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Felicia Chu
DOS 522 Radiation Dose Calculations
3/1/2019
Enhanced Dynamic Wedge Transmission Factor Calculation

Objective:​ The following analysis of an enhanced dynamic wedge (EDW) will explore the
measurement process of the transmission factor, demonstrate the impact of that factor on a
monitor unit calculation, and consider clinical implications in a patient case study.

Purpose: ​Dosimetrists often use enhanced dynamic wedges to obtain optimal dose distributions
in treatment planning. Wedges create a gradual decrease in beam intensity with their sloping
geometry, tilting the isodose curve at an angle horizontal to the central axis.¹ Enhanced dynamic
wedges are created with the movement of the collimator leaves in the y direction, and eliminate
the need for therapists to manually insert a wedge into the head of the machine.² As the beam
traverses through the EDW, the moving leaves will attenuate the beam and reduce the dose to
Dmax on the central axis. We measure a wedge transmission factor (WF) through the center of
the wedge to correct for the presence of the EDW in the beam. This factor must be used in all
monitor unit (MU) calculations to deliver the correct dose to patients. The wedge transmission
factor is:
WF = ​Dose with wedge in the beam path
Dose without wedge

Methods and materials:​ The linear accelerators at our clinic are calibrated at source-axis
distance (SAD), at a depth of 10 cm, 10x10 cm field size, and 1 cGy/MU at Dmax for photon
treatments. With Navneeth Hariharan, a physicist at Lahey Hospital, we measured output on a
Varian 21EX using 6 and 15 megavoltage (MV) energies, a 10x10 cm field size, and 100 cm
source-to-skin distance (SSD). We delivered 100 MU at a dose rate of 300 MU per minute to
depth of 10 cm in a solid water build up phantom. Our clinic uses an Exradon A12 standard
farmer type ionization chamber, and a Keithley electrometer to measure the accumulated charge
in nanocoulombs (nC). We conducted 3 trials for both 6 and 15 MV energies, and used the
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average to calculate the wedge transmission factor. For comparison, we also measured charge
with a 30 degree EDW in the beam path.

Results:
Table 1

Energy Readings without EDW (nC) Readings with EDW (nC)

6 MV 16.090 8.921
16.081 8.922
16.031 8.910

15 MV 18.253 11.410
18.241 11.390
18.220 11.382

Table 2​: We then obtained averages of the charge for 3 trials for each energy, with and without
the EDW to account for slight variations in measurements. We summed the results of each trial
and divided by 3, the number of trials.

Energy Average of readings without Average of readings with

EDW (nC) EDW (nC)

6 MV 16.090 8.921
16.081 8.922
+16.031 +8.910

48.202/3=​16.067 nC 26.753/3=​8.918 nC

15 MV 18.253 11.410
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18.241 11.390
+18.220 +11.382

54.714/3=​18.238 nC 34.182/3=​11.394 nC

Table 3​: The transmission factor is the ratio of the average measurement with the wedge to that
without the wedge.

Energy Reading with EDW/Reading Wedge Transmission Factor

without EDW

6 MV 8.918 nC / 16.067 nC = .555

15 MV 11.394 nC / 18.228 nC = .625

Discussion:​ The wedge transmission factor for the 6 and 15 MV beam was .555 and .625
respectively. The 30 degree EDW attenuates 45.5% of the primary 6 MV beam, and 37.5% of the
15 MV beam. The decrease in fluence occurs because the lead leaves forming the dynamic
wedge partially absorb the beam as it shapes the isodose distribution. According to Khan¹, wedge
filters impact beam quality by “preferentially attenuating lower energy photons (beam
hardening), and, to a lesser extent, by Compton scattering which results in beam degradation
(beam softening.)”
Table results show that the wedge transmission factor is also dependent on beam energy.
Additionally, the wedge transmission factor varies according to wedge angle, field size, and
linear accelerator model.³ Ahmad et al² demonstrated that, unlike physical wedges, enhanced
dynamic wedges are independent of depth. They measured variation in transmission factor at
different depths to be clinically insignificant at under 2%.

Clinical Application: ​In an isocentric spine treatment of L1-L5, the impact of the wedge
transmission factor is quite apparent. The patient was prescribed 400 cGy per treatment for 5
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fractions to a total dose of 2000 cGy. The plan consists of an equally weighted oblique wedge
pair of 15 MV. The following demonstration below shows a monitor unit calculation for each
field with the wedge transmission factor. The wedge factor of .625 is the final number in the
denominator.
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The image below demonstrates the calculation with identical conditions, minus the wedge factor
from the calculation.

The addition of the EDW results in a 37.70% increase in monitor units to deliver the
prescribed dose to the target volume. The monitor units are higher because the machine needs
more time to deliver the prescription dose through the wedge than time to deliver the prescription
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dose without the EDW in the path. If the patient was treated with the planned 321 monitor units,
but by mistake without the EDW in place, the patient would be overdosed. This mistake would
be an immense clinical error. Fortunately, there are mechanic safety interlocks in place to
prevent this from occurring in practice.
The image below is a plan report of the L1-L5 case described. Both fields are the same.
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We typically use Radcalc as a second check that Eclipse, our treatment planning system,
is reporting the correct dose. However, because Radcalc incorporates the wedge factor into the
scatter rather than listing it independently, it is difficult to use for the purposes of this discussion.
I’ve chosen instead to insert a table of a manual monitor unit calculation sheet.

Photon Monitor Unit Calculation Check (Lahey Health-Radiation Oncology)

Calculation Site: L1-L5

Prescription Name Prescribed Dose Dose per Treatment Fractions

(cGy) (cGy)

A L1-L5 2000 400 5

Beam ID A.A A.B

Beam Description RPO LPO

Accelerator Varian 21EX Varian 21EX

Energy 15X 15X

Dose per Treat (cGy) 200 200

Normalization 100% 100%

Gantry 225 135

Collimator Angle 90 90

X1 (cm) 10 10

X2 (cm) 10 10

Y1 (cm) 10 10
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Y2 (cm) 10 10

Wedge 30 EDW 30 EDW

Wedge Factor .625 .625

Scp 1.057 1.057

Inverse Square .879 .879

Cal. Output 1 cGy/MU 1 cGy/MU

Monitor Units (MU) 321 321

Below is a beam’s eye view of the ports with the EDW in.

RPO
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LPO

Conclusion:​ Enhanced dynamic wedges attenuate the beam as they create desirable dose
distribution, and must therefore be accounted for in monitor unit calculations. The wedge
transmission factor depends on wedge angle, beam energy, field size, and linear accelerator
model.³
Overall, the wedge transmission factor is a major consideration in the delivery of correct
dose to target volume. If a patient was treated with the planned monitor units incorporating the
wedge but for some reason, without the wedge in place for actual beam delivery, he or she would
be significantly overdosed. It is therefore critical to understand the impact of an enhanced
dynamic wedge on dose delivery.
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References
1. Khan FM. ​Khans the Physics of Radiation Therapy.​ Philadelphia: Lippincott Williams
and Wilkins; 2014.
2. Njeh CF. Enhanced dynamic wedge output factors for Varian 2300CD and the case for a
reference database. Journal of Applied Clinical Medical Physics.
https://aapm.onlinelibrary.wiley.com/doi/full/10.1120/jacmp.v16i5.5498. Published
September 8, 2015. Accessed March 18, 2019.
3. Chang SX, Gibbons JP. Clinical Implementation of Non-Physical Wedges. ​AAPM​. 1999.