CHAPTER-1

1. BEAM MODIFIERS IN RADIOTHERAPY

INTRODUCTION

In radiotherapy, tumours under varying body contour are very often

encountered. In such cases, due to the irregular body surface, the dose distribution

within the target volume will be non-uniform. But, beam dose distribution data which

are used for treatment planning, are obtained under standard conditions such as

perpendicular beam incidence, homogeneous unit density medium and flat surface etc.

During treatment the beam may be obliquely incident with respect to the surface and in

addition the surface may be curved or irregular in shape as mentioned above. Under

such situations, the standard dose distributions cannot be applied without proper

modifications or corrections. Hence, beam modification is attempted to achieve a

uniform dose to the target volume and tumour volume. The important types of beam

modifiers are : Internal beam modifiers known as flattening filters , beam modifiers

added externally to a treatment unit, asymmetric collimators, multileaf collimators,

dynamic wedges etc. Flattening filter is virtually incorporated into the machine and
1
remains unchanged and was first described by Chester and Meredith< >. The second is

an external beam modifier which is added externally to the machine.

1
1.1. Internal beam modifiers or Flattening filters

A flattening filter is used to reduce the amount of radiation in the centre

of the beam relative to that at the periphery. When such filters are placed in the path of

the beam, results in beam hardening at the centre of the field with appreciable
2
modification of the depth dose. Because of this, Kemp and Oliver< > reported the use of

a filter composed of low atomic number material such as perspex for orthovoltage

beam. This attenuated the orthovoltage beam without significant modification of its

quality. In cobalt teletherapy machines where the isodoses are more uniform, the

need for flattening filters is less marked. Still they could be attempted with a view that

the variation between the peripheral doses and central axis doses is a minimum.

1.1.1 Flattening filter for megavoltage x-rays

The use of flattening filters is absolutely essential in the case of linear

accelerators. To ensure flattening of the beam at the appropriate depth, it is sometimes

necessary for the peripheral dose near the surface to be larger than at the central

axis. Without this filter, the isodose curves will be conical in shape, showing increased

x-ray intensity along the central axis and a rapid reduction transversely. The function of

the flattening filter is to make the beam intensity distribution relatively uniform across

the field. Therefore, the filter is thickest in the middle and tapers towards the edges.

As beam energy increases, the thickness of the flattening filter also

increases. The cross-sectional variation of the filter thickness also causes variation in

the photon spectrum or beam quality across the field owing to selective hardening of

the beam by the filter. In general the average energy of the beam is somewhat lower

2
for the peripheral areas compared with the central part of the beam. This change in

quality across the beam causes the flatness to change with depth. However, the

change in flatness with depth is caused not only by the selective hardening of the

beam across the field but also the changes in the distribution of radiation scatter as the

depth increases. Beam flatness is usually specified at a depth of 10cm with the

maximum limits set at the depth of maximum dose. By careful design of the filter and

accurate placement in the beam, it is possible to achieve flatness to within ±3% of the
11 31
central axis dose value at 10cm depth< · l. This degree of flatness should extend over

the central area bounded by at least 80% of the field dimensions at the specified

depth or 1cm from the edge of the field. This specification is satisfactory for the

precision required in radiotherapy.

A high dose area near the surface need to be accepted to obtain an

acceptable flatness at a depth of 10 cm. Though the extent of the high dose regions or

horns varies with the design of the filter, lower energy beams exhibit a larger variation

than higher energy beams. In practice, it is acceptable to have these "superflat"

isodose curves near the surface provided no point in any plane parallel to the surface
4
receives a dose greater than 107% of the central axis value< >.

1.1.2 Flattening filters for electron beam

In the case of electron beam, the beam is flattened by the interposition of

a thin foil of low atomic number, the thickness of which can be calculated at any point

knowing the energy of the electrons and the amount of change in the isodose surface

which is necessary. The scattering effect of the material traversed by the electrons is

3
such as to cause a marked spreading of the isodose surface beyond the geometrical

beam. This feature prevents electron beams from treating deep seated tumours.

Uniformity of the electron beam is usually specified in a plane perpendicular to the

beam axis and at a fixed depth. The International Commission on Radiation Units and

Measurements(ICRU)(5)specifies beam flatness in terms of a uniformity index. This is

defined in a reference plane and at a reference depth as the ratio of the area where

the dose exceeds 90% of its value at the central axis to the geometric beam cross-

sectional area at the phantom surface. The uniformity index should exceed a given
2
fraction eg:-0.80 for a 1Ox1 0 cm field size and at depth of dose maximum. In addition

the dose at any arbitrary point in the reference plane should not exceed 103% of the

central axis value. Because of the presence of lower energy electrons in the beam ,

the flatness changes significantly with depth. Therefore it has been recommended that

the uniformity index be defined at the depth of half the therapeutic range(6).eg:- half the

depth of 85% depth dose. Furthermore, it is defined as the ratio of the areas inside the

90% and 50% isodose lines at this depth. A uniformity index of 0.7 or higher is
2
acceptable with field sizes larger than 100cm . The peak value in this plane should be

less than 103%. The American Association of Physicists in Medicine (AAPM)(7)

recommends that the flatness of an electron beam be specified in a reference plane

perpendicular to the central axis, at the depth of the 95% isodose beyond the depth of

dose maximum. The variation in dose relative to the central axis should not exceed

. ±5%, optimally to be within ±3% over an area confined within lines 2cm inside the
2
geometric edge of fields equal to or larger than 1Ox1 Ocm . Beam symmetry compares

a dose profile on one side of the central axis to that on the other. The American

4
 Gi 3oc,C)b
Association of Physicists in Medicine (AAPM) recommends that the cross-beam profile

in the reference plane should not differ more than 2% at any pair of points located

symmetrically on opposite sides of the central axis.

Accelerators with magnetically scanned beam do not require scattering

foils. Others use one or more scattering foils, usually made of lead, to widen the beam

as well as to give a uniform dose distribution across the treatment field. Present day

accelerators employ a dual foil system for uniform electron beam. The first foil widens

the beam by multiple scattering , the second foil is designed to make the beam uniform

in cross-section. The thickness of the second foil is differentially varied across the

beam to produce a desired degree of beam widening and flattening. Studies by

5
Werner et.a1 < > confirmed that there is close agreement between the dual foil systems

and scanning beam systems in minimising angular spread and hence the effect on

dose distribution characteristics.

1.2. EXTERNAL BEAM MODIFIERS

The most important external beam modifiers used in radiotherapy are

wedge filters, compensators and beam shaping blocks.

1.2.1. Wedge filters

Wedge filters were first used by Frank Ellis and he established the
3
validity of the concept< >. This is a wedge shaped absorber which causes a

progressive decrease in the intensity across the beam, resulting in a tilt of the isodose

curves from their normal positions. The degree of tilt depends on the slope of the

wedge filter. The wedge ·is normally made of a dense material such as lead, lipowitz,

5
 l
-
ILECTIION 11AM
'.-----ILICTIIION UAM

X-RAY TARGET

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Figure 1.1. Components of treatment head. A, X-ray therapy mode.

B, Electron therapy mode..

Source

Figure 1.2. Schematic representation of a compensator designed for

an irregular surface.
5.\
brass, copper, steel etc. and is mounted on a transparent plastic tray or light metal

holder which can be inserted in the beam at a specified distance from the source. This

distance is chosen such a way that the wedge tray is always at a distance of at least

15cm from the skin surface to avoid electron contamination of the beam. Otherwise it

will reduce the skin sparing effect of the megavoltage beam.

The use of wedge filters with orthovoltage radiations was limited due to

the presence of hot spot under the thin end of the wedge and the bulge of the

isodoses away from the axis of the beam due to the scattering of the radiation. But the

usefulness of wedge filters is well demonstrated with mega voltage radiations due to

higher depth doses, associated greater focus to skin distance, less side and back

scatter and skin sparing effect due to buildup effect.

1.2.1.1. Wedge angle

The term wedge isodose angle or simply wedge angle refers to the

angle through which an isodose curve is tilted at the central ray of a beam at a

specified depth. ie, Wedge angle is the angle between the isodose curve and the

normal to the central axis. As the scattered radiation causes the angle of isodose tilt to

decrease with increasing depth in the phantom, the wedge angle should be described

at a specific depth. However, there is no general agreement to the choice of the

reference depth. Some choose depth as a function of field size such as one-half or

two-third of beam width etc. while others define wedge angle as the angle between the

50% isodose curve and the normal to the central axis. However the latter choice

becomes impractical when high energy beams are used. For example, the central axis

6
depth of the 50% isodose curve for 1OMV beam lies at about 18cm for a 1Ox10cm field

and 100cm SSD. This depth is too large in the context of most wedge filter
11
applications< >. The wedge filters are mostly used for treating tumours, not more than

10 cm deep. Therefore, the current recommendation is to use a single reference depth

9
of 10cm for wedge angle specification< >.

1.2.2. Tissue Compensators

1.2.2.1. Bolus

Bolus is a tissue equivalent material placed directly on the skin surface

to even out the irregular contours of a patient to present a flat surface normal to the

beam. This use of bolus should be distinguished from that of a bolus layer, thickness

of which is sufficient enough to provide adequate dose build up over the skin surface.

The latter should be called as build-up bolus. Placing bolus on the skin surface is

desirable for orthovoltage radiations and even for cobalt-60 gamma radiations. This

ensures that to reach a tumour at a known depth, the amount of matter traversed by

the beam corresponds to that for the isodose measurements. The isodose surface at

the tumour is then perpendicular to the central ray.

1.2.2.2 Compensating filters (Compensating

wedges or C-wedges)

In the case of megavoltage radiations, the use of bolus may neutralise

the lack of build up in the surface tissues, with consequent loss of skin sparing. To

preserve this advantage, but to get the effect of bolus, several methods are possible.

In such situations, a compensating filter may be used which approximates the effect

7
of the bolus as well as preserves the skin sparing effect. A prefabricated

compensating filter may be placed in the path of the beam at a suitable distance to

retain the build up advantage. It should also be of such a density and of such

dimensions that each pencil of radiation is attenuated as much in the compensating

wedge as it would have been in the patient if there had been no surface obliquity. This

method is justifiable when there is a slight curvature in one dimension as is usual with

the thorax and abdomen.

To attempt to compensate for curvature in two directions, Fulton used

two brass wedges of suitable dimensions placed at a sufficient distance from the skin

to get the build up advantage. They could be rotated relative to each other and to the

beam collimators so as to compensate for curvature in two directions simultaneously.

If a uniform dose is to be delivered to the target volume , an account of

the differences between patient and different parts of the body must be taken into

account. Contours and heterogeneity of the body tissues both modify the beam and

tend to reduce the precision with which dose can be delivered. These modifications by

the tissues of the patient should be corrected as far as possible. The oblique surface

modifies the beam inside the patient so that the isodose curves, instead of being at

right angles to the central ray are more nearly parallel to the surface. If the tissue

curves in other directions, corresponding distortions can occur. Thus surface

irregularity gives rise to unacceptable non-uniformity of dose within the target volume

or causes excessive irradiation of sensitive structures. To overcome this problem,

many techniques have been employed including the use of wedged fields or multiple

fields and the addition of bolus material or compensators.

8
 A wedge filter can be effectively used as a compensator. A wedge is

primarily designed to tilt the standard isodose curves through a certain wedge angle.

The wedge filter isodose curves must be available and used to obtain the composite

isodose curves before the filter is used in a treatment set up. The C-wedge on the

other hand is used just as a compensator so that the standard isodose charts can be

used without modification. Also, no wedge transmission factors are required for the C-

wedges. An important advantage of C-wedges over wedge filters used as

compensators is that the C-wedges can be used for partial field compensation. i.e.,

The C-wedge is used to compensate only a part of the contour, which is irregular in

shape. A wedge filter, in this case, could not be used as a compensator because it is

designed to be placed in the field in a fixed position.

1.2.2.3 Design of Compensators

The use of a compensator is to provide the required beam attenuation

which would otherwise occur in the "missing" tissue when the body surface is irregular

or curved. Because the compensator is designed to be positioned at a distance from

the surface, the dimensions and the shape of the compensator must be adjusted for

(a) the beam divergence, (b) the relative linear attenuation coefficients of the filter

material and soft tissues, and (c) the reduction in scatter at various depths when the

compensator is placed at a distance from the skin rather than in contact with it. To

compensate for this scatter, the compensator is designed such that the attenuation of

the filter is less than that required for primary radiation onll 3 ,14,15,16,17,18 &19). Minification

of the compensating filter for geometric divergence of the beam has been achieved in

9
 1.0.....---------------------,

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er
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0.5'-----'----J...--....L....--......_----l__-L__�
0 5 10 15 20 25 30 35

DISTANCE d OF ABSORBER (cm)

Figure 1.3. A plot of density ratio or thickness ratio as a function of
compensator distance of a uniformly thick compensator. 6°Co y-rays,
field size =lOxlO, SSD=80 cm, Compensation depth =7 cm, and tissue
deficit =S.O cm.
many ways. One method is to construct the compensator out of aluminium or brass

blocks, using a matrix of square columns corresponding to the irregular

13 1 5 16 1
surface< • • • 7). The dimension of each column is minified according to the geometric

divergence correction which is calculated from the SSD and the filter-surface distance.

If the thickness of a tissue equivalent compensator is equal to that of

the missing tissue, it will overcompensate .i.e., the dose to the underlying tissues will

be less than that indicated by the standard isodose chart. This decrease in depth

dose, which is due to the reduction in scatter reaching a point at depth, depends on

the distance of the compensator from the patient, field size, depth and beam quality.

To compensate for this decrease in scatter , one may reduce the thickness of the

compensator to increase the primary beam transmission. The compensator thickness

should be such that the dose at a given depth is the same whether the missing tissue

is replaced with the bolus in contact or with the compensator at the given distance from

the skin surface.

The required thickness of a tissue-equivalent compensator along a ray

divided by the missing tissue thickness along the same ray may be called the density

ratio or thickness ratio (h'/h)<20>. Thickness ratio (-r) depends in a complex way on

compensator-surface distance, thickness of missing tissue, field size, depth and beam

quality. A detailed study of this parameter has shown that -c is primarily a function of

distance of absorber(d) for d �Ocm and that its dependence on other parameters is
11
relatively less critica1 < >. Thus a fixed value of -c , based on a given d usually 20cm,
2
1Ox1 Ocm field, 7cm depth and a tissue deficit of 5cm can be used for most

compensator work. The concept of thickness ratios also reveals that a compensator

10
cannot be designed to provide absorbed dose compensation exactly at all depths. If for

a given irradiation conditions, 1 is chosen for a certain compensation depth, the

compensator overcompensates at shallower depths and undercompensates at greater

depths. Considering the limitations of the theory and too many variables affecting 1 ,

an average value of o.7 for 1 may be used for all irradiation conditions provided d 2':
11
20cm< >. In actual design of the compensator, the thickness ratio is used to calculate

the compensator thickness (tc) at a given point in the field

tc = TD.(1/pc) where TD is the tissue deficit at the point

considered and pc is the density of the compensator material. A direct evaluation of

thickness (1/pc) for a compensator system may be made by measuring dose at an

appropriate depth and field size in a tissue equivalent phantom with a slab of

compensator material placed in the beam at the position of the compensator tray.

Pieces of phantom material are removed from the surface until the dose equals that

measured in the intact phantom, without the compensator. The ratio of compensator

thickness to the tissue deficit gives the thickness ratio. Another term compensator

ratio (CR) has also been used in the literature to relate tissue deficit to the required
21
compensator thickness< >. It is defined as the ratio of the missing tissue thickness to

the compensator thickness necessary to give the dose for a particular field size and

depth. The concepts of compensator ratio and thickness ratio are the same , except

that the two quantities are inverse of each other.

1.2.3.4. Compensators for tissue heterogeneity

Compensators for tissue heterogeneity may

11
be attempted and should be achieved if possible. In a case of esophageal carcinoma,
32>
it was shown by Ellis< that compensation for tissue heterogeneity as checked by

small thermoluminescent dosimeters in the lumen reduced by 30% the dose in the

oesophagus when compared with the dose without the compensation. Large air

spaces produces appreciable change in the dosage values as in the case of lungs, it

less commonly realised that air spaces in the larynx and in the trachea can also

introduce dosage changes, particularly on the surface of a tumour, when a

megavoltage beam first traverses the air cavity. If the beam passes through the tumour

before passing through the cavity, this effect, which is due to loss of scattered

electrons, is much less.

Compensators can be designed to compensate for tissue heterogeneity

from the knowledge of cross-sectional anatomy using transaxial tomography or a

photographic film Compensators for total body irradiation including lung compensators

were described by Khan et.al < > . Compensators have also been used to improve
22

dose uniformity in the fields where non-uniformity of the dose distribution arises from

the sources other than contour irregularity such as reduced scatter near the field

edges and unacceptable high dose regions or "horns" in the beam profile.

Another method of providing compensation for tissue heterogeneity has

33>
been suugested by Ellis et.a1 < which involves two radiographs at right angles in the

position and with the beams to be used< >. Each radiograph indicates the amount of
12

matter traversed by each pencil of the beam since with suitable film, blackening is

proportional to the dose at the film. This can be plotted by a scanning densitometer.

Modifying filters for two pairs of parallel opposed fields at right angles can be

12
constructed from the densitometer data. The division of the compensation between the

fields on each parallel opposed pair is decided by inspection of full width ordinary

radiographs, from which can be estimated the proportion of the absorbing tissue on

each side of the tumour in the path of the beams. When wedge fields are being used

so as to treat from one side of the body only, the proportion of compensation can be

estimated in the same way, but it is only necessary to use the appropriate amount on

the side from which the treatment is being given.

1.2.3.5. Positioning of Compensators

A compensator must be placed at a distance of 15cm or more away from

the skin surface to preserve the skin-sparing properties of the megavoltage beams.

Because the dimensions of the compensator are reduced compared to the bolus in

the plane perpendicular to the beam axis to allow for beam divergence, the filter must

be placed at the filter-surface distance for which it is designed. In addition, the

nominal SSD should be measured from the plane perpendicular to the beam axis,

containing the most elevated point on the contour included in the field. For isocentric

treatments, it is most convenient to use field dimensions projected at the isocentre in

compensator design. Accordingly, the depth of the isocentre is measured from the

level of the most elevated point on the contour to be compensated.

1.2.4. Beam Shaping Blocks

Beam shaping blocks are used in producing irregular fields in all clinical

situations where they happened to be useful or necessary for confining the radiation to

the target volume or protecting important structures. For example, In treating some

13
orbital or sinus carcinomas and some intracranial tumours it is desirable to protect the

eye or the middle and internal ear. The protection achieved by removing part of the

primary beam, also diminishes the amount of scattered radiation and thus affects the

dose distribution in other parts of the beam. The beam shaping is primarily dictated by

tumour distribution i.e., Local extension and regional metastases. Not only should the

dose to vital organs not exceed their tolerance, but the dose to the normal tissue, in

general, should be minimised . As long as the target volume includes, with adequate

margins, the demonstrated tumour as well as its presumed occult spread, significant

irradiation of the normal tissue outside this volume must be avoided as much as

possible.

1.2.4.1. Thickness of blocks

Usually high Z materials such as lead or lipowitz are used for shielding.

The thickness of the material required to provide adequate protection of the shielded

areas depends on the required transmission through the blocks and the beam quality

of the radiation under question. A primary beam transmission of 5% through the block

is considered acceptable for most clinical situations. To obtain this transmission ratio,

the number (n) of half value layers (HVL) needed is

(%)" = 0.05

2" = 1/0.05

= 20

n log2 = log20

n = log20/ log2

14
Table 1.1
Recommended Minimum Thickness of Lead for Shielding.
Beam Quality Required Lead Thickness
1.0mm Al HVL 0.2mm
2.0mm Al HVL 0.3mm
3.0mm Al HVL 0.4mm
1.0mm Cu HVL 1.0mm
3.0mm Cu HVL 2.0mm
4.0mm Cu HVL 2.5mm
1a1cs
soco 3.0 cm
5.0 cm
4MV 6.0 cm
6MV 6.5 cm
10MV 7.0 cm
25MV 7.0 cm
* Approximate values to give s5% primary transmission .
 = 4.32

Thus a material thickness below 5 HVL is adequate for primary

11
transmission less than 5% and is recommended for most of the clinical situations< l .

Shielding for superficial and orthovoltage beams can be readily achieved by thin

sheets of lead where as for megavoltage beams the thickness of lead increases

substantially. The blocks are placed above a transparent acrylic tray called shadow

tray. The recommended values of shielding thickness of lead for various energy
11>
beams< are given in Table 1.1.

The primary transmission of the blocks can be reduced further by increasing

the thickness of the block. But the dose to the shielded area may not be significantly

reduced due to the presence of scattered radiations from the adjoining open areas of

the field. Ideally, the beam shaping blocks used should be tapered to match the

geometric divergence of the beam. This minimises the block transmission penumbra.

However, divergent blocks offer little advantage for beams with large geometric

penumbra. Hence, for cobalt-60 beams, the sharpness of the beam cut off at the beam

edge is not significantly improved by using divergent blocks. Divergent blocks are

most suited for beams having small focal spots.

1.3. ASYMMETRIC COLLIMATORS

A part of the radiation fileld is sometimes shielded asmmetrically with

respect to ioscentre without changing the position of the isocentre by using

asymmetric collimators. The asymmetric collimators have idependently movable jaws.

Some machines have one independent jaw, some others have two independent jaws,

15
and some have all four jaws as independent. The independent jaw option is

interlocked to avoid errors in the setting of symmetric fields, in which case the

opposite jaws open or close symmetrically. One of the effects of asymmetric

collimation is the change in the physical penumbra and the tilt of the isodose curves

toward the blocked edge. This effect is simply the result of blocking which eliminates

the photon and electron scatter from the blocked portion of the field, thereby

reducing the dose near the edge. The same effect would occur on the isodose

curves if the blocking were done with a lead or lipowitz block on a tray. When

asymmetric fields are used, special considerations must be given to the beam flatness

and the dosimetric parameters used to calculate monitor units<

23>
_

1.4. MULTILEAF COLLIMATORS

A multileaf collimator (MLC) for photon beams has multiple vanes

with more than 40 pairs of collimating blocks or leaves that can be driven

automatically, independent of each other. The MLCs can create any shape by jagged

stepwise boundary of leaves to conform to any non-geometrical shape of the tumour or

treatment volume. The thickness of the leaves along the beam direction is sufficient to

provide acceptably low beam transmission. The width of each leaf is usually about 1

cm as projected at the isocentre. The field edges are therefore formed stepwise, 1

cm wide. The double-focussed MLC systems provide sharp beam cut off at the edge.

The use of MLCs for the stationary fields is the conformity between the planned field

boundary, which is continuous, and the jagged stepwise boundary created by the

MLC. The degree of conformity between the two depends not only on the projected

16
leaf width but also on the shape of the target volume and the angle of rotation of the
and 36
>. The MLC system is used in place of custom made cerrobend
collimator<34 ,35

blocking, automatic beam shaping for multiple fields, dynamic conformal radiotherapy

for which beams are shaped as they are rotated and modifying dose distributions

within the field by computer controlled dwell time of the individual leaves.

Recent studies have demonstrated that three dimensional MLC

conformal radiation therapy allows an increase in the dose to the target volumes than

with conventional radiotherapy. The improved accuracy of tumour coverage and the

increase in tumour dose are expected to improve local tumour control. This reduces

the normal tissue complications as well. Studies by Zvi Fuks et. <10> al showed that

patients with carcinoma of prostate and nasopharynx demonstrated an excellent acute

tolerance for a dose of 81 Gy for the prostate and 75.6 Gy for nasopharynx

respectively.

1.5. DYNAMIC WEDGES

The concept of the dynamic wedge was originally proposed by

2
Kijewski et. a1 < 5) who postulated that a computer connected to a linear accelerator

could be used to step a collimator jaw across the intended treatment field while

radiation treatment was in progress, creating a wedge shaped beam profile. Until very

recently, when computer controlled consoles were introduced to control linear

accelerator collimator jaws, dynamic wedge capabilities were not available. Leavitt et.
25 2
al. < • 7l successfully implemented a dynamic wedge for Varian accelerators. One

difficulty in the clinical implementation of the Varian dynamic wedge is the strong

17
 25 29 30
variation of its output factor with field size< • • > as well as discontinuity in this

variation.

The output factor is defined as the ratio of output measured for a rectangular

collimator setting, Cx X Cy, to that for Cx = Cy = 10 cm. Sets of lower and upper

collimator jaws are represented by x and y respectively. The dynamic wedge, as it is

implemented in a Varian accelerator, uses Segmented Teatment Tables (STis) to

control dose rate and jaw movement. Each STI contains information on subsequent

jaw position versus cumulative weighting of a monitor unit. A total of 132 STis were

created for the four wedge angles, 15° ,30° ,45° and 60° ; including 33 different STis for

each wedge angle for field sizes, y, from 4 to 20 cm.

In principle, the STI allows the determination of all dosimetry

characteristics of the dynamic wedge if the basic dosimetric parameters for open fields

are explicitly known. Any changes in STis will change the output factor of the dynamic

wedge. Since there are so many STis for each wedge angle, it is desirable to

calculate the output factor for the dynamic wedge from the STis directly. Waldron et.
29>
a1·< have shown that the wedge factor in water for the Varian dynamic wedge can be

calculated simply by noting the percentage of accumulated monitor units (MU)

25
delivered up to the central axis with the moving collimator jaw. Bidmead et. a1·( > have

characterised the field size dependence of dynamic wedge factors by experimentally

24>
measuring the output for each STI. Liu et. a1( characterised the behaviour of the

output factor for a dynamic wedge and introduced a normalisation factor which

simplifies the output calculations for the Varian dynamic wedge. The amount of data

required to commission dynamic wedges and quality assurance issues has

18
discouraged institutions from clinically implementing this modality.

1.6. CONCLUSION

Beam modification is an integral part of present day radiation therapy

without which in most tumours under varying bogy contour a uniform dose distribution

cannot be achieved. The subject of beam modification is a vast one and at all

energies involves a great deal of insight into physical processes. The primary aim of

beam modification should be such that throughout the target volume, the tolerance of

normal tissues within that volume should not be exceeded except with serious

consideration of the possible consequences. Within the tumour volume the given dose

should be as high as is possible compatible with clinical requirements and technical

feasibility.

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References

1. Chester AE and Meredith WJ. The design of filters to produce "flat" x-ray

isodose curves at a given depth. British Journal of Radiology, 18:382 (1945).

2. LAW.Kemp and R.Oliver, British Journal of Radiology,25:500(1952)

3. Ellis F, and Miller H. The use of wedge filters in deep x-ray therapy. British

Journal of Radiology 17:904 (1944).

4. Nordic Association of Clinical Physics.Procedures in external beam radiation

therapy dosimetry with electron and photon beams with maximum energies

between 1 and 50 MeV.Acta Radiology Oncology,19:58(1980)

5. International Commission on Radiation Units and Measurements (ICRU):

Radiation dosimetry:electron beams with energies between 1 and 50

MeV.ReportNo.35.Bethesda,MD.(1984).

6. Almond PR Characteristics of current medical electron accelerator

beams.ln:Chu F (editor). Proceedings of the symposium on electron beam

therapy. Newyork: Memorial Sloan Kettering Cancer Centre,43(1979)

7. Khan FM, Doppke K,Hogstrom KR et alClinical electron beam dosimetry.

Report of American Association of Physicists in Medicine(AAPM) Radiation

Therapy Committee Task Group No.25, Medical Physics18:73(1991 ).

8. Werner Bl, Khan FM, Deibel FC . Model for calculating depth dose distributions

for broad electron beam, Medical Physics 10:582(1983)

9. International Commission on Radiation Units and Measurements (ICRU):

20
 Determination of absorbed dose in a patient irradiated by beams of x or gamma

rays in radiotherapy procedures.Report No.24, Washington, DC:National

Bureau of Standards, (1976).

1O. Fuks Z, Leibel SA. Preliminary results of dose escalation studies using 30

conformal radiotherapy.Proceeinds of lnternation Radiation Oncology

Congress(ICRO): 177:1993.

11. Khan FM. The Physics of radiation Therapy (second edition). Published by

Williams & Wilkins, Baltimore, Maryland(1994).

12. Norman M.Bleehen, Eli Glatstein, John L. Haybittle(Editors). Radiation therapy

planning.Published by Marcel Dekker,lnc, Newyork(1983)

13. Ellis F, Hall EJ, Oliver R. A compensator for variations in tissue thickness for

high energy beam. British Journal of Radiology,32:421(1959)

14. Cohen M, Burns JE, Sear R. Physical aspects of cobalt 60 teletherapy using

wedge filters II. Dosimetric considerations. Acta Radiology ,53:486(1960).

15. Hall EJ, Oliver R. The use of standard isodose distributions with high energy

radiation beams - the accuracy of a compensator technique in correcting for

body contours. British Journal of Radiology,34:43(1961).

16. Sundblom I. Individually designed filters in cobalt-60 teletherapy . Acta Radial

Therapy Physics Boilogy ,2:189(1964).

17. Van De Geijn J . The construction of individualised intensity modifying filters in

cobalt 60 teletherapy. British journal of Radiology,38:865(1965).

18. Khan Fm, Moore VC, Burns DJ. The construction of compensators for cobalt

teletherapy. Radiology, 96:187(1970).

21
19. Sewchand W, Bautro N, Scott RM. Basic data of tissue equivalent

compensators for 4MV X-rays. International journal of Radiation Oncology

Biology Physics,6:327(1980).

20. Mackie TR, Scrimger JW, Battista JJ. A convolution method of calculating dose

for 15MV X-rays. Medical Physics,12:188(1985).

21. Henderson SD, Purdy JA, Gerber RL, Mestman SJ . Dosimetriy considerations

for a Lipowitz metal tissue compensator system. International Journal of

Radiation Oncology Biology Physics, 13:1107 (1987).

22. Khan FM, Williamson JF, Sewchand W, Kim TH. Basic data for dosage

calculation and compensation. International Journal of Radiation Oncology

Biology Physics, 6:745 (1980).

23. Khan FM, Gerbi BJ, Deibel FC. Dosimetry of asymetric x-ray collimators.

Medical Physics,13:936 (1986).

24. Liu C, Zhu TC and Palta JR. Characterising output for dynamic wedges.

Medical Physics,23:1213 (1996).

25. Kijewski PK, Chin Lm and Bjarngard BE. Wedge Shaped dose distributions by

computer-controlled collimator motion. Medical Physics, 5:426 (1978).

26. Leavitt DD, Martin M, Moeller JH and Lee WL. Dynamic wedge field

techniques through computer- controlled collimator motion. Medical Physics,

17:87 (1990).

27. Leavitt DD. Dynamic beam shaping. Medical Dosimetry, 15:47-50 (1990).

28. Bidmead AM, Garton AJ and Childs PJ. Beam data measurements for dynamic

wedges on Varian 600C (6 MV) and 21OOC (6 and 10 MV) linear accelerators.

22
 Physics in Medicine and Biology, 40:393 (1995).

29. Waldron TJ, Boyer AL, Wells NH and Otte VA. Calculation of dynamically -

wedged isodose distributions from segmented treatment tables and open fiekl

measurements. Medical Physics, 21:873 (1994).

30. Klein EE, Low DL, Meigooni AS and Pudy JA Dosimetry and clinical

implementation for dynamic wedge. International Journal of Radiation

Oncology, Biology, Physics, 31:583 (1995).

31. National Council on Radiation Protection and Measurements (NCRP):

Dosimetry of x-ray and gamma ray beams for radiation therapy in the energy

range of 10 keV to 50 MeV. Report No.69, Bethesda, MD (1981)

32. Ellis F, Feldman A and Oliver R. British Journal of Radiology, 37:442 (1964).

33. Ellis F and Lescrenier C. Combined compensation for contours and

heterogeneity, Radilogy: 106:191-194 (1973).

34. Heijmen BJM, Dirkx MLP and van Santvoort JPC. Calculation of leaf

trajectories for dynamic multileaf collimation to realise optimosed intensity

modulated beam profiles. Proceedings of World congress on Medical Physics

and Biomedical Engineering, Nice, France:918 (1997).

35. Jordan TJ and Williams PC. The design characteristics of a multileaf

collimator. Physics in Medicine and Biology, 39:239-251 (1994).

36. Huq MS, Yu Y, Chen ZP and Suntharalingam N. Dosimetric characteristics of a

commercial multileaf collimator. Medical Physics, 22:241-247 (1995)..

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