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Krzysztof Karteczka Transmission Factor Calculation February, 17 2012

Wedge Transmission Factor Calculations Objective: To demonstrate the transmission factor for a wedge and demonstrate the incorporation of this transmission factor in a monitor unit calculation. Purpose: The primary goal of radiation therapy treatment planning is to deliver an even (homogenous) dose to a target while minimizing the dose delivered to normal tissue. To assure that radiation is being directed to the prescribed volume, customization of dose delivery may require the addition of devices that modify the distribution of the radiation dose across the treatment field. One such device is the wedge.The wedge is designedto change the angle of the isodose curve relative to the beam axis at a specified depth within the patient. The wedge is made of lead or steel. When placed in the path of the photon beam, a wedge attenuates the beam. This attenuation must be accounted for in order to deliver an accurate dose to the target volume.1 The general formula for the Transmission Factor (TF), is expressed by the equation:2 TF = Dose with the objectin the path of beam / dose without the object in the path of beam A Wedge Transmission Factor expresses the ratio of the dose rates on the central axis with and without the wedge. It is calculated as follows: Wedge TF = Dose with the wedge in the path of beam / dose without the wedge in the path of beam When the wedge is used, some of the beam is absorbed by the wedge and the monitor unit MU setting must be increased to ensure that the prescribed dose is delivered. Two measurements need to be taken. The first measurement is with the wedge in the path of the beam, and the second measurement is without the wedge in the path of the beam. The ratio of these two measurements is known as a wedge transmission factor. Methods and Materials: The data was generated on the Xio Treatment Planning System and then confirmed on a Varian Trilogy linear accelerator. On the Xio Treatment Planning System I created 30X30 cm and 40X40 cm phantoms using 6 megavoltage (MV) and 10 MV photon

energies at 100 cm SAD, 5x5, 10x10 and 20x20 field sizes. I have used 15, 30, 45, and 60 degrees wedges applying 1000 centi-Grays (cGy). MU readings were taken at 10 cm depth. Results: Table 1 illustrates obtained measurements for phantom 40x40 cm using 6MV energy. 15oMU reading 1513 1422 1357 30o MU reading 1973 1855 1770 45o MU reading 2235 2101 1997 60o MU reading 2727 2564 Wedge doesnt cover treatment field Table 1

Field size

No Wedge MU reading

5x5 10x10 20x20

1064 999.9 950

Table 2 illustrates obtained measurements for phantom 40x40 using 10MV energy. Field size No Wedge MU reading 5x5 10x10 20x20 1066 999.9 950 15o MU reading 1431 1342 1276 30o MU reading 1795 1683 1600 Table 2 45o MU reading 2107 1976 1878 60o MU reading 2544 2386 -

Table 3 illustrates obtained measurements for phantom 30x30 cm using 6MV energy. Field size No Wedge MU reading 5x5 10x10 20x20 1064 999.9 950 15o MU reading 1513 1422 1357 30o MU reading 1973 1855 1770 Table 3 45o MU reading 2235 2101 1997 60o MU reading 2727 2564 -

Table 4 illustrates obtained measurements for phantom 30x30 using 10MV energy. 15o MU reading 1431 1322 1276 30o MU reading 1795 1683 1600 Table 4 45o MU reading 2107 1976 1878 60o MU reading 2544 2386 -

Field size

No Wedge MU reading

5x5 10x10 20x20

1066 999.9 950

Based on these measurements I can tell that transmission factor is independent of the phantom size and the field size, but varies with different energies. Table 5 illustrates the calculation of transmission factor using the measurements obtained from readings with and without wedges for the 6MV energy, phantom 40x40. 6MV Reading w/o wedge Reading w/wedge Transmission Factor Table 5 Table 6 illustrates the calculation of transmission factor using the measurements obtained from readings with and without wedges for the 10MV energy, phantom 40x40. 10MV Reading w/o wedge Reading w/wedge Transmission Factor Table 6 0.745 0.594 0.506 0.419 1431 1795 2107 2544 15o MU reading 1066 30o MU reading 1066 45o MU reading 1066 60o MU reading 1066 0.703 0.539 0.470 0.390 1513 1973 2235 2727 15o MU reading 1064 30o MU reading 1064 45o MU reading 1064 60o MU reading 1064

To confirm these findings I obtained a second set of measurements using a Varian Trilogy linear accelerator with 6MV and 10 MV photon energies with 5x5 field size at 100 cm SAD. This was taken at 100 MU at a dose rate of 600 MU per minute was delivered to a depth of 5 cm in the Solid Water blocks. The Solid Water, seen on the picture 1, its a dosimetrically tissue equivalent material.

Picture 1 A DTW Farmer Ionization Chamber was placed in a pre-cut hole in one of the Solid Water blocks at a depth of 5 cm. An ionization chamber was connected by a triaxial cable to the Keithley electrometer to measure the accumulated charge in nano-Coulombs. This can be seen on the picture 2.

Picture 2

A total of two 100 MU trials each were tested for both 6MV and 10MV beams energies. Once the data was obtained, another two trials each for both 6MV and 10MV beams energies was performed, but this time with 30o and then with 45o wedge in the path of the beam. Table 7 illustrates readings taken for 6MV, with and without 30 and 45 degrees wedges, followed by calculation of the transmission factor. 6MV Reading w/o wedge (nC) 5x5 field size 15.808 15.815 10x10 field size 17.125 17.120

Average: 15.812 Reading with 30owedge (nC) 8.560 Average:8.560 Reading with 45o wedge (nC) 7.617 Average:7.628 Table 7 WTF 30o = 8.560/15.812 = 0.541 WTF 45o = 7.628/15.812 = 0.482 7.639 8.560

Average:17.123 9.307 Average: 9.311 8.263 8.269 9.315

Average:8.8.262

Table 8 illustrates readings taken for 10MV, with and without 30 and 45 degrees wedges, followed by calculation of the transmission factor.

10MV Reading w/o wedge (nC)

5x5 field size 16.894 Average: 16.91 16.888

10x10 field size 18.150 18.150

Average:18.150 10.134 10.937 10.939

Reading with 30owedge (nC)

10.136

Average:10.135 Reading with 45o wedge (nC) 8.775 Average:8.774 Table 8 WTF 30o = 10.135/16.91 = 0.599 WTF 45o = 8.774/16.91 = 0.518 8.773

Average: 10.938 9.455 Average:9.456 9.457

These numbers varies by about 1 to 3% from data obtained fron XiO Treatment Planning System. Discussion: The Transmission Factor for 6MV photon energy is 0.703 (15o), 0.539 (300), 0.470 (45o), 0.390 (60o). The data shows that the wedge attenuates, respectively 30%, 46%, and 53% and 61% of 6MV beam. The Transmission Factor for 10MV photon energy is 0.745 (15o), 0.594 (300), 0.506 (45o), 0.419 (60o).The data shows that the wedge attenuates, respectively 26%, 41%, 50% and 58% of 10MV beam. This result is reasonable as photons from the lower energy beam interact more with the wedge resulting in a lower reading due to higher attenuation. The photons in the higher energy beam interact less with the wedge and therefore resulted in less attenuation and a higher transmission factor. Clinical Application: The wedge transmission factors are measured for their use in dose calculations. Hypothetically speaking, if 100 centi-Grays were to be given in one fraction using 6MV beam with output equal to 1 cGy/MU and percent depth dose of 10x10 cm field at 10 cm depth equaling 67%, one would need to deliver 149 MU (100/0.67) if no wedge was used. To deliver 100 cGy with a 45o wedge in the path of the beam, one would need to deliver 314 MU (100/0.67x0.474), assuming all parameters remain the same. If the patient were accidentally treated without the wedge in place for a single fraction, the patient would potentially receive 210 cGy, instead of the prescribed 100 cGy, resulting in 110% (210 cGy/100 cGy) overdose of the treatment. The use of wedges for cancer treatments has two benefits. First, the wedges reduce the amount of radiation transmitted, therefore reducing a dose to critical structures. Secondly, the wedges even out the isodose lines, which can be observed on diagram 1.

Diagram 1

The patient in Diagram 1 is prescribed 5940 cGy in 33 fractions, 180cGy per fraction. By using wedge in the LPO treatment field treating left axilla, we can observe a proper coverage of the 100% isodose line (red in the diagram). Thanks to the use of 30 degree wedge, the hot spot is reduced to 109% of the prescribed dose. The application of transmission factor can be seen on table 9, which illustrates the monitor unit calculation sheet.

Table 9 Note the 30owedge transmission factor 0.597. MU calculation for the LPO field with the wedge:

MU30o = 63/ (0.597x1.021x1.015x0.685x1.001x1.140) MU 30o= 132 If no wedge was used for the LPO field, MU calculation would look as follows: MU 00= 63/ (1x1.021x1.015x0.685x1.001x1.140)) MU 00= 78 Percent difference in MU:

This difference shows that after including a 30o wedge in the path of the beam requires more monitor unit to deliver prescribed dose to the patient. If the patient were accidentally treated without the wedge in place for a single fraction, this could result in overdosing of the patient. Conclusion: To assure that radiation is being directed to the prescribed volume, customization of dose delivery may require the addition of devices that modify the distribution of the radiation dose across the treatment field. This project demonstrates that addition of beam modifying devices, like the wedge, results in dosimetric changes. The transmission factor of the wedge must be considered in order to calculate a correct dose to the target volume. If the wedge is accidentally omitted during a treatment, this can create a misadministration of the dose. This project also demonstrates that the transmission factor varies with different angle of the wedge, and different energy of the beam.

References: 1. Washington CM, Leaver D. Principles and Practices of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby Inc; 2010. 2. Bentel GC. Dose Calculation for External Beams: Radiation Therapy Planning. 2nd ed. New York: McGraw-Hill; 1996.