© International Commission on Radiation Units and Measurements 2007
6 TREATMENT PLANNING
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6.1 INTRODUCTION
Treatment planning is the process of simulating a number of delivery strategies for a radiation treatment and choosing the best one to use for treatment. The simulation of the patient is based on a reconstruction of the patient's normal anatomy and tumor(s) derived from imaging studies supplemented by delineation of target volumes and organs at risk (OARs). A plan consists of an ensemble of beams, together with their weighting factors. The beam properties and weights can be generated manually, automatically, or semi-automatically. The dose within the patient can be calculated for any arrangement of beams using physical models of the beam properties. The resulting dose distributions within the patient can then be compared among rival plans. The judgement of which plan is best
6.2 WHAT IS DIFFERENT ABOUT PLANNING PROTON-BEAM THERAPY?
6.2.1 Heterogeneities
6.2.2 Beam-delivery techniques
6.2.3 Single beams
6.2.3.1 Inverse beam design
6.2.3.2 Selection of beam directions
6.2.3.3 The PTV
6.2.3.4 The proton RBE
6.2.3.5 The design of beam-modifying devices
6.2.3.6 Repainting
6.2.3.7 Dose algorithms
6.2.4 Plans
6.2.4.1 Number of beams
6.2.4.2 Intensity-modulated proton therapy (IMPT)
6.2.4.3 Imaging
6.2.4.4 Positioning accuracy, immobilization, and localization
6.2.4.5 Uncertainty analysis
6.2.4.6 Target volume size
6.2.5 Quality assurance
6.3 THE PATIENT'S ANATOMY
6.4 HETEROGENEITIES
6.4.1 Introduction
6.4.2 Interactions of protons in matter
6.4.2.1 Mass thickness
6.4.2.2 Energy loss
6.4.2.2.1 Water-equivalent density
6.4.2.3 Multiple Coulomb scattering
6.4.3 Bulk heterogeneity intersecting the full beam
6.4.4 Bulk heterogeneity partially intersecting the beam
6.4.5 Complexly structured heterogeneities
6.4.6 Compensation for heterogeneities
6.4.6.1 Conversion from CT Hounsfield number to water-equivalent density
6.4.6.1.1 Direct-fit method
6.4.6.1.2 Stoichiometric method
6.4.6.1.3 Confirmation of calibration
6.4.6.1.4 Accuracy
6.4.6.2 Design of compensators
6.4.6.2.1 Choice of range
6.4.6.2.2 Compensator design close to, and outside, the projected target boundary
6.4.6.2.3 Real and virtual compensators
6.4.6.2.4 The effect of an air gap between compensator and patient
6.4.6.2.5 High-Z heterogeneities
6.5 DESIGN OF INDIVIDUAL PROTON BEAMS
6.5.1 Compensation for heterogeneities
6.5.1.1 Choosing beam directions
6.5.1.2 Tangential irradiation
6.5.2 Categories of models for dose computation
6.5.2.1 Uniform-intensity beam algorithms
6.5.2.2 Pencil-beam algorithms
6.5.2.3 Monte Carlo algorithms
6.5.3 Normalization and the calculation of monitor units
6.6 DESIGN OF GROUPS OF BEAMS: THE TREATMENT PLAN
6.6.1 Treatment goals and constraints
6.6.1.1 Setting goal(s) and constraints
6.6.1.2 Establishing a score combiningtarget-volume and normal-tissue effects
6.6.1.3 Target-volume goals and constraints
6.6.1.4 Normal-tissue constraints
6.6.2 Approaches to treatment design
6.6.2.1 Uniform-intensity radiation therapy
6.6.2.2 Intensity-modulated radiation therapy (IMRT)
6.7 PLAN ASSESSMENT
6.7.1 Inspection of the dose distribution
6.7.2 Clinical feasibility
6.7.3 Dose-summarizing quantities
6.8 PLAN COMPARISON
6.8.1 Plan comparison by inspection
6.8.2 Automated plan comparison
6.9 PLAN OPTIMIZATION
6.10 COMPARISON OF UNIFORM-INTENSITY VERSUS IMPT TREATMENT PLANS
6.11 SPECIAL TECHNIQUES
6.11.1 Intraocular treatments with protons
6.11.1.1 Model of the patient anatomy
6.11.1.2 Beam simulation
6.11.1.3 Output of the planning process
6.11.1.4 Presentation of results
6.11.1.5 Treatment example
6.11.2 Stereotactic treatments with protons
6.11.2.1 Immobilization
6.11.2.2 Imaging
6.11.2.3 Planning
6.11.2.4 Treatment
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