Presenter:- Dr.

Musaib Mushtaq

Moderator:- Prof. Dr. Malik Mohib-ul-Haq

 IMRT is the product of advances in RT technology.

 Aims to deliver radiation more precisely to the tumour while

relatively limiting dose to the surrounding normal tissues.

 The purpose of the presentation is to discuss IMRT, its

applications and comparison with other RT method.
 Conventional radiotherapy treatment are delivered with
radiation beams that are of uniform intensity across the field .

 Wedge or compensators are used to modify the intensity

profile to offsets contour in irregularities and produce more
uniform composite dose distributions such as in techniques
using wedges.

 This process of changing beams intensity profile to meet the

goal of a composites plan is called intensity modulation.
Intensity Modulated Radiotherapy is a special
form of 3D-CRT, where conformal dose delivery can be
enhanced by generating a non-uniform photon fluence
within each beam, calculated by treatment planning
system designed to meet specified dosimetric objectives.
IMRT 3DCRT

 Intensity Modulated  3 Dimensional Conformal

Radiotherapy is a special Radiotherapy is the use of 3
form of 3D-CRT conformal dose dimensional anatomical
delivery can be enhanced by information to plan and deliver
generating a non-uniform treatment so that the resultant
photon fluence within each dose distribution conforms as
beam, calculated by an inverse closely as possible to the target
treatment planning process volume in 3 dimensions with
designed to meet specified minimum dose to the
dosimetric objectives. surrounding normal tissue.
 Better normal tissue sparing
 Complex target shapes
 Less toxicity
 Possibly higher dose to target
 More dose in a fraction
 A treatment planning computer system that can calculate non
uniform fluence maps for multiple beams directed from different
directions to minimizing dose to the critical normal structures.

 A system of delivering the no uniform fluence as planned.

  To deliver high dose to
tumour.
 While normal tissue should
receive minimal dose as
much as possible.

 The further NTCP curve is

to the right of TCP curve,
larger is the therapeutic
ratio.
 Positioning & Image acquisition Delineation of Target
Immobilization & Registration Volumes & Organs at risk

3DCRT Decide dose to PTV

‘Forward Beam arrangement Dose constraints
Planning’
Field shaping Beam arrangement
Beam modification Plan generation IMRT
Dose calculation ‘Inverse
Select technique
Planning’

Plan evaluation, Treatment Quality

comparison & Delivery Assurance
selection
Vital component of conformal treatment.
• Thermoplastic sheets
• Polyurethane foam
• Vacuum forming mold

Must be attached
reproducibly on
patients !
Components
Multislice CT Scanner
With a flat couch-top

Laser localization system

Precisely controllable
couch movements.

Simulation software
allows segmentation, contouring and
generates DRRs, 3D volumes and
isoceneters
1 Immobilise Physicians 3
in treatment outline
position target
Align organs-
Use contrast isocenter
localized
Scan

2 Transfer Isocenter 4
images to marked on
graphics patient
workstation with laser
alignment
system
5

Virtual
simulation
 CT Scan is most commonly used procedure, even other
modalities after special advantages in imaging certain types
of tumours and locations.
The CT image
Other Imaging
CT numbers are used to
calculated electron modalities
density
MRI

PET

SPECT

MRS
The reference cut is defined

Individual CT slices are used

to create a 3 dimensional
image which can be viewed in
coronal and sagittal planes.
 It is a process of correlation different image data to identify
corresponding structures or region.

 Image fusion is the seamless mixing up of two image sets of

the same patient, it may be two different image modalities.

 Same modality in which image sets are taken at different

point of time.
 Co-Registration
Surface based / Image based / Point
based.

Fused Images
Allows superior
outlining of targets in
selected areas.
PET provides functional
information to an
anatomical scan

Combined PET-CT Scanners

reduce setup discrepancies

Information from PET can can help modify PTV volumes

Soft tissue window Lung window FDG - PET

Green outline: CT only Red outline: CT& FDG

 It refers to slice by slice delineation of anatomic regions of
interest.

 The segmented regions can be rendered in different colours

and can be viewed in beams eye view configuration or in
other planes using digital reconstruction radiographs
Usually the body and the
bones are contoured first
specialized images
segmentation features -
automatic process

Digitally Reconstructed
Radiographs (DRRs) –
place fields according to bony
landmarks
Verify with portal imaging
Fast DRRs – virtual fluoroscopy
Digital Composite
Radiographs (DCRs) –
View different ranges of CT
numbers – soft tissue, skin
marks
GTV – the gross palpable/ visible/
demonstrable extent and
localization of tumor
CTV – the volume containing GTV
and/ or subclinical microscopic
malignant disease
ITV – the CTV + the
internal margin (for normal
body movements)

PTV – geometrical concept that takes

into account the net effect of all
possible geometrical variations, in
order to ensure that the prescribed
dose is actually absorbed in the CTV.
= ITV + setup margin (for setup
variations)
Contour all normal structures of relevance
In IMRT : what is not contoured, the program
cannot shield

Margins around the OAR for

geometric variations ?
1. How many beams? – IMRT usually require more
than 4 beams

2. Coplanar or Non-
coplanar?

Use the Room’s Eye View (REV) to

get a practical idea about the
geometry of beam placement.
Even in IMRT, you
have to decide the
beam arrangement.

Mainly coplanar
beams are used,
although non-
coplanar beams
are possible
MLCs are used to shape the field
around the PTV
- automatic margins around PTV
(different margins in each co-
ordinate axis?)
- Use the Beam’s Eye View (BEV)
to place MLCs – take into account
structures to be shielded
Once the
parameters are
defined, the
Treatment
Planning Software
generates the
dose distribution.
Dose constraints have to be set to both target volumes and organs
at risk. Appropriate priorities must be set for each volume.

Practical issues :
Don’t set impossible constraints. Set appropriate priorities.
First start with constraints to a few structures – then improve the
plan by adding more constraints.
In the Plan Evaluation mode of a treatment planning
system, look at the doses received by each structure
of interest.
Evaluate the dose distribution characteristics of one
or more plans using dose volume histograms (DVH)

The cumulative (integral)

DVH represents a
cumulative frequency PTV
Bladder
distribution of the dose
integrated over the VOI. Rectum

In the differential DVH,

the ordinate represents
the absolute or relative
PTV
volume which receives the
dose specified on the
abscissa within a specified
range of dose.
Always verify the anatomical dose distribution slice by
slice, in order to identify where underdosage or
overdosage is occurring.

Overdosage : 117%

Underdosage: <90%
 An optimal plan should deliver tumouricidal dose to the entire tumour
and spare all the normal tissue.

 To achieve quantitative biological endpoint ,model have been

developed involving biological indices such as TCP and normal tissue
complication probability.

 Dose distributions of competing plan are evaluated by viewing isodose

curves in individual slices, orthogonal planes or 3D isodose surface.
 3DCRT IMRT

• Change beam arrangement • Change beam arrangement

• Change beam weightage • Change dose constraints
• Adjust field margins • Contour new areas/
• Add modifiers dummy areas.
 Based on inverse planning

 initially , a ct scan is performed on the affected region.

 radiation oncologist defines the ptv.

 enters the plan criteria ; max dose ,mini dose, desired

limiting dose and a dose volume histogram.

 Then ,an optimisation program is run to find the treatment

plan which best matches all the input criteria.
 MLC based IMRT

IMRT Delivery Tomotherapy

Compensator based
IMRT
 1. The fluence 2. A special software converts it
map is into a compensator file
generated

3. A computerized milling
4. The mold is filled with the machine creates a Styrofoam
compensator material (eg. Tin mold
granules, brass cubes, cerrobend)
and the compensator box can be
attached to the wedge slot.
 Temporally modulated
slit MLC with 1 or 2
banks. Nomos MIMiC

Attached to a linac or dedicated systems

Rotating Slit Beam

Serial tomotherapy
Helical tomotherapy
Mainly delivered in 2 ways: static & dynamic MLCs
1. Static Mode (Step & Shoot)
The intensity pattern is decomposed into a number of static
segments, each of uniform intensity

The number of intensity levels determine the complexity or

the smoothness of the delivered fluence.
2. Dynamic mode (Sliding window)
The beam stays ON, and the MLC
leaves move continuously at
variable speeds
dose rate is also modulated to
achieve efficient delivery

When viewed from BEV, a

narrow slit slides across the
beam from one edge to other –
sliding window

3. Intensity Modulated Arc Therapy (IMAT)

4. Volumetric Modulated Arc Therapy (VMAT)
 Static Mode Dynamic mode
(Step & Shoot) (Sliding window)
• Conceptually simpler • Smoothly varying intensities
• No need to control individual • Only one field per beam
leaf speeds direction
• interrupted treatments are • Less time consuming
easier to resume
• Easier to verify intensity
patterns in each subfield
• Fewer MUs
• Regions with zero dose are
more easily delivered
1. Check beam 2. Position & 3. Match/Change
data transfer Immobilize isocenter with lasers

4. Visually verify 5. Take Portal 6. Match with DRRs

MLC positions images in EPID software
 MORE COMPLEXITY

 NEED FOR NEW EQUIPMENTS

 MORE NEED FOR QA

 LONGER TREARMENT TIMES

 HIGHER RISK OF GEOGRAPHICAL MISS

THANKS