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Dosimetric Evaluation of Dose-to-Medium vs. Dose-to-Water using Acuros XB for Lung,

Spine and Head and Neck Plans
Authors: Joanne Li, B.S., R.N., Ashley Hunzeker, M.S., C.M.D., Nishele Lenards, M.S., C.M.D.,
R.T.(R)(T), FAAMD
Medical Dosimetry Program at the University of Wisconsin - La Crosse, WI

ABSTRACT
The aim of this study was to evaluate the dosimetric differences between the absorbed dose-tomedium (Dm) and dose-to-water (Dw) reporting modes using Varians Acuros XB (AXB)
calculated stereotactic body radiation therapy (SBRT) or volumetric modulated arc radiotherapy
(VMAT) on patient treatment plans for lung, spine, and head and neck (H&N) cancer. Fifteen
patients were selected: 5 SBRT lung, 5 SBRT spine, and 5 VMAT H&N using 6 MV external
photon beams. All treatment plans were calculated with identical beam geometries, monitor unit
(MU) values, body structure sets, dose objectives and CT images using Dw and Dm modes
respectively within Eclipse AXB. The most notable differences were observed in planning target
volumes (PTV) maximum doses, spinal cord and the mandible with all p-values < 0.05. This
study showed the dosimetric difference between Dm and Dw reporting mode in AXB was more
relevant in bone anatomy, where the dose difference in the Dw measurement was higher in
mandible when compared to Dm measurement. Therefore, Dm is the preferred reporting mode in
AXB to generate the most therapeutic dose distributions in the treatment planning system (TPS).

Key Words: Dose-to-medium; Dose-to-water; Acuros XB

Introduction
Conventional photon beam dose calculation algorithms in a TPS compute the absorbed
dose in Dw mode with the assumption of water-like tissues in the human body. The historical
water-based dose calculation is reasonable because the majority of the human body is water.1
Therefore, the linear accelerators are calibrated based on water phantoms. The American
Association of Physicists in Medicine (AAPM) Task Group 51 (TG-51) also recommended the
dosimetry calibration protocol for high-energy photon and electron beams base absorbed dose on
Dw.2 Since there are water inequivalent body materials and tissue-specific tumors with various

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densities such as lung, bone, air cavity, and muscles, there are limitations in using the Dw based
mode to calculate the absorbed dose within the body.
Previous researchers studied the absorbed dose in Dm and Dw with Monte Carlo (MC) and
AXB algorithms to investigate the clinical significant difference between Dm and Dw dose
calculation reporting modes.1,3,4 Currently, both MC and AXB are the advanced dose calculation
algorithms in supporting Dw and Dm dose computations modes. However, there are controversies
between Dm and Dw dose reporting. The proponents for using Dm believed the consideration of
heterogeneity of body tissues is a unique advantage of the advanced dose calculation algorithms
which promotes dose accuracy and delivery. In the proposal for the use of Dm dose reporting, Liu
et al5 also argued the conversion of Dm to Dw was not necessary but increased uncertainties and
errors in treatment target and surrounding normal tissues. On the other hand, the opponents
proposed the report of Dw rather than Dm for dose computation in compliance with quality
assurance (QA) calibration, clinical experience, and protocols based on absorbed Dw. Subsequent
studies also revealed the dosimetric differences between the Dw and Dm computations were not
clinically significant, but rather depended on the type and location of cancer and individual
patients.4 Due to the results of both sides of studies, the debate of absorbed dose computation
between Dm and Dw remains.
In comparison to the MC algorithm, AXB is a grid-based linear Boltzmann solver type
algorithm used to compute dose with Dm mode.6 The Linear Boltzmann transport equation
(LBTE) describes the physical interaction of ionizing radiation particles such as neutrons,
photons, or electrons with the matter in the path of the beam. The calculation of AXB in Dw is
based on electron energy deposition in various water-like densities, while the computation in Dm
relies on the mass density with different Hounsfield Unit (HU) values in the voxels. The HU
values are obtained from CT simulation scans and chemical composition of materials in each
voxel of the image grid in the Eclipse TPS. The fundamental heterogenetic densities in Eclipse
include five biological structures (lung, adipose tissue, muscle, cartilage and bone) and 16 nonbiological materials. Unlike the MC algorithm, which employs stopping power ratios to convert
Dm to Dw, the computations for calculating Dw and Dm in AXB mainly relies on an energy
dependent electron fluence in voxels. The calculation of AXB in Dw is processed to calculate the
dose received by the tissue equivalent water in the materials. The previous studies of Dm in AXB
were not enough to support the superiority of AXB Dm over AXB Dw dose reporting mode in

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treatment planning. Therefore, the purpose of this study was to evaluate the statistical
significance differences between Dw and Dm dose computation reporting modes using AXB
calculated for 6 MV photon beams on actual patient treatment plans for SBRT lung, SBRT spine,
and VMAT H&N cancer.
Methods and Materials
Patients Selection
In this study, 15 patients were selected from the patient cohort previously treated based
on the tumor sites with typical composition of materials in soft tissues (H&N), lung, and bone
(spine). The research pool included 5 SBRT lung (10-12 Gy x 5 fractions, group 1), 5 spine
SBRT (7-8 Gy x 5 fractions, group 2), and 5 VMAT H&N (2 Gy x 30-35 fractions, group 3)
cases. All patients were simulated with a GE Light speed RT 16 CT simulator following
immobilization standards for each treatment location. The CT images obtained in simulation
were 2.5 mm slice thickness with 512 x 512-pixel resolution. The CT images were then
transferred via Digital Imaging and Communications in Medicine (DICOM) to the Eclipse TPS.
Target Delineation
Contour delineation included the contouring of the treatment targets and the organs at
risk (OR). The radiation oncologists were responsible for delineating the treatment targets
encompassing gross tumor volumes (GTV) or clinical target volumes (CTV) and the expanded
PTV in each treatment plan. The corresponding OR were carefully contoured by the medical
dosimetrists on the axial DICOM CT images obtained from simulation in the Eclipse TPS. The
OR in 3 groups of patients are listed in Table 1.
Treatment Planning
All treatment plans were generated in Varian Eclipse TPS using RapidArc techniques
with 6 MV external photon beam energy at 600 MU/min for VMAT H&N plans and at 1000
MU/min in SBRT lung and spine plans. Dose prescription and dose constrains were based on
Radiation Therapy Oncology Group (RTOG) 0813 for SBRT Lung, RTOG 0225 for VMAT
H&N, and institutional standards for SBRT spine. Dose prescriptions and daily dose per fraction
for all 15 patients in the 2 groups were listed in Table 2. Lung and spine treatment plans were
generated with a SBRT technique that included 2-3 full and partial arcs at clockwise or counter
clockwise rotations. The total doses of each plan were prescribed to the PTV. For H&N

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treatments, typically a VMAT technique was used with 2 dynamic full arcs with inverse
rotations.
All 15 selected patient treatment plans were optimized using the Varian Eclipse Progressive
Resolution Optimizer (v13.6) to achieve the dose constraints to OR and PTV based on the
institutional guidelines and RTOG protocols. Each plan was calculated with identical beam
geometries, MU values, body structure sets, dose coverages and CT images using Dw and Dm
reporting modes respectively within AXB. Heterogeneity correction was turned on in both
computation modes. The calculation grid size was 0.25 cm for all the plans. With the default
100% to isocenter field normalization type, the calculated treatment plans were normalized to
achieve at least 95% of the PTV volume covered by the prescribed dose for SBRT lungs and
VMAT H&N plans and at least 90% for SBRT spine plans. The isodose line (IDL) distribution,
regions of high dose, and dose-volume histogram (DVH) were evaluated for plan conformities.
The relative difference in dose of PTV and certain OR were calculated with Equation 1.4
(1)

(AXB Dw AXB Dm)/AXB Dw *100

Results
Plan Analysis and Evaluation
The dosimetric differences between Dw and Dm of the same plan for all 3 groups of
patients were analyzed and graphed. Since the sample of 15 patients for each selected structure
were identical for Dm and Dw based measurements, the paired sample t-test is an appropriate
method to evaluate the statistical significance difference between Dm and Dw reporting modes in
AXB.7 The Dw variable represented the experimental group while the control group was the Dm
variable. The significance level of mean difference between Dw and Dm measurements was
evaluated with p-values (2-tailed). A p-value 0.05 represented there was strong evidence for
the difference between Dw and Dm measurements. Otherwise, the difference between Dw and Dm
measurements was not significant if the p-value 0.05.
For SBRT lung cancer, the relative difference in maximum dose of spinal cord and the
mean dose of contralateral lung and heart in the Dw based plans were consistently greater than
Dm based plans with average differences of 1.4% (spinal cord), 0.2% (contralateral lung), and
0.8% (heart) as seen in Figure 1. Both the spinal cord and the contralateral lung had p-values of
0.047 and 0.001, respectively. The difference in trachea maximum dose with Dw based were

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lower than Dm based plans with an average of - 0.97% while only one patient plan had a greater
Dw value of 0.3%. There was no clear trend in PTV maximum, ipsilateral lung mean doses and
esophagus maximum doses. The percentage of the volume of total normal lung tissues that
received at least 5Gy (V5) and 20 Gy (V20) in Dw and Dm based plans remained the same in all 5
plans. Figures 2 and 3 showed IDL distributions at isocenter in transverse views and DVH with
Dw and Dm computation modes respectively for one of the SBRT lung plans. Figure 1
demonstrated IDLs distributions in Dw and Dm based calculations were comparable with the
exception of the 100% IDL noticeably different at bony rib area between Dw and Dm
computations. The maximum dose in Dw based computation was about 1% lower than in Dm
based measurement but approximately 7% greater coverage of PTV on the DVH evaluation.
The SBRT spine plans demonstrated Dw based dose computation produced greater doses
than Dm based plans to maximum dose of PTV, total lungs, spinal cord, and heart (Figure 4). The
only two exceptions included the doses in esophagus which were 0.1% and 0.3% lower in Dw
based plans with p-value of 0.2. The greatest difference was in the PTV maximum dose with an
average of 8.5% higher in Dm, while the least difference was in mean dose of total lungs at an
average of only 0.099%. Figure 5 illustrated the comparison of dose computation IDLs in Dw
and in Dm modes of a SBRT spine plan. The 100% prescription dose line was noticeably close to
spinal cord in Dw plan but distant to the spinal cord in Dm plan. The IDLs covering the spine in
the Dm plan were steeper than in the Dw plan. The DVH in Figure 6 reflected a great systematic
shift especially in PTV coverage in Dw plans.
For H&N plans (Figure 7), the difference in the PTV maximum doses, spinal cord,
mandible, and brainstem were consistently greater in the Dw plans compared to Dm plans which
ranged from 1.5-10.1% in average. The greatest difference was in the mandible, with an average
difference up to 10.1% and p-value of 3.95306e-6. The extremely small p-value in mandible
represented strong evidence of difference between Dw and Dm based measurements.7 Figures 8
and 9 showed IDL distributions and DVH for Dw and Dm based calculations for a VMAT H&N
plan. The IDL extended well into the left mandible in Dw measurement with the consideration of
water homogeneity. At a different level, the IDL in Dw based plans were also noticeably close to
brainstem and vertebrae while the same IDLs in Dm plans were distant to brainstem and less
extension into the mandible indicated by an orange arrow in Figure 8. The 50% IDL did not
show a dramatic difference between Dw and Dm based plans. As shown in Figure 9, the DVH for

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PTV and OR converting from Dm to Dw significantly shifted in PTV coverage and mandible dose
due to greater stopping power ratio in the mandible than primary soft tissues in H&N area.1
Further analysis of the results for all 3 groups of SBRT lung, SBRT spine, and VMAT
H&N cancer demonstrated that the greatest difference between Dw and Dm modes was seen in the
mandible for H&N cases, where the Dw computation was greater than Dm ranging from 9.5% 10.8%. The Dw dose computation was also greater than Dm for PTV maximum dose in these
cases ranging from negative 1.05-11.4%. However, the p-value of PTV maximum dose in SBRT
lung plans was 0.5 whereas the p-values in SBRT spine plans and H&N plans were much smaller
with 0.003 and 0.0006 respectively. The Dm and Dw dose computation results did not show strong
evidence for differences among all other dosimetric parameters including heart, esophagus,
pharynx, parotid glands in H&N, spine and lung SBRT plans. The Dw based computation was
consistently higher for the spinal cord in all cases ranging from 1.4-3.9%, and lower for trachea
in the lung plans with an average of -0.97%.
Discussion
The dosimetric parameters of Dm and Dw dose computation modes in AXB of the same
plan for the SBRT lung, SBRT spine, and VMAT H&N cancer were studied and evaluated. The
results of the calculations with each computation mode were retrieved from the DVHs in the
Eclipse TPS. The relative difference between Dw and Dm reporting modes were calculated by
equation 1 and compared in Figures 1, 4, and 7. The preliminary dosimetric results of 15 clinical
cases from 3 different groups showed the cancer sites with different tissue heterogeneity
determined the degree of dose agreeance between Dw and Dm computations. For example, the
average differences for the maximum PTV doses in Dw based plans for H&N cancer were higher
than in lung cancer, but lower than in spine plans. The same results were also observed for
maximum spinal cord dose in all 3 cancer groups. Other researchers also reported the finding of
higher results in Dw computation when compared to Dm in AXB.1,3,4
The results in this study demonstrated the conversion of Dm to Dw dose computation in
AXB should be avoided due to large systematic uncertainties and the inherent advantage of Dm in
AXB algorithm. In the current study, a significant difference between Dw and Dm based
measurements in AXB was observed in bone (mandible) and adipose (spinal cord) with the
greatest difference in bone anatomy. The difference in lungs did not produce significant trend

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with nearly the same results of V5 and V20 as well. The results between Dw and Dm measurements
for the other OR did not show clear trends either. Therefore, the Dm reporting mode is more
related to tumor locations with greater consideration of tissue inhomogeneity than Dm
computation. The report of dose distribution was more accurate in Dm based computation than
Dw based. The Dm computation is an inherent advantage of AXB algorithm and should be
preferred to generate more tissue-specific doses to tumors and normal tissues and provide a
smooth transition from conventional to up-to-date treatment planning. The conversion of Dm to
Dw in order to comply with the water phantom based calibration is not necessary, but attributes
additional complexities in dose report with systematic uncertainties.5 In a new regulation of NRG
protocol for clinical trials, Gladstone et al8 also discouraged the conversion of Dm to Dw for the
reasons of numerical and conceptual uncertainties, but agreed that the cortical bone produced
significant differences than other tissues in the report of dose calculation with Dm and Dw modes.

Conclusion
Since the improvement of accuracy is an endless effort for dosimetric planning, the selection
of a valid method on a routine clinical basis is crucial for accurate dose evaluation. The
controversies between Dm and Dw reporting modes in AXB suggests a need of more studies to
determine which measurement supports a closer clinical outcome. By comparing the
measurements with both methods based on 15 clinical cases, the initial dosimetric results in this
study showed the dose distribution report calculated by Dm and Dw modes in AXB produced
comparable dose computation in most clinical cases. However, the dose difference between Dm
and Dw computation modes was more relevant in bone anatomy. The significantly small p-value
in mandible strongly supports this finding. With better agreement with Dm for dose computation
in AXB, the tendency of dose reporting process with Dm is inevitable in the future.8 It is not
recommended to convert Dm to Dw in order to keep consistence to the historical practice but
rather introduces uncertainties from conversion. The limitations of this study are the small
sample size with only 15 cases and the restricted time to measure three typical cancer sites.
Additional clinical studies of Dm and Dw computations for different types of cancer with bigger
samples are needed to support a better selection of the reporting mode.

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References
1. Dogan N, Siebers JV, Keall PJ. Clinical comparison of head and neck and prostate IMRT
plans using absorbed dose to medium and absorbed dose to water. Phys Med Biol.
2006;51(19):4967-4980. http://dx.doi.org/10.1088/0031-9155/51/19/015
2. McEwen M, DeWerd L, Ibbott G, et al. Addendum to the AAPMs TG-51 protocol for
clinical reference dosimetry of high-energy photon beams. Med Phys. 2014;41(4):041501041501-20. http://dx.doi.org/10.1118/1.4866223
3. Siebers JV, Keall PJ, Nahum AE, et al. Converting absorbed dose to medium to absorbed
dose to water for Monte Carlo based photon beam dose calculations. Phys Med Biol.
2000;45(4):983-995. http://dx.doi.org/10.1088/0031-9155/45/4/313
4. Rana S, Rokharel S. Dose-to-medium vs. dose-to-water: Dosimetric evaluation of dose
reporting modes in Acuros XB for prostate, lung and breast cancer. Int J Cancer Ther Oncol.
2014;2(4):1-7. http://dx.doi.org/10.14319/ijcto.0204.21
5. Liu, HH. Keall, P. Hendee WR. Dm rather than Dw should be used in Monte Carlo treatment
planning. Med Phys. 2002;29(4):922-924. http://dx.doi.org/10.1118/1.1473137
6. Failla GA, Wareing T, Archambault Y, et al. Acuros XB advanced dose calculation for the
EclipseTM treatment planning system. Varian Medical System Web Site.
https://www.varian.com/sites/default/files/resource_attachments/AcurosXBClinicalPerspecti
ves_0.pdf. Accessed August 14, 2016.
7. Dorey F. In brief: The p value: What is it and what does it tell you? Clin Orthop Relat Res.
2010;468(8):2297-2298. http://dx.doi.org/10.1007/s11999-010-1402-9
8. Gladstone DJ, Kry SF, Xiao Y, et al. Dose specification for NRG radiation therapy trials. Int
J Radiat Oncol. 2016;95(5):1344-1345. http://dx.doi.org/10.1016/j.ijrobp.2016.03.044

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Figures

Figure 1. Relative dosimetric difference between Dw and Dm of the same plan for 5 different
SBRT lung cancer cases in group 1.

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Figure 2. The comparison of isodose distribution in Dw mode (left) and in Dm mode (right) for
patient 4 in SBRT lung group at isocenter. Red line=100% (50 Gy IDL), Green line=95% (49 Gy
IDL), Blue line=90% (45 Gy IDL), and Cyan line=50% (25 Gy IDL). The orange arrow
indicates the less extended IDL to bone anatomy (rib) calculated with Dm method.

Figure 3. The DVH comparison of the dose to PTV and OR in Dm and Dw for patient 4 in SBRT
lung group. The square line represents Dw whereas triangle line represents Dm in AXB.

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Figure 4. Relative dosimetric difference between Dw and Dm of the same plan for 5 different
SBRT spine cancer plans in group 2.

Figure 5. The comparison of isodose distribution with 100% IDL [30 Gy (red line)], 95% IDL
[28.5 Gy (green line)], 90% IDL [27 Gy (blue line)], and 50% IDL [15 Gy (cyan line)] in Dw
(left) and in Dm mode (right) at the same level transverse view for patient 3 in SBRT spine

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group. The orange arrow indicates the IDL with steeper distribution in spine calculated with Dm
mode.

Figure 6. The DVH comparison of the PTV and OR in Dm and Dw modes for patient 2 in SBRT
spine group. The square line represents Dw mode whereas triangle line represents Dm mode.

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Figure 7. Relative dosimetric difference between Dm and Dw modes of the same plan for 5
different VMAT H&N cancer plans in group 3.

Figure 8. The comparison of isodose distribution with 100% IDL [60 Gy (red line)], 95% IDL
[57 Gy (green line)], 90% IDL [54 Gy (blue line)], and 50% IDL [30 Gy (cyan line)] in Dw (left)
and Dm mode (right) at the same level transverse view for patient 2 in VMAT H&N plans. The
orange arrow indicates the less extended IDL to mandible in Dm based calculation due to
stopping power ratio.

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Figure 9. The DVH comparison of the PTV and OR in Dm and Dw modes for patient 2 in VMAT
H&N group. The square line represents Dm whereas triangle line represents Dw.

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Tables
Table 1. The OR in 3 groups of treatment plans.
SBRT Lung Cancer
(Group 1)
Contralateral-Lung
Ipsilateral-Lung
Spinal Cord
Heart
Esophagus
Trachea

SBRT Spine Cancer

(Group 2)
Total Lungs
Heart
Spinal Cord
Esophagus
Trachea

H&N Cancer
(Group 3)
Mandible
Parotid Glands
Pharynx
Brainstem

Table 2. The prescription doses for 3 groups of patients.

Patients in Each
Group
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5

SBRT Lung Cancer

(Group 1) (Gy)
60 (12 Gy x 5)
50 (10 Gy x 5)
60 (12 Gy x 5)
50 (10 Gy x 5)
50 (10 Gy x 5)

SBRT Spine Cancer

(Group 2) (Gy)
35 (7 Gy x 5)
40 (8 Gy x 5)
40 (8 Gy x 5)
40 (8 Gy x 5)
40 (8 Gy x 5)

VMAT H&N Cancer

(Group 3) (Gy)
70 (2 Gy x 35)
60 (2 Gy x 30)
70 (2 Gy x 35)
60 (2 Gy x 30)
64 (2 Gy x 32)