Tsai Kevin Tsai February 16, 2013 DOS 422/522: Dose Calculations Attenuation Project

Objective: The goal of this project is to measure and calculate the wedge transmission factor for a 30-degree physical wedge (Figure 1). Wedges, usually made out of lead or steel, are placed in the path of the radiation beam to change the isodose distribution and decrease the intensity of the beam. The wedge tray to the skin surface is usually at a distance of 15 centimeters (cm) to keep skin-sparing effect in megavoltage (MV) treatments.1 This will result in a tilt of the isodose curve towards the thin end of the wedge also known as the toe. The degree of the tilt depends on the slope of the wedge filter.1 Using a 30-degree wedge angle refers to the angle that the isodose curve is tilted at the central axis of the beam at a specific depth, not the angle of the actual wedge (Figure 2).2

Figure 1: 30-degree physical wedge mounted to the gantry.

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Figure 2. Isodose tilted at CAX for a 30, 45, and 60-degree wedge. Purpose: The purpose of this activity is to test the attenuation of the beam when it passes through a 30-degree physical wedge. Anything that can attenuate the radiation beam should be added into the dose calculations to account for the correction. Wedges are definitely one of those attenuators and should be accounted for. The thinner part of the wedge is known as the toe and attenuates the beam less than the thicker side known as the heel of the wedge.2 After testing the attenuation of a 30-degree wedge, I will use the wedge transmission factor in a dose calculation and see the difference when using a wedge factor. I will also use the Eclipse treatment planning system to test the effects of a 30-degree wedge on a breast patient. The treatment plan will show us the isodose levels with and without a wedge. The human body is not homogenous or flat so wedges are used to help shape the body. Methods and Materials: The test will be performed on a Varian 21 EX Linear Accelerator. The 2D ionization chamber array used to collect the data is called IBA Matrixx. The dose will be tested at a depth of 10 cm therefore 10 cm of water equivalent blocks are placed on top of the ionization chamber (Figure 3). There are 1020 ionization chambers inside the IBA Matrixx at a

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depth of 0.4 cm. When converting the 0.4 cm depth to water equivalent, it comes out to 0.32 cm; therefore, the total depth actually delivered to the ionization chamber is 10.32 cm (Figure 4). Using an energy of 6 MV and 400 dose rate, 100 monitor units (MU) was delivered to 100 cm source to axis distance (SAD) at a field size of 10x10 cm (Figure 5). First, the dose was delivered to the ion chamber at central axis (CAX) with an open 10 x 10 cm field to a depth of 10.32 cm. Then the 30-degree physical wedge was inserted into the beam to test the attenuation also at the CAX. The software OmniPro ImRT will read the data received and show us how much dose between the open and wedge fields.

Figure 3: IBA Matrixx ion chamber with 10 cm of water equivalent blocks.

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Figure 4: Depth of Ion Chamber is 0.4 cm but 0.32 cm water equivalent

Figure 5: Settings

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Results: The dose is delivered to the CAX and collected by the ionization chamber. In this case, there is no ionization chamber exactly at the CAX so the data will be taken from the 4 closest ionization chambers and averaged. The dose measured at the CAX at a 10.32 cm depth is approximately 83 centigray (cGy) for the open field. In figure 6, you can see that the dose is delivered symmetrically across the field. The dose profile in figure 7 shows that most of the field is receiving approximately 83 cGy. The dose received at the CAX with the 30-degree wedge averaged out to 46.1 cGy. In figure 8, you can clearly see that the toe side of the wedge attenuates the beam less and that the heel side attenuates the beam much more. The dose profile in figure 9 also shows less dose is delivered to the heel than the toe side of the wedge. Table 1 shows the dose measured with and without the 30-degree wedge and the wedge transmission factor of the 30-degree physical wedge. To calculate the wedge factor (WF), the equation is WF= dose with wedge/ dose without wedge. Table 1. Dose with and without wedge Energy Depth Field Size Dose without Dose with 30 30-degree Physical Wedge Transmission Factor 6 MV 10.32 cm 10 x 10 cm 83 cGy 46.1 cGy 46.1 / 83 = 0.56

Wedge @ CAX Wedge @ CAX

Figure 6: Dose distribution of a 10x10 open field.

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Figure 7: Dose Profile of a 10x10 open field.

Figure 8: Isodose distribution of 30-degree wedge.

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Figure 9: Dose profile of a 30-degree wedge. Discussion: The 30-degree physical wedge attenuates the beam 44% of the beam allowing 56% to get through the wedge. The presence of a wedge filter decreases the output of the machine, which must be taken into account in treatment calculation.1 When doing a dose calculation for a wedge filter, a wedge transmission factor must be included. The wedge transmission factor is the ratio of the dose rates on the central axis with and without the wedge.2 Clinical Application: Physical wedges are used to produce the desired isodose distribution to the target. One of the most common areas treated that almost always uses a wedge are breast treatments. The breast has slopes and curves that make covering the whole breast difficult. To see how important wedges are in breast treatments, I created a treatment plan with and without a 30-degree wedge. The breast fields include a left medial and left lateral field. The prescribed dose will be 4680 cGy @ 180 cGy per fraction for 26 fractions. The breast is much thicker towards the chest wall and is thinner towards the anterior surface. In the treatment plan I created without the wedge, there was a hot spot of 113.8% near the anterior surface of the breast (Figure 10). Treating with this plan can cause redness and pain to the breast patients. To fix the problem, I entered a 30-degree wedge to the lateral field with the heel portion of the wedge to the thinner part of the breast. The thicker side of the wedge will attenuate the radiation beam more so that less dose will be delivered to the anterior surface of the breast (Figure 11). As you can see in

Tsai the treatment plan in Figure 11, the wedge has significantly reduced the dose to the anterior surface of the breast. This is one of the main reasons why wedges are used in breast treatments.

Figure 10: Breast treatment without wedge

Figure 11: Breast treatment with Lateral 30-degree wedge.

Tsai MU Calculation: Since the 30-degree wedge is only added to the lateral field, the MU calculation below will show the difference in MU between the lateral field with and without a 30-degree wedge.

Tsai 10 Conclusion: The goal of radiation therapy is to treat a target to the desired dose while minimizing the dose delivered to normal tissue. If every patient had a flat surface the isodose distributions would be perfect. Therefore, wedges are used in radiation therapy to change the angle of the isodose curve to match the patients shape. The results from the test show that 44% of the beam is attenuated from the wedge. If the radiation therapist forgets to insert the physical wedge during patient treatment, the patient can receive up to 44% more dose. When a wedge is inserted into the beam, then it needs to be accounted for in the dose calculation. This project has really helped me understand the effects of a wedge and how to apply it in treatment planning. Even though physical wedge are not used as much as before because of the emergence of enhanced dynamic wedges (EDW), it was still helpful to learn the effects of attenuators.

Tsai 11 References 1. Khan FM. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010. 2. Bentel GC. Radiation Therapy Planning. 2nd ed. Bogota, Colombia: McGraw-Hill; 1996.

Special Thanks to Kang the Medical Physicist for helping me on this project.