Ryan Pohl

Dos 522: Rad. Dose Calculations

March 10, 2017

Attenuation Factor of Treatment Table Support Bar

Objective: To determine the attenuation factor of a conventional couch support bar (see figure
1), show how it could affect monitor unit calculation, and assess the significance this factor has
in a clinical setting.

Figure 1: Metal support bar at head of treatment table proximal to linear accelerator.

Purpose: The goal of radiation therapy is to give a specific amount of radiation to a treatment
site while avoiding surrounding normal tissue and critical structures. As such, it is important to
ensure the radiation fields used to deliver this dose are calculated and measured in an accurate
manner. There are many factors that need to be accounted for in order to correctly predict how
much radiation a specific field will impart to a patient. One of these factors is the attenuation
factor, which is defined by the following equation:1
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dose with device in beam

C attenuation=
dose without devicebeam where Cattenuation is a constant value for each device and

beam quality. There needs to be an attenuation factor for all beam modifying devices (any
device that intercepts the treatment field). Objects such as block trays, wedges, compensating
filters, or treatment tables are classified as beam modifying devices and their interaction with a
radiation beam reduces dose the patient receives. Since the objective of this report is to evaluate
the impact of treating through a metal treatment table support bar, the specific equation used to
analyze data collected will be:

dose wi t h support beam

attenuation by support =
dose without support beam
C

The purpose of this report is to examine how the attenuation factor of a couch support bar affects
the dose provided by a field and, more importantly, assess how this factor could affect a patients
treatment.

Methods: The data used for this assignment was collected on a Varian Clinic 21EX linear
accelerator using an 0.6cc Farmer type ionization chamber. A solid water phantom was placed at
133 cm source to surface distance (SSD) and the ion chamber was inserted at a depth of 7cm (see
figure 2). The phantom was centered on the central axis and the incident beam had a field size of
10cm x 10cm. The linear accelerator was set at a gantry angle of zero and there was no
collimator rotation throughout the entire experiment. The first beam reading was taken without
interference from the table top. Then, the metal couch support bar was placed above the ion
chamber at an SSD of 118 cm (see figure 3) to obtain the second reading. This study tested the
attenuation of a fixed 6 megavoltage (MV) photon beam set to deliver 100 monitor units (MU) at
a rate of 600 MU/min.
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Figure 2: Metal couch support bar and solid water phantom in relation to linear accelerator

Results: The data obtained from this experiment showed a large difference between the
ionization chamber reading with the support bar in the way and without the support bar. Without
interference from the treatment table support bar, the ionization chamber registered a reading of
0.934 nanocoulombs (nC). When the radiation beam was forced to interact with the support
beam first, the ionization chamber only picked up a reading of 0.324 nC.
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Figure 3: Schematic of experiment set-up. A) First reading where beam interacts directly with the
solid water phantom. B) Reading where support bar (in treatment table) blocks the photon beam
incident on the phantom.

The results of these trials were then inserted into the attenuation factor equation to find how dose
was affected by this particular beam modifying device. This value represents the percentage of
the radiation beam that was actually transmitted through the table top support structure.
Therefore, the resulting calculation of 0.347 indicates that the metal support bar reduced beam
intensity by approximately 65%.

0.324 nC
attenuation by support =
0.934 nC
C
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Clinical Application: Patient AR presented with metastatic disease spread to her cervical spine
and was prescribed a dose of 3000 cGy in 10 fractions. She was treated on a carbon fiber
treatment table that has a low specific density and is relatively radio-translucent.2 This allowed
the treatment planner to arrange fields that interacted with the couch without significantly
affecting dose. The dosimetrist decided to incorporate four oblique angles, each with a wedge to
create a more even dose distribution. This section will be used to calculate the MU needed for
treatment of patient AR on the carbon fiber couch, compare this to the number of MU needed to
theoretically treat her on a conventional couch (when interacting with a metal support bar), and
then evaluate target volume dose difference if the attenuation factor of the bar was not accounted
for when treating on a conventional couch.

Figure 4: Axial view of patient AR's treatment plan showing beam arrangement and dose distribution
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Figure 5: Beams-eye View (BEV) of RPO. Rectangular pink contour represents treatment table. Note
how the treatment table is blocking the target volume (red contour).

Right Posterior Right Anterior Left Anterior Left Posterior

Oblique (RPO) Oblique (RAO) Oblique (LAO) Oblique (LPO)
Dose (cGy) 69 81 81 69
Equivalent Square (cm2) 7.6 7.7 7.6 7.7
Sc (cGy/MU) 0.981 0.982 0.981 0.982
Sp (cGy/MU) 0.992 0.993 0.992 0.993
Depth/Eq. Path (cm) 8.8 5.9 5.9 11.7
TMR 0.792 0.881 0.880 0.692
IDL 0.96 0.96 0.96 0.96
WF 0.551 0.404 0.404 0.551
TF 1 1 1 1
Cattenuation 1 1 1 1
ISF 1.03 1.03 1.03 1.03
Resulting MU 164 236 237 188
Table 1: Pertinent plan information used to calculate MU and resulting MU values. Figures taken
from physics report sheets (see appendix 1) and beam data profiles
In order to calculate the number of MU needed to deliver the prescribed dose, the treatment
machines calibration condition must be known. Linear accelerators are calibrated in specific
conditions and any deviation from these conditions needs to be taken into account. Using an
energy of 6 MV, the linear accelerator was calibrated to deliver 1 cGy per MU at a depth of
1.5cm, SSD of 100cm, field size of 10cm x 10cm, and no beam modifying devices. The
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following equation is used to address any deviation from these reference points; it essentially
shows the relationship between MU used in treatment condition and the output of the machine in
calibration condition.

Dose
MU =
S c S p TMR IDLWF TF Cattn ISF

where Sc is scatter from the collimator, Sp is scatter from the phantom (or tissue), TMR is tissue
maximum ratio, IDL is the isodose line dose is prescribed at, WF is wedge factor, TF is tray
factor, Cattn is the factor of other beam modifying devices (such as treatment table), and ISF is the
inverse square factor. When information from table 1 is inserted into this equation, the number of
MU for each beam can be calculated. The following MU calculations are for patient ARs
treatment on a carbon fiber couch:

69
MU RPO= =164 MU
0.981 0.992 0.792 0.96 0.551 1 1 1.03

81
MU RAO= =236 MU
0.982 0.993 0.881 0.96 0.404 1 1 1.03

81
MU LAO= =237 MU
0.981 0.992 0.880 0.96 0.404 1 1 1.03

69
MU LPO= =188 MU
0.982 0.993 0.692 0.96 0.551 1 1 1.03
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If the patient was treated on the couch with a metal support bar, a conscientious effort would be
taken to avoid inserting treatment beams at angles that interact with these bars. To treat through
the support bar, there would need to be a dramatic increase in MU. The value Cattn = 0.347
(derived from previous measurements) can be inserted into the MU equation to account for
attenuation of the RPO and LPO beams. Using this value may simplify the effect of the support
bar by assuming that the field traverses the same amount of material used when collecting data.
However, this value still provides a decent approximation of how much of the field is attenuated
by a support bar. The following MU calculations adjust for the interaction of posterior beams
with the metal couch support bar.

69
MU RPO= =473 MU
0.981 0.992 0.792 0.96 0.551 1 0.347 1.03

69
MU LPO= =541 MU
0.982 0.993 0.692 0.96 0.551 1 0.347 1.03

These results demonstrate how the number of MU needed to deliver the same prescribed dose
increases as a result of treating through the support bar. The RPO went from 164 MU to 473 MU
and the LPO went from 188 MU to 541 MU; meaning both fields increased MU output by 288%.
This calculation would be used in the unlikely event that a radiation oncology team decided to
treat a patient through the support structure and accounted for its attenuation factor. However,
another possible and more harmful occurrence would be treating a patient without correcting for
the attenuation of the support bar. This could happen if the base plate was indexed in the wrong
area (perhaps high on an extender), putting the target volume on the same plane as the metal
support structure. The dose deposited by each beam can be calculated using the following
formula.
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Dose=MU S c S p TMR IDL WF TF C attn ISF

This formula can be used to determine how much radiation the patients target volume receives
when treatment fields are unknowingly traversing through the support bar and its attenuation
factor is not taken into account.

Dose RPO=164 0.981 0.992 0.792 0.96 0.551 1 0 .347 1.03= 24 cGy

Dose LPO=188 0.982 0.993 0.692 0.96 0.551 1 0.347 1.03= 24 cGy

Planned Target Dose Actual Target Dose with

without Couch Support Bar Couch Support Bar Percent Difference
Attenuation Factor (cGy) Attenuation (cGy)
RPO 69 24 -65.2%
LPO 69 24 -65.2%
RAO 81 81 0%
LAO 81 81 0%
Total 300 210 -30%
Table 2: Difference in dose per fraction when patient is treated through support bar

Conclusion: Treatment planning systems can adjust densities associated with treatment tables.
However, taking into account metal support structures is tough to do because they are not part of
the planning CT. This report has demonstrated that the field can be reduced by approximately
65% if it interacts with a support beam. The four-field clinical example shown in this report
resulted in an 30 % decrease in overall dose. The International Commission on Radiation Units
and Measurements (ICRU) calls for dose delivery to be within 5% of the treatment plan.3 This
goal is based on the sharp dose response curves for tumor control and normal tissue
complications. With these standards, it is obvious that treating through a metal support bar is
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unacceptable and a serious form of mistreatment. Caution should be taken when treating a
patient around sections of a couch that need an attenuation factor; it is best practice to avoid
these areas.

References:
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1. Abing, C. Introduction to Dose Calculations: Beam Modifying Devices. [Softchalk]. La

Crosse, WI: UW-L Medical Dosimetry Program; 2017.
2. Olch, Arthur J. et al. Dosimetric effects caused by couch tops and immobilization
devices: report of AAPM Task Group 176. Medical Physics 41.6 (2014): 061501. 9 Mar.
2017. http://dx.doi.org/10.1118/1.4876299

3. McDermott PN, Orton CG. The Physics & Technology of Radiation Therapy. Madison,
WI: Medical Physics Publishing; 2010.

Appendix 1. Physics report sheets for patient AR c-spine treatment

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