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Nick Piotrowski 2/14/13 Attenuation Project Objective: When a radiation therapy treatment is taking place, highly accelerated x-rays, or photons enter the patient. Within the body, these photons are attenuated through different types of interactions.1 It would be detrimental to many organs if the beam was solely attenuated by the body. For this reason, the industry has developed ways to attenuate the photon beam before it ever reaches the patient. Through the use of multileaf collimators (MLCs), blocks, wedges, and other beam modifiers, we are now able to limit the dose to the critical structures surrounding the tumor. To create treatment plans that behave in this fashion, it is important that medical dosimetrists fully understand how these devices will change the way a photon beam acts. Materials: The best way to learn how these interactions and concepts work, is to see it firsthand. To see the attenuation of a photon beam, a plan was designed to measure dose both with and without a beam absorber. However, before moving forward with this calculation, I first had to make a decision as to what type of attenuator I was going to test. When looking at our current patient plans, I determined that wedges would be a good representation of beam attenuation. While they essentially have the same concept, there is a crucial distinction between enhanced dynamic wedges and the more archaic physical wedge. For the purpose of calculations, with the enhanced dynamic wedge being in the head of the gantry, there is no need for a tray factor. Being more advanced, most of the plans nowadays use the enhanced dynamic wedges, but the wedge angles still vary from patient to patient. The angle of wedge is the key determinant in how steep the isodose lines are tilted towards the central axis.2 When looking at a wedge, the heel, or thicker portion of the wedge, is used to attenuate more of the beam.2 On the other side, the toe, allows more radiation to be transmitted, creating the tilted wedge effect.2 Clinical Application: After looking through numerous patient plans, I decided on testing the wedges for a patient in which we are treating her left flank. With the tumor protruding out of the body, it made it an easy candidate for a tangential plan. When creating a plan of this nature, it is easy to accumulate hot spots along the lateral edge of the body. When an unmodified beam passes through her body, the thin portion of the body allows less attenuation and therefore more

dose accumulation. The main purpose for using wedges in treatment planning is to compensate for tissue differential.2 In order to equally distribute the dose across this tangential plan, the heel of the wedges can help attenuate some of the beam that the thin portion of the body could not do on its own. However, the addition of these wedges brings about extra complexity to the calculation process. Anytime a wedge is added to a plan, the output of a beam is decreased, creating the need for a wedge factor.3 Simply put, this wedge factor is a ratio of the dose with versus without the wedge at a certain depth along the central axis.3 In order to measure this wedge factor for our tangential plan, we set up a quality assurance procedure. As seen in Table 1, with the use of an ion chamber we were able to measure the output dose for the actual plan. Before implementing the wedges, we first recorded the output dose for an open field at a given depth at the central axis. Once the standard was set, we implemented the 30 degree enhanced dynamic wedges and recorded the dose once again. After recording all the measurements, we were able to take the average of the doses with the wedge, and divide it by the average of the doses without the wedge. As seen at the bottom of the dose calculation sheet, the resulting ratio representing our wedge factor, will be less than one as the output has indeed decreased. Table 1: Output of fields with and without wedges LAO Open Field 1 Open Field 2 Open Field Average Wedge Field 1 Wedge Field 2 Wedge Field Average 28.82 nC 28.83 nC 28.825 nC 26.64 nC 26.66 nC 26.65 nC RPO 24.93 nC 24.94 nC 24.935 nC 22.79 nC 22.81 nC 22.80 nC

Discussion: While some plans are more complex and require more than two wedges, each monitor unit (MU) calculation needs to be performed in the same way. As seen on the dose calculation form, the prescribed dose for each field often differs, creating the need for multiple calculations. In this case, the prescribed doses are divided by the tissue maximum ratio, off-axis ratio, output factor, and lastly the wedge factor. In both the left anterior oblique (LAO), and

right posterior oblique(RPO), the MUs were increased due to the wedge factor. To get to the dose that was decreased by the wedge to match the unmodified dose, the MUs had to be driven up. These MUs that were the finished product of the calculation will be used for each field during the treatment of our tangential patient. The MU calculation that was used is as follows. The prescribed dose was divided by the product of the wedge factor (WF), the tissue maximum ratio (TMR), and off-axis ratio (OAR). For the LAO the equation was set up below. MU= 142.1 centigray (cGy) .925 x .910 x 1.0 Conclusion: While most of the calculations that take place in treatment planning today are performed by computer software, it is still crucial that dosimetrists fully understand this concept. Besides just the possibility of computer malfunctions, doing hand calculations is the only way to know that the calculation was done correctly. There are times in emergency situations where there is no time for a computer calculation. It is the responsibility of the physicist and dosimetrist to make sure these patients are treated correctly with the proper factors in place. Whether it is a wedge, block, or open field, we must all know the accurate calculations to keep our patients safe from possible mistreatment.

References 1. Bentel GC. Dose determination for external beams. In: Bentel GC, ed. Radiation Therapy Planning. 2nd ed. Columbia: McGraw-Hill; 1996:49-53. 2. Khan FM. Interactions of ionizing radiation. In: Khan FM. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010:58. 3. Khan FM. Treatment planning In: isodose distributions. In: Khan FM. The Physics of Radiation Therapy. 4th ed. Baltimore, MD: Lippincott Williams and Wilkins; 2010:183184.