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Glenda Longoria
Spring 2016

15 Wedge Transmission Factor Calculation

Objective: The purpose of this study is to determine the transmission factor of a 15 physical
wedge and be able to understand and explain the effect it has on monitor units (MU) when
incorporated or omitted from radiation therapy planning.
Purpose:

Treatment delivery in radiation oncology consists of several different treatment

techniques along with a wide array of medical equipment and accessories involved in the
process. Physical wedges are still commonly used in radiation therapy and it must be noted that
they have a considerable impact on treatment planning as they absorb a significant amount of
radiation from the beam.1 In turn, they also yield a steady reduction of intensity across the
radiation path, a quality that has proven to be very beneficial for treatment planning.2 The
degree of shift in the isodose curves caused by wedges corresponds directly to the wedge angle
used. The most common physical wedges still found in radiation oncology departments are the
15, 30, 45, and the 60 wedges, with four different orientations available for each wedge (in,
out, right, left).3
The use of wedges in radiation therapy is important to understand because when used properly,
wedges compensate for sloped surfaces on a patients body and change the dose distribution as
the radiation enters the body.3 This allows the radiation to better conform to the patients
anatomy, an important factor when producing a viable treatment plan.
In order to find out how each wedge modifies the radiation beam as it passes through the given
wedge, precise measurements must be made by the medical physicist to ensure that all
information gathered is correct before incorporating the wedge factor into algorithms for
treatment planning. These measurements produced by the physics team are then integrated into
the treatment planning system (TPS) for computational use.
Methods and Materials: The data gathered for this study was performed on a Varian Trilogy
linear accelerator and the medical physicist on staff, Di Chen, Ph.D., performed the study. We
used a 6 megavoltage (MV) photon beam, a 10 x 10 cm field size, a CNMC electrometer, a
farmer-type ion chamber connected to the electrometer, and build up material in the form of solid
water plates. Also to be noted, the gantry, collimator and table were all set to 0.

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Spring 2016

First, the solid water was placed on the treatment table, where the physicist made sure there was
at least 20 cm build-down material under the ion chamber, and then he centered solid water to
the 10 x 10 field size which was set at 100 SSD. The two plates at the top of the set up measured
2.5 cm thickness when measured together. The top plate of solid water measured 0.5 cm
thickness and the second plate was a 2 cm thick plate with the ion chamber to be placed in a
fitted opening located in the center of the plate. The ion chamber was placed in the small
opening and pushed through the solid water until it reached the central axis for proper
measurements. The cable from the ion chamber was secured to the solid water material with
tape so that it would not move during the readings. Ultimately, the depth of the ion chamber was
set at 1.5 cm, or depth of maximum dose (dmax), and was placed at the central axis of the beam.
Image 1 demonstrates the set-up used for this study.
Image 1: Set up for this study with 15 wedge

A series of measurements were recorded, two exposures per condition, then the averages of each
condition were used for our final transmission factor calculation. The first two exposures were
taken without a wedge in the collimator. The second set of exposures were taken with the 15
Right wedge placed in the collimator, and the third set of exposures were taken with the 15 Left
wedge placed in the collimator. Each exposure was set at 100 MU with a dose rate of 600
MU/min. Immediately after each exposure was completed, the readings on the electrometer

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Spring 2016

were recorded so we could later get an average for each setting. Image 2 shows the electrometer
used for the study with one of the readings recorded.
Image 2: Electrometer used for this study

Results: Below you will find our mathematical results from the study.
Table 1: Electrometer readings with and without a 15 wedge

1st exposure
2nd exposure
Average

No Wedge
10.48
10.46
10.47

15 right
7.32
7.30
7.31

15 left
7.39
7.39
7.39

Table 2: Average of 15 Wedge readings

Average with 15 Wedge

(7.31 + 7.39) / 2

= 7.35

Table 3: Wedge Transmission Factor calculation

Wedge Transmission Factor

7.35 / 10.47

= 0.702

Discussion: Our findings from this assessment tells us that when a 15 wedge is placed in the
path of the beam using 6 MV, 29.8% of the beam is absorbed or attenuated by the wedge and
70.2% of the beam is transmitted through the wedge. If the wedge transmission factor was

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Spring 2016

neglected in the MU calculations, the patient would be under-dosed by about 30% for each of the
wedged fields of their prescribed dose.
Clinical Application: To further explain the effect of the 15 wedge in treatment planning, this
section will reference an actual treatment plan for a palliative shoulder and demonstrate the
calculated doses with and without the wedge factor in order to observe the difference in
calculated monitor units. This patient received 10 fractions of 300 cGy per day, for a total of
3000 cGy. This plan used a two field isocentric technique, treating an AP and a PA field at 100
cm isocenter incorporating the 15 wedge in both fields. Also included are comparison images
of the shoulder planned with and without the wedge to note the change of the tilt of the isodose
curves.
Image 3 demonstrates the plan without involving the 15 wedge. Notice the hot spot outlined in
red in the lateral portion of the shoulder shows a 117.7% maximum dose, as well as the uneven
isodose distribution throughout the area. The 100% isodose curve shown in yellow also does not
properly cover the bony anatomy.
Image 3: Palliative shoulder treatment plan without 15 wedge

Hot Spot

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Spring 2016

Also notice in the treatment planning image, Image 4, after the 15 wedge was added to the plan
the improvement of the dose distribution is visible, the hot spot has been reduced to 110.2%
maximum dose, and the uniformity looks much better.
Image 4: Palliative shoulder treatment plan with 15 wedge

In cases such as the one listed above it is evident that the use of wedges in radiation therapy is an
extremely useful tool in the treatment planning process to ensure better care for patients
receiving radiation therapy. The wedge in this example reduced the hot spot and redefined the
isodose curves to conform to the patients anatomy.
The physicist and I tested our measurements of the wedge factor by performing hand calculations
to determine the monitor units for the plan with the 15 wedge, and then we compared our
findings to the TPS monitor unit calculations.

Also performed was a hand calculation to

determine the change in monitor units if the wedge factor was accidentally omitted from the
calculation. The formula used for our hand calculations is displayed below.

Glenda Longoria
Spring 2016

MU =

In Images 5a & 5b you will see the hand calculations performed testing our wedge factor.
Image 5a: Hand Calculation for Monitor Units with Wedge Factor

Image 5b: Hand Calculation for Monitor Units without Wedge Factor

The hand calculations performed showed a 1% difference in monitor units for both the AP and
PA fields when calculating with the wedge factor established during our study, which is an

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Spring 2016

acceptable tolerance for the difference of monitor units between the treatment planning system
and the secondary check.4 This also means that our calculations were correct based on the
information that our calculations matched with the treatment planning system computations.
Using the hand calculation to determine the monitor units without the wedge determined that the
patient would be receiving only 70% of the prescribed dose from each field, resulting in a
significant under-dose for each field. This finding is also compatible to our wedge factor
determination of 0.702 performed in this study.
The images listed below represent the treatment plan report from the treatment planning system
used for this patient. Observe the monitor units calculated by the TPS for both fields are within
1% variance from the hand calculations.
Also, it was brought to my attention as I was looking for the wedge factor in the treatment plan
report, there was no evidence that showed a wedge factor was in fact being used.

After

discussing this with our physicist, he further explained to me that we cannot see the wedge
transmission factor in our report because it is a fixed number already placed into the treatment
planning software from the time of commissioning of the linear accelerators. The wedge factors
are already part of the algorithms in use for treatment planning at our facility.
In Images 6a & 6b, you will find the treatment report that was used to compare with our hand
calculations.
Image 6a: Treatment Plan Report with 15 Wedge

Glenda Longoria
Spring 2016

Image 6b: Treatment Plan Report with 15 Wedge contd

As part of a quality assurance standard, it is recommended by the American Association of

Physicists in Medicine (AAPM) that all radiation oncology departments employ a secondary MU
verification system that functions independently of the treatment planning software.4 This is
done to ensure there are no errors in dose calculations. Operating a system of this nature would
also serve as a double check to ensure that the dose delivered to patients does not deviate more
than 5% from the prescribed dose recommended by the International Commission on Radiation
Units and Measurements (ICRU).
Image 7, below, displays the report from the secondary MU check system we have at Doctors
Hospital at Renaissance Cancer Center. Our facility uses the program called MU Check for all
of the monitor unit secondary verifications. Notice the monitor units are within reasonable limits
from our hand calculations and the treatment planning software calculations.

Glenda Longoria
Spring 2016

Image 7: MU Check Report

Conclusion: The use of a 15 wedge at our facility absorbs approximately 30% of the radiation
beam when using 6 MV on the Trilogy unit. Given this information, it is crucial that wedge
factors are incorporated into the treatment planning systems, verification systems, as well as
hand calculations to avoid errors in treatment and dose delivery. If the wedge transmission
factor is neglected or calculated incorrectly, the patient could potentially suffer a significant
under-dose of radiation during their course of radiation therapy.

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Spring 2016

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References:
1. Bentel GC. Dose Determination for External Beams. In: Wonsiewicz MF, Navrozov M,
eds. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996: 33-58.
2. Khan FM, Gibbons JP. Treatment Planning: Isodose Distributions. In: Pine JW, Moyer E,
eds. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, a Wolters Kluwer business; 2014: 170-194.
3. Stanton R, Stinson D. Treatment Planning. In: Applied Physics for Radiation Oncology.
Madison, WI: Medical Physics Publishing; 1996: 215-246.
4. Sellakumar P, Arun C, Sanjay SS, et al. Comparison of monitor units calculated by
radiotherapy treatment planning system and an independent monitor unit verification
software. Physica Medica. 2011; 27:21-29. doi:10.1016/j.ejmp.2010.01.006