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Block Tray Attenuation Factors in Photon Monitor Unit Calculations

In a linear accelerator, dose delivery is dependent on the monitor units assigned for treatment.
The basis of any MU calculation system used for the verification of the delivered dose is the
derivation of a dose (or dose rate) delivered in patient from the known dose rate under the
reference conditions.1 For most systems, physicists will calibrate a system to deliver 1MU/1cGY
of a 10x10cm2 field size, for a 6MV photon beam at 100cm source to surface distance within a
water phantom or water equivalent phantom. Any deviation from these reference conditions
requires a monitor unit calculation to be performed. The monitor unit calculation takes into
account the various factors that may alter the dose delivered to the patient. This paper will focus
on the purpose and application of the attenuation correction factor for a patient’s treatment
requiring a block tray (TF), and its effect on the monitor unit calculation and total dose delivered.
Since a block tray is inserted directly into the path of the beam, it is imperative that the amount
of radiation that is attenuated by the beam traversing through the tray is considered to ensure the
calculated dose that is delivered is accurate. The following equation is the calculation formula
for determining the monitor units needed to deliver a prescribed dose in a treatment unit and will
be referred to later in this paper.

Dose cGy
MU¿
Sc∗Sp∗TPR∗WF∗TF∗ISF∗IDL∗OAF

Block trays are thin plastic trays placed into the treatment beam to support field‐shaping blocks
and typically reduce the beam intensity by a few percent. They are frequently characterized by a
single factor, TF, depending only on beam energy for all points in the field.2
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To determine the tray factor, a series of water equivalent blocks are stacked on top of the
treatment table beneath the linac head. The blocks are stacked as backscatter material to ensure
that no scatter from the treatment table will be accumulated in the reading.

The final top block is fitted with a hole that measures

exactly 1 cm from the surface to the middle of the
opening. This opening is designed specifically to fit
the farmer ionization chamber, such that no gapping
is present, eliminating the possibility of air molecule
interference. The farmer ionization chamber is
connected via a 3NC connector to a Fluke
electrometer which measures and displays the
accumulated charge of the ion chamber.

A digital ruler was then placed in the front pointe assembly to ensure the distance from the
source, measured exactly 100cm from source to surface.

The field size was set to 10x10cm2 on top of the water

equivalent blocks. Machine settings were set to 100MU at
a dose rate of 600MU/min and readings were tested at
both 6MV and 16MV with and without the tray in place.
A series of three readings were taken at both energies and
in both tray scenarios to determine the average nC
obtained.
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The following data was obtained and averaged:

Beam Energy Readings w/o blocking tray Readings w/ blocking tray

(nC) (nC)
6MV 18.045nC 17.457nC
18.047nC 17.454nC
18.043 nC 17. 461nC
Average: 18.045nC 17.457nC
16MV 19.584nC 19.435nC
19.854nC 19.432nC
19.859nC 19.430nC
Average: 19.855nC 19.432nC

The attenuating tray factor for a photon beam, is defined as the ratio of the radiation field output
with the tray in place to that of the open field of the same field size and quality.2 Calculating the
tray factor (TF) can be done with the averages obtained in the readings and these values can be
used within the following equation.

Dose with tray

TF¿ Dose without tray

The results are as follows:

17.457 nC
TF(6MV)¿ 18.045 nC TF=0.969

19.432nC
TF(16MV)¿ 19.855nC TF=0.97

Higher energy photon beams have greater penetrating power and therefore are not attenuated as
much as lower energy beams traveling through material of equivalent density. This can be seen
by the above equations as only 2.1% of the higher 16MV was attenuated by the tray and 3% of
the 6MV beam was attenuated by the tray under the same reference conditions.
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Clinical Application: A common clinical procedure that may require a tray factor for monitor
unit calculations is an external beam whole brain treatment. This treatment uses two opposing
equally weighted lateral beams for a daily prescribed dose of 200cGy. Many of the factors that
are needed to perform these calculations can be found within the beam data tables of the
department. It is still important to understand how these values are obtained and practically
applied, as a failure to properly account for beam attenuation can over/underdose the patient’s
treatment volume. The whole brain treatment conditions are as follows: 6MV beam energy,
exposed equivalent field size is 18.6cm2, separation 15cm, Gantry angles 270 and 90 degrees,
Lucite tray, total prescription dose of 3000cGy in 15 fractions (200cGy/fraction), to a depth of
7.5cm. The image below is an example of how a typical field block for whole brain radiotherapy
of primary CNS lymphoma may appear, with the areas of green depicting the areas of block
placement.

Image source see reference 3.

To determine the appropriate monitor unit selection from each treatment beam, we can devise the
dose by the product of the appropriate factors. The following calculations show a hand monitor
unit calculation, as well as a secondary monitor unit calculation by RadCalc for calculation
comparison of the lateral beams. Because the dose is equally weighted and all correction factors
stay the same for each beam, one beam calculation will be displayed here.
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200 cGy x 0.5

LAT BEAM- MU¿
1.051 ( Scp )∗0.863 ( TPR )∗0.969 (TF )∗1.03 ( ISF )

LAT BEAM MU= 110 (Hand Calculation)

RadCalc Value MU= 111

Omitting the tray factor from the formula produces the following results:

200 cGy x 0..5

LAT BEAM (w/oTray)- MU¿ 1.051(Scp)∗0.863(TPR)∗1.03(ISF )∗¿ ¿

LAT BEAM (w/o Tray) MU=107 (Hand

Calculation)

Rad Calc Value: MU= 107

Both the hand calculation and secondary

software calculation are within 1% and fall
within the 3% action level for homogeneous
conditions using different calculation
algorithms and approximate patient geometry
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with minimal field shaping in agreement.2 Calculating the monitor units without including the
tray factor value, shows a decrease in monitor units. Thus, insufficient monitor units would be
assigned to the treatment field, resulting in a dose reduction to the target volume. The difference
in monitor units proven by the calculation is a 2.7% difference. Although 2.7% percent may
seem like a relatively small number, this difference in percentage equates to a reduction of
5.4cGy/fraction and over the entire course of treatment is a total reduction of 81cGy lost to
attenuation.

The cumulative deviation can have a significant impact on the actual dose delivered during
treatment. In some cases where organ threshold is near tolerance, this could deliver
consequential dose that would not be accounted for if the tray factor were not included. It is
important that all corrective factors be considered any time there is a beam modifying device that
intersects the field. Performing calculations can demonstrate how evident even slight deviations
in attenuation can affect the whole scale of treatment.

References

1. Stern R, L Heaton, R Fraser, et al.Verification of monitor unit calculations for non‐IMRT

clinical radiotherapy: Report of AAPM Task Group 114. Med. Phys., (2011) 38: 504-
530. https://doi.org/10.1118/1.3521473. Published December 30, 2010. Accessed March 15,
2021.

2. Stern R, Heaton R, Fraser M, et al. Verification of monitor unit calculations for non‐IMRT
clinical radiotherapy: Report of AAPM Task Group 114. Med. Phys., 2011; 38: 504-
530. https://doi.org/10.1118/1.3521473. Published December 30, 2010. Accessed March 15,
2021.

3. Ambedker B, Adhikari N, Ahitagni B. Management of primary CNS lymphoma. Department

of Radiation Oncology. Institute Rotary Cancer Hospital.
https://www.slideshare.net/NarayanAdhikari4/management-of-primary-cns-lymphoma-pcnsl .
Published January 20, 2016. Accessed March 15, 2021.