Margins for geometric uncertainty around organs at risk in radiotherapy

ICRU Report 62 suggests drawing margins around organs at risk (ORs) to produce planning organ at risk volumes (PRVs) to account for geometric uncertainty in the radiotherapy treatment process. This paper proposes an algorithm for drawing such margins, and compares the recommended margin widths with examples from clinical practice and discusses the limitations of the approach.

The use of the PRV defined in this way is that, despite the geometric uncertainties, the dose calculated within the PRV by the treatment planning system can be used to represent the dose in the OR with a certain confidence level. A suitable level is where, in the majority of cases (90%), the dose-volume histogram of the PRV will not under-represent the high-dose components in the OR. In order to provide guidelines on how to do this in clinical practice, this paper distinguishes types of OR in terms of the tolerance doses relative to the prescription dose and suggests appropriate margins for serial-structure and parallel-structure ORs.

In some instances of large and parallel ORs, the clinician may judge that the complication risk in omitting a margin is acceptable. Otherwise, for all types of OR, systematic, treatment preparation uncertainties may be accommodated by an OR-->PRV margin width of 1.3Sigma. Here, Sigma is the standard deviation of the combined systematic (treatment preparation) uncertainties. In the case of serial ORs or small, parallel ORs, the effects of blurring caused by daily treatment execution errors (set-up and organ motion) should be taken into account. Near a region of high dose, blurring tends to shift the isodoses away from the unblurred edge as shown on the treatment planning system by an amount that may be represented by 0.5sigma. This margin may be used either to increase or to decrease the margin already calculated for systematic uncertainties, depending upon the size of the tolerance dose relative to the detailed planned dose distribution. Where the detailed distribution is unknown before the OR is delineated, then the overall margin for serial or small parallel ORs should be 1.3Sigma+0.5sigma. Examples are given where the application of this algorithm leads to margin widths around ORs similar to those in use clinically.

Using PRVs is appropriate both for forward and inverse planning. Dose-volume histograms of PRVs for serial- and parallel-structure ORs require careful interpretation. Nevertheless, use of the proposed algorithms for drawing margins around both serial and parallel ORs can alert the dosimetrist/radiation oncologist to the possibility of high-dose complications in individual treatment plans, which might be missed if no such margins were drawn.