Conformal Terminology Discussion

Conformity Index (CI) and Dose Distribution

Conformity Index (CI) is a comprehensive tool to evaluate conformity and dose gradients
of the treatment plan proposed to conformal radiotherapy.1 Currently there are several measures
of conformity, such as PITV, CIPaddick, conformality gradient index (CGI), and conformity
distance index (CDI). The PITV is the most commonly used CI which was first recommended in
Radiation Therapy Oncology Group (RTOG) radiosurgery guideline in 1993. It is defined as the
ratio of the target volume (TV) over the prescription isodose volume (PIV), known as
CI=TV/PIV.1 The ideal CI result is 1. If CI is greater than 1, the treated volume includes normal
tissues.3 For example, in a prostate cancer treatment plan, the volume of a prostate PTV is 157cc
while the volume of the 95% volume (TV) is 198 cc. Therefore, CI=198cc/157cc=1.26 which
indicates over-coverage of normal tissues; when CI is smaller than 1, the target volume is only
partially irradiated. In a partial breast irradiation plan, the volume of PTV is 144cc, the volume
of 95% volume (TV) is 138cc. The CI=138cc/144cc=0.98, which reveals under-coverage of
target volume.
The conformity index between 1 and 2 indicates a good compliance of treatment with the
treatment plan; an index between 2 and 2.5, or 0.9 and 1, is a minor violation of the treatment
plan; an index less than 0.9 or greater than 2.5 is a major violation.7 Even with CI 1, the coverage
of the target may not be adequate. Figure 1 shows four possibilities for which the It can be
simply understood that CI is the evaluation of quality coverage of the treatment plans.

Figure 1. Four possibilities for which the PIV/TV ratio is equal to 1 (index proposed by RTOG)( TV is
target volume, shaded; PIV is the reference isodose volume, enclosed in black dashes). 4

Dose distribution refers to the absorbed radiation dose of an anatomical structure at any
given depth in patients with radiation.1, 5 It is best represented by dose volume histogram (DVH)
which summarizes dose levels in the treatment target and organs at risk (OAR).1 Dose
distribution can also be well evaluated through axial, sagittal, coronal views at the isocentric
position with color wash. Absolut dose and relative dose can be switched to view specific dose
distribution in the treatment plan. Dose distribution can be influenced by variable anatomy, beam
energy, tissue heterogeneity, imaging modalities, treatment planning systems, and algorithms.
The components of dose distribution include surface dose, exit dose, skin sparing, beam flatness,
beam symmetry, and penumbra.6 ICRU protocol recommends a minimal dose of 95% (usually
reference dose) and a maximal dose of 107% of prescribed dose into target volume (mostly
PTV).7 The evaluation of dose distribution is based on algorithm calculations such as Accuro and
Monte Carlo.
I attached a DVH and the corresponding axial, sagittal, coronal views of dose distribution
in a lung treatment plan I created before.

References:

1. Khan FM, Gerbi BJ. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 2012: 269-273.
2. Wu Q, Wessels B, Einstein D, Maciunas r, Kim E, Kinsella T. Quality of coverage:
Conformity measures for stereotactic radiosurgery. Am. Coll. Med. Phys. 2003;4(4):374381. http://dx.doi.org/ 10.1120/1.1621372
3. Murphy BD. Treatment plan evaluation techniques & tools.
https://www.medicaldosimetry.org/pub/397ad10c-2354-d714-5132-906c5cedf3d8.
Accessed March 29, 2016.
4. Feuvret L, Noel G, Mazerron JJ, Bey P. Conformity index: A review. Radiation Oncology
Biol. Phys. 2006;64(2):333-342. http://dx.doi.org/10.1016/j.ijrobp.2005.09.028
5. Dykstra C, Bortfeld T, Debus J, Lomax A, Harrop R, Schlegel W, Munkel G.
Characterization of dose distribution in radiation therapy plans. Radiotherapy and
Oncology. 1996;41(3):281-284. http://dx.doi.org/10.1016/S0167-8140(96)01847-6
6. Photon beam charts. Descriptors of Dose Distribution (Photons). Wikidot Website.
http://ozradonc.wikidot.com/descriptors-of-dose-distribution-photons. Accessed March
30, 2016.
7. Petkovska S, Tolevska C, Kraleva S, Petreska E. Conformity index for brain cancer
patients. Proceeding of the Second Conference on Medical Physics and Biomedical
Engineering. From Google.com search.
http://www.iaea.org/inis/collection/NCLCollectionStore/_Public/43/026/43026160.pdf.
Accessed March 30, 2016.