Int. J. Cancer (Radiat. Oncol. Invest): 96 (Suppl.

) 125–130 (2001) Publication of the International Union Against Cancer

© 2002 Wiley-Liss, Inc.

Doses Near the Surface during Total-body

Irradiation with 15 MV X-Rays
1
A. Kassaee, * Y. Xiao, Ph.D.,2 P. Bloch, Ph.D.,1 J. Goldwein, M.D.,1
Ph.D.,
D.I. Rosenthal,1 and B.E. Bjärngard, Ph.D.1
1
Department of Radiation Oncology, Hospital of the University of Pennsylvania,
Philadelphia, Pennsylvania
2
Department of Radiation Oncology, Thomas Jefferson University, Philadelphia,
Pennsylvania

SUMMARY An extended source–surface distance (SSD) is often employed in total-body

irradiation (TBI) to obtain fields sufficiently large to encompass the total body. It is
clinically desirable to administer a uniform dose to all tissues, including the surface,
especially to counteract the skin-sparing of high-energy X-rays. The electrons generated
from the air contribute more to the dose near the surface at extended distances than at
regular SSDs. However, if further increase of the dose at shallow depths is desired a
spoiler can be employed. Monte Carlo simulations were used to study these effects for the
electron component of the beam and the parameters needed for the pencil-beam dose
calculation of this component. Measurements were performed to confirm these studies.
The energy spectrum of electrons generated in air is independent of SSD. All the electrons
in the beam, however, originate from the spoiler when one is used. The spectrum of these
electrons is nearly independent of the SSD. The pencil-beam dose kernels were calculated
using the derived electron spectra. To calculate doses in the buildup region with and
without a spoiler, we use one pencil-beam kernel for the electrons generated in air and one
for the electrons generated from the spoiler. Measured depth-dose data agreed with the
calculation results. © 2002 Wiley-Liss, Inc.

Key words: surface dose; extended SSD; TBI; pencil-beam kernel

INTRODUCTION small children. This dose depends on the source–

Total-body irradiation (TBI) is used for the purpose of
achieving total malignant cell kill and for immuno-
suppression. The technique is being used with in-
creasing frequency as a component of preparatory
regimens for bone-marrow reconstitution of patients
with refractory malignancies, including leukemia,
non-Hodgkin’s lymphoma, and neuroblastoma [1]. In
order to attain uniform dose throughout the whole
body, high-energy photon beams are often employed.
Sometimes it is necessary to increase the dose to the
superficial tissues to kill the circulating cells close to
the skin surface, especially for thin patients and for
surface distance (SSD), field size, and the photon-
beam energy [2]. It can be increased with a beam
spoiler [3– 6], the effects of which are determined by
the atomic number, the thickness of the spoiler, field
size, and the spoiler-to-surface distance (STSD)
[6 – 8]. The electrons generated in the spoiler have a
wide angular distribution and modify the dose at
shallow depths both inside and outside the photon
beam [9,10]. Previous studies of spoilers have been
limited to SSDs of approximately 100 cm [6 – 8,11],
which we here extend to the long SSDs used for TBI.
For short SSDs, 80 –100 cm, the electrons gen-
erated in air contribute little to the dose near the

*Correspondence to: Alireza Kassaee, Ph.D., Department of Radiation Oncology, 3400 Spruce Street, 2 Donner,
Philadelphia, PA 19104. Phone: (215) 662-6204; Fax: (215) 349-5978; E-mail: Kassaee@xrt.upenn.edu
Received 7 May 2001; Revised 21 September 2001; Accepted 2 October 2001
DOI 10.1002/ijc.10349
Published online 14 March 2002 in Wiley InterScience (www.interscience.wiley.com).
126 Kassaee et al.: Dose Near Surface for TBI
Fig. 1. Geometrical configuration for Monte Carlo calcu-
lations. The spoiler consists of a 1-cm thick water-equiva-
lent plate. Source–surface distance (SSD) ⫽ 100, 300, 500
cm, and spoiler-to-surface distance (STSD) ⫽ 1, 30, 100
cm.
surface compared to those originating in the acceler-
ator head [12–14]. At longer SSDs, the relative con-
tribution from electrons generated in air increases
with increasing irradiated air volume and ultimately
dominates as the head-generated electrons are lost
[14].
In this study, our objective was to evaluate the
electron component at long SSDs generated in air and
from a spoiler. We focused on the following ques-
tions: 1) Is a spoiler necessary or are the “contami-
nating” electrons produced in the head and in air
sufficient? 2) How can one easily determine a kernel
for the incident electrons to be used for dose calcula-
tions?
MATERIALS AND METHODS
Monte Carlo Studies
A 15-MV X-ray beam, produced by a Varian 2100
C/D linear accelerator, was selected for this study.
The photon spectrum of this beam had been deter-
mined previously by Monte Carlo simulations using
the manufacturer’s design of the target and flattening
filter [11]. From this spectrum, the spectrum and the
fluence of the contaminating electrons were calculated
using the cylindrical option Cyltran of the Integrated
Tiger Series (ITS3/PC) of coupled electron-photon
Monte Carlo transport code [15,16]. The geometry
shown in Figure 1 was employed, with the following
parameters: 1) the circular field has a radius of 50 cm
at 500 cm from the source; 2) a 0.5-cm thick lead
plate positioned 10 cm from the X-ray target is used
to simulate a source of “contaminating electrons” in
the accelerator head; 3) the SSD is 100 cm, 300 cm,
or 500 cm, and this volume is either air or vacuum; 4)
a spoiler consisting of 1 cm of water-equivalent ma-
terial is positioned at 1, 30, or 100 cm (STSDs) from
the water phantom.
The electron fluence and spectrum in water were
evaluated on the central axis of the beam for the three
geometries shown in Figure 1. The variation of the
electron energy fluence with distance from the central
ray was determined with air and vacuum between the
lead plate and the water and, in the case of air, with
and without the spoiler. The sampling volumes were
1 cm high circular annuli with 5-cm radial increments.
The Monte Carlo simulations employed approxi-
mately 8 ⫻ 106 histories, with photon and electron
cutoffs of 0.01 and 0.1 MeV, respectively.
With the electron spectrum derived, a pencil-
beam energy-deposition kernel for the electron com-
ponent in the photon beam was calculated. The kernel
was incorporated in a previously described dose-cal-
culation algorithm [11]. This kernel was used to cal-
culate the depth dose in the superficial region due to
electrons generated in air or in spoiler for similar
geometries.
Measurements
The dose was measured at shallow depths with a
parallel-plate ionization chamber (Capintec Model
PS-033) having 0.5 cm3 air volume and 0.5 mg/cm2
window thickness. The collimator setting (field size
100 cm from the source) was 40 ⫻ 40 cm2 A solid-
water phantom (30 ⫻ 30 cm2 entrance area, 15 cm
depth) was surrounded with acrylic plates for a total
volume of 100 ⫻ 50 ⫻ 30 cm2 Depth dose was
measured for a 15-MV photon beam for SSDs of 300
and 500 cm, with and without a beam spoiler. The
STSD was 10, 20, or 30 cm. The ion-chamber re-
sponse was corrected for the secondary electrons scat-
tered from the side-wall of the chamber [17] as de-
scribed by Gerbi and Khan [18]. This correction was
approximately 2% at the surface and 0.3% at a 7-mm
depth.
RESULTS
Monte Carlo Simulations
Electrons Generated in Air
The calculated electron spectra 500 cm from the
source in vacuum and air are shown in Figure 2. The
sources of these “contaminating” electrons are both
the lead plate (simulating the flattening filter) and the
intervening air. The figure demonstrates that electrons
generated in air shift the spectrum towards lower
energies. Additional calculations indicated that the
electron spectrum does not change with distance for
SSD greater than 300 cm. The electron fluence times
the square of the distance from the lead plate is shown
in Figure 3 for intervening air and vacuum. In the
latter case, the electron fluence obeys the inverse
square law, with the lead plate being a well-defined
source of electrons. However, in air the electron

Fig. 2. Monte Carlo generated electron spectra in air and
in vacuum 500 cm from the source.
Fig. 3. Electron fluence ⫻ L2 in air (circles) and in
vacuum (squares) as a function of distance L from the lead
plate used to simulate the treatment head. The error bars
represent the standard deviation in the Monte Carlo simu-
lations. The normalization point is at 1 cm from the lead
plate.
fluence exceeds that from the lead, as electrons are
generated along the air path.
Variation of Electron Spectrum with Distances
Monte Carlo results showed no significant change of
the contaminating electron spectrum as a function of
SSD with the spoiler in the beam. Thus, the electrons
generated in the accelerator head and the air are
virtually completely absorbed in the spoiler, which
produces the entire electrons incident on the phantom.
The electron spectra at the surface of a phantom with
500 cm SSD and STSD of 1, 30, and 100 cm are
shown in Figure 4.
An energy-deposition kernel for the electrons
from the spoiler at a fixed 500-cm SSD was generated
by taking a weighted linear combination of kernels for
monoenergetic electrons. The weights of the monoen-
Kassaee et al.: Dose Near Surface for TBI 127
Fig. 4. Electron spectrum as a function of distance from
the 1-cm thick spoiler with spoiler-to-surface distances
(STSD) of 1, 30, 100 cm without the phantom.
Fig. 5. Calculated depth dose, normalized to 5 mm depth,
for the contaminating-electron component using the con-
taminating-electron kernels at 1 (circles) and 30 cm
(squares) from the spoiler.
ergetic electrons corresponded to the electron spectra
at the phantom surface, with STSDs of 1 and 30 cm.
The kernel was incorporated in a superposition dose-
calculation algorithm [11] and then was used to cal-
culate the depth dose for the contaminating electrons.
Figure 5, in which the doses are normalized to 0.5 cm
depth, demonstrates that the depth dose of the elec-
trons is nearly independent of distance from the
spoiler for depths greater than 3 mm.
Electron Fluence Profile
The in-air electron fluence profiles with or without a
spoiler, shown in Figure 6, were calculated with the
Monte Carlo program, with air between the source
and the phantom with an SSD of 500 cm. For calcu-
lation with the spoiler, the STSD was 30 cm and the
electron fluence profiles are calculated in air at 1 and
5 cm from the spoiler. Contaminating electrons from
the accelerator head were neglected by removing the
128 Kassaee et al.: Dose Near Surface for TBI

Fig. 7. Measured depth doses for open beams (symbols,

Fig. 6. Variation of in-air electron fluence from central
ray at 5 cm from a spoiler located 400 cm away from the
source (solid line and symbols) and without the spoiler
(solid line).
dashed curves) at source–surface distance (SSD) ⫽ 100 cm
(triangles), 300 cm (squares), and 500 cm (diamonds). Mea-
sured depth doses with a spoiler at spoiler-to-surface dis-
tance (STSD) ⫽ 30 cm (solid curve), SSD ⫽ 300 cm
(squares), and 500 cm (not shown, overlaying the one for
SSD ⫽ 300 cm).

lead plate in the beam for the Monte Carlo simula-

tions. The profile 5 cm from the spoiler is shown in
Figure 6, together with the profile without the spoiler
at the same distance from the source. When the
spoiler is used, the profile of contaminating electrons
is flatter inside the beam, with a sharper fall-off at the
edges. These are consequences of the angular spread
of the electrons: when the spoiler is used the electrons
from it have little opportunity to diverge and the
characteristics of the flat, sharply collimated photon
beam are reflected by the electron fluence. Corre-
spondingly, the penumbra broadens with increasing
distance from the spoiler. For example, at 1 and 5 cm
from the spoiler, the penumbra region (90 –10%) is
14.3 cm and 16.3 cm, respectively. Fig. 8. Measured depth doses (upper curves) for 500 cm
The contaminating electrons have limited range source–surface distance for open beam (diamonds) and
and they influence the dose distribution only near the spoiled beam with spoiler-to-surface distance (STSD) ⫽ 30
surface. At 3-cm depth in water, the approximate cm (triangles) and 10 cm (squares), normalized to 6 cm
depth, and the difference in depth dose (lower curves)
depth of dose maximum, the profiles from photons between the open and spoiled beams with STSD ⫽ 30 cm
alone and with electrons generated in air and the (triangles) and 10 cm (squares).
spoiler were the same within ⫾1%. Hence, although
some contaminating electrons may reach the depth of
increase with decreasing spoiler-phantom distance,
dose maximum, they do not influence the dose profile
but these changes do not extend to depths greater than
at this or greater depths.
0.3 cm. Also shown in the figure is the difference in
Results of Measurement the depth doses between the open field and with the
The measured depth doses in the buildup region for an spoiler in place. At depths greater than 3 mm, the
irradiated area of 100 ⫻ 50 cm2 are shown in Figure differences with STSD are insignificant.
7 for 300 and 500 cm distance to the source with and
without the spoiler 30 cm above the phantom surface. DISCUSSION
The depth doses are normalized to a 6-cm depth. For In an X-ray beam without a spoiler, the contaminating
an open field, the dose at the surface and in the electrons are originated in the accelerator head (here,
buildup region increases at longer SSDs but is nearly the lead plate) and in the irradiated air. The electrons
independent of the SSD with a spoiler. Figure 8 shows from the accelerator head are degraded in energy by
that the measured depth doses in the buildup region the intervening air (Fig. 2). The number of electrons

Fig. 9. Energy-deposition kernels for electrons generated
from air (left) and electrons generated from the spoiler
(right). The curves are for fractions of energy deposited.
generated in air increases simultaneously (Fig. 3) and
at an SSD of 500 cm there is 3.4 times as many
electrons generated in air as from the simulated ac-
celerator head for a 15-MV beam. In Figure 7, the
measured depth dose at the surface at 500 cm SSD is
nearly twice that at 100 cm. Since air-generated elec-
trons dominate at extended SSD, the spectrum of the
electrons is nearly independent of the distance from
the source beyond 300 cm from the source. Thus, a
single pencil-beam kernel, shown in Figure 9, can be
used for calculating the dose due to electrons gener-
ated in air regardless of the distance from the source
When a spoiler is inserted in the beam, most of
the electrons originated in the accelerator head are
absorbed in or scattered away by the spoiler [4,7,8].
Figure 7 shows that 1 cm water-equivalent material
eliminates nearly all electrons produced upstream.
Instead, the electrons generated by photon interac-
tions in the spoiler appear in the beam. The electron-
fluence characteristics downstream of the spoiler are
approximately independent of the distance to the
source, as shown for the electron spectrum (Fig. 4).
Therefore, this permits the use of a single pencil-beam
kernel to calculate doses for these electrons. This
kernel is shown in Figure 9.
In Figure 4, there is a larger fraction of low-
energy electrons present near the spoiler. These low-
energy electrons dissipate energy and are lost to the
beam at larger spoiler phantom distances. Electrons
from the spoiler have limited range and affect the dose
only close to the surface, down to the depth of max-
imum dose (Fig. 7).
The broad, roughly Gaussian directional distri-
bution of the electrons generated in air and the accel-
erator head manifests itself at shallow depths as a
large dose-profile variation inside the beam and a
broadened penumbra [1] (Fig. 6). When a spoiler is
introduced these electrons are absorbed, resulting in
the flat profile and the sharper beam edge that just
below the spoiler characterize the collimated X-ray
beam. Further away from the spoiler, however, the
penumbra width at shallow depths is larger due to the
wide angular spread of electrons from the spoiler.
Kassaee et al.: Dose Near Surface for TBI 129
As shown in Figure 7, 500 cm (0.65 g/cm2) of air
is not sufficient to achieve full electron equilibrium
for a 15-MV photon beam, although the fractional
surface dose increases significantly at the extended
SSDs. If further increase in surface dose is desired, a
spoiler can be employed. This absorbs the electrons
generated in the accelerator head or in air but pro-
duces new ones that, if the spoiler–skin distance is not
too large (ⱕ30 cm), effectively provide electron equi-
librium at the surface.
Can we extrapolate the findings to beams of
other energies? To answer this question the same
Monte Carlo analysis was performed for a 6-MV
X-ray beam. Depth doses in the water phantom were
obtained for an air column and with a spoiler in the
beam with similar geometries used for the 15-MV
beam. The results were similar to those obtained for
the 15-MV beam with surface percent dose 80% and
95% without and with the spoiler, respectively, for an
SSD of 500 cm and an STSD of 30 cm. In general, the
dose due to contaminating electrons emanating from
the spoiler depends on the clinical photon beam en-
ergy, STSD field size, and spoiler thickness.
CONCLUSION
In TBI treatment with high-energy photons without a
spoiler at typical distances of 300 –500 cm from the
source, the air-generated electrons are a dominant
source of contaminated electrons. The dose in the
buildup region at these extended distances are signif-
icantly greater than the standard treatment distances
of 80 –100 cm. At SDD of 300 cm and greater, the
electron spectrum is nearly independent of distances
and could be represented with a single pencil-beam
kernel for dose calculations. Depending on the desired
dose in the superficial tissues, these electrons gener-
ated in air may be sufficient enhancement to satisfy
the dose prescription requirements. However, if full
dose relative to dose at the depth of maximum is
required, the use of a beam spoiler is warranted. With
a beam spoiler, the dose in the buildup region is
increased, depending on the STSD, field size, beam
energy, and spoiler thickness and material. Use of a
beam spoiler in the beam with a thickness of about
half of the electron range effectively stops the elec-
trons generated in air. The spoiler becomes the new
source of contaminating electrons. At the typical
STSDs of 10 –30 cm, the electrons generated within
the spoilers traveling downstream are nearly indepen-
dent of STSD and therefore a single pencil-beam
kernel for the contaminating electrons component
may be used for dose calculations. This approxima-
tion results in errors of less than 1% for depths greater
than 3 mm (Fig. 5). If the dose very close to the
surface needs to be precisely known, the contaminat-
130 Kassaee et al.: Dose Near Surface for TBI
ing electron kernel needs to be calculated using finer
energy bins down to 0.2 MV and finer depth incre-
ments less than 1 mm.
A spoiler increases the dose at the surface by a
significant amount, depending on the distance be-
tween the spoiler and surface. The dose profile at the
phantom surface with a spoiler is flatter inside the
beam and sharper at the edges compared to that from
air-generated electrons. The profile at the surface at
extended SSD depends on SSD and spoiler–phantom
distance, which needs to be measured for clinical
beams, especially when matching fields are used.
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