DOSIMETRY OF PHOTON.

BEAMS IN PATIENT

DR: Mufeida Elmusrati

Radiation oncologist
WATER VERSUS PATIENT
The physical characteristics of radiation beams are usually
measured in phantoms under standard conditions that are
as follows:
● A homogeneous, unit density phantom;
● A flat phantom surface;
● A perpendicular beam incidence on the phantom.
WATER VERSUS PATIENT
Dose to patient is different from dose to water because:
 Patient surface is not perfectly flat.

 Patient tissue is not perfectly water-equivalent: it

contains air, bone, metal etc.
 Clinical treatments often contain more than one radiation
field.
 A TYPICAL DOSE DISTRIBUTION ON THE CENTRAL AXIS OF A
MEGAVOLTAGE PHOTON BEAM STRIKING A PATIENT

Dose deposition from a

megavoltage photon beam
.in a patient
Ds is the surface dose at
the beam entrance side,
Dex is the surface dose at
the beam exit side. Dmax
is the dose maximum often
normalized to 100,
resulting in a depth dose
curve referred to as the
percentage depth dose
.(PDD) distribution
The region between z = 0
and z = zmax is referred to
as the dose buildup region
Tissue excess and deficit(irregularity).
These values are measured as centimeters of deviation from a perfectly flat
surface
 An inhomogeneity
can be characterized by its location(depth), density and
thickness

High-density tissue (bone) increases attenuation, while low-density tissue

(lung) decreases attenuation.
Therefore the dose distal to an inhomogeneity will be different than the
dose in a homogeneous phantom
CORRECTIONS FOR PATIENT CONTOUR

Two approaches are used to address this problem:

1. The effect can be corrected through various calculation
methods;
2. The effect may be compensated for through the use of
wedges, bolus materials or compensators (missing tissue
compensation) .
CALCULATION METHODS .1
Several different methods exist to calculate the dose with an irregular
surface:
A. Classical Methods ( correction based algorithms)
 Uses beam data measured in water, and applies simple correction
factors for irregularities in surface contour and they also correct for
organ inhomogeneities to account for varying electron densities of
organs, in contrast to the uniform electron density of a water
phantom.
 These methods are rarely used in modern era radiotherapy

 The three most commonly used methods, applicable for angles of

incidence up to 45º for megavoltage X ray beams and up to 30º for
orthovoltage X ray beams, are:
 The effective SSD method;

 The TAR or TMR method;

 The isodose shift method.

B. Model based algorithms
 For conventional treatment techniques the correction
based algorithms work reasonably well and produce
reliable dose distributions; however, for the new
sophisticated treatments such as 3-D conformal
radiotherapy and intensity modulated radiotherapy
(IMRT), they become problematic, because of the radical
corrections that are required for these techniques.
 Model based algorithms hold great promise for the
future.
 Modern treatment planning systems use computer
models to calculate dose.
 In order from least sophisticated to most sophisticated, the
common computer models are:
 Pencil beam (PB) kernel: Only accounts for central axis of the
beam.
 Superposition/Convolution method: Also accounts for lateral
inhomogeneities.
 Collapsed Cone method: Also accounts for lateral
inhomogeneities.
 Analytical anisotropic algorithm (AAA)

 Accuros

 Monte Carlo:The most accurate and computationally intensive

algorithm.
 The details of computer based models are beyond the scope of
this lecture
EFFECTIVE SOURCE TO DISTANCE
METHOD
EFFECTIVE SOURCE-TO-
SURFACE DISTANCE
METHOD

 Uses a SSD/PDD calculation and

corrects for depth in tissue.
 the effective SSD method consists of
sliding the isodose chart down so that
its surface line is at Sʼ, reading off the
percent dose value at A and
multiplying it by the inverse square
law factor to give the corrected
percent depth dose value
 The above method applies the same
way when there is excess tissue above
A instead of tissue deficit. In such a
case, the isodose chart is moved up so
that its surface line passes through the
point of intersection of the contour
line and the ray line through A. The
value of h is assigned a negative
value in this case.
 The parameter h is the thickness of missing tissue, while the
parameter –h represents the thickness of excess tissue.
 The resulting PDD is normalized to 100 at point P on the
central beam axis.
TAR RATIO( OR TMR ) METHOD

Uses a TAR correction factor based on the thickness of tissue excess or tissue
deficit.

where T stands for tissue-air ratio or tissue-maximum ratio and rA is the field
size projected at point A (i.e., at a distance of SSD + d + h from the source).

P corr = P ʼ.CF
ISODOSE SHIFT METHOD

 Uses a “shift factor” to move the

isodose lines based on tissue
excess or deficit
 In the isodose shift method, the
value of the dose at S is shifted on
a vertical ray line by (h × k), where
h is the thickness of the missing or
excess tissue and k is a factor
depending on beam energy.
 The factor k is smaller than 1 and
has a value of 0.7 for 60Co beams
to 5 MV beams, 0.6 for 5–15 MV
beams and 0.5 for 15–30 MV
beams.
 For missing tissue h is positive and
the isodose is shifted away from
the source, while for excess tissue
h is negative and the isodose is
shifted towards the source
MISSING TISSUE COMPENSATION .2
Many relatively simple techniques have been devised to compensate for missing
tissue, most notably the use of wedges, bolus materials and compensators.
Wedge filters :
 used to even out the isodose surfaces for photon beams striking relatively flat
patient surfaces under an oblique beam incidence.
 A wedge produces a sloped isodose distribution with less dose on one side (the
heel) and more dose on the other (the toe).
 Two types of wedge filter are in use:

 Physical wedges are a wedge-shaped piece of metal. made of lead, brass or steel.
When placed in a radiation beam, they cause a progressive decrease in the
intensity across the beam and a tilt of isodose curves under normal beam
incidence.
 Dynamic wedges :(soft-wedge )is a software program that moves the

collimator jaw in a calibrated fashion to produce a wedge-shaped dose

distribution.
provide the wedge effect on isodose curves through a closing motion of a
collimator block during irradiation.
 Physical wedges generate scatter. Non-physical wedges do not.
The wedge angle
 The angle through which an
isodose curve at a given
depth in water (at which the
central axis crosses the 50%
isodose line ,if E > 6
MVusually 10 cm) is tilted at
the central beam axis under
the condition of normal beam
incidence.
 Physical wedges are usually
available with wedge angles
of 15º, 30º, 45º and 60º;
dynamic wedges are available
with any arbitrary wedge
angle in the range 0–60º.
 The wedge (transmission) factor (WF) is defined as the
ratio of doses at zmax in a water phantom on the beam
central axis with and without the wedge.
 WF depends on beam energy, wedge angle, field size and
depth.
 BE VERY CAREFUL WITH WF! Any error can cause a
serious dosimetric error and mistreatment.
 Wedges may be used with parallel opposed fields to
compensate for a sloping patient contour:
 Breast Tangents
 Neck Laterals
 Thorax AP/PA.
 Wedge pair : very common radiotherapy beam
arrangement
This technique is used to create a homogeneous field with
non-opposed beams.

Remember the direction of the wedges: Heels together.

Three field box:
• (Wedged laterals and PA) uses
wedges to compensate for an
“unbalanced” beam .
Heels toward the “unbalanced”
beam.
• Optimal wedge angle depends
on many factors including
beam weights.
• No easy equation, use
computer planning to
determine the angle.
• This technique is used to treat
a box-shaped field while
avoiding the use of an anterior
beam.
• This may decrease bowel dose
when treating the pelvic
tumors.
Hot spots and wedging.
The “optimal”
wedge angle produces three
very small hot spots, while
“underwedging” or
“overwedging” results
in much larger hot spots.
Bolus
 is a tissue equivalent material placed directly on the skin
surface to even out the irregular patient contour and
thereby provide a flat surface for normal beam
incidence.
 In principle, the use of bolus is straightforward and
practical; however, it suffers a serious drawback: for
megavoltage photon beams
 it results in the loss of the skin sparing effect in the skin
under the bolus layer (i.e. skin sparing occurs in the
bolus).
Bolus material and its effect on the skin dose
Compensators are used to produce the same effect as the bolus
yet preserve the skin sparing effect of megavoltage photon
beams.
 They are custom-made devices that mimic the shape of the
bolus but are placed in the radiation beam at some 15–20 cm
from the skin surface so as not to disrupt the skin sparing
properties of the beam.
 Although compensators may be made of water equivalent
materials, they are usually fabricated from lead or special low
melting point alloys, such as Cerrobend (Lipowitz’s metal)
 Cerrobend is a mixture of lead (26.7%), bismuth (50%), zinc
(13.3%), and cadmium (10%) that melts at 70ºC has an HVL
of 1.3
CORRECTION FOR INHOMOGENITY

 The effects of inhomogeneities on radiation dose distributions depend

on the amount, density and atomic number of the inhomogeneity, as
well as on the quality of the photon beam, and may be separated into
two distinct categories:
 Increase or decrease in the attenuation of the primary beam, which
affects the distribution of the scattered radiation;
 Increase or decrease of the secondary electron fluence.

 Three separate regions, in addition to inhomogeneity boundaries, are

considered with regard to inhomogeneities:
(1) the point of interest P located in front of the inhomogeneity;
(2) P inside the inhomogeneity;
(3) P beyond the inhomogeneity
 Boundaries

Interface effects.
When a photon beam encounters an inhomogeneity, hot and cold spots
occur due to differences in secondary electron production.
Doses at an inhomogeneity interface are difficult to calculate or measure
accurately, but several of the algorithms can handle inhomogeneities
.
 In region (1), in front of the inhomogeneity, especially for
megavoltage photon beams, the dose is not affected by the
inhomogeneity.
 In region (2) the dose is mainly affected by changes in the
secondary electron fluence and to a lesser extent by changes
in the primary beam attenuation in the inhomogeneity.
 Four empirical methods are available for correcting the water
phantom dose to estimate the dose at points in region (3):
 The TAR method;

 The power law TAR method;

 The equivalent TAR method;

 The isodose shift method.

 Beyond healthy lung (density ~0.3 g/cm3) the dose in
soft tissues will increase, while beyond bone (density
~1.6 g/cm3) it will decrease in comparison with dose
measured in a uniform phantom.
 Typical corrections for dose beyond healthy lung are:
4%, 3%, 2% and 1% per centimeter of lung for 60Co
beams and 4, 10 and 20 MV X rays, respectively.
 The shielding effect of bone depends strongly on the
beam energy;
 appreciable at low X ray energies because of a strong
photoelectric effect
 negligible in the low megavoltage energy range
because mainly Compton effect .
 High at energies above 10 MeV because of the increase
in the pair production cross-section.
 Reduction in dose beyond 1m of hard bone,-3.5,-3,-2 for
CO60,4MV,10MV respectivly.
Any question
 SSD setup

MU = Desired Dose
K x ISF x PDD x Sc x Sp x WF x TF
PDD:
It is the ratio, expressed as a percentage, of the absorbed dose on the
central axis at depth d to the absorbed dose at the reference point d0.
 SAD setup

MU = Desired Dose
K x ISF x TMR x Sc x Sp x WF x TF
K=output factor ISF=inverse square factor
The output factor for a given field size is defined as the ratio of the dose
rate at the depth of maximum dose for a given field size to that for the
reference field size (usually 10 X10 cm) at its d.max