Technology in Cancer

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Surface Dose for Five Telecobalt Machines, 6MV Photon Beam from Four Linear Accelerators and a Hi-Art
TomoTherapy
Rajesh A. Kinhikar
Technol Cancer Res Treat 2008 7: 381
DOI: 10.1177/153303460800700505
The online version of this article can be found at:
http://tct.sagepub.com/content/7/5/381

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Technology in Cancer Research and Treatment

ISSN 1533-0346
Volume 7, Number 5, October 2008
Adenine Press (2008)

Short Communication

Surface Dose for Five Telecobalt Machines,

6MV Photon Beam From Four Linear
Accelerators and a Hi-Art TomoTherapy
www.tcrt.org
The purpose of this study was to estimate the surface dose for five telecobalt machines
(four from Best Theratronics Limited, Canada, one from Panacea Medical Technologies,
India), 6 MV photon beam (static) from four linear accelerators (three Varian linear accelerators and one Siemens) and Hi-Art Tomotherapy unit. The surface dose was measured
with Thermoluminescent dosimeters in phantom slabs. For Tomotherapy 6 MV beam the
surface dose was estimated as 32% while it was 35%, 33%, and 36% for Clinac 6EX, Clinac
2100CD, and Clinac 2100C linear accelerators, respectively. Similarly, the surface dose for
6 MV photon beam from Primus linear accelerator was estimated as 35%. Surface doses
from telecobalt machines Equinox-80, Elite-80, Th-780C, Th-780, and Bhabhatron-II was
found to be 30%, 29.1%, 27.8%, 29.3%, and 29.9% for 10 cm 10 field size, respectively.
Measured surface dose from all four linear accelerators were in good agreement with that of
the Tomotherapy. The surface dose measurements were useful for Tomotherapy to predict
the superficial dose during helical IMRT treatments.

Rajesh A. Kinhikar, M.Sc.

Medical Physicist

Department of Medical Physics

Tata Memorial Hospital
Parel, Mumbai 400012
India

Key words: Surface dose; Tomotherapy; Linear accelerators; Telecobalt; Thermoluminescent dosimeters.

Introduction
Surface dose from a photon beam during radiotherapy (RT) treatments cannot
be ignored and does contribute to the major extent. The surface dose results
from the scatter from the machine head as well as the patients. The machine
head design, internal components, and the treatment geometry play an important
role in contributing the surface dose to the patient. The effect of surface dose
from different clinical setups is discussed elsewhere (1). The surface dose from
IMRT has also been reported (2). The superficial dose for the patients treated
with Tomotherapy has been studied (3).
The TomoTherapy system is a relatively new RT treatment modality, which has
come into use in the treatment of various malignant lesions. This system offers
a unique way of delivering intensity modulated radiation therapy (IMRT) as
well as having the benefit of image-guided radiation therapy (IGRT). The TomoTherapy unit consists of a linear accelerator (linac) mounted onto a computed
tomography (CT) ring gantry. The details about the design and the characteristics of Tomotherapy have been discussed (4-5).
Recently Hi Art II Tomotherapy machine (Tomotherapy Inc, Madison, WI), first
in India, was installed at Advanced Centre for Treatment Research and Education

Corresponding Author:
Rajesh A. Kinhikar, M. Sc.,
Email: rkinhikar@rediffmail.com

381
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382

Kinhikar

Gantry Angle 0
Zt
Yt
Xt
Figure 2: Picture of a TLD packet (LiF powder enclosed in a polyethylene
pouch) used in measurements.

Figure 1: Picture of the TomoTherapy unit with the IEC table coordinates
and gantry angle 0 defined.

in Cancer (ACTREC) in July 2007. The machine was clinically commissioned in December 2007 with 6 MV photon
beam. A picture of the TomoTherapy unit along with the
International Electrotechnical Commission (IEC) table (Xt,
Yt, Zt) coordinate system is shown in Figure 1.
TomoTherapy is currently being used primarily to treat a variety of deep-seated tumors. As the TomoTherapy system does
not have an electron beam modality, as do traditional linacs,
it is important to know TomoTherapys ability and potential
for treating superficial diseases, which are often treated with

electron beams. If helical TomoTherapy is to be used as a

superficial treatment, it is essential that the dose to the surface must be estimated. Therefore, it was decided to estimate
the surface dose from a static TomoTherapy beam (i.e., the
gantry and table are stationary). Thus, this work concentrates
on measuring the surface dose from a static TomoTherapy
beam at normal incidence. In addition, the goal was to compare this surface dose to 6 MV photon beam from the linac.
Further measurements were extended to the surface dose estimation for telecobalt machines as well. Thermoluminescent
dosimeters (TLD) were used to measure the surface dose.
Methods and Materials
Several pieces of phantom material were used to create
depth for the measurements. Both Plastic Water and Stan120

Tomotherapy
Clinac6EX

100

Clinac2100CD

Percentage CADD

Clinac2100C

80

Primus

60

40

20

Figure 3: The setup used for measurement of surface dose with virtual
water slabs in Tomotherapy.

10

Depth (cm)

15

20

25

Figure 4: The comparison of the normalized CADD values for Tomotherapy

and four linear accelerators. The CADD values were normalized to the reference depth of 1.5 cm for linac while it was normalized at 1.1 cm for Tomotherapy. The results depicted a good agreement among the five machines.

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Surface Dose from Tomotherapy, Linear Accelerator for 6MV Photons and Telecobalt 383
dard Imaging Virtual Water slab phantoms were used. The
Plastic Water slab phantoms used were 30 cm 30 cm and
ranged from 0.1 to 0.5 cm in thickness with the density of
this material to be 1.014 gcm3 1.1%. The Virtual Water
slab phantoms used were 55 cm 15 cm and were ranged
from 1 to 5 cm thick. The manufacturer states that the density of this material is 1.03 g/cm3. They also quote the error
in thickness to be 0.15 mm.
Prior to each irradiation, TLD-100 (LiF:Mg,Ti) powder (The
Harshaw Chemical Co. Solon, Ohio, USA) was annealed using a thermal cycle: 400 C (5) for 1h-cooling for 5 min
-100C for 2 h in a Programmable Muffle Furnace (Model-126, Fisher Scientific Co. Pittsburgh, PA, USA) and then
cooled to normal room temperature. For annealing, the TL
powder was placed inside a glass petty dish with cover. Rexon UL-320 TLD Reader (TLD systems Inc. USA) was used
to record TL output at maximum acquisition temperature of
280 C using constant heating rate of 14 C/sec.
For measurements using TLD, about 40 mg of the freshly
annealed TLD-100 powder was packed in square polyethylene pouch (1cm 1cm) as shown in Figure 2. This
TL pouch was placed in the phantom at dmax along the
central axis of the beam and was irradiated for 100 MUs.
The TL output of about 10 mg powders was recorded using Rexon TLD reader and this way four readings were
obtained from each TL pouch. The mean value of net TL
output per unit weight (nC/mg) of these four readings was
used for calculation. The uncertainty in TLD-100 powder
measurements was 2%.
Constant time gap of 24h was maintained between irradiation and read out. Dose response curve for the TLD-100
powder was generated in 60Co gamma ray beam (Equinox
80, MDS Nordion, Canada) and was found linear in the range
of 0.5-4.0 Gy. One packet was not irradiated to determine
the background signal.
For surface dose measurements with Tomotherapy, the TLDs
were placed at various depths (ranging from surface to 20
cm) in virtual water slabs for a field size of 5 cm 40 cm at
source to surface distance (SSD) 85 cm. This setup (Figure
3) helped us to measure the central axis depth dose (CADD).
The phantom and TLDs were placed on the TomoTherapy
couch so that the TLD was at the virtual isocenter position
(70 cm from the axis of rotation, in the -Y direction). The
fixed position green lasers are used to setup this position.
Dose was measured on the central axis for static and normally incident TomoTherapy beams. The delivery system
was operated in physics mode, which allows beams to be
delivered while the gantry and table are stationary. The procedure with all central multileaf collimator (MLC) leaves
open for 10 seconds was used to irradiate the TLDs.

Subsequently, the surface dose measurements were also

carried for four linear accelerators. Clinac 6EX, Clinac
2100CD, and Clinac 2100C (Varian Medical Systems, Palo
Alto, USA) were used for these measurements. The TLDs
were placed in plastic water slabs at the above mentioned
depths for 10 cm 10 cm field size at SSD 100 cm for 6
MV photon beam. TLDS were also irradiated for Primus
(Siemens Medical Systems, Concord, USA) for same field
size. The irradiation was performed for 100 monitor units
(MU). Phantom material (7 cm) was placed beneath the
TLDs to serve as backscatter material.
Further, surface dose was measured for five telecobalt machines. Equinox-80, Elite-80, Th-780C, Th-780 (Best Theratronics Ltd., Ottawa, Canada), and Bhabhatron-II (Panacea
Medical Technologies Pvt. Ltd., Bangalore, India) were used
for this measurement. The surface dose was measured for 10
cm 10 cm field size at SSD 80 cm in plastic water slabs.
TLDs were placed at the surface and at 5 mm depth in plastic
water slabs with 7 cm backscatter.
The un-normalized percentage CADD curves were plotted
against the depth and the depth of dose maximum (Dmax)
was estimated for each machine. The values were then normalized to Dmax and the normalized CADD values were
recorded for individual machine. The surface dose was estimated from these data. The ratio of ionization at 20 cm to
10 cm was also estimated.
Results
The Dmax of 1.1 cm was obtained for 6 MV beam from Tomotherapy while the Dmax for Clinac 6EX, Clinac 2100CD,
and Clinac 2100C was found to be 1.42, 1.5, and 1.5 cm, respectively. Similarly, the Dmax for Primus linear accelerator
was obtained as 1.5 cm as well.
Figure 4 shows the comparison of the normalized CADD
values for Tomotherapy and four linear accelerators. The
CADD values were normalized to the reference depth of
1.5 cm for linac while it was normalized at 1.1 cm for Tomotherapy. The results depicted a good agreement among
the five machines.
For Tomotherapy 6 MV beam the surface dose was estimated as 32% while it was 35%, 33%, and 36% for Clinac
6EX, Clinac 2100CD, and Clinac 2100C linear accelerators,
respectively. Similarly, the surface dose for 6 MV beams
from Primus linear accelerator was estimated as 35%. Surface doses from telecobalt machines Equinox-80, Elite-80,
Th-780C, Th-780, and Bhabhatron-II was found to be 30%,
29.1%, 27.8%, 29.3%, and 29.9%, respectively. Thus, measured surface doses from linear accelerator, tomotherapy, and
telecobalt showed comparable results.

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384

Kinhikar

The ratio of ionization at 20 cm to 10 cm (D20/D10) was

calculated and found to be 0.52, 0.55, 0.55, 0.53, and 0.54 for
Tomotherapy, Clinac 6EX, Clinac 2100CD, Clinac 2100C,
and Primus linear accelerator, respectively.
Discussion
This study deals with the surface dose estimation from five
teletherapy machine including the unconventional treatment
modality like Tomotherapy. The surface doses were also
measured for telecobalt machines as well. Since the SSD
from telecobalt machine (80 cm) is nearly close to Tomotherapy (85 cm), it was necessary to measure the surface dose
and compare each other. The surface dose is usually measured with the parallel plate ion chamber. The ion chamber
has the limitation the electrode separation that results in uncertainties in estimating the accurate surface dose and, hence,
the utility of TLD become more prominent.
Dose to the skin surface in a normally incident megavoltage photon beam is the sum of two components. The first
component is electrons created from photon interactions in
the patient. Most of these electrons are scattered in a forward direction because they are created from primary photons traveling in a forward direction. However, some of
these electrons may side scatter or back scatter to the surface. The second component of surface dose is electrons
created from photon interactions prior to the patient. These
electrons are created somewhere in the treatment head or
the air column above the patient. They deposit their energy
at the surface and superficial depths. These electrons are
called contaminant electrons.
The main sources of contaminant electrons are the flattening
filter and the air below it. The air produces electrons of low
energies, of which the mean of the energy spectra vary from
1 to 2 MeV, depending on the nominal energy of the photon
beam. The flattening filter produces a wide energy spectrum
of electrons similar to the bremsstrahlung spectrum. At 6
MV, however, the air below the accelerator generates the majority of contaminant electrons.
TomoTherapy is unique in the design of its beam filtration
system in the treatment head. Conventional accelerators
have a flattening filter downstream of the target. The filter
is used to produce a uniform photon beam at a depth of 10
cm. TomoTherapys treatment head does not have a flattening filter. The unit does have a set of uniform thickness
filters that provide electronic buildup to the monitor chambers (which monitor the output of the machine) and filter
low-energy photons from the beam.
The dose measured in each TLD packet represents an average
of the doses deposited within the volume of powder. Since

the powder was not arranged in a monolayer within the packet, the measurement represents an average of doses obtained
at different depths within the packet. Assuming the depth
dose varied linearly through the packet, the measurement represents the dose at an average depth. The surface dose might
be relatively more for Tomotherapy beam compared to linac.
The reason may be due to the absence of flattening filter and
the short treatment distance. The nominal treatment distance
(NTD) for linear accelerators and tomotherapy is 100 cm
and 85 cm, respectively. The shorter NTD may relatively
increase the surface dose compared to the longer NTD from
linear accelerators. Hence, it was necessary to take this study
to quantify the surface dose from the tomotherapy unit. Being the first installation in India, this data would be useful
for the future installations of tomothearpy in India. Since
the maximum field size with Tomotherapy is 5 cm 40 cm
and, hence, the contribution of the surface dose is not likely
to increase further. Moreover, the helical treatment delivery
restricts the secondary scatter reaching to the patient.
The surface dose measured for all three Varian linacs was
comparable with that of Siemens linac. The ratio of D20/
D10 was also estimated for five machines and the results are
comparable. Similarly, the surface doses from all the telecobalt machines were comparable. TLD was very useful as
a reliable dosimeter for surface dose estimation. Strict handling procedures of TLD were followed in the institution.
Conclusion
The results for the surface dose estimation for Tomotherapy
were satisfactory and acceptable. Moreover the results were
in good agreement with the surface dose measurements carried out for 6 MV photon beam from four linear accelerators
and telecobalt machines from different vendors. The surface
dose measurements were useful for Tomotherapy to predict
the superficial dose during helical IMRT treatment.
Acknowledgement
Conflict of Interest: Nil. Source of Funding: Nil
References
1. Kim, S., Liu, C. R., Zhu, T. C., Palta, J. R. Photon beam skin dose
analyses for different clinical setups. Med Phys 25, 860-866 (1998).
2. Mitchell, M. J., Ramsey, C. Surface dose measurements for Intensity
Modulated Radiation Therapy. Med Phys 33, 2249-2250 (2006).
3. Mutic, S., Low, D. A. Superficial doses from serial tomotherapy delivery. Med Phys 27, 163-165 (2000).
4. Mackie, T. R., Olivera, G. H., Kapatoes, J. M., Ruchala, K. J., Balog,
J. P., Tome, W. A., et al. Helical TomoTherapy Intensity-Modulated
Radiation Therapy: The State of the Art. 2003 AAPM Summer School
Proceedings, Medical Physics Publishing: Madison, WI.
5. Jeraj, R., Mackie, T. R., Balog, J., Olivera, G., Pearson, D., Kapatoes,
J., Ruchala, K., Reckwerdt, P. Radiation characteristics of helical tomotherapy. Med Phys 31, 396-403 (2004).

Technology in Cancer Research & Treatment, Volume 7, Number 5, October 2008

Received: May 8, 2008; Revised: August 14, 2008;

Accepted: August 22, 2008

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