved. The ability to define treatment goals at the
outset and communicate them to both the planner and the
treatment planning system is part of the IMRT learning
process, which will hopefully become easier with clinical
experience and available outcome data.

FIGURE 11-15. A three-dimensional dose display showing the dose
distribution between 60 and 70 Gy (yellow-red-green). Two high-dose
regions are evident. One is near the mandible and the other is in the
posterior neck, outside the contour of the neck nodes (cyan). Another
intensity-modulated radiation therapy plan should be attempted to
remove or reduce these hot spots outside the target. The gross tumor
volume is shown in red wire mesh within the clinical target volume. (To
view a color version of this image, please refer to the CD-ROM).
The physician and planner need a method to achieve
their planning goals. We have used an approach that is help-
ful for those new to IMRT planning and even for experi-
enced IMRT users when treating new sites. The first step is
to ask the physician to make a difficult decision. If one had
to choose between treating the target (ie, push normal
tissue to near tolerance dose) or spare critical structures
(ie, underdose part of the target), what would be more
important for this patient? This question will help guide
the planner’s focus during the planning process. Next, it
is important to understand what the physician will absolute-
ly not accept in terms of dose to a structure. Whether or
not it is expressed explicitly, every physician has a dose limit
in mind. The job of the IMRT planner is to understand
what those limits are for each physician and for each case.
Another aspect of IMRT planning is that the goals of spar-
ing critical structures may change during the planning
process. It may be decided by the physician that a structure
can take a large fraction of the dose, but once the planning
begins, the planner may realize that the achievable dose
may be much lower. In IMRT treatment planning, slight
modification of the planning goals should be expected until
the physician and planner have gained a considerable
amount of experience.
As can be seen from the discussion above, good physician
and planner communication is essential for successful IMRT
planning. This is partly due to the fact that IMRT is a rela-
tively new technology with minimal long-term outcome data.
References
1. Followill D, Geis P, Boyer A. Estimates of whole-body dose
equivalent produced by beam intensity modulated
confor mal ther apy. Int J R a d iat O nco l Bio l P hys
1997;38:667–72.
2. Williams PO, Hounsell AR. X-ray leakage considerations for
IMRT. Br J Radiol 2001;74:98–100.
3. Waller EJ. Neutron production associated with radiotherapy
linear accelerators using intensity modulated radiation
therapy mode. Health Phys 2003;85(5 Suppl):S75–7.
4. Hall EJ, Wuu CS. Radiation-induced second cancers: the impact
of 3D-CRT and IMRT. Int J Radiat Oncol Biol Phys
2003;56:83–8.
5. International Commission on Radiation Units and
Measurements (ICRU). Prescribing, recording, and reporting
photon beam therapy. ICRU report 50. Bethesda (MD), 1993.
6. International Commission on Radiation Units and
Measurements (ICRU). Prescribing, recording, and reporting
photon beam therapy (supplement to ICRU report 50). ICRU
report 62. Bethesda (MD), 1999.
7. Martinez-Monge R, Fernandes PS, Gupta N, et al. Cross-
sectional nodal atlas: a tool for the definition of clinical
target volumes in three-dimensional radiation therapy
planning. Radiology 1999;211:815–28.
8. Grégoire V, Coche E, Cosnard G, et al. Selection and delineation
of lymph node target volumes in head and neck conformal
radiotherapy. Proposal for standardizing terminology and
procedure based on the surgical experience. Radiother Oncol
2000;56:135–50.
9. Levendag P, Braaksma M, Coche E, et al. Rotterdam and
Brussels CT-based neck nodal delineation compared with
the surgical levels as defined by the American Academy of
Otolaryngology-Head and Neck Surgery. Int J Radiat Oncol
Biol Phys 2004;58:113–23.
10. Lee N, Chuang C, Quivey JM, et al. Skin toxicity due to
intensity-modulated radiotherapy for head-and-neck
carcinoma. Int J Radiat Oncol Biol Phys 2002;53:630–7.
11. 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.
12. Wang JZ, Li XA, D’Souza WD, et al. Impact of prolonged
fraction delivery times on tumor control: a note of caution
for intensity-modulated radiation therapy (IMRT). Int J
Radiat Oncol Biol Phys 2003;57:543–52.
13. Sethi A, Leybovich L, Dogan N, et al. Matching tomographic
IMRT fields w ith static photon fields. Med Phys
2001;28:2459–65.
14. Dogan N, Leybovich LB, Sethi A, et al. Automatic feathering of
split fields for step-and-shoot intensity modulated radiation

therapy. Phys Med Biol 2003;48:1133–40.
15. Laub W, Alber M, Birkner M, et al. Monte Carlo dose
computation for IMRT optimization. Phys Med Biol
2000;45:1741–54.
16. Jeraj R, Keall PJ, Siebers JV. The effect of dose calculation
accuracy on inverse treatment planning. Phys Med Biol
2002;47:391–407.
17. 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.
18. Yu CX, Jaffray DA, Wong JW. The effects of intra-fraction organ
motion on the delivery of dynamic intensity modulation.
Phys Med Biol 1998;43:91–104.
19. Keall PJ, Kini VR, Vedam SS, et al. Motion adaptive x-ray
therapy: a feasibility study. Phys Med Biol 2001;46:1–10.
20. Manning MA, Wu Q, Cardinale RM, et al. The effect of setup
uncertainty on normal tissue sparing with IMRT for head-
and-neck cancer. Int J Radiat Oncol Biol Phys 2001;51:1400–9.
21. Bortfeld T, Jokivarsi K, Goitein M, et al. Effects of intra-fraction
motion on IMRT dose delivery: statistical analysis and
simulation. Phys Med Biol 2002;47:2203–20.
22. Chui CS, Yorke E, Hong L. The effects of intra-fraction organ
motion on the delivery of intensity-modulated field with a
multileaf collimator. Med Phys 2003;30:1736–46.
23. George R, Keall PJ, Kini VR, et al. Quantifying the effect of
intrafraction motion during breast IMRT planning and dose
delivery. Med Phys 2003;30:552–62.
24. Samuelsson A, Mercke C, Johansson KA. Systematic set-up
errors for IMRT in the head and neck region: effect on dose
distribution. Radiother Oncol 2003;66:303–11.
25. Duan J, Shen S, Fiveash JB, et al. Dosimetric effect of
respiration-gated beam on IMRT delivery. Med Phys
2003;30:2241–52.
26. Hugo GD, Agazaryan N, Solberg TD. The effects of tumor
Plan Evaluation / 177
motion on planning and delivery of respiratory-gated IMRT.
Med Phys 2003;30:1052–66.
27. Mundt AJ, Mell LK, Roeske JC. Preliminary analysis of chronic
gastrointestinal toxicity in gynecology patients treated with
intensity-modulated whole pelvic radiation therapy. Int J
Radiat Oncol Biol Phys 2003;56:1354–60.
28. Mohan R, Wang X, Jackson A, et al. The potential and
limitations of the inverse radiotherapy technique. Radiother
Oncol 1994;32:232–48.
29. Tsien C, Eisbruch A, McShan D, et al. Intensity-modulated
radiation therapy (IMRT) for locally advanced paranasal
sinus tumors: incorporating clinical decisions in the
optimization process. Int J Radiat Oncol Biol Phys
2003;55:776–84.
30. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue
to therapeutic irradiation. Int J Radiat Oncol Biol Phys
1991;21:109–22.
31. Eisbruch A, Ship JA, Dawson LA, et al. Salivary gland sparing
and improved target irradiation by conformal and intensity
modulated irradiation of head and neck cancer. World J Surg
2003;27:832–7.
32. Tsujino K, Hirota S, Endo M, et al. Predictive value of dose-
volume histogram parameters for predicting radiation
pneumonitis after concurrent chemoradiation for lung
cancer. Int J Radiat Oncol Biol Phys 2003;55:110–15.
33. Hirota S, Tsujino K, Endo M, et al. Dosimetric predictors of
radiation esophagitis in patients treated for non-small-cell
lung cancer with carboplatin/paclitaxel/radiotherapy. Int J
Radiat Oncol Biol Phys 2001;51:291–5.
34. Fiorino C, Sanguineti G, Cozzarini C, et al. Rectal dose-volume
constraints in high-dose radiotherapy of localized prostate
cancer. Int J Radiat Oncol Biol Phys 2003;57:953–62.
35. Zelefsky MJ, Fuks Z, Leibel SA. Intensity-modulated radiation
ther apy for pro s tate cancer. S emin R a d iat O nco l
2002;12:229–37.