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Treatment Planning in Radiation Therapy
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DOI: 10.1007/978-3-319-61540-0_4
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Chapter 4
Treatment Planning in Radiation Therapy
Amjad Hussain and Wazir Muhammad
Contents
4.1 Section A: Photon Beam Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.2 Section B: Electron Beam Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
4.1 Section A: Photon Beam Treatment Planning
4.1.1 Introduction
Radiation therapy is the clinical use of ionizing radiation as part of a comprehensive

cancer treatment to eradicate malignant/cancerous cells. It works by damaging the
DNA of cancerous cells, which is the primary cause of cell death. Normal cells are
also damaged by ionizing radiation; however, they generally have a better recovery
mechanism than the cancerous cells.
Radiotherapy is used to treat cancer with two main intentions: Radical radio-
therapy is meant to cure the patient, while palliative radiotherapy is mainly used to
relieve the symptoms caused by the cancer. There are two major types of radiation
therapy strategies: external beam radiotherapy (EBRT) and brachytherapy. EBRT
is the most frequently used form of radiotherapy, where the radiation source is at a
certain distance outside the patient, during treatment. Brachytherapy treatment is
performed by placing a radioactive source inside or next to the tumor.
More than 50% of cancer patients would benefit from radiation as part of their
treatment (Porter et al. 1999). The benefits of cancer treatment using ionizing
radiation are widely known in terms of increase in disease-free survival rates,
A. Hussain, PhD, MCCPM (*)

Radiation Oncology, Western Manitoba Cancer Centre, Brandon R7A 2B3, MB, Canada
e-mail: [email protected]
W. Muhammad, PhD
Department of Therapeutic Radiology, Yale University School of Medicine,
New Haven, CT, USA
© Springer International Publishing AG 2017 63

M. Maqbool (ed.), An Introduction to Medical Physics, Biological and Medical
Physics, Biomedical Engineering, DOI 10.1007/978-3-319-61540-0_4
64 A. Hussain and W. Muhammad
prolongation of life, and improvement in quality of life (Fodo et al. 2000; Ferreri
et al. 2000; Vargas et al. 2005). Radiation therapy relies significantly on techno-
logical innovations and the collaborative technical reports developed by teams of
professionals that heavily influence the outcome of cancer treatment worldwide.
4.1.1.1 Historical Evolution
X-rays were discovered by Wilhelm Roentgen in 1895. As a result of the investi-

gations performed by Henri Becquerel and Marie Curie in 1896, a new treatment
method using radioisotopes was implemented. The noninvasive and penetrating
nature of ionizing radiation made it an alternative treatment to surgery. The first
ever patient was successfully treated using ionizing radiation in 1899 (Kramme
et al. 2011). Bremsstrahlung x-rays with peak energy of ~300 kVp were widely
used for treatment purposes, up until 1950s. Cobalt-60 teletherapy machines were
very popular during the 1950s for cancer treatment (Khan 2010) and were subse-
quently complemented by high-energy medical linear accelerators. Currently, lin-
ear accelerators are the most commonly used medical devices for treating cancer
patients with megavoltage photon and electron beams, worldwide. Radiation ther-
apy technology has evolved immensely over the last 50 years. Computers were
introduced for complicated dose distribution calculations, in the early 1960s. In the
1970s, computed tomography (CT) scanners were developed for imaging purposes
(Curry et al. 1990). These CT scanners played a key role in localization and
delineation of radiotherapy targets and healthy organs, thus providing the basis
for three-dimensional conformal radiation therapy (3D–CRT). Multileaf collima-
tors (MLC) were available during 1970s; however, intensity-modulated radiation
therapy (IMRT) was not developed until the 1990s (Bortfeld et al. 1990a; Keller-
Reichenbecher et al. 1999).
4.1.2 Therapeutic Response
Optimally effective radiotherapy is not possible without some understanding of the

biological effects of radiation. Radiation biology describes the complex biological
response of tissue in relation to the given radiation dose. With increasing radiation
dose above a certain threshold, tissue response may increase. Practically, such a
dose response is expressed by a sigmoidal relationship, shown in Fig. 4.1, where
tumor control probability (TCP) and normal tissue complication probability
(NTCP) are plotted as a function of absorbed dose. In reality, a typical radiotherapy
treatment is considered to be effective if the magnitude of TCP is 50% and NTCP is
5% (Podgorsak and IAEA 2005). For a given NTCP (usually 5%), the therapeutic
response or therapeutic index is defined as the ratio of TCP to NTCP (Podgorsak
and IAEA 2005; Hall and Giaccia 2006). Hence, the farther apart the NTCP and
TCP curves are from each other, the higher is the therapeutic index. Different
4 Treatment Planning in Radiation Therapy 65
Fig. 4.1 Conventional

representation of normal
tissue and tumor response to
radiation dose. Cell kill
increases in a sigmoidal
fashion above a threshold
Fig. 4.2 Radiotherapy Diagnosis Structures Dose

treatment planning chain & Imaging Delineation Calculation
CT/Conventional Treatment
Simulation & Dose Delivery &
Immobilization Prescription Evaluation
fractionation schemes and, in selected cases, chemotherapy drugs are used to

increase the therapeutic index. Frequently, the tumor response to radiation is greater
than that of the adjacent normal tissue. This makes radiotherapy an effective cancer
treatment methodology in many cases.
4.1.3 Radiation Therapy Process
Radiotherapy treatment planning is the process of determining optimal treatment

parameters for patient irradiation. The entire process encompasses the following
essential activities:
• Diagnostic and imaging
• Patient positioning and immobilization
• Simulation imaging
• Treatment volume and dose-limiting structures delineation
• Radiation dose prescription and fractionation
• Optimal dose distribution calculation and evaluation
• Dose delivery and verification
Figure 4.2 summarizes these points as a treatment planning chain. Determination
of the extent and nature of the tumor, using various diagnostic tools, prior to
treatment planning is essential. Depending on the type, extent, and location of the
tumor and the patient condition, the tumor is either surgically removed or treated
with radiation and/or chemotherapy agents. Frequently there is a remnant of the
tumor, even after surgery, which needs to be irradiated to avoid recurrences. Such a
group of patients is referred to radiation oncologists for further management. The
treatment planning process starts from this point of referral onward.
4.1.4 Patient Data Acquisition
Figure 4.2 describes the entire radiation treatment planning procedure. The radia-
tion oncologist assesses the patient and decides a suitable treatment protocol. The
first step in the treatment planning process is to decide which volume of the patient
needs to be irradiated and which volumes are to be spared. Such information is
available to radiation oncologists from state-of-the-art imaging modalities such as
CT, MRI, ultrasound, and PET. Generally, there are two types of imaging inten-
tions: diagnosis and treatment planning. The former is a requirement for detailed,
disease diagnosis and staging and is therefore acquired in high resolution and
contrast. Treatment planning imaging, also called simulation imaging, may not
need to be of high resolution and contrast. However, all planning images must be
acquired in the geometrical configuration intended for treatment. In other words it is
essential to be able to reproduce the simulation imaging coordinates during actual
treatment on the radiotherapy machine. Simulation can be performed on a conven-
tional simulator, CT or MR simulator, depending on the type of tumor and treat-
ment intent and equipment availability. During conventional simulation, beam
directions and apertures are determined, while the patient is on the couch for a
short period of time. Whereas in CT simulation, the patient’s anatomical informa-
tion is acquired in three dimensions and is available for radiation beam arrangement
design even in the absence of the patient. This concept, known as virtual simulation,
is pivotal in achieving optimal and conformal dose distributions.
4.1.5 Patient Positioning and Immobilization
Patient positioning is one of the most crucial and frequently weakest links in the
treatment process (Fig. 4.2). Accurate and reproducible patient positioning is
necessary to make it possible to deliver the prescribed dose precisely to the target
and spare healthy tissues over the many fractions that a course of radiotherapy
entails. There is also, of course, the possibility that patient who is not immobilized
moves during an individual treatment, while on the treatment table. One of the
reasons for patient movement during treatment is uncomfortable positioning.
Extended treatment duration is another common reason for these movements.
Involuntary actions, such as breathing and coughing may also cause the tumor to
move away from the intended treatment position. In order to facilitate positioning
reproducibility and to limit patient movement during treatment, various immobili-

zation devices are employed. Body supports, straps, thermoplastic sheets, vacuum
bags, and stereotactic frames are few examples of commonly used immobilization
devices.
In addition, there are a number of systems and methods, used to locate patient
position relative to the treatment unit geometry and/or the treatment beam, e.g.,
portal images/films, cone beam CT, radio-opaque markers, lasers, infrared tracking
cameras, etc.
4.1.6 Pretreatment Simulation
Prior to external beam radiation therapy of the patient, it is essential to simulate the
proposed treatment on the individual patient anatomy. This can be done with the
patient present and positioned on a conventional simulator which mimics the
geometry of the treatment machine. Or the simulation can be performed on a
computer using three-dimensional images, from CT, for example, of the patient.
This entire process is time consuming and therefore cannot be performed on a
treatment unit.
4.1.6.1 Conventional Simulator
A conventional simulator (Fig. 4.3) is a machine with a diagnostic x-ray tube that
mimics the functions and motions of a radiation therapy treatment unit. The main
function of a simulator is to correctly position the treatment fields in order to
accurately encompass the target and avoid surrounding normal tissues from receiv-
ing excessive irradiation. Internal body structures are dynamically visualized using
the fluoroscopic capability of the simulator. Radiographic images are finally
acquired for the appropriate body site. The radiation oncologist may draw outlines
for shielding blocks based on these images. The radiographic images and patient
and machine coordinates can be transferred to the treatment planning system via
DICOM, instantly. During simulation the patient separation/thickness is also mea-
sured for dosimetric calculation.
There is a strong justification for using simulators prior to treatment. The need
for simulators arises from four facts (Khan 2010): (a) commercially available
diagnostic x-ray machines cannot be used because their geometric properties are
different from those of treatment machines; (b) field localization on the patient
needs to be done with high-quality images, which can not be acquired with high-
energy therapy machines; (c) the entire simulation process is time consuming and
hence impractical to be performed in a treatment room; and (d) unanticipated
problems with a patient positioning or beam arrangements can be resolved in the
simulation room, hence conserving time on the treatment machine.
Fig. 4.3 A photograph of a

conventional radiographic
simulator (Courtesy
Medical Systems,
Palo Alto, CA)
Fig. 4.4 A planar

radiograph of the pelvis,
taken on a conventional
simulator
Patient body contouring, treatment depth measurement, and preparation of

immobilization devices are also performed, while the patient is on the simulator
table. Another important use of a simulator is pretreatment QA of patient-specific
shielding blocks and boluses. In Fig. 4.4 a planar radiograph of a pelvis is shown.
The square region marked by bold white lines encompasses the volume to be
treated. The intersection of the dashed lines denotes the central axis of radiation
beam. If additional shielding needs to be implemented, for example, to protect a
structure in the corner of the rectangular field, it is marked on such a radiograph.
4.1.6.2 Computed Tomography Simulator
CT simulators have become an essential part of patient simulation for the majority
of radiation therapy practices all over the world. CT images provide good tissue
contrast in three dimensions, as opposed to the two-dimensional projection of a
conventional simulator, allowing for improved tumor localization and contouring.
The CT data also provides relative electron density, which can be converted to
physical density, of the various body tissues. Modern dose calculation algorithms
use this information for dose determination in heterogeneous media, i.e., patient
body. A therapy CT simulator as shown in Fig. 4.5 is similar to a conventional
diagnostic CT with a few additional features. The tabletop is flat, to mimic the
couch top on the treatment machine. The bore of the gantry is generally larger than
that of a diagnostic unit to accommodate immobilization devices during special
patient positions. The CT room is equipped with movable lasers for setup purposes
including marking the patient.
A complete CT data set provides a 3D anatomical model of the patient. The CT
images can be visualized in transverse, sagittal, and coronal planes (Fig. 4.6). The
3D planning process in the modern radiotherapy era is performed on planning
computers in the absence of the patient. Most CT simulators are equipped with
virtual simulation software. This software is used to determine field
Fig. 4.5 A photograph of computed tomography simulator (Courtesy: Philips Healthcare, Cleve-
land OH)
Fig. 4.6 Three-dimensional view of the patient anatomy, reconstructed from CT data in Eclipse™
arrangements for optimal tumor coverage and maximal avoidance of normal critical
structures.
In contrast to acquiring conventional simulation projection radiographs, virtual
simulation is based on digitally reconstructed radiographs (DRRs) for treatment
field arrangement. These DDRs are produced from the patient CT data set using
various reconstruction methods. The DRRs have become more important in newer
treatment planning systems and have largely replaced the conventional radio-
graphic/fluoroscopic imaging methods. The main advantage of DRRs is that any
field arrangement can be simulated without calling the patient back which is not the
case with conventional simulation. DRRs are also used for treatment verification
purposes (to be discussed later). Figure 4.7 shows a DRR for an anteroposterior
(AP) view of the pelvis.
4.1.6.3 Magnetic Resonance Imaging (MRI)
Treatment planning calculations are generally performed on CT images. However,

for target delineation, additional modalities can be helpful in some cases. Magnetic
resonance (MR) imaging is one such modality that provides better soft tissue
contrast compared to CT, and this can be especially useful in brain and prostate
Fig. 4.7 An
anteroposterior DRR
of pelvis, showing field
borders and the beam
central axis
tumors. For contouring purposes, MR images are fused (overlapped) with the
CT data set. Newer sophisticated algorithms may use MR images for dose
computation.
4.1.6.4 Positron Emission Tomography (PET)
Positron emission tomography (PET) is also used as a complementary imaging tool

for target delineation. PET provides useful information on the physiological func-
tion of organs based on their metabolic activity. PET-CT is a technique where both
the CT and PET images are acquired simultaneously with the same patient setup.
The additional information can help the oncologist to accurately and precisely
contour certain target volumes.
4.1.7 Contouring
Contouring of various anatomical structures and the tumor volume is an essential

part of the 3D treatment planning process. Contouring is performed, most of the
time, on CT simulator images alone (Fig. 4.6). However, diagnostic CT, PET,
and/or MRI scans can also be used for accurate contouring in selected patients.
ICRU Reports (No. 50 and No. 60) (International Commission on Radiation
Units and Measurements (ICRU) 1993, 1999) provide recommendations on defin-
ing several target and critical structure volumes and for specifying absorbed dose,
in order to provide standardization for the comparison of treatment outcomes. For
3D treatment planning, the following volumes, shown in Fig. 4.8, are defined.
Fig. 4.8 Schematics of

ICRU defined volumes of
interest for radiotherapy
4.1.7.1 Gross Tumor Volume (GTV)
GTV is the gross palpable, visible, or demonstrable position and extent of malig-
nant growth (International Commission on Radiation Units and Measurements
(ICRU) 1993).
4.1.7.2 Clinical Target Volume (CTV)
The clinical target volume is a volume of tissue that contains a GTV and/or
subclinical microscopic malignant disease. The CTV is therefore a conceptual
anatomical-clinical volume. This entire volume has to be eradicated with radio-
therapy for recurrence free cure of the disease.
4.1.7.3 Internal Target Volume (ITV)
The relative position of the CTV is not always fixed with reference to bony anatomy
of the patient. Variation in size and position of CTV may be due to breathing or
filling of the rectum or bladder. The ITV is thus formed by CTV plus extra margin
for these variations.
4.1.7.4 Planning Target Volume (PTV)
The PTV is a geometrical definition, used in treatment planning and evaluation.

PTV is the ultimate target volume that includes GTV and CTV with added margins,
to account for setup and motion uncertainties. The aim is to deliver the prescribed
dose to the entire GTV/CTV with a clinically acceptable probability.
4.1.7.5 Organs at Risk (OAR)
The ultimate goal of radiotherapy is to deliver the prescribed dose to the target
while minimizing the dose to the adjacent tissue, known as organs at risk (OAR).
OARs need to be accurately delineated and spared during treatment, to avoid
radiation-induced morbidity. The spinal cord, eye lens, parotids, lungs, optic
chiasm, brain stem, kidneys, rectum, and bladder are common examples of
OARs. Specific tolerance doses and expected morbidities are defined for these
OARs (Emami et al. 1991).
4.1.8 Dose Prescription and Reporting
A general rule for prescribing and reporting doses to a reference point in the PTV is
based on the recommendations of ICRU (International Commission on Radiation
Units and Measurements (ICRU) 1993, 1999). The reference point is selected such
that it is clearly defined and where the dose can be accurately determined, e.g., not
in a steep dose gradient region. For dose prescription and reporting, it is
recommended that minimum, maximum, and mean target doses be included.
4.1.9 Dosimetric Data for Clinical Photon Beams
It is obviously not possible to measure radiation dose distributions in patients

directly. An alternative is to acquire dose distribution data from measurements in
tissue-equivalent, flat phantoms and to use such data as the basis of calculations of
dose distributions in complex patient geometries. Water is the best (soft) tissue-
equivalent material, since its effective atomic number and electron density are
almost identical to those muscles. However, solid water phantoms and acrylic
phantoms can also be used for certain relative measurements. The dimensions of
the phantom needs to be large enough to provide the full-scatter conditions neces-
sary for dose measurements. Dosimetric measurements are typically performed for
standard field sizes and with the beam axis normal to the phantom surface. The
measured data is then used in a dose calculation engine for the estimation of the
dose distribution in an actual patient.
In order to present the measured data in a convenient and useful format for
manual and computerized dose calculations, a number of physical parameters and
mathematical functions are used. Details are given below.
Fig. 4.9 Measurement

setup for percent depth
dose (PDD)
4.1.10 Depth-Dose Profiles
The absorbed dose in the patient (or a phantom) from an incident beam varies with
depth. This variation depends not only on penetration depth but also on beam
energy, distance from the radiation source, and field size and shape. Depth-dose
variation along the beam central axis is an essential concept in dose calculation
systems. Depending on the measurement setup, this variation can be described as
percent depth dose (PDD), tissue-air ratio (TAR), tissue-phantom ratio (TPR), or
tissue-maximum ratio (TMR).
4.1.10.1 Percent Depth Dose (PDD)
Percent depth dose (PDD) is the ratio of the absorbed dose at a given depth d to the
absorbed dose at a fixed reference depth dref (usually the depth of maximum
dose, dm) along the central axis of the beam, expressed as a percentage (Fig. 4.9).
Mathematically,
Dd
PDDðd; r; SSDÞ ¼ 100 ð4:1Þ
Dd m
where r represents the edge of an equivalent field size at the surface of the phantom
and SSD is the source-surface distance, which is kept fixed during measurements.
Note: the field size is always defined at the surface when referring to PDD and SSD
geometries.
Fig. 4.10 Percent depth dose, measured along central axis for various photon beams with
10 10 cm2 field size
Variation of PDD with Beam Quality
The percentage depth dose (beyond the dose buildup region) decreases almost
exponentially for all therapeutic photon beams. At a given depth, higher-energy
photons deliver a higher percentage depth dose because of their greater penetrating
power. Therefore, at a given depth, beyond the depth of maximum dose, PDD
increases with increasing beam quality (which is a way of describing the beam’s
energy spectrum), as shown in Fig. 4.10.
For x-rays generated at potentials up to about 400 kVp, the maximum dose is
effectively at the surface. Since the dose is deposited by secondary electrons and
because the range of the secondary electrons (along the beam direction) is <0.4 mm
at these low energies, energy deposition (absorbed dose) occurs almost at the site of
the photon interaction. For higher-energy photons, however, the dose maximum
occurs at some depth below the surface. Because the range of the secondary
electrons increases with photon energy, the depth of maximum dose, dm, also
increases with increasing photon energy. This is called dose buildup or the skin-
sparing effect. For deep-seated tumors, dose buildup is an inherent benefit of
megavoltage beams to spare healthy skin tissues. Table 4.1 summarizes character-
istics of the surface doses and depths of maximum dose for various photon beams.
Field Size Dependence
Until the advent of highly conformal techniques, the radiation beam irradiating the
patient was often in the form of a rectangle or square. This shape is defined by
four independently adjustable collimator jaws. An example of a square field is
Table 4.1 Characteristics of Photon energy Depth (dm) Field size Surface dose
the surface doses and depth of
Orthovoltage ~ at surface All apertures ~100%
maximum dose (dm) for
various photon beams Cobalt 60 ~ 5 mm 10 10 cm2 ~30%
6 mv ~ 15 mm 10 10 cm2 ~15%
18 mv ~ 35 mm 10 10 cm2 ~10%
Fig. 4.11 A square field

defined by four adjustable
collimator jaws
shown in Fig. 4.11. For an infinitesimally small field size, the dose distribution in an
irradiated medium is due to the primary, unscattered radiation. However, for
non-zero field sizes, the scatter contribution to the dose in the phantom from scatter
within the phantom and from the machine head increases with increasing the field
size. Hence, the percentage depth dose, which includes both primary and scattered
radiation, increases with field size. For larger field sizes, this dependence is less
prominent, since very little extra scatter reaches the central axis within the phantom
and contributes to the depth dose.
Depth dose also varies with the shape of the field. It is slightly higher for a
circular field of a given area than for a square field with the same area. For
elongated field of the same area, dose at a given point is even smaller. This is
because scatter from the field edges of elongated fields and corners of square fields
is less likely to reach the central axis and hence contribute to the dose there,
compared to the scatter from circular fields.
The majority of the beam data, including depth-dose profiles, acquired for
calculation purposes, are measured for square fields. However, during patient
treatment, the radiation field is generally not. Much of the time rectangular fields
are used. It is therefore necessary to be able to deduce rectangular field depth doses
from square field measurements. Sterling et al. (Sterling et al. 1964) developed a
simple rule of thumb for this calculation. The rule states that, rectangular and square
field are equivalent if they have the same area to perimeter ratio (A/P).
Area of rectangle with sides “a” and “b” ¼ a b

Perimeter of rectangle ¼ 2(a b)
Area of square with sides “x” ¼ x2
Perimeter of square ¼ 4 x
Now, according to the A/P definition:

x2 a b
¼ ð4:2Þ
4xsquare 2ða þ bÞrectangle
therefore,
2ab
x¼ ð4:3Þ
ð a þ bÞ
The field of side x which satisfies this relationship is known as the equivalent
square of the a b rectangular field.
SSD Dependence
The absolute dose at a given point in a medium decreases with increasing SSD from
a point source, whereas the percentage depth dose increases. This is due to the
inverse square law and can be understood from Fig. 4.12. Consider three points A,
B, and C on the curve with the same intervals along the abscissa (distance). The
dose rate drop from point A to point B is greater than that between points B and
C. Stated another way, the ratio of dose rates at C to B is higher than that at point B
to A, which means that the percent depth dose increases with increasing SSD. By
Fig. 4.12 The effect of Inverse Square Law on percent depth dose
multiplying by the Mayneord factor, a PPD measured at one SSD (SSD1) can be
closely approximated to a PDD at another SSD (SSD2). The field size r is always
defined at the phantom or patient surface:
½ðSSD1 þ d Þ=ðSSD2 þ dÞ2

PDDðd; r; SSD2 Þ ¼ PDDðd; r; SSD1 Þ ð4:4Þ
½ðSSD1 þ d m Þ=ðSSD2 þ dm Þ2
where
½ðSSD1 þ dÞ=ðSSD2 þ dÞ2

¼ Mayneord factor ð4:5Þ
½ðSSD1 þ d m Þ=ðSSD2 þ d m Þ2
Example 4.1 Calculate the treatment time required to deliver 150 cGy to a point
7 cm below surface, using 8 8 cm2 60Co beam at an SSD of 80 cm with a dose rate
of 135.3 cGy/min at dm. Percent depth dose for 8 8 cm2 field size at 7 cm depth is
67.6%.
Solution The given dose at dm may be determined using Eq. (4.1):
100 150 cGy

¼ 222 cGy
67:6
Since dose rate at dm is 135.3 cGy/min, so:
222 cGy
Treatment time ¼ ¼ 1:64 min
135:3 cGy=min
Example 4.2 The percent depth dose for a 10 10 cm2 field size 60Co beam at
80 cm SSD is 55.0% for a 10 cm depth. Calculate the corresponding PDD at an SSD
of 100 cm.
Solution The Mayneord factor using Eq. (4.5) will be:
½ð80 þ 10Þ=ð100 þ 10Þ2

Mayneord Factor ¼ ¼ 1:043
½ð80 þ 0:5Þ=ð100 þ 0:5Þ2
Hence:
PDD(10, 10 10, 100) ¼ 55.0 % 1.043 ¼ 57.4% (From Eq. (4.4))
An increase of ~2% in PDD is noted for every 10 cm increase in SSD for 60Co.
Example 4.3 The PDD at 10 cm depth for 6 MV photons and 10 10 cm2 field
size at 100 cm SSD is 67.0%. At what SSD will the PDD be 70% for the same
energy and field size?
Solution Using Eq. (4.4), the Mayneord factor is calculated to be 70/67 ¼ 1.0448.
The extended SSD2 can be calculated from Eq. (4.5) as follows:
½ð100 þ 10Þ=ðSSD2 þ 10Þ2

1:0448 ¼
½ð100 þ 1:5Þ=ðSSD2 þ 1:5Þ2
Taking the square root on both sides and solving for SSD2 gives a value
of ~140 cm.
Note that the increase in PDD is ~1.1% for every 10 cm increase in SSD for a
6 MV photon beam.
4.1.10.2 Tissue-Air Ratio (TAR)
In radiotherapy, mostly multiple fields, each coming from a different direction, are
used for the treatment of tumors other than skin lesions. These fields are typically
delivered by treatment units that are mounted isocentrically with a source to axis
distance (SAD) of 80 cm or 100 cm. Hence, SSDs on the patient will change for the
different fields which are incident on the patient from different angles. It is
important that the patient remains stationary during the entire isocentric treatment
as the treatment plan has been generated under this assumption. Planning an
isocentric treatment requires a dosimetric quantity that is independent of SSD.
Tissue-air ratio (TAR) and tissue-phantom ratio (TPR) are the quantities intro-
duced for dosimetric calculations under isocentric or SAD treatment conditions.
Tissue-air ratio (TAR) is the ratio of the absorbed dose Dd at a given point in the
phantom to the absorbed dose at the same point in air (Da). As shown in Fig. 4.13,
Fig. 4.13 Experimental

setup for measuring tissue-
air ratio (TAR)
the points of measurement should be at the same distance from the source, to avoid
the inverse square effect. A buildup cap, with thickness large enough to provide
electronic equilibrium, is used with the ionization chamber, in air. By definition:
Dd
TARðd; r Þ ¼ ð4:6Þ
Da
where r represents the field size at the point of measurement. The point of mea-
surement is usually at the isocenter of the machine.
Characteristics of Tissue-Air Ratio
The tissue-air ratio and percentage depth dose both vary with beam energy, field
size and shape, and depth, almost in a similar fashion. However, the TAR does not
vary with SSD. In the special case, when the measurement depth d in phantom is at
the depth of maximum dose (dm), the tissue-air ratio is called the backscatter factor
(BSF) or peak scatter factor (PSF).
Limitations of TAR
For high-energy photon beams, larger buildup caps are required to provide elec-
tronic equilibrium at the point of measurement. Such buildup caps are impractical
for measurements with small fields. TAR is therefore rarely used in modern
radiation therapy.
Example 4.4 A 60Co teletherapy unit delivers a dose rate of 197 cGy/min in air at
the isocenter (80 cm) for a reference 10 10 cm2 field size. Calculate the dose rate
and daily treatment time for a 5 cm deep tumor, to receive 180 cGy daily dose with
a field size of 6 6 cm2. The dose rate for a 6 6 cm2 field is 0.966 relative to a
10 10 cm2 field.
Solution The output factor relative to a 10 102 field in air for this machine for a
6 6 cm2 beam is 0.966 and TAR is 0.875.
Dose rate for 6 6 cm2 beam in air ¼ (197 0.966) cGy/min
¼ 189 cGy/min
Tumor dose rate at 5 cm depth ¼ 189 cGy/min 0.875 ¼ 165 cGy/min
(Eq. (4.6), for dose rates)
180 cGy
Daily treatment time ¼ ¼ 1:09 min
165 cGy=min
Fig. 4.14 Experimental

setup for measuring tissue-
phantom ratio
4.1.10.3 Tissue-Phantom Ratio (TPR) and Tissue-Maximum

Ratio (TMR)
The tissue-phantom ratio (TPR) is defined as the ratio of the absorbed dose Dd at a
given depth d in a phantom to the absorbed dose Ddr at the same point at a fixed
reference depth dr in the phantom, as shown in Fig. 4.14.
The point of measurement is usually at the isocenter of the machine.
Mathematically:
Dd
TPRðd, r d Þ ¼ ð4:7Þ
Ddr
The tissue-maximum ratio (TMR) is a special case of TPR where the reference
depth dr is considered to be at the depth of maximum dose, dm. TMR may be defined
as the absorbed dose at a given point in a phantom to the absorbed dose at the same
point, but at the depth of maximum dose in the phantom.
Note that dm also varies slightly with field size.
Dd
TMRðd; r d Þ ¼ ð4:8Þ
Dd m
TMR and TAR can be related using the following equation:
TARðd, r d Þ TARðd, r d Þ
TMRðd, r d Þ ¼ ¼ ð4:9Þ
TARðdm , r d Þ BSFðr d Þ
Figures 4.9 and 4.13 may be used to derive the relationship between TMR and
PDD:

PDD ðd; r; SSDÞ BSFðr dm Þ SSD þ d 2
TMRðd; r d Þ ¼ ð4:10Þ
100 BSF ðr d Þ SSD þ dm
where

SSD þ dm SSD þ d
r dm ¼ r and r d ¼ r
SSD SSD
4.1.11 Practical Applications of Dosimetric Data
The absorbed dose at a given point in a medium or in air is the sum of the
contributions from primary and scattered radiation. The radiation reaching the
point that originates from the source and experiences no interaction in the machine
head or phantom is known as the primary radiation. Radiation that interacts in the
medium and is deflected from its original path to the point of interest is called
scattered radiation. The scattered radiation can be classified as collimator scatter
and phantom scatter, depending on where the interaction takes place. For accurate
dose calculation, collimator and phantom scatter need to be calculated explicitly.
The effect of partial blocking of the field on collimator scatter may not be important
under many conditions; nevertheless, such blocking may reduce the phantom
scatter significantly. In contrast to primary radiation, scattered radiation is directly
related to the field size and shape (Fig. 4.15).
Fig. 4.15 Diagram (not to

scale) showing primary and
scattered components of Primary
radiation beam
Scatter
Relative dose
Field size
In air, ionization In air,

chamber ionization
measurement with chamber
build-up cap for a measurement
10×10 cm2 field size with build-up
cap for all other
field sizes (r × r)
Fig. 4.16 Experimental setup for the measurement of collimator scatter factor (Sc)
4.1.12 Collimator Scatter Factor
The collimator scatter comes mainly from the flattening filter and collimator jaws.
Interactions of photons with other components in the treatment head and air may
also contribute to this scatter. The collimator scatter factor (Sc) is the ratio of the
dose in air for a given field to that for a reference field, usually 10 10 cm2. The
setup for Sc measurement is shown in Fig. 4.16. It can be measured with an
ionization chamber inside a buildup cap that provides electronic equilibrium for
the given beam energy. Sc is most appropriately measured at the source to axis
distance (SAD).
4.1.13 Phantom Scatter Factor
The scatter at a given depth in a phantom depends also on the volume of the
phantom in the field. The phantom scatter factor (Sp) is the ratio of the dose or
dose rate for a given field at a reference depth to the dose or dose rate at the same
depth for the reference field size, with fixed collimator scatter. This definition
excludes the effect of collimator scatter, which will change, and is limited purely
to phantom scatter so Sp cannot be measured directly for higher photon energies.
However, for 60Co, it may be defined as the ratio of backscatter factor (BSF) for the
given field to that for the reference field as in Eq. (4.13). (Khan 2010):
BSFðr Þ
Sp ðr Þ ¼ ð4:11Þ
BSFðr 0 Þ
For higher energies Sp has to be calculated from the total scatter factor Sc,p(r) that
includes both the collimator and phantom scatters, as presented in following
equation:
Scp ðr Þ ¼ Sc ðr Þ Sp ðr Þ ð4:12Þ
By excluding the collimator scatter component, Sc,p(r) may be expressed as a

quotient of the dose rate at a reference point in a phantom for a given field size r and
the dose rate at the same point for the reference field size ro. It is also known as the
relative output factor or relative dose factor. Linear accelerators are calibrated such
that 1 monitor unit is equal to 1 cGy dose at a stated reference depth for a stated
reference field. The beam output O(r) for a given field size can then be represented
as follows:
1cGy cGy
O ðr Þ ¼ Scp ðr Þ Oðr Þ ¼ Scp ðr Þ ð4:13Þ
MU MU
4.1.14 Off-Axis Dose Profile
A one-dimensional dose distribution representation in an irradiated volume is

referred to as a dose profile. Dose profiles are usually measured normal to the
central axis. Measurement of these profiles is very important, especially for the
description of beam flatness, symmetry, and penumbra. The data is usually normal-
ized to the dose on the central axis (Fig. 4.17).
100 100
Relative depth dose
80 80
60 60
40 40
20 20
0 0
-12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12
Off-axis distance
Fig. 4.17 Dose profile taken along a normal to the central axis
Measurement of off-axis factors or off-axis ratios is also essential for dose

determination at off-axis points in a phantom. The projected field size can be
determined from the profile, which is defined as the lateral distance between 50%
dose points (represented by the arrow in Fig. 4.17).
4.1.15 Central Axis Dose Calculations
In radiation therapy, as per ICRU guidelines (International Commission on Radi-

ation Units and Measurements (ICRU) 1993, 1999), the prescribed tumor dose must
be delivered to a reference point, using either the constant SSD or the fixed SAD
(isocentric) treatment setup.
4.1.15.1 Fixed SSD (Non-isocentric) Setup
In this method the patient is positioned such that the skin is at a fixed distance
(nominal SSD) from the source. The field size is also defined at this distance on the
patient skin. Linear accelerators are usually calibrated to deliver 1 cGy per monitor
unit (MU) to a reference point in a water phantom for a 10 10 cm2 field size.
Source to calibration point distance (SCD) may vary depending on the calibration
protocol used. The output of a Cobalt-60 machine is expressed in terms of cGy per
minute at a reference point. For a prescribed dose PD (the dose to be delivered) to
point p at depth d for fixed SSD setup, MUs may be calculated using the following
equation:
Prescribed dose 100

Monitor Units ¼ ð4:14Þ
D_ PDDðd; r Þ Sc ðr c Þ Sp ðr Þ ISFSSD TF
where D_ is the machine dose rate (1 cGy/MU

for linear accelerator), rc is the
collimator defined field size r c ¼ r SAD , ISFSSD is the inverse square factor

2 SSD
SCD
SSDþd m , and TF (1) is the combined transmission factor for in-beam modifying
devices. The modifying devices could be the physical wedges, compensators, or
acrylic trays used for supporting the shielding blocks on treatment machine. These
devices will be discussed in details in later sections.
Example 4.5 Beam output from a 15 MV linear accelerator is 1 cGy/MU at dm
under reference conditions (10 10 cm2 field size and 100 cm SSD). Determine the
number of MU if an 18-cm-thick patient needs 250 cGy to be delivered at midpoint,
with a single field (12 8.5 cm2) and 100 cm SSD. What is the maximum dose
received by the tissue in this case. No beam modifier is used.
Solution From Eq. (4.3), the side of the equivalent square field:
2128:5
10 cm Equivalent square field: 10 10 cm2
ð12þ8:5Þ
PDD ¼ 79.2%
ISFSSD ¼ 1.000
Using Eq. (4.16):
250 100
MU ¼ ¼ 316
1:000 79:2 1:000 1:000 1:000
The maximum dose is at dm and is:
250 100
Dmax ¼ ¼ 316 cGy
79:2
Example 4.6 The whole spine, at a depth of 4 cm, is to be treated to 3600 cGy in
18 fractions on a 6 MV linac (dm ¼ 1.5 cm) using fixed SSD setup. The patient is
lying in the prone position. To accommodate the entire spine, a field size of
54 8 cm2 at the patient’s skin is required.
(i) Determine the minimum required treatment SSD for a linac with maximum
field size of 40 40 cm2 at isocenter.
(ii) What should the collimator settings be for the required SSD to achieve the
required treatment field?
(iii) Calculate the required number of MUs per treatment fraction.
Solution
(i) The field size is directly proportional to the distance. To obtain a 54-cm-long
field edge, the required extended SSD will be (54/40) 100 cm ¼ 135 cm.
The collimator settings are 54 cm ½100=135 ¼ 40 cm and
(ii)
8 cm ½100=135 ¼ 6 cm:
(iii) The PDD at an extended SSD of 135 cm, field size of 40 6 cm2 (equivalent
field, 10 10 cm2 at iso-centre) and depth of 4 cm, can be calculated from the
PDD at 100 cm SSD, using Eq. (4.5):
½ð100 þ 4Þ=ð135 þ 4Þ2

PDD ¼ 91% ¼ 92%
½ð100 þ 1:5Þ=ð135 þ 1:5Þ2
The relative output factor for a field size of 10 10 cm2 at the extended SSD of
135 cm can be derived from the standard data (Appendix-A2) by applying inverse
square law. Change in the phantom scatter factor for larger field at extended SSD is,
however ignored.
Output at standard SSD ¼ 1.000 cGy/MU

2
Using the inverse square law, output at 135 cm ¼1:000 100þ1:5
135þ1:5 ¼ 0:553
cGy/MU
200 100
MU ¼ ¼ 392
92:3 0:553
4.1.15.2 Fixed SAD (Isocentric) Setup
The main advantage of an isocentric technique is that the patient does not need to be
repositioned between fields. The patient is usually positioned such that the isocenter
of the machine lies in the tumor. The field size is always defined at the isocenter.
TMR or TPR data may be used for dose calculation at the point of interest using
Eq. (4.17):
Prescribed dose
Monitor units ¼ ð4:15Þ
D_ TPRðd; r Þ Sc ðr c Þ Sp ðr Þ ISFSAD TF
SCD2
where ISFSAD is equal to SAD
Example 4.7 A total dose of 200 cGy is prescribed to a depth of 7 cm using a

single 15 MV photon beam with SAD setup. The treatment field size is 8 8 cm2
and the beam is calibrated at dm (1.0 cGy/MU; 10 10 cm2 field, 100 cm SSD).
Calculate the required MU.
Solution Dose rate at dm ¼ 1.000 cGy/MU
TMR (8 8 cm2, 7) ¼ 0.943
Relative output factor ¼ 0.983
Source to calibration distance (SCD) ¼ 100 þ 3(dm) ¼ 103 cm, hence:

103 2
ISFSAD ¼ ¼ 1:061
100
From Eq. (4.17):
200
MU ¼ ¼ 203
1:0 0:943 0:983 1:000 1:061
Example 4.8 A 6 MV linear accelerator is calibrated to deliver 1.2 cGy/MU for a

10 10 cm2 field at depth of dm for 100 cm SAD. The relative output factor for a
12 16 cm2 field is 1.031. Calculate the monitor units to deliver 300 cGy at
midpoint using equally weighted, parallel opposed fields in an SAD setup. The
patient is 16 cm thick.
Solution From Eq. (4.3), equivalent square field ¼ 13.7 13.7 cm2
Dose rate at dm for 10 cm 10 cm field is 1 cGy/MU
ROF for 13.7 13.7 cm2 field ¼ 1.031 cGy/MU
TMR at 8 cm depth for 13.7 cm 13.7 cm field is 0.855
ISFSAD ¼ 1, TF ¼ 1
Use Eq. 4.17 to determine MUs per field:
150
MU ¼ ¼ 142
1:200 0:855 1:031 1:000 1:000
Example 4.9 A brain tumor is treated isocentrically with an orthogonal 6 MV

wedged pair, using 45 wedges. A daily tumor dose of 200 cGy is prescribed at
isocenter (9 cm from anterior and 7 cm from lateral beam entry points). The beam
output factor at dm ¼ 1.0 cGy/MU (SAD setup). With 1.2 and 1.0 weightings for the
anterior and lateral fields, respectively, calculate the MU per fraction for both fields
(7 7 cm2 each).
Solution Anterior field weightage: 1.2
Prescribed dose ¼ (1.2/2.2) 200 cGy ¼ 109 cGy
Treatment depth ¼ 9 cm, wedge transmission factor ¼ 0.720
TMR ¼ 0.795 Appendix-A1
ROF ¼ 0.963 Appendix-A2
Using Eq. (4.17):
109
MU ¼ ¼ 197
1:000 0:795 0:963 0:720
Lateral field weightage: 1.0

Prescribed dose ¼ (1.0/2.2) 200 cGy ¼ 91 cGy
Treatment depth ¼ 7 cm, wedge transmission factor ¼ 0.720
TMR ¼ 0.857 Appendix-A1
ROF ¼ 0.963 Appendix-A2
Using Eq. (4.17):
91
MU ¼ ¼ 153
1:000 0:857 0:963 0:720
Example 4.10 A large tumor is to be treated with a single, 30 50 cm2 field at an

extended SSD of 125 cm, using 6 MV photon beam. A total tumor dose of 3000 cGy
is prescribed in 10 daily fractions on the central axis at a depth of 6 cm. The
machine is calibrated to deliver 1 cGy/MU at dm with an SAD setup. Sc and Sp data
for 6 MV beam is given in Table 4.2. Other values can be approximated by linear
interpolation.
(a) Calculate the number of monitor units, using Appendix-A1 TMR data.
(b) Calculate the number of monitor units, using Appendix-A2 PDD data.
Table 4.2 Scatter factors (Sc Field size 30 30 cm2 40 40 cm2

and Sp) for 6 MV beam
Sc 1.041 1.051
Sp 1.060 1.072
Solution Prescribed daily dose at 10 cm depth ¼ 300 cGy

At 125 cm SSD, the jaw setting ¼ 24 40
Equivalent square (eq. sq.) fields using Eq. (4.3) are:
For collimator settings ¼ 24 40 cm2 eq. sq. ¼ 30 30 cm2
Field size at surface, Ao at 125 cm ¼ 30 50 cm eq. sq. ¼ 37.5 37.5 cm2
2
Field size at depth d (¼6 cm), Ad eq. sq. ¼ 39.5 39.5 cm2
at 131 cm ¼ 31.5 52.5 cm 2
(a) MU calculation at extended SSD – using TMRs

TMR(39.5 39.5, d ¼ 6) ¼ 0.930
Sc(30 30) ¼ 1.041 (for actual collimator setting)
Sp(39.5 39.5) ¼ 1.071 (for the field size defined at 131 cm in patient)
ISF ¼ (100/131)2 ¼ 0.583
0
D ¼ 1.0 cGy/MU
Using Eq. (4.17):
300
MU ¼ ¼ 497
1:0 0:930 1:041 1:071 0:582
(b) MU calculation at extended SSD – using PDDs

PDD(SSD ¼ 100, 30 30, d ¼ 6) ¼ 85.0%
Using the Mayneord factor:
2
ð106=131Þ
PDDðSSD ¼ 125, 30 30, d ¼ 6Þ ¼ 85:0% ¼ 86:4%
ð126:5=101:5Þ
Sc(30 30) ¼ 1.041 (for fixed collimator jaws)

Sp(37.5 37.5) ¼ 1.069 (for field size defined at 126.5 cm)
ISF ¼ (100/126.5)2 ¼ 0.6249
0
D ¼ 1.0 cGy/MU
Use Eq. (4.16):
300 100
MU ¼ 499
1:00 86:4 1:041 1:069 0:625
4.1.15.3 Clarkson’s Dose Calculation Method
As discussed earlier, basic beam data is available for rectangular or square fields
only. These data may not be directly applied for dose calculation in cases where
very irregular fields are used. Furthermore, central axis beam data are not sufficient
for dose determination at off-axis points. Those fields in which metallic blocks are
used to shield normal structures from irradiation are considered irregular fields.
Inverted Y and mantle fields used for the treatment of Hodgkin’s disease are two
examples of irregular fields. Although every irregular field can be represented by an
equivalent square or circular field, it is not always easy to determine the dimensions
of the equivalent field.
A simple solution to this problem was presented by Clarkson (1941) and is
referred to as the Clarkson segmental integration technique. The technique is based
on separate calculations of primary and scattered radiation. The primary radiation is
independent of the field size and shape, whereas scatter is not. To account for the
scatter at a given point, the irregular field is divided into sectors of circular beams
surrounding the point of interest. The scatter is calculated from each sector, using
the concept of scatter-air ratio (SAR). SAR is defined as the quotient of the
scattered dose at a given point in a phantom to the primary dose at the same point
in air.
Let us consider a point P at depth d in an irregularly shaped field as shown in
Fig. 4.18. To find the scattered dose at point P, the field is divided into sectors of
fixed angular width (10 in this case). Each sector is characterized by a radius r and
approximated as a part of a circular field of the same radius r. For a sector of 10
angle, the scatter contribution to point P from this sector will be 1/36 (10/360) of
the total scatter contributed by a circular field of the same radius, centered at P.
Similarly, the scatter contribution from all other sectors are calculated and summed
for the entire irregular field and the average value of the scatter-air ratio (SAR) is
finally determined at point P.
Fig. 4.18 An irregular

mantle field, divided into
36 segments. The first sector
with radius r1 is fully open
with no shielded region,
whereas the 27th sector
includes one blocked and
two open portions
Consider the 27th sector that passes through both open and blocked areas. In this
case the sector is divided into three portions with three radii (ra < rb < rc). The net
SAR for this entire sector is estimated by subtracting the scatter contribution of the
blocked portion of the sector. For this sector, the net SAR is:
SAR ¼ ðSARÞrc ðSARÞrb þ ðSARÞra :
Finally, the average tissue-air ratio (TAR) is determined by Eq. (4.18) below:
TAR ¼ TARð0Þ þ SAR ð4:16Þ
where TAR(0) is the TAR for the primary contribution only, i.e., that received from
a notional 0 0 field size and is approximated by:
TARð0Þ ¼ eμd
where μ is the mean linear attenuation coefficient of the photon beam and d is the
depth of point P beyond dm.
The rest of the calculation is similar to those performed earlier.
4.1.15.4 Field Shaping
Asymmetric Fields
Unlike symmetric fields (Fig. 4.19a), asymmetric fields may be described as those
in which the beam central axis (i.e., the axis of rotation of the collimator) is not
coincident with the geometric center of the field. Such a geometry can be achieved
by independently moving the collimator jaws with reference to the central axis of
the beam (Fig. 4.19b). Both x and y jaws can be independently adjusted to produce
doubly asymmetric fields. This helps the radiation oncologist to easily and appro-
priately shape the field to the tumor. It also helps in producing a half beam blocked
shape in order to remove beam divergence at field matching (e.g., tangent breast
and mono-isocentric techniques).
Fig. 4.19 Collimator jaw setting for (a) symmetric field and (b) asymmetric field.
Fig. 4.20 (a) Beam eye view of shielded region drawn on DRR, (b) a custom Cerrobend block on
acrylic tray, and (c) MLC adjusted to shielded area drawn in (a)
Irregular Fields
In Fig. 4.20a, the planning target volume (not shown) is to be irradiated to a uniform
dose. In order for the field aperture to conform to the shape of the treated area, the
rectangular field defined by the collimator jaws (x and y) needs to be modified. This
may be achieved either with custom made blocks or a MLC.
Custom Shielding Blocks

One of the purposes of radiotherapy simulation is to assist the radiation oncologist
with the design of field arrangements and beam shaping. As has been noted earlier,
to achieve a higher therapeutic ratio, it is necessary to keep radiation doses to
normal tissues as low as possible. This can be achieved, in part at least, through
treatment field shaping. With a reasonably thick lead or metallic alloy blocks,
megavoltage photon beams can be attenuated by a clinically meaningful amount.
Ninety-five percent attenuation of the primary beam through a block is generally
considered clinically acceptable for the majority of the cases. This corresponds to a
block thickness of 4.5–5.0 half-value layers. One of the low melting point alloys,
known as Cerrobend (brand name), is commonly used for casting shielding blocks.
It is a high-density alloy that melts at about 70 C. The shielding blocks are
mounted on an acrylic tray for loading into the treatment machine head
(Fig. 4.20b). The mounting tray also attenuates the radiation beam, and this effect
needs to be quantified and corrected for in dosimetry calculations. Placement of
shielding blocks in the field also changes the phantom/patient scatter component of
the radiation beam by changing the effective area of the beam.
Multileaf Collimator
An alternative to custom-made blocking is the multileaf collimator (MLC) (Sofia
1979) available on modern teletherapy machines. It consists of a set of motorized
leaves, made of tungsten alloy, that can easily produce the required field shape
(Fig. 4.20c). Depending on the type of MLC, the projected leaf width at the
isocenter ranges from 10 mm down to 1.6 mm. The thickness of the leaves along
the beam direction is sufficient to provide acceptably low beam transmission
(3%), whereas the inter-leaf leakage is ~3–4% (LoSasso et al. 1998; Boyer
et al. 1992; Galvin et al. 1993).
Three-dimensional conformal radiotherapy (3DCRT) techniques require an
increased number of fields per fraction as well as more complex field shaping.
This makes the use of MLC for field shaping the most practical approach.
Using a MLC for blocking purposes offers many advantages. Fabrication and
mounting of poured blocks is time consuming and labor intensive and involves the
handling of a toxic material (alloys). The mounting and demounting of heavy
blocks is both strenuous for therapists and poses a risk of injury to both therapists
and patients. The use of MLCs overcomes these inherent disadvantages and con-
siderably reduces patient setup time.
4.1.16 Treatment Planning
4.1.16.1 Isodose Distribution
For simplicity, dose distributions in two dimensions are represented by isodose

lines. The dose at each point along an isodose line is the same. An isodose chart is a
representation of isodose curves, drawn at regular increments, for a given beam in a
plane parallel to the central axis. As shown in Fig. 4.21, each isodose line represents
a percentage of the dose at some reference point. These charts are useful in
treatment planning calculations with fixed SSD setup.
The regions near the field edges where the dose drops sharply represent the beam
penumbra. Penumbra is some times expressed by the lateral distance between two
isodose lines at a certain depth. The field size at any depth is defined by the lateral
Fig. 4.21 Isodose charts for (a) 6 MV and (b) 18 MV beams, calculated at fixed 100 cm SSD and
10 10 cm2 field size
distance between the 50% isodose lines. It may also be obtained from the
corresponding off-axis beam profile (Fig. 4.17). A sharper penumbra is generally
better for patient treatment as it affords more dose sparing of normal tissues
adjacent to the target. The penumbra size depends on the beam energy and source
size. Because of their smaller source sizes and less side scatter, penumbras from
high-energy linacs are sharper than that for 60Co beams and also sharper for higher-
energy photon beams (Fig. 4.21b) than for low-energy photons.
4.1.16.2 Wedge Filters
Wedge filters are frequently used in treatment planning to modify the isodose
distribution as shown in Fig. 4.22. There are three designs of wedge filters currently
in use: physical, motorized, and dynamic. A physical wedge is made of a wedge-
shaped metallic block, manually placed in the beam. A motorized wedge is a
physical wedge, but one which is installed permanently in the machine head and
remotely controlled. Unlike physical wedges, a dynamic wedge produces a tilted
profile by gradually moving one of the collimator jaws during dose delivery.
The degree of isodose tilt depends on the slope of the physical wedge filter. For
dynamic wedges, the tilt depends on speed of the jaw and machine dose rate. The
modern intensity-modulated radiation therapy (IMRT) treatment techniques take
advantage of the considerable flexibility of the multileaf collimator (MLC), with no
need to use wedge filters at all.
Fig. 4.22 Wedged isodose

curves and wedge angle
definition
The wedge angle (θ) for a given wedge is defined as “the angle made by the
isodose curve and the normal to the central axis, at a given depth in a water
phantom,” as shown in Fig. 4.22. The wedge transmission factor or simply wedge
factor (WF) is the ratio of doses at a reference depth in a water phantom at the beam
central axis with and without the wedge in the beam.
4.1.16.3 Bolus
Bolus is a tissue equivalent material placed on top of the skin to increase the skin
dose by reducing the skin-sparing effect within the patient of megavoltage x-ray
beams. Tissue equivalence means an electron density similar or very close to tissue
(or water). The thickness of the bolus is selected on the basis of beam energy. Bolus
may also be used to even out patient surface irregularities.
4.1.16.4 Compensators
Compensators are used to account for the non-planar nature of the patient’s surface
contour or to modify the beam intensity to conform the dose to irregular target
shapes (Khan et al. 1970; Sewchand et al. 1980). These are usually made of lead or
Cerrobend. Custom-made compensators are placed at a distance of 10–15 cm above
the patient in the beam (Fig. 4.23) to maintain the skin-sparing effect.
Fig. 4.23 Design and

placement irregular surface
compensator
4.1.17 Treatment Planning Techniques
4.1.17.1 Single Field Treatment
Single field treatment with high-energy photons are used only for shallow tumors.
For a single-photon beam, the dose gradient across the PTV is large, especially for
low energies due to exponential attenuation. Beyond dm, the dose fall off for
18 MV, 6 MV, and 60Co photon beams in water is approximately 2%, 3.5%, and
4.5% per cm, respectively (Halperin et al. 2008a). Care should be taken with such
treatments, since dose homogeneity as recommended by ICRU 50 may not be
achieved within the tumor, for a single field. By using higher-energy beams, the
distribution will be more uniform, but the exit dose will increase as well. Sites
commonly treated with single, photon fields are the supraclavicular region, internal
mammary nodes, and the spinal cord.
4.1.17.2 Two-Field Treatment
Sometimes a combination of two beams may be used to obtain an acceptable dose

distribution within the tumor as well as to reduce the dose to adjacent normal tissue.
The simplest combination is a pair of opposing fields along the same axis. These
parallel opposed beams are used for situations where a uniform dose is required
throughout the irradiated volume but a high level of conformity is not required. The
shape of the isodose distribution is that of an hourglass as can be seen in Fig. 4.24a.
Fig. 4.24 Isodose distribution from parallel opposed beams, (a) hourglass effect in a water
phantom with 6 MV beam, (b) 18 MV beam
However, with increasing patient separation, the dose distribution uniformity

decreases. The dose uniformity can be improved by using higher-energy
beams as clear from Figs. 4.24b and 4.25. If the tumor is not in the center of the
body and is closer to one side, beam weighting can be adjusted to improve the dose
uniformity.
Wedges can be used with parallel opposed beams when treating shallow tumors
under sloping surfaces. Treatment of the breast, chest wall, and larynx is an
example of such applications. In these situations, wedges are essentially used to
compensate for missing tissue but obviously only in one plane. The thick edge of
the wedge is always toward the thinner section of the treated volume (Fig. 4.26). In
some situations, combinations of nonparallel wedged beams are used. One such
example is treating brain lesions with an orthogonal, wedged (45 ) pair of beams
(Fig. 4.27).
4.1.17.3 Multiple Fields
In order to confine higher doses to the tumor only, the use of multiple fields/beams
is essential. Three or more beams may provide better dose conformality to the
tumor and with minimal doses to the organs at risk. The selection of appropriate
beam angles and beam modifiers is crucial for producing acceptable treatment
Fig. 4.25 Percent depth

doses along the central axis 120
from parallel opposed
Relative depth dose (%)

beams in a 25-cm-thick
water phantom for different
100
photon energies
60
80 Co
4MV
10MV
25MV
60
40
-12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12
Distance (cm)
Fig. 4.26 Chest wall and breast irradiation planning with wedged parallel opposed beams
plans. An example of a three-field rectum treatment plan is shown in Fig. 4.28.

In this case two lateral wedged fields and one open posterior field are used. This
arrangement results in reduced dose to the bladder.
Four-field box technique is extensively used in treating pelvic tumors. An
example of a phase-1 prostate plan with a four-field box is shown in Fig. 4.29a.
A four-field Bedford plan for prostate phase-2 is shown in Fig. 4.29b.
Fig. 4.27 Treating brain lesion with an orthogonal pair of wedged beams
Fig. 4.28 Three-field setup for the treatment of the rectum in a prone position
4.1.18 Rotation (or Arc) Therapy
In the multiple field isocentric technique, the tumor is irradiated with a number of
fields of different shape, directed from different fixed angles (e.g., the four-field
technique for prostate cancer). A logical extension of this method is to use a single
Fig. 4.29 Prostate plans, (a) phase-1 four-field box technique, (b) phase-2 four-field Bedford
technique
radiation field and rotate it around the isocenter (which is placed inside the tumor)
at a constant speed, for single or multiple partial or complete revolutions. This
technique is referred to as rotation therapy. If the radiation source moves through
an arc around the patient, this is known as arc therapy. It should be noted that this is
possible only with the machines capable of isocentric treatments. The technique is
well suited for small, deep-seated tumors in pelvic region.
Theoretically rotation therapy can be considered as treating the patient
isocentrically with an infinite number of fixed fields, directed at the PTV. In
practice, 18 fields, equally weighted and equally spaced at 20 angular intervals
(18 20 ) 1 complete rotation), are sufficient to produce an acceptably accurate
calculation of the dose distribution. The dose calculation formalism is similar to
that for the isocentric technique, except an average TPR is calculated from all the
TPRs for individual beams:
X
n
TPR ¼ TPRi ð4:17Þ
i¼1
where i represents a given beam angle.

A more conformal dose to the target may be achieved by continuously adjusting
the shape of the field to match the beam’s eye view (BEV) projection of a planning
target volume (PTV) during an arc rotation. This can only be achieved by dynam-
ically adjusting the MLC leaves during the rotation while radiation is
on. Volumetric modulated arc therapy (VMAT) techniques evolved from this
approach. Machine dose rate and gantry speed also change during rotation, for
optimal dose delivery.
Example 4.11 A patient with prostate cancer is to be treated to a tumor dose of
4500 cGy in 25 daily fractions (fr), using 360 rotation therapy (18 20 fields)
with a 17 12 cm2 field at an SAD of 100 cm on a 15 MV photon beam, as shown
in the diagram below (Fig. 4.30).
(a) Calculate the number of monitor units for daily dose delivery.
(b) Calculate the gantry speed in MU/degree for the daily treatment, given in two
complete rotations.
Solution Since the contour is elliptical, the effective TPR calculation needs to be
performed only for a quarter of the 360 rotation. The equivalent field size is
14 14 cm2.
The TPRs for the various depths (Table 4.3) are averaged to obtain an effective
TPR of 0.821
(a) Daily tumor dose ¼ 4500 cGy/25 fr ¼ 180 cGy/fr
Effective TPR ¼ 0.821
Fig. 4.30 Rotation therapy

beam arrangements for a
prostate treatment plan
Table 4.3 Effective TPR Angle Depth (cm) TPR (Appendix-A3)

0 10.5 0.860
18 11.0 0.851
36 12.0 0.830
53 13.0 0.812
72 14.0 0.790
90 14.5 0.780
TPR 0.821
Dose rate for 14 14 cm2 field size is 1.022 cGy/MU at dm with isocentric
setup:
180 cGy
Daily MU ¼ ¼ 215
0:821 1:022 cGy=MU
(b) Since 214 MUs are to be delivered in two complete rotations, the angular speed
will be:
∘
215MU=ð2 360 Þ 0:30MU=degreeÞ
4.1.19 IMRT
Based on the shape of the body contour and beam arrangements, wedge filters,
compensators, or other modifying devices are employed in the field to modify the
beam intensity. This is the simplest form of intensity modulation. The concept of
the dynamic MLC may be extended to achieve more complicated and precise
intensity modulation. This type of beam intensity modulation with the help of a
computer-controlled dynamic MLC is known as intensity-modulated radiation
therapy (IMRT) (IMRT Collaborative Working Group 2001). IMRT uses modern
technology to manipulate radiation beams to conform the dose to the three-
dimensional shape of the tumor. Multiple intensity-modulated radiation beams,
irradiating the patient from different angles, are used. The dose distribution can
be manipulated to avoid or minimize exposure to healthy tissue while delivering a
therapeutic dose to the target volume. IMRT treatment planning is performed on
three-dimensional CT or MRI images of the patient with the help of inverse dose
calculation algorithms. Previously considered untreatable tumors may now be
easily treated with the help of IMRT. Potentially, better quality of life and higher
cure rates are observed in cancer patients treated with IMRT.
A number of inverse planning algorithms have been developed to calculate
optimized fluences for IMRT (Webb 1989; Bortfeld et al. 1990b; Convery and
Rosenbloom 1992; Holmes and Mackie 1994; Webb 1997). During the treatment
planning process, each beam is divided into multiple beamlets. The fluence asso-
ciated with each beamlet is optimized based on predetermined dosimetric objec-
tives and constraints. Inverse optimization methods include analytical methods
(such as backprojection) and iterative methods (such as simulated annealing and
constrained least squares) (IMRT Collaborative Working Group 2001).
During iterative optimization, fluences of the individual beamlets for all the
fields are iteratively adjusted so that the value of a cost function fT,N is minimized. A
cost function describes the deviations of the calculated dose distribution from the
desired (prescribed) dose distribution. The process continues until no further
improvement can be achieved. A cost function may be expressed as in Eq. (4.20):
X X 2
f T, N ¼ ðDi Do Þ2T þ Dj Do N
ð4:20Þ
i i
where T stands for target volume and N for normal tissue, Di and Dj are the expected
(calculated) doses in respective volume elements, whereas Do is the desired
(prescribed) dose.
4.1.20 Plan Evaluation
3D-CRT and IMRT treatment plans are evaluated on the basis of the calculated
dose distribution in the patient, using 2D isodose line displays over the region of
interest on CT images (Figs. 4.26, 4.27, 4.28, and 4.29). This is a qualitative or
visual analysis of the plan. For a summary, standardized evaluation of a plan,
various tools have been developed (Halperin et al. 2008a) of which the dose-
volume histogram (DVH) is widely considered to be the most useful (Drzymala
et al. 1991). A DVH is a plot, showing the relationship between the volume of an
organ or PTV and the dose the volume receives. It may be expressed in absolute or
relative terms.
There are two ways to represent the dose-volume histogram: differential and
cumulative. A differential DVH is a plot of the frequency of occurrence of
different dose levels. The entire irradiated volume is divided into a finite number of
small volume elements (voxels). Similarly, the 3D dose distribution is divided into
dose bins. All the voxels receiving dose from a specific dose bin are counted. The
process is repeated for all the voxels in the volume of interest. A graph showing the
number of voxels in each bin and the bin dose range is a differential DVH. Figure 4.31a
shows differential DVHs for a PTV and lungs in a mediastinum treatment plan.
A cumulative DVH describes how much of the volume receives a dose equal to
or greater than the dose in question. In mathematical terms, a cumulative DVH can
be calculated by integrating the differential DVH. Figure 4.31b shows the
corresponding cumulative DVH for the PTV and the lungs. Radiation oncologists
usually make their decisions for plan approval on the basis of a cumulative DVH as
well as slice by slice evaluation of 2D dose distributions.
Fig. 4.31 Schematics of (a) differential DVHs and (b) cumulative DVHs for the PTV and lungs in
a phase-2 mediastinum treatment plan
4.1.21 Treatment Verification
There are various methods used to verify whether or not the actual target area is
irradiated and critical organs are shielded as prescribed. Some of these methods are
summarized below.
4.1.21.1 Port Film (Radiograph)
This is a conventional radiographic method that can be performed in two

different ways: (a) radiographic films with wet processing and developing tech-
nique or (b) a reusable digital imaging device. Each of these imaging devices has to
be positioned manually every time, and the image is not available immediately for
verification. The image quality is relatively poor at these high photon energies. For
verification purposes, these images need to be compared visually against the
simulation images or DRRs. If errors outside some stated level of acceptability
are observed in the patient setup, adjustments are made accordingly and port films
are repeated.
4.1.21.2 Electronic Portal Imaging Device (EPID)
An EPID is an online, standard imaging system, available with the majority of

modern day linear accelerators. It consists of an imaging device opposite to the
linac head in a C-arm type arrangement. The conventional imaging panels were
made of a phosphor screen or a matrix of liquid filled ionization chambers.
Amorphous silicon flat panels have replaced these systems in modern day EPIDs.
An EPID provides “instantaneous” images, thus allowing in real time, both intra-
treatment and inter-treatment verification. Images can also be archived for later
viewing. Image quality at megavoltage photon energies is reasonable, as image
processing can be employed, but still a challenge.
4.1.21.3 kV Cone Beam Computed Tomography (kVCBCT)
A kV cone beam imaging system consists of a conventional kilovoltage x-ray

source and a flat-panel x-ray detector, both mounted orthogonally to the beam
central axis. Cone beam CT images are reconstructed by acquiring multiple planar,
kV images, as the gantry rotates around the patient. Cone beam CT allows setup
corrections in three dimensions, based on bony land marks, as well as soft tissues.
kVCBCT can also produce simple planar images, with better quality than MV
images, for treatment verification.
4.1.22 Photon Beam Treatment Planning Methods

(Algorithms)
Treatment planning is one of the most important steps in the process of clinical
radiotherapy. The goal is to prepare for the delivery of an accurate and uniform dose
to the target and spare the organs at risk. Based on the available information of the
patient, an optimized treatment plan is created, usually with multiple radiation
beams. Target dose uniformity should be within þ7% and 5% of the prescribed
target dose for a better clinical outcome (International Commission on Radiation
Units and Measurements (ICRU) 1993). Modern day EBRT is carried out with a
variety of beam energies, beam geometries, and field sizes. Dose calculation
algorithms in radiotherapy treatment planning systems can be broadly classified
into correction-based and model-based algorithms. Both classes of algorithm
require basic beam data, including depth dose profiles, off-axis profiles, dose rate
tables, and transmission factors.
With the correction-based approach (Cunningham et al. 1972; Sontag and
Cunningham 1978), dose distributions in a homogeneous water phantom is
corrected to account for the internal inhomogeneities found in a real patient,
beam modifiers, and body contour variations. With model-based algorithms,
measured beam data is used to model physical descriptions of the primary photons,
scattered photons, and electrons separately. Based on the physical parameters of
the beam and anatomical information of the patient/phantom, dose calculation can
be easily performed in any geometry, without any additional corrections.
Accurate volumetric dose estimation in a patient is only possible with model-based
algorithms.
4.1.22.1 Correction-Based Calculation Methods
Beam data is typically collected in a geometric setup, where a homogeneous, flat

water phantom is irradiated with a perpendicular beam. In reality, however, a
patient’s body is nonhomogeneous, and there are large variations in body contours.
To perform more accurate dose calculations in patients, a number of corrections
need to be applied. Patient contour variation and tissue density information must be
available to apply such corrections.
4.1.22.2 Correction for Contour Variation
The following methods have been widely used for dose calculations at points under
an irregular body surface.
Effective SSD Method
This method is used for dose adjustment, based on variations in SSD due to an
irregular surface and the inverse square reduction in fluence. As an example,
suppose the dose at point A, away from the central axis, needs to be calculated
(Fig. 4.32). The percent depth dose (P), measured in a phantom with a flat surface,
cannot be used for this situation. Due to a tissue deficit of thickness t cm, the dose at
point A will be higher than at the same level at the central axis. Suppose, the beam
is incident on a flat surface at level L1. Another flat surface L2 is assumed to be
drawn at t cm below L1. Depths of maximum dose relative to these levels are dm1
and dm2. The isodose chart is shifted down by t cm at level L2. Now the dose to point
A can be approximated as:
DA ¼ P:Ddm2 ð4:21Þ
where P is the percent depth dose at A relative to dose at depth dm2 for surface L2.
The thickness t must be small to guarantee dos calculation accuracy.
Dose at point A with respect to Ddm1 is:
DA ¼ Pc :Ddm1 ð4:22Þ
where Pc is the corrected percent depth dose.

From Eqs. (4.21) and (4.22):
Ddm2
Pc ¼ P: ð4:23Þ
Ddm1
Fig. 4.32 An example of dose distribution determination under an irregular surface. The solid and
dashed isodose curves are assumed for flat surfaces located at L1 and L2, respectively
Dose at dm2 and dm1 can be related each other by inverse square law
(distance t cm):
2
Ddm2 SSD þ dm
¼ ð4:24Þ
Ddm1 SSD þ dm þ t
so:
2
SSD þ dm
Pc ¼ P: ð4:25Þ
SSD þ dm þ t
For excess tissues a similar approach can be used, while moving the isodose
charts upward.
Tissue-Air Ratio Method
An alternative to the effective SSD method, TAR correction method can also be
used. In this method the value of percent depth dose P1 relative to surface L1 is
corrected for TAR ratio that differs by a depth of t cm. The correction factor CF is:
TARðd; r A Þ
CF ¼ ð4:26Þ
TARðd þ t; r A Þ
Therefore:
TARðd; r A Þ
Pc ¼ P: ð4:27Þ
TARðd þ t; r A Þ
Isodose Shift Method
The isodose shift method is a simplified manual correction method applied to

irregular body contours. Figure 4.33 illustrates the method in detail. User-defined
grid lines are drawn parallel to the beam central axis all across the field. The isodose
chart is shifted partially along these rid lines by a factor k t, where k is a factor
Fig. 4.33 An example of isodose shift method for dose determination under an irregular surface
Table 4.4 Values of k factor, defined for various beam energies

Photon energy (MV) <1 Co60-5 5–15 15–30 >30
k (approximate) 0.8 0.7 0.6 0.5 0.4
defined for various beam energies, given in Table 4.4 (Giessen 1973), and t is the
thickness of missing or excess tissue along the grid line. k values are empirically
generated by taking into account the primary and secondary radiations and inverse
square effect.
With the help of isodose shift method, dose distribution in the entire plane is
estimated.
4.1.22.3 Inhomogeneity Correction
The presence of an inhomogeneity, e.g., the air cavity, lung, tissue, or bone, alters
the attenuation of primary as well as scattered radiation. The scatter correction is
difficult to perform in the presence of inhomogeneities. We shall limit our discus-
sion to primary radiation only. In the therapeutic range, the photon energy is high
enough to assume that attenuation of radiation is predominantly due to the Compton
interaction. Another assumption is that, the lateral dimensions of the inhomogeneity
are infinite or much larger than the field size. Under these conditions, the absorption
and scattering per unit mass, produced in the inhomogeneity will be proportional to
the electron density. The following methods are used for inhomogeneity
corrections.
TAR Method
Consider a simple geometry where a point A is located at depth d in a homogeneous

medium (ρw ¼ 1.0), as in Fig. 4.34a. The absorbed dose at point A may be
determined using standard depth dose data (e.g., TAR, TPR, or PDD). Now suppose
an inhomogeneity of thickness t, with relative electron density ρe ¼ 1.5 (with
respect to water), is introduced above point A. The physical depth to point A0 in
Fig. 4.34b is the same as in Fig. 4.34a, whereas the effective depth d0 , to the same
point as shown in Fig. 4.34c may be determined by Eq. (4.28).
d0 ¼ ðd tÞ þ t:ρe ð4:28Þ
This makes the problem easy for dose estimation. The magnitude of the dose at
point A0 depends on the type and thickness of the inhomogeneity. If ρe for the
inhomogeneity is greater than 1, as in this case, the equivalent depth d0 will be
greater than the physical depth (Fig. 4.34c), and vice versa. The corresponding
correction factor to the dose at point A0 , in the presence of an inhomogeneity, may
be calculated by the following equation:
Fig. 4.34 Geometrical explanation of the effect of an inhomogeneity on dose. (a) Water-
equivalent phantom, (b) inhomogeneity of thickness t is introduced, and (c) water-equivalent
depth of point A0 in part (b)
Table 4.5 Approximate Beam quality Air gap Lung Compact bone
changes in dose per cm,
Cobalt-60 +6% +4% 3%
beyond inhomogeneity as a
function of beam energy 6 mv þ3.5% +3% 2%
18 mv +2% þ1.5% 1%
TARðd0 ; r d Þ
CF ¼ ð4:29Þ
TARðd; r d Þ
where rd is the field size at depth d.

A major limitation to this method is that the position of the inhomogeneity
relative to the point of calculation is not taken into account. This method may be
used to determine approximate correction factors for points beyond the inhomoge-
neity. Such corrections, in percent dose per centimeter of inhomogeneity are shown
in Table 4.5 for different beam energies.
Batho’s Method (Power Law TAR Method)
In the TAR method, described above, it was noted that the correction factor is
independent of the position of the inhomogeneity relative to the point of dose
calculation. However, in reality, the absorbed dose at P0 in Fig. 4.34b does depend
on its distance from the lower border of the inhomogeneity. Batho’s method takes
this position dependence of the point of dose calculation into account. The correc-
tion factor is now given by:

TARðd 2 ; r d Þ ρe 1
CF ¼ ð4:30Þ
TARðd 1 ; r d Þ
where d1 and d2 are the respective distances from the point of dose calculation to the
lower and upper boundaries of the inhomogeneity.
Modified Batho Power Law Method (MBPL)
Batho’s power law method does not apply to dose correction at points inside the
inhomogeneity or in the dose buildup region in the vicinity of different tissue
interfaces. MBPL uses the descending part of TMR curves, by adding depth of
maximum dose to the depth, so that:
ρe 1
TARðd2 þ dm ; r d Þ
CF ¼ ð4:31Þ
TARðd1 þ dm ; r d Þ
Equivalent TAR Method
The amount of scatter, as discussed earlier is related to the amount of phantom/

patient irradiated. In an inhomogeneity, the scatter is no longer equivalent to that
produced in the same volume of water. To account for this scatter variation, the
field size is scaled to the weighted density e
ρ of the irradiated volume (Sontag and
Cunningham 1978).
The correction factor is thus given by the following equation:
TARðd0 ; r 0 Þ
CF ¼ ð4:32Þ
TARðd; r Þ
where d0 is the effective depth and r 0 ¼ r:e ρ is the effective field size.
The weighted density e ρ is determined using the following equation:
P
ρijk W ijk
i, j, k
ρ¼ P
e ð4:33Þ
W ijk
i, j, k
where Wijk is the weighting of the scatter contribution from the relevant volume
element (voxel) in the field.
Fig. 4.35 Dose determination beyond inhomogeneity (lung tissue) with three-field technique
Example 4.12 A patient is treated with an SAD setup, using three fields on a 6 MV
photon beam. Patient positioning and beam arrangements are shown in Fig. 4.35.
The dose rate at isocenter at the calibration depth of dm for the 10 cm 10 cm field
size is 1.0 cGy/MU. The average lung density (ρ) is 0.25 g/cm3. Calculate the
number of MU per field, for a tumor dose of 100 cGy from each field at the
isocenter.
Solution Field 1; 10 8 cm2, depth d1 ¼ 7 cm, ROF ¼ 0.988, TMR ¼ 0.866
MU for field 1 can be determined using Eq. (4.17):
100
MU ¼ ¼ 117
0:988 0:866
Field 2 Field 3; 10 12 cm2, physical depth d2 ¼ d3 ¼ 16 cm, ROF ¼ 1.009

Central axis of both Fields 2 and 3 passes through 8 cm lung tissue.
Use Eq. (4.28) to calculate water-equivalent depth Fields 2 and 3:
d 02 ¼ d03 ¼ ð16 8Þ þ 8 0:25 ¼ 10 cm

TMR for fields 2 and 3 is 0.779. Hence, the corresponding MUs can be calculated
using Eq. (4.17):
100
MU ¼ ¼ 127
1:009 0:779
4.1.22.4 Model-Based Calculation Methods
More accurate and precise volumetric dose estimation in patient is only possible
with the model-based dose calculation algorithms. The most difficult component of
dose calculation in a heterogeneous media is estimating the scattered radiation. In
the modern treatment planning systems (TPS), three-dimensional dose distributions
are computed from first principles (Ahnesj€o and Aspradakis 1999; Ahnesj€o 1989;
Mackie et al. 1985; Mohan et al. 1986). These algorithms generally model the
primary photons, scattered photons, and electrons separately. Hence, any changes
in the scattering, caused by variations in the radiation field size and shape, beam
energy and intensity, patient geometry, and internal heterogeneities, can be
modeled individually (Dyk 1999). However, in dose calculations, some approxi-
mations have also been introduced due to computer speed limitations and incom-
plete physics of the model.
4.1.22.5 Pencil Beam Convolution/Superposition Algorithm (PBCS)
Dose calculation with these models is based on the concept of dose deposition
kernels (Knoos et al. 2006; Ulmer and Kaissl 2003; Ulmer et al. 2005; Ulmer and
Harder 1996). The dose deposition kernel is a representation of the distribution of
energy around the point of interaction of primary photon, as shown in Fig. 4.36a.
This in reality models the transport of electrons and photons away from the
interaction point. These kernels are usually calculated by Monte Carlo
(MC) simulation for a given beam quality.
Dose deposition in a homogeneous medium can be calculated by a three-
dimensional convolution of the energy released by the primary beam and the
dose deposition kernel, as in the following equation:
Fig. 4.36 Types of kernels. (a) Point scatter kernel, (b) line scatter kernel, and (c) collapsed cone
approximation
Z
μ 0
D ~
r ¼ ψ ~
r :k ~ r 0 d 3~
r ~ r ð4:34Þ
ρ
v
μ
where ψ ~r is the total energy released per unit mass and k ~ r ~ r 0 is a
ρ
generalized scatter kernel.
To compensate for the scattering changes in a heterogeneous medium, the kernel
is scaled to the density of inhomogeneities around the point of interaction. Total
dose at a given point in the medium is obtained by the superposition of doses from
primary and scattered photons and electrons.
A pencil beam kernel is obtained by convolution of the dose kernel along the
depth in water (Fig. 4.36b). Hence, three-dimensional dose distribution can be
generated by a two-dimensional integration of pencil beam kernel over the energy
fluence across the field. This considerably reduces the calculation time as compared
to convolution of the point dose kernel. Heterogeneities are corrected for via
effective path length along the longitudinal axis only. With the PBCS model, the
dose calculation accuracy in heterogeneous medium is less accurate unlike the
modern calculation algorithms (Knoos et al. 2006).
Anisotropic analytical algorithm (AAA) is a modern version of the PBCS,
introduced by Varian Medical Systems. AAA suggests separate modeling of the
primary and scattered photons and electrons. The pencil beam in this case is
acquired from Monte Carlo simulation and is further adjusted to conform to the
measurements. The pencil beam along the longitudinal direction is scaled according
to the equivalent (effective) path length (EPL), as in PBCS. The pencil beam is
further scaled according to EPL in the lateral directions (i.e., normal to the pencil
beam). This ensures more accurate and reliable dose calculation in heterogeneous
media.
4.1.22.6 Collapsed Cone Convolution/Superposition Algorithm
The pencil beam convolution superposition formulation is the simplest and fast
dose calculation formalism. However, there are several limitations to this method,
e.g., kernel invariance due to heterogeneities and beam divergence (Ahnesj€o and
Aspradakis 1999). The collapsed cone convolution superposition (CCCS) model
addresses these limitations by introducing a unique dose deposition kernel with a
finer resolution than pencil kernel. The shape of the analytical kernel is in the form
of multiple discretized conical sectors called collapsed cones (Fig. 4.36c) (Ahnesj€o
1989). The CCCS algorithm has been reported to calculate more accurately dose
distributions in the presence of inhomogeneities and at interfaces compared to the
PBCS and AAA algorithms at the expense calculation speed (Knoos et al. 2006;
Nakaguchi et al. 2010; Han et al. 2011).
Several other dose calculation engines are available in the market (Knoos et al.
2006; Fogliata et al. 2011).
4.1.22.7 Monte Carlo Method
Analytical dose calculation methods imply various approximations for increasing

the calculation speed. This compromises the dose calculation accuracy, especially
at the tissue interfaces. Monte Carlo, on the other hand, is the most accurate dose
computation methodology, currently available. It is capable of accurately estimat-
ing doses near the interfaces as well as for small radiation fields (Sewchand et al.
1978). Slower calculation speed is however a major limitation to the Monte Carlo
calculation. The Monte Carlo is a probabilistic method of dose calculation, based
on known interaction cross sections for electrons and photons in different media. It
calculates the trajectories and interaction probabilities for a large number (~ several
millions) of photons and electrons, to accurately model the dose distribution. In the
above mentioned algorithms, the Monte Carlo simulations are partially introduced
for defining the physical characteristics of the photon beams and treatment head of
linear accelerators (Sievinen et al. 2007).
4.2 Section B: Electron Beam Treatment Planning
4.2.1 Introduction
The purpose of this section is to discuss the treatment planning with electron beams.
High-energy electron beams are considered crucial treatment modalities in radio-
therapy. Electron therapy may be used for the treatment of superficial tumors
(<5 cm deep), such as cancers of the skin and lips, chest wall boost in the breast
treatment, and boost to various nodes in the body (Khan 2010; Podgorsak and IAEA
2005; Halperin et al. 2008b). It is preferred over orthovoltage therapy in cases
where there are overlying cartilage or bone to the PTV that result in an increased
photo absorption due to photoelectric effect. Megavoltage photon beams may also
be used for the treatment of superficial tumors, provided a bolus of suitable
thickness is applied to eliminate the skin-sparing effect. However, these photons
have a higher penetration power and unnecessarily irradiate underlying normal
tissue. On the other hand, there is a sharp dose fall off beyond the 90% isodose line
for lower electron energies (12 MeV). The rate of energy loss is ~2 MeV/cm in
water and soft tissue for high-energy electrons (Podgorsak and IAEA 2005). The
electron energy must be chosen so that the PTV is entirely encompassed by the 90%
isodose line. Bolus may also be applied if necessary.
Modern megavoltage energy linear accelerators are typically equipped with a
number of electron energies (4–22 MeV). Higher-energy electron beams
(>12 MeV) may be used for the treatment of cervical lymph nodes and
parotid tumors and in certain cases mixed with photon beams (Khan 2010; Halperin
et al. 2008b).
4.2.2 Dosimetric Data for Clinical Electron Beams
4.2.2.1 Depth Dose Profiles
Percent depth doses for electron beams are measured in a water phantom similar to
those for photon beams. There are, however, fewer standard square fields (cones or
applicators), designed for electron beam delivery. Electron depth dose curves vary
with varying field size, beam energy, and SSD.
Figure 4.37 shows a typical electron depth dose distribution in water. A number
of important parameters associated with the electron PDD are presented and
explained below:
Dsurf – Surface dose
R90 – Depth of 90% dose beyond dm
R50 – Depth of 50% dose
Rp – Practical range; the depth to the point where tangent to the descending linear
portion of PDD intersects the extrapolated x-ray contamination, as shown in
Fig. 4.37
Dx-ray – Bremsstrahlung x-ray contamination beyond practical range
4.2.2.2 Variation with Beam Energy
As expected, the percent depth dose increases with increase in electron energy for a
given field size (Fig. 4.38). A unique behavior shown by these percent depth doses
is that the surface dose increases with increasing electrons energy. This phenom-
enon may be explained by understanding the electron scattering properties. Elec-
trons at lower energies scatter through larger angles, and their scattering probability
Fig. 4.37 Typical electron

beam depth dose curve 100
demonstrating the concepts 90
of R90, R50, Rp, Dsurf, and
Dx-ray
Percent depth dose
Dsurf
50
Dx-ray
0
R90 R50 RP
Depth in phantom
Fig. 4.38 Depth dose 6Mev

variation with increasing 100 9Mev
beam quality 12Mev
15Mev
80 18Mev
Relative dose (%)

60
40
20
0
0 2 4 6 8 10 12 14
Depth (cm)
Fig. 4.39 Applicator/cone 3x3

size dependence on % depth 100 6x6
dose distribution for 10x10
25x25
18 MeV an electron beam
80
Relative dose (%)
60
40
20
0
2 4 6 8 10 12
Depth (cm)
is also higher. This results in a higher electron fluence at a shorter distance relative
to the fluence on the surface. Therefore, the ratio of these fluences is less for the
low-energy electrons compared to the high-energy electrons (Khan 2010).
4.2.2.3 Variation with Field Size
Percent depth dose increases with field size, due to increased scatter from the
collimator and the phantom (Fig. 4.39). Most of the electron beams are shaped by
various applicator (cone) sizes and inserts (cutouts), provided a recommended fixed
jaw opening. With the fixed jaw settings, variation in cone scatter is minimum and
beam output is almost constant. The use of the applicators is essential for producing
a uniform fluence at the patient surface.
The change in the shape of PDD is prominent for smaller fields than for larger
field. Loss of the side-scatter equilibrium is the major reason for this behavior. It has
been demonstrated that for the establishment of lateral scatter equilibrium, the
minimum field diameter (Deq) on the central beam axis may be approximated by
the following relationship (Khan and Higgins 2001):
pffiffiffiffiffiffiffiffi
Deq ¼ 1:76 Ep, o cm ð4:35Þ
where Ep,o (MeV) is the most probable energy, related to Rp by Eq. (4.36).
It is to be noted that the field-size dependence on PDD is more dominant for
higher electron energies.
4.2.2.4 Off-Axis Dose Profile
Dose distributions in the direction normal to the central axis can be described by
off-axis profiles. These dose profiles are measured in a water phantom and may also
be used to describe the beam flatness and symmetry.
The specification for electron beam flatness and symmetry as per the IEC
recommendations are as follows. The electron beam flatness is considered to be
acceptable if the 90% isodose level is within 1.0 cm of the geometrical beam edge
and 2 cm along the diagonals as shown in Fig. 4.40. The dark black line represents
the geometrical beam edge. Furthermore, point dose in the plane bounded by the
90% isodose line should not exceed the central axis absorbed dose by more than
5%. For acceptable beam symmetry, any pair of the symmetric points of the beam
profile on either side of the central axis should not differ by more than 3%. These
definitions are valid at dm only (Podgorsak and IAEA 2005).
Fig. 4.40 Planar isodose distribution normal to the electron beam central axis, demonstrating
beam penumbra, symmetry, and flatness
Table 4.6 Characteristics of the electron beams produced by Varian’s accelerator (DHX), with a
15 15 cm2 Applicator
Nominal electron energy R100 R90 R50 Rp Epo Eo Dx-ray
(MeV) (mm) (mm) (mm) (mm) (MeV) (MeV) (%)
6 14 18.5 24.7 30.9 6.49 5.88 0.1
9 20 28.2 36.5 44.9 9.22 8.60 0.4
12 28 38.9 50.2 60.8 12.31 11.82 0.9
15 30 47.8 62.9 76.2 15.33 14.86 1.5
18 18 53.8 74.8 91.1 18.38 17.84 1.9
4.2.2.5 Electron Beam Energy Specification
A number of different parameters are used to describe the electron beam energy.
The energy of electron beam on the phantom surface is expressed by the most
probable energy Ep,o and the mean energy E0 . The most probable energy (Ep,o) is
the energy carried by most of the electrons and may be estimated by the following
relation:
Ep, o ðMeVÞ ¼ 0:022 þ 0:198Rp þ 0:00011R2p ð4:36Þ
where Rp is in mm and Ep,o in MeV.

The mean energy ( E0 ) at the phantom surface may be calculated as follows
(Podgorsak and IAEA 2005):
E0 ¼ 2:33R50 ð4:37Þ
A detailed description of the electron beam characteristics is presented in

Table 4.6.
4.2.2.6 Isodose Curves
The isodose curves measured for the electron beams are much different than those
for the photons (Fig. 4.41). The dose distribution expands with depth in the medium
due to side scattering of the electrons. The spread of the individual isodose curve
varies as a function of the isodose level, beam quality, and field shape. To some
extent, all the isodose curves bulge out for low-energy electrons, as a result of the
increased side scattering. However, only low-level isodoses expand laterally in case
of high-energy electron beams. The higher-value isodoses (>80%) narrow down
for high-energy beams. The effective width of these curves is considerably smaller
than the field size, and further decreases with depth. This is referred to as “tapering
or constriction” of the high-value isodose curves. Keeping in view all these, it is
extremely important to choose beam energy and field size such that the tumor is
completely encompassed by the 90% isodose level. Depending on the situation, the
clinician may accept tumor coverage at lower isodoses. Figure 4.41a, and b shows
the isodose curves for 6 MeV and 18 MeV electron beams, respectively.
Fig. 4.41 Isodose distribution of electron beams with, (a) 6 MeV and (b) 18 MeV
4.2.3 Treatment Planning
Surface lesions extending to a depth of up to 5 cm may be easily treated with a

single direct electron beam. The following practical considerations should be noted
when preparing a treatment plan.
4.2.3.1 Treatment Setup
The majority of electron beam treatments are carried out with a single field and
fixed SSD. A nominal treatment SSD of 100 cm is typically used. If required,
however, extended SSDs may also be used. During lateral neck boost, an SSD of
115 cm is commonly used to avoid hitting of the patient shoulders by applicator.
4.2.3.2 Beam Energy and Field Size
Based on the above discussion on the electron isodose distribution, the beam energy
and field size should be appropriately selected to provide adequate coverage of the
lesion within the 80–90% isodose.
4.2.3.3 Field Shaping
Electron applicators (cones) as shown in Fig. 4.42a are typically used for field
shaping and collimation. When required additional shielding cutouts may also be
used.
The photon beam collimation system (movable jaws) alone cannot be used for
electron beam shaping because of multiple scatterings in the space between the
electron exit window and the patient. Electron dose uniformity in this case will be
unacceptable for the treatment purposes. Electron beam applicators or cones are
attached to the treatment unit head. The distal edge of the applicator is 95 cm away
from the source, providing a 5 cm clearance from the patient surface.
Modern linear accelerators are equipped with various applicators, typically in
square field sizes (5 5 cm2 to 25 25 cm2). For irregular field shapes, lead or
Cerrobend cutouts (Fig. 4.42b) may be placed in the distal end of the applicator.
Customized field shapes may be determined from conventional or virtual simula-
tion, but are most often marked clinically by the physician. For electron beams in
therapeutic range (6–20 MeV), a thickness of ~0.5 mm lead per MeV or 0.6 mm
Cerrobend per MeV is sufficient for shielding purposes. A 1-cm-thick lead shield
can attenuate
95% of the electrons in this energy range. Figure 4.42b shows an
external shield to be used with a specific applicator.
Fig. 4.42 (a) Electron applicator/cone (Courtesy: Varian Medical Systems, Palo Alto, CA), (b)
Cerrobend cutout
Fig. 4.43 Internal eye

shields made of silver (left)
and Tungsten (right)
(Courtesy: RPD©, Inc.,
Albertville, MN)
4.2.3.4 Internal Shielding
During treatment of the eyelid, lip, or buccal mucosa, where the underlying
structures need to be spared from radiation, internal shields are used. Figure 4.43
shows two types of internal eye shields. Electron backscatter is a serious issue,
associated with the internal shielding. An excess dose of about 30–70% magnitude
may be received by the lead-tissue interface on the entrance side of the beam (Khan
2010). However, the dose drops exponentially with distance from the interface. To
reduce this unnecessary dose from backscatter, internal shields are coated with a
layer of wax (1 or 2 mm).
4.2.3.5 Use of Bolus
In electron therapy, bolus may be used to smooth out the sharp irregularities in the
patient’s surface, increase the surface dose, or decrease the effective depth of
treatment. Bolus must be placed in close contact with the patient’s skin to avoid
air gapes.
4.2.3.6 Monitor Unit Calculation
Absolute electron dosimetry is performed using the available standard dosimetry

protocols (e.g., TG-51 or TRS-398). Dose rate is usually adjusted to 1.0 cGy/MU at
the depth dm in water, for a standard field size (applicator) and given energy.
Applicator factors are measured for other applicators relative to the standard one.
The relative dose rates at dm for other applicators are expressed in terms of
applicator factors or cone factors. For example,
Dose rate for Ca

Applicator Factor, AFðCa Þ ¼ ð4:38Þ
Dose rate for Co
where Ca and Co are the field sizes for a given applicator and reference applicator,
respectively.
Additionally, if a cutout is used, the dose rate may further be changed. Cutout
factors are defined relative to the applicator they are used with. The cutout factor for
a given cutout (X) used with a specific applicator (Ca) is given by the following
relation:
Dose rate with cut-outðXÞ

COFðXÞ ¼ ð4:39Þ
Dose rate for Ca
For example, the cutout factor for a 3 5 cm2 cutout used with a 6 6 cm2
applicator may be calculated as below:
Dose rate with cut-outð3; 5Þ

COFðXÞ ¼ ð4:40Þ
Dose rate for Applicatorð6; 6Þ
The output factor for a given applicator (Ca) and cutout (X) is:
OðCa ; XÞ ¼ AFðCa Þ COFðXÞ ð4:41Þ
For a prescribed dose PD, at nominal SSD, the number of MU can be

calculated as:
PD 100
MU ¼ ð4:42Þ
D0o OðCa ; XÞ PDD
where D0o is the dose rate at the depth of maximum dose for the reference applicator.
The PDD is proved to be the insert size dependent, not the applicator size
dependent (Tung et al. 1994).
Example 4.13 The chest wall of a mastectomy patient is to be treated with a single
6 MeV electron field, at 100 cm SSD, using a 4 5 cm2 cutout with a 6 6 cm2
applicator. A daily dose of 200 cGy per fractions is prescribed to dm. Determine the
number of MU per fraction.
Solution
Cone factor (6 6 cm2) ¼ 0.955
Cutout factor (4 5 cm2) ¼ 0.994
Dose prescription per fraction at dm ¼ 200 cGy
Using Eq. (4.42):
200 cGy 100

MU ¼ ¼ 211
1:000 cGy=MU 0:955 0:994 100
4.2.4 Electron Beam Abutting
In certain situations electron beams may be abutted to other adjacent electron or

photon fields. Examples are treating very large areas, a curved surface or conjunc-
tions of electron, and photon beams in head and neck treatment.
Fig. 4.44 Electron-electron (9 MeV) field junctions, (a) zero gap, (b) 1.0 cm gap
Fig. 4.45 Electron (9 MeV) and photon (6MV) beam junction with zero gap
Unlike photon fields, abutting of the electron-electron fields is very complicated

and requires extreme caution. Bulging of the isodose lines result in under- or
overdosage in the target volume. The dosimetric characteristics of the electron
beams with depth need to be carefully assessed. Hot and cold spot sizes and their
location depend on the gap between field edges (Fig. 4.44a, and b). Matching of the
electron-photon fields is relatively simple because of the sharper penumbra of the
photon beam. However, electron-photon field matching on the skin still produces a
hot spot at a certain depth (Fig. 4.45).
4.2.5 Oblique Beam Incidence
Electron dose distribution in a medium is perturbed by surface irregularities. In

cases when curved surfaces (e.g., chest wall, head and neck, and limbs) are
irradiated with large electron fields, the dose distribution drastically changes due
to oblique incidence. Figure 4.46a, and b demonstrates the changes in percent depth
dose as a function of angle of incidence on a flat phantom. PDDs are taken along
two different directions:
Fig. 4.46 Depth dose 140 o

0
variation as a function of o
30
oblique incidence, (a) along 120 45
o
the beam central axis, (b) 60

o
normal to the phantom 100
Relative dose (%)

surface
80
60
40
20
0
0 2 4 6 8
(a) Depth (cm)
160 o
0
o
30
140 o
45
o
60
120
Relative dose (%)
100
80
60
40
20
0
0 1 2 3 4 5 6 7 8
(b) Depth (cm)
• Along the beam central axis (Fig. 4.46a)

• Normal to the phantom surface (Fig. 4.46b)
It is clear that with the increasing angle of incidence (International Commission
on Radiation Units and Measurements. Bethesda 2004):
• Depth of maximum dose (dm) decreases.
• R90 decreases.
• Maximum dose increases.
• Surface dose increases.
In addition, there is an increase in the range of penetration along beam central
axis. As a result of decrease in R90, tumor coverage is compromised to a level that
may be clinically significant. It is therefore recommended to avoid treatments with
large angles of beam incidence.
4.2.6 Electron Treatment Planning Algorithms
Electron transport in a medium is dominated by multiple scattering and is difficult

to model analytically with high accuracy, for treatment planning purposes. Such
methods do not accurately predict doses for oblique incidences and tissue inter-
faces. Inhomogeneities are typically accounted for by scaling the depth dose curves.
Since 1981, the model-based pencil beam algorithm (PBA) is universally used
for electron beam dose computation. The algorithm can account for tissue inhomo-
geneities, contour variation, and irregular cutouts. There are however limitations to
PBA, when it comes to dose calculation at the interfaces. Currently, several, more
accurate, analytical, and Monte Carlo-based dose calculation algorithms are com-
mercially available.
Problems
1. 200 MU need to be delivered for a prescribed dose of 180 cGy to a point on the
central axis. If the prescription point is changed to be 5 cm away laterally from
the beam central axis where off-axis ratio (OAR) is 1.03, how many MU are
required to deliver the same dose?
2. A tumor dose of 200 cGy is prescribed at a depth of 8 cm on a 15 MV linear
accelerator for a field size of 15 20 cm2. The machine is calibrated at dm
isocentrically, i.e., 100 cm SAD (1 cGy/MU). If the treatment SSD is 80 cm,
calculate the number of MU.
3. The number of MU calculated for a given treatment field of 13 13 cm2 is 204.
The machine dose rate (beam output) was supposed to be 1.000 cGy/MU for
a standard field size of 10 10 cm2; however, on that morning, output was found
to be 0.970 cGy/MU. If no adjustment was made to the dose rate, calculate the
revised MU for the same tumor dose.
4. For a 6 MV photon beam of 12 12 cm2 field (at isocenter), 200 cGy dose is
prescribed at a depth of 7 cm in phantom, using as SAD setup.
(a) What will be the dose at 12 cm for the same SAD and jaw settings?
(b) If the SSD is now changed to 100 cm, what will be the dose at 12 cm for the
same jaw settings?
5. An elliptical, water equivalent phantom is to be irradiated using an arc therapy
technique with 20 beam angles such a point at the phanton centre receives
300 cGy dose. The long and short axis of the ellipse are 15 cm and 10 cm,
respectively. Calculate the number of MU for each beam angle if the field size is
15 15 cm2 and beam energy is 15 MV.
6. The relative out factors (ROF) for a given teletherapy machine are measured at
dm with an SAD setup. However, the chief physicist wants these factors to be
determined at 5 cm depth. Devise a relation to calculate the ROF at 5 cm depth
from those measured at dm.
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Treatment Planning in Radiation Therapy

Chapter · November 2017

Amjad Hussain Wazir Muhammad

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4.1 Section A: Photon Beam Treatment Planning

Radiation therapy is the clinical use of ionizing radiation as part of a comprehensive

A. Hussain, PhD, MCCPM (*)

© Springer International Publishing AG 2017 63

4.1.1.1 Historical Evolution

X-rays were discovered by Wilhelm Roentgen in 1895. As a result of the investi-

4.1.2 Therapeutic Response

Optimally effective radiotherapy is not possible without some understanding of the

Fig. 4.1 Conventional

Fig. 4.2 Radiotherapy Diagnosis Structures Dose

fractionation schemes and, in selected cases, chemotherapy drugs are used to

4.1.3 Radiation Therapy Process

Radiotherapy treatment planning is the process of determining optimal treatment

4.1.4 Patient Data Acquisition

4.1.5 Patient Positioning and Immobilization

reproducibility and to limit patient movement during treatment, various immobili-

4.1.6 Pretreatment Simulation

4.1.6.1 Conventional Simulator

Fig. 4.3 A photograph of a

Fig. 4.4 A planar

Patient body contouring, treatment depth measurement, and preparation of

4.1.6.2 Computed Tomography Simulator

4.1.6.3 Magnetic Resonance Imaging (MRI)

Treatment planning calculations are generally performed on CT images. However,

4.1.6.4 Positron Emission Tomography (PET)

Positron emission tomography (PET) is also used as a complementary imaging tool

Contouring of various anatomical structures and the tumor volume is an essential

Fig. 4.8 Schematics of

4.1.7.1 Gross Tumor Volume (GTV)

4.1.7.2 Clinical Target Volume (CTV)

4.1.7.3 Internal Target Volume (ITV)

4.1.7.4 Planning Target Volume (PTV)

The PTV is a geometrical deﬁnition, used in treatment planning and evaluation.

4.1.7.5 Organs at Risk (OAR)

4.1.8 Dose Prescription and Reporting

4.1.9 Dosimetric Data for Clinical Photon Beams

It is obviously not possible to measure radiation dose distributions in patients

Fig. 4.9 Measurement

4.1.10 Depth-Dose Proﬁles

4.1.10.1 Percent Depth Dose (PDD)

Variation of PDD with Beam Quality

Field Size Dependence

Fig. 4.11 A square ﬁeld

Area of rectangle with sides “a” and “b” ¼ a b

½ðSSD1 þ d Þ=ðSSD2 þ dÞ2

½ðSSD1 þ dÞ=ðSSD2 þ dÞ2

100 150 cGy

Since dose rate at dm is 135.3 cGy/min, so:

½ð80 þ 10Þ=ð100 þ 10Þ2

½ð100 þ 10Þ=ðSSD2 þ 10Þ2

where D_ is the machine dose rate (1 cGy/MU

SAR ¼ ðSARÞrc ðSARÞrb þ ðSARÞra :