CopyrIght

BORDER

SEPARATION

FOR ADJACENT

1991 Amencan

0739-021 l/91
Association
of Medical

ORTHOGONAL

$3.00 + .oo
Dosnnetrists

FIELDS

BARRY L. WERNER, PH.D., FAIZ M. KHAN, PH.D., SUBHASHC. SHARMA,*PH.D.,

CHUNG K. K. LEE, M.D. and TAEH. KIM, M.D.3
Department of Therapeutic Radiology-Radiation Oncology, University of Minnesota Hospitals, Harvard Street
at East River Road, Minneapolis, MN 55455, U.S.A. Department of Radiology-Radiation
Oncology
Division, Sparrow Hospital, 12 15 East Michigan Avenue, Lansing, MI 48909-9986, U.S.A. 3Radiation Therapy
Department, Abbott North Western Hospital, 800 E. 28th St., Minneapolis, MN 55407, U.S.A.
border separations for adjacent orthogonal fields can be calculated geometrically, given the
validity of some important assumptions such as beam alignment and field uniformity. Thermoluminescent dosimetry (TLD) measurements were used to investigate dose uniformity across field junctions as a function of field
separation and, in particular, to review the CCSG recommendation for the treatment of medulloblastoma with
separate head and spine fields.
Abstract-Field

Key Words: Treatment planning, Border separation, Gap

to a long spinal field, as is sometimes done in the CNS

irradiation treatment of medulloblastoma. The inferior borders of the cranial fields are not blocked in the
region of the cord and are perpendicular to the plane
of the page. A solid line represents the spinal light field
at the surface of the patient. The dashed line shows
the spinal field at the depth of the spinal cord (beam
divergence is exaggerated). The field separation, S, is
equal to the divergence of the spinal field at the depth
of the spinal cord.
Figure 3 presents the setup of Fig. 2 in lateral
view. The dashed line represents the border of the
cranial field at the midsagittal plane. The cranial light
field is visible at the back of the neck, as shown. By
similar triangles it can be seen that the divergence, S,
of the superior border of the posterior field at the cord
is given by

INTRODUCTION

Clinical complications can arise from overlapping,

adjacent radiation fields in multiport therapy.,* Several techniques have been suggested for matching
fields,3 usually when their central axes are parallel to
each other (adjacent fields on the same plane or parallel opposed fields). The techniques include: geometrical matching,*4,5 isodose curve matching,2v6*7moving
junctions, split beams, x8adjoining angled beams,g
the use of penumbra generators or spoilers,lo~l
and standard separations. It has been shown**13that
when adjoining fields are orthogonal to each other
(for example, when lateral and AP fields abut), small
variations in gap size result in large variations in dose
at the junction.
This paper presents a discussion of the geometrical method for calculating field separation for orthogonal fields, the dosimetric consequences of errors in
gap width, the significance of the assumption of field
uniformity, and the Childrens Cancer Study GroupI
(CCSG) recommendation for the treatment of medulloblastoma with separate head and spine fields.
GEOMETRICAL

S=d-

iL
SSD

(1)

where d is the posterior depth of the cord at the gap,

SSD is the source to skin distance, and the length of
the field, L, is measured in the plane perpendicular to
the central ray of the beam and tangent to the patients surface. It is advisable to view the patient as
shown in Fig. 2 in order to take advantage of the
bodys symmetry when locating the spinal cord.
Figure 4 shows the borders of the cranial field
rotated and blocked below the line from the occipital
protuberance to the mastoid tip. The lower border of
the cranial field is approximately parallel to the upper
edge of the spinal field. Assume the light field can be
visualized on the side of the patients neck, as shown.
The distance S is now the divergence of the cranial
field at the depth of the midplane. The point A is a
point on the surface of the neck, directly over the spi-

ANALYSIS

Figures la and lb describe abutting orthogonal

radiation fields. An idealized three-dimensional cylindrical phantom is irradiated by two parallel opposed fields and one field orthogonal to them. The
requirement that the dose distribution along the spinal cord be uniform is met by separating the shared
border of the opposed fields from the border of the
third field by the distance S.
Consider the application of geometrical analysis
to the orthogonal field setup shown in Fig. 2. In this
diagram bilateral cranial fields are incident, adjacent
79

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Medical Dosimetxy

Volume 16, Number 2, I99 1

(4

Fig. 2. CNS irradiation setup. Solid lines indicate light

fields. Dashed lines indicate the spinal field at the depth of
the spinal cord.

(b)
Fig. 1. Orthogonal radiation fields incident on a cylindrical
phantom: (a) light fields on the surface and gap width S; (b)
intersection of the fields internally.

nal cord at distance S below the mastoid tip. The superior border of the posterior spinal field is positioned so
as to pass through point A. Distance S is given by

(2)
where T is the lateral head thickness at the mastoid
tip, ;L, is the distance from the center of the field to
the field border closest to point A in the plane perpen-

Fig. 3. CNS irradiation setup. Figure 2 presented in lateral

view. Dashed line indicates cranial fields at the midsagittal
plane.

Border separation for adjacent orthogonal fields 0 B. L. WERNERet al.

superior border of the posterior
cord. .

81
fields used to treat the spinal

NOTATION:
. . This

[recommendation] is based on very precise ahgnment of fields which may not be obtainable in all departments.
Treating without a gap may cause concern to individual radiation
oncologists. Therefore, discretion is allowed to individuals to put in
a gap if they have reservations about this recommendation. The gap
should normally be not greater than 0.5 cm. .
12.26634
A wedge filter may be used to broaden the penumbra around
the posterior border of the large head field so that an appropriate
match is made with the penumbra of the leading edge of the posterior spinal field.
12.26635
The junction line is moved 1 cm cephalad after each 1260
cGy to smooth out any dose inhomogeneity occurring at the junction.

We will discuss this recommendation.

MEASUREMENT

Fig. 4. Rotated CNS irradiation setup. The cranial field is

rotated and blocked below the line from the occipital protuberance to the mastoid tip. The solid lines indicate the light
fields, the dashed line indicates the cranial fields at the midsagittal plane.

dicular to the central ray of the beam and tangent to

the patients surface, and SSD is the source to skin
distance of the cranial field. Distance L can be approximated by the length of the cranial field, L, since
the gap distance, S, need only be accurate to the nearest millimeter.
The geometrical analysis makes no distinction
between narrow and wide penumbras, and it assumes
perfect beam alignment and field flatness. It also assumes that the light fields can be visualized at the sides
of the cylinder, and that they point to the 50% isodose
line in a flat homogeneous water phantom. These assumptions are not always valid in practice.
THE CCSG PROTOCOL
Consider the CCSG protoco114 which recommends that geometrical analysis not be used, and that
S be set equal to zero. The protocol reads:
12.266 Separation for Adjacent Fields
12.2661
It is recommended that there he abutment of the light field edge
between the parallel opposed fields used to treat the brain and the

We constructed a polystyrene copy of the Alderson Rando phantom* with sections that are interchangeable with the original phantom. The polystyrene sections each have a &-in hole at the spinal cord
(usually about 4 cm from the back). The spinal cord
holes were filled with polystyrene plugs partially
sliced at .5locations, 5 mm apart, each slice becoming
a shelf, holding a $ in. X $ in X .015 in LiF thermoluminescent dosimeter (TLD) chip snugly. (See Fig. 5.)
See a similar study described in Ref. 13.
We chose to study the rotated, orthogonal setup
shown in Fig. 4 using a cobalt-60 therapy unit with a 2
cm diameter source and a 45 cm source to collimator
distance. Phantom sections numbered 4 through 8
(Rando phantom section numbers) were loaded with
25 TLD chips, spaced 5 mm apart, in a line along the
spinal cord. Sections 4 and 5 were wholly in the cranial fields. By adjusting the upper border of the spinal
field according to the geometrical method described
above, sections 7 and 8 were wholly in the spinal field
and section 6 was in the gap region.
The cranial fields had an SSD of 80 cm, the unblocked field size was 2 1 X 16.5 cm, the effective field
size was 19 X 15 cm (the field borders extended
beyond the head and were partially blocked as shown
in Fig. 4) and the lateral head thickness at the mastoid tip was 13.7 cm.
The lateral head thickness at the mastoid tip was
13.7 cm, the unblocked field size of the cranial fields
was 2 1 x 16.5 cm, the effective field size was 19 X 15
cm (the field borders extended beyond the head and
were partially blocked as shown in Fig. 4) and the
SSD was 80 cm. The calculated gap was 0.7 cm. The
spinal field had an SSD of 160 cm, an open field size
* Alderson Research Laboratory, Stamford, CT.

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Volume 16, Number 2, 199 I

Medical Dosimetry

scribed dose was delivered to the center of the brain

and to the spinal cord at a depth of 4 cm on the central
axis of the spinal field. The TLD measurements have
a standard deviation of 1.5%. The calculated curve in
Fig. 7 is the sum of the two curves in Fig. 6. The
measured and predicted curves in Fig. 7 agree spatially to within about 1 mm.
RESULTS

AND

DISCUSSION

Figures 7 and 8 show that the spinal and cranial

fields are not flat, the dose distributions
in both fields
fall to about 90% of the prescription
dose in the vicinTLD

Phantom

ity of the gap. The spinal field falls off because the gap
lies at the end of a long narrow field. The cranial fields
fall off because of the loss of phantom scatter at point
A. Matching the field borders according to the geometrical method results in overlapping the 45% isodose
lines not the 50% isodose lines. Figure 7 shows that a
25% local cold spot results from using the gap calculated according to Eqn. 2.
Figure 8 shows the effect of widening or reducing
the field separation. The curves shown were constructed by adding the cranial dose distribution to the
spinal dose distribution after shifting their spatial relationship by a variable gap error. Widening or reducing
the field separation by l/2 cm increases or decreases
the junction dose as shown. Van Dyke et al. show
the results of measurements,
similar to the ones de-

Holder

Top View
of Phantom
Sections

Fig. 5. A polystyrene copy of the Alderson Rando phantom.

The phantom sections have holes to accommodate TLD
holders at the position of the spinal cord. When assembled
and loaded, the phantom holds 25 TLD chips, spaced 5 mm
apart, along the spinal cord.

of 65 X 65 cm and a blocked field size of 5 X 60 cm.

The blocking tray was 85 cm from the phantom.
We performed three irradiations
with the cranial
fields alone, two irradiations
with the spinal field
alone, (see Fig. 6) and two with the combined
field,
(See Fig. 7). For the combined irradiation, the pre-

scribed here, for dose as a function of depth below the

gap region. Errors in field separation can be expected

to cause more significant hot or cold regions with

sharper edged, linac beams.

90

60-

4
Position

6
Along

Spinal

8
Cord

IO

12

(cm)

Fig. 6. Dose distribution at the inferior edge of the cranial field and at the superior edge of the spinal field. Doses
were measured with TLD chips along the spinal cord. Dose is normalized to 100% at the center ofthe brain and at

a depth of 4 cm on the central axis of the spinal field.

Border separation for adjacent orthogonal fields 0 B. L. WERNERet

al.

83

108

calculated

.$

84 80 76 -

Sect/on

, Section

4
Position

6
8
along Spinal Cord (cm)

10

12

Fig. 7. Dose distribution

in the gap region. The solid line represents the dose distribution measured with TLD
irradiated by all the cranial and spinal fields. The dashed line represents the arithmetic sum of the dose distributions measured in the cranial field alone and in the spinal field along, from Fig. 6. Dose is normalized to 100% at
the center of the brain, and at a depth of 4 cm on the central axis of the spinal field.

Consider the CCSG recommendation

that instead of introducing a gap, the penumbra edges could
be broadened and the junction line should be moved.
In our case, following the CCSG recommendation
means subtracting 0.7 cm from the calculated gap.
Figure 8 shows that this procedure would restore the
dose to 100% over most of the gap region. A hot spot
greater than 10% would be produced over a small part

of the gap region, but moving the junction would reduce its significance. According to the graph shown in
section 12.266 1 of the CCSG protocol. the hot spot
should only have been about 5%.
Differences in beam characteristics and patient
shape will result in different dose distributions in the
junction region. To be sure of the dose distribution
everywhere in the junction region, isodose distribu-

180
160

120
2
-

100

8
g

80
60

Fig. 8. Dose distribution in the gap region. The curves represent the arithmetic sum of the dose distribution
measured in the cranial field alone and in the spinal field alone, as shown in Fig. 6, after adding or subtracting the
indicated distance from the calculated gap. Dose is normalized to 100% at the center of the brain, and at a depth of
4 cm on the central axis of the spinal field.

Medical Dosimetry

84

tions should be constructed and the field separation

verified radiographically.
We conclude that care should be taken when
matching adjacent fields on the spinal cord. Since
there is a significant reduction of dose at the edges of
the fields, using a gap calculated by the geometrical
matching method can result in a significant cold spot.
On the other hand, unless the field edges are broadened and the junction line is moved, abutting the
fields with no separation, as recommended by the
CCSG protocol, can result in a hot spot.
REFERENCES
1. Hopfan, S.; Reid, A.; Simpson, L.; Ager, P. Clinical complications arising from overlapping
of adjacent radiation
fields-physical
and technical considerations. Znt. J. Radiut.
Oncol. Biol. Phys. 2:801-808; 1977.
2. Glenn, D.W.; Faw, F.L.; Kagan, A.R.; Johnson; R.E. Field
separation in multiple portal radiation therapy. Am. J. Roent.
102:199-206; 1968.
3. Khan, F.M. The Physics ofRadiation Therapy, Chapter 13.
Baltimore: Williams and Wilkins; 1984:287-295.
4. Caravaglia, Cl. Field separation of adjoining therapy fields.
Med. Phys. 8:882-884; 198 1.

Volume 16, Number 2, 1991

5. Siddon, R.L. Solution to treatment planning problems using
coordinate transformations. Med. Phys. 8:766-774; 198 1.
6. Faw, F.L.; Glenn, D.W. Further investigations of physical
aspects of multiple field radiation therapy. Am. J. Roent.
108:184-192; 1970.
7. Hale, J.; Davis, L.W.; Bloch P. Portal separation for pairs of
parallel opposed portals at 2 MV and 6 Mv. Am. J. Roentgenol.
114:172-175; 1972.
8. Williamson, J.R. A technique for matching orthogonal megavoltaae fields. Znt. J. Radiat. Oncol. Biol. Phvs. 5:11 l-l 16:
19799. Lance, J.S.; Morgan, J.E. Dose distribution between adjoining
therapy fields. Radiology 7924-29; 1962.
10. Armstrong, D.I.; Tait, J.J. The matching of adjacent fields in
radiotherapy. Radiology 108:4 19-422; 1973.
11. Griffin, T.W.; Schumacher, D.; Berry, H.C. A technique for
cranial-spinal irradiation. Br. J. Radiol. 49:887-888; 1976.
12. Bukovitz, A.G.; Deutsch, M.; Slayton, R. Orthogonal fields:
Variations in dose vs. gap size for treatment of the central nervous system. Radiology 126:795-798; 1978.
13. Gillin, M.T.; Kline, R.W. Field separation between lateral and
anterior fields on a 6 MV linear accelerator. Znt.J. Radiat. Oncol. Biol. Phys. 6:233-237; 1980.
14. CCG-945, 9/15/88. Childrens Cancer Study Group, 199
North Lake Avenue, third floor, Pasadena, CA 9 110 1.
15. Van Dyk, J.; Jenkin R.D.T.; Leung, P.M.K.; Cunningham,
J.R.: Medulloblastoma: Treatment technique and radiation dosimetry. Znt.J. Radiat. Oncol. Biol. Phys. 2:993-1005; 1977.