The effect of carbon fiber couch inserts on surface dose with beam size variation

Photon beam attenuation characteristics of three commercial radiation therapy treatment couch-tops

Aim

The purpose of the study was to investigate the detailed angularly dependent attenuation characteristics of three different commercial couch-tops: Varian IGRT, Qfix kVue Standard and Qfix kVue Dose Max couch-tops used in radiation therapy.

Materials and methods

The attenuation of photon beams by the treatment couch-tops was measured using a farmer chamber inserted at the centre of a 16 cm diameter cylindrical acrylic phantom for five different photon energies: 6 MV, 6FFF MV, 10 MV, 10FFF MV and 15 MV photon beams. The Varian IGRT couch-top has three different thicknesses thus attenuation measurements were done at the three different longitudinal locations. Measurements were made with the sliding support rails of the Qfix kVue Standard and Qfix kVue Dose Max couch-tops at both ‘rails-in’ and ‘rails-out’ positions. All measurements were taken for several projections through 360° movement of the gantry and for two different field sizes; 5×5 cm2 and 10×10 cm2.

Results and findings

The results indicate that the maximum attenuation of the Varian IGRT couch-top at the thin, medium and thick portions are 5·1, 5·7 and 8·9%, respectively, the Qfix kVue Standard couch with the rails-in and rails-out are 11·2 and 13·7%, respectively, and Qfix kVue Dose Max couch-top with rails-in and rails-out are 9·7 and 13·8%, respectively. The results from this study can be used to account for the couch-top attenuation during radiation treatment planning of patients treated with these couch-tops.

An Update of Couch Effect on the Attenuation of Megavoltage Radiotherapy Beam and the Variation of Absorbed Dose in the Build-up Region

PURPOSE

Fiber carbon is the most common material used in treating couch as it causes less beam attenuation than other materials. Beam attenuation replaces build-up region, reduces skin-sparing effect and causes target volume under dosage. In this study, we aimed to evaluate beam attenuation and variation of build-up region in 550 TxT radiotherapy couch.

MATERIALS AND METHODS

In this study, we utilized cylindrical PMMA Farmer chamber, DOSE-1 electrometer and set PMMA phantom in isocenter of gantry and the Farmer chamber on the phantom. Afterwards, the gantry rotated 10°, and attenuation was assessed. To measure build-up region, we used Markus chamber, Solid water phantom and DOSE-1 electrometer. Doing so, we set Solid water phantom on isocenter of gantry and placed Markus chamber in it, then we quantified the build-up region at 0° and 180° gantry angels and compared the obtained values.

RESULTS

Notable attenuation and build-up region variation were observed in 550 TxT treatment table. The maximum rate of attenuation was 5.95% for 6 MV photon beam, at 5×5 cm² field size and 130° gantry angle, while the maximum variation was 7 mm for 6 MV photon beam at 10×10 cm² field size.

CONCLUSION

Fiber carbon caused beam attenuation and variation in the build-up region. Therefore, the application of fiber carbon is recommended for planning radiotherapy to prevent skin side effects and to decrease the risk of cancer recurrence.

Effects of Siemens TT-D carbon fiber table top on beam attenuation, and build up region of 6 MV photon beam

AIM

This study deals with Monte Carlo simulations of the effects which the 550 TXT carbon fiber couch can have on the relevant parameters of a 6 MV clinical photon beam in three field sizes.

BACKGROUND

According to the reports issued by the International Commission on Radiation Units and Measurements (ICRU), the calculated dose across a high gradient distribution should be within 2% of the relative dose, or within 0.2 cm of the isodose curve position in the target volume. Nowadays, the use of posterior oblique beam has become a common practice. It is clear that, in radiotherapy, the presence of the couch affects the beam intensity and, as a result, the skin dose.

MATERIALS AND METHODS

Firstly, Siemens linear accelerator validation for 6 MV photon beam was performed, and satisfactory agreement between Monte Carlo and experimental data for various field sizes was observed. Secondly, the couch transmission factor for the reference field size and depth was computed, and the skin dose enhancement by the couch was assessed.

RESULTS

The largest impact of the carbon fiber couch effect was observed for the 5 × 5 cm2 field size. Such evaluation has not been reported for this couch before.

CONCLUSION

Despite providing minimal attenuation for the primary radiation, the assumption that carbon fiber couches are radiotranslucent is not valid, and the effects of couches of this type on the transmission factor, and on the skin dose should be carefully investigated for each field size and depth.

Surface dose measurements and comparison of unflattened and flattened photon beams

The purpose of this study was to evaluate the central axis dose in the build-up region and the surface dose of a 6 MV and 10 MV flattened photon beam (FB) and flattening filter free (FFF) therapeutic photon beam for different square field sizes (FSs) for a Varian Truebeam linear accelerator using parallel-plate ionization chamber and Gafchromic film. Knowledge of dosimetric characteristics in the build-up region and surface dose of the FFF is essential for clinical care. The dose measurements were also obtained empirically using two different commonly used dosimeters: a p-type photon semiconductor dosimeter and a cylindrical ionization chamber. Surface dose increased linearly with FS for both FB and FFF photon beams. The surface dose values of FFF were higher than the FB FSs. The measured surface dose clearly increases with increasing FS. The FFF beams have a modestly higher surface dose in the build-up region than the FB. The dependence of source to skin distance (SSD) is less significant in FFF beams when compared to the flattened beams at extended SSDs.

Generation and verification of QFix kVue Calypso-compatible couch top model for a dedicated stereotactic linear accelerator with FFF beams

This study details the generation, verification, and implementation of a treatment planning system (TPS) couch top model for patient support system used in conjunction with a dedicated stereotactic linear accelerator. Couch top model was created within the TPS using CT simulation images of the kVue Calpyso-compatible couchtop (with rails). Verification measurements were compared to TPS dose prediction for different energies (6 MV FFF and 10 MV FFF) and rail configurations (rails in and rails out) using: 1) central axis point-dose measurements with pinpoint chamber in water-equivalent phantom at 42 gantry angles for various field sizes (2 × 2 cm², 4 × 4 cm², 10 × 10 cm²); and 2) Gafchromic EBT3 film parallel to beam in acrylic slab to assess changes in surface and percent depth doses in PA geometry. To assess sensitivity of delivered dose to variations in patient lateral position, measurements at central axis using the pinpoint chamber geometry were taken at lateral couch displacements of 2, 5, and 10 mm for 6 MV FFF. The maximum percent difference for point-dose measurements was 3.24% (6 MV FFF) and 2.30% (10 MV FFF). The average percent difference for point-dose measurements was less than 1.10% for all beam energies and rail geometries. The maximum percent difference between calculated and measured dose can be as large as 13.0% if no couch model is used for dose calculation. The presence of the couch structures also impacts surface dose and PDD, which was evaluated with Gafchromic film measurements. The upstream shift in the depth of dose maximum (dmax) was found to be 10.5 mm for 6 MV FFF and 5.5 mm for 10 MV FFF for 'Rails In' configuration. Transmission of the treatment beam through the couch results in an increase in surface dose (absolute percentage) of approximately 50% for both photon energies (6 MV FFF and 10MV FFF). The largest sensitivity to lateral shifts occurred at the lateral boundary of the rail structures. The mean magnitude (standard deviation) of the deviation between shifted and centered measurements over all field sizes tested was 0.61% (0.61%) for 2 mm shifts, 0.46% (0.67%) for 5 mm shifts, and 0.86% (1.46%) for 10 mm shifts.

A practical method of modeling a treatment couch using cone-beam computed tomography for intensity-modulated radiation therapy and RapidArc treatment delivery

The effect of a treatment couch on dose perturbation is not always fully considered in intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT). In the course of inverse planning radiotherapy techniques, beam parameter optimization may change in the absence of the couch, causing errors in the calculated dose distributions. Although modern treatment planning systems (TPS) include data for the treatment couch components, they are not manufactured identically. Thus, variations in their Hounsfield unit (HU) values may exist. Moreover, a radiotherapy facility may wish to have a third-party custom tabletop installed that is not included by the TPS vendor. This study demonstrates a practical and simple method of acquiring reliable computed tomography (CT) data for the treatment couch and shows how the absorbed dose calculated with the modeled treatment couch can differ from that with the default treatment couch found in the TPS. We also experimentally verified that neglecting to incorporate the treatment couch completely in the treatment planning process might result in dose differences of up to 9.5% and 7.3% for 4-MV and 10-MV photon beams, respectively. Furthermore, 20 RapidArc and IMRT cases were used to quantify the change in calculated dose distributions caused by using either the default or modeled couch. From 2-dimensional (2D) ionization chamber array measurements, we observed large dose distribution differences between the measurements and calculations when the couch was omitted that varied according to the planning technique and anatomic site. Thus, incorporating the treatment couch in the dose calculation phase of treatment planning significantly decreases dose calculation errors.

Dosimetric effects of immobilization devices on SABR for lung cancer using VMAT technique

The purpose of this study was to investigate the dosimetric effects of immobilization devices on the dose distributions of stereotactic ablative radiotherapy (SABR) for lung cancer using volumetric‐modulated arc therapy (VMAT) technique. A total of 30 patients who underwent SABR for lung cancer were selected retrospectively. Every patient was immobilized using Body Pro‐Lok with a vacuum bag customized for each patient body shape. Structure sets were generated to include the patient body inside the body structure with and without the immobilization device. Dose distributions, with and without the immobilization device, were calculated using identical VMAT plans for each patient. Correlations between the change in dose‐volumetric parameters and the MU fraction of photon beams penetrating through the immobilization device were analyzed with Pearson correlation coefficients (r). The maximum change in D95%,D100%, and the minimum, maximum and mean dose to the planning target volume (PTV) due to the immobilization device were 5%, 7%, 4%, 5%, and 5%, respectively. The maximum changes in the maximum dose to the spinal cord, esophagus, heart, and trachea were 1.3 Gy, 0.9 Gy, 1 Gy, and 1.7 Gy, respectively. Strong correlations were observed between the changes in PTV D95%, the minimum, the maximum, and the mean dose to the PTV, the maximum dose to the esophagus and heart, and the MU fractions, showing values of r higher than 0.7. The decrease in dose to the target volume was considerable for lung SABR using VMAT technique, especially when MU fraction was large.

PACS number: 87.55.‐x

Depth dose comparison of measured and calculated dose for the Eclipse virtual carbon couch top models with air gap variation

This study assessed the accuracy of Eclipse™ (Varian Medical Systems, Palo Alto, CA, USA) treatment planning system (TPS) dose calculations when using virtual couch top models to account for couch presence in patient treatments. The Flat panel and Unipanel couch tops for the Varian Exact Couch were used in this study. Assigned Hounsfield unit (HU) for the virtual couch tops were varied and TPS calculated dose was compared to measured data to determine an optimal assigned HU. Air gaps of up to 10 cm were introduced between couch and phantom to assess the ability of the models to replicate dose in this situation, commonly seen clinically. Dose was measured at a range of depths, for each air gap thickness, in order to assess the model both near surface and at various depths beyond the dose maximum. Optimal HU was taken to be that which had the best agreement between measured and calculated dose over the range of gaps and depths tested. For the Flat panel couch top this was found to be -500 HU and for the Unipanel couch top, -200 HU. Default HU parameters originally set in the models was found to be not optimal for the whole range of depths studied. With optimal HU parameters set, there was good agreement between calculated and measured dose for depths greater than 0.5 cm, but discrepancies were still observed near surface. When implementing virtual couch top models, users could improve dose calculation accuracy by determining the optimal HU from comparisons over several clinical depths rather than a single depth.

Confirmation of Skin Doses Resulting from Bolus Effect of Intervening Alpha-cradle and Carbon Fiber Couch in Radiotherapy

In this study, we verified the treatment planning calculations of skin doses with the incorporation of the bolus effect due to the intervening alpha-cradle (AC) and carbon fiber couch (CFC) using radiochromic EBT2 films. A polystyrene phantom (25 × 25 × 15 cm3) with six EBT2 films separated by polystyrene slabs, at depths of 0, 0.1, 0.2, 0.5, 1, 1.4 cm, was positioned above an AC, which was ~1 cm thick. The phantom and AC assembly were CT scanned and the CT-images were transferred to the treatment planning system (TPS) for calculations in three scenarios: (A) ignoring AC and CFC, (B) accounting for AC only, (C) accounting for both AC and CFC. A single posterior 10 × 10 cm2 field, a pair of posterior-oblique 10 × 10 cm2 fields, and a posterior IMRT field (6 MV photons from a Varian Trilogy linac) were planned. For each radiation field configuration, the same MU were used in all three scenarios in the TPS. Each plan for scenario C was delivered to expose a stack of EBT2 films in the phantom through AC and CFC. In addition, in vivo EBT2 film measurement on a lung cancer patient immobilized with AC undergoing IMRT was also included in this study. Point doses and planar distributions generated from the TPS for the three scenarios were compared with the data from the EBT2 film measurements. For all the field arrangements, the EBT2 film data including the in vivo measurement agreed with the doses calculated for scenario (C), within the uncertainty of the EBT2 measurements (~4%). For the single posterior field (a pair of posterior-oblique fields), the TPS generated doses were lower than the EBT2 doses by 34%, 33%, 31%, 13% (34%, 31%, 31%, 11%) for scenario A and by 27%, 25%, 22%, 8% (25%, 21%, 21%, 6%) for scenario B at the depths of 0, 0.1, 0.2, 0.5 cm, respectively. For the IMRT field, the 2D dose distributions at each depth calculated in scenario C agree with those measured data. When comparing the central axis doses for the IMRT field, we found the TPS generated doses for scenario A (B) were lower than the EBT2 data by 35%, 34%, 31%, 16% (29%, 26%, 23%, 10%) at the depths of 0, 0.1, 0.2, 0.5 cm, respectively. There were no significant differences for the depths of 1.0 and 1.4 cm for all the radiation fields studied. TPS calculation of doses in the skin layers accounting for AC and CFC was verified by EBT2 film data. Ignoring the presence of AC and/or CFC in TPS calculation would significantly underestimate the doses in the skin layers. For the clinicians, as more hypofractionated regimens and stereotactic regimens are being used, this information will be useful to avoid potential serious skin toxicities, and also assist in clinical decisions and report these doses accurately to relevant clinical trials/cooperative groups, such as RTOG.

Skin dose during radiotherapy: a summary and general estimation technique

The skin dose associated with radiotherapy may be of interest for clinical evaluation or investigating the risk of late effects. However, skin dose is not intuitive and is difficult to measure. Our objectives were to develop and evaluate a general estimation technique for skin dose based on treatment parameters. The literature on skin dose was supplemented with measurements and Monte Carlo simulations. Using all available data, a general dosimetry system was developed (in the form of a series of equations) to estimate skin dose based on treatment parameters including field size, the presence of a block tray, and obliquity of the treatment field. For out‐of‐field locations, the distance from the field edge was also considered. This dosimetry system was then compared to TLD measurements made on the surface of a phantom. As compared to measurements, the general dosimetry system was able to predict skin dose within, on average, 21% of the local dose (4% of the Dmax dose). Skin dose for patients receiving radiotherapy can be estimated with reasonable accuracy using a set of general rules and equations.

PACS numbers: 87.53.‐j, 87.53.Bn, 87.55.ne

Increased beam attenuation and surface dose by different couch inserts of treatment tables used in megavoltage radiotherapy

The use of solid carbon fiber table materials in radiotherapy has become more common with the implementation of image‐guided radiotherapy (IGRT), since the solid materials give less imaging artifacts than the so‐called tennis racket couchtops. The downside of the solid carbon fiber couch inserts is that they increase the beam attenuation, resulting in increased surface doses and inaccuracies in determine the dose in the patient. The purpose of this study was to evaluate the interaction of 6 and 15 MV photons with eight different couch inserts. The presented results enable direct comparison of the attenuation properties of the studied couchtops. With a direct posterior beam the maximum attenuations reach 3.6% and 2.4% with 6 and 15 M V, respectively. The measured maximum attenuation by a couchtop with an oblique gantry angle was 10.8% and 7.4% at 6 and 15 MV energies, respectively. The skin‐sparing effect was decreased substantially with every couchtop. The highest increases in surface doses were recorded to be four‐ and threefold, as compared to the direct posterior open field surface doses of 6 and 15 MV, respectively. In conclusion, the carbon fiber tabletops decrease the skin‐sparing effect of megavoltage photon energies. The increased beam attenuation and skin doses should be taken into account in the process of treatment planning.

PACS number: 07.90.+c

The effect of the carbon fibre insert for the Varian Exact™ couch on the attenuation and build-up of high energy photon beams

Carbon fibre couch inserts are widely used in external beam radiotherapy to provide rigid and lightweight patient support. Carbon fibre is often perceived to be essentially radiotranslucent implying that it does not interfere with the radiation beam. However, there is evidence in the literature which suggests that this perception may not be appropriate, particularly at oblique angles of incidence. Furthermore, there is evidence indicating that the use of carbon fibre significantly reduces the skin sparing effect. In this study, the radiation attenuation and surface dose enhancement characteristics of the carbon fibre insert for the Varian ExactTM couch have been investigated. It was found that attenuation increased significantly with increasing angle of incidence, resulting in in-phantom dose reductions of up to 6% at 6 MV and 4% at 15 MV. It has been shown that it is possible to model couch attenuation on a commercial treatment planning system (Elekta CMS XiO) by including the carbon fibre insert in the planning computed tomography (CT) dataset. Finally, the carbon fibre insert was found to significantly increase skin dose to the patient. The skin dose was approximately three times as large when the couch insert was added to 6 and 15 MV photon beams. However, even with this substantial increase it is highly unlikely that the skin tolerance dose will be exceeded.

Characterization of dose impact on IMRT and VMAT from couch attenuation for two Varian couches

In intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT), the use of posterior oblique beams has become common. Beam attenuation by the treatment couch is not negligible when the couch is in the beam portal. In this study, we established the relationship of relative dose vs. beam angle for two Varian 21EX linacs, one equipped with the Exact couch (standard couch) with sliding side support rails, and the other equipped with the Exact image-guided radiation therapy (IGRT) carbon fiber couch. Measurements were performed using an ion chamber placed at the center of an acrylic cylindrical phantom positioned at the linac isocenter for 6 MV and 18 MV photon beams. Measurements were performed at three different field sizes (3 × 3, 5 × 5, and 10 × 10 cm2), and were repeated with the phantom positioned at different longitudinal locations on the couches. To evaluate beam attenuation by the standard couch in a clinical setting, two test IMRT plans and two test VMAT plans on the standard couch were delivered. The plans were generated with the sliding rails at the "in" position and delivered with the rails at both "in" and "out" positions. The dose difference to the ion chamber was determined. For oblique fields with 6 MV photons, the standard couch attenuated the radiation beam by up to 26.8%, while the carbon fiber IGRT couch attenuated the beam by up to 4.1%. In the clinical evaluation, the highest dose difference between rails set at the "in" and "out" positions was 2.6% in the IMRT case and 2.1% in the VMAT case. The magnitude of potential dose difference has been quantified and could be used for a quick estimation of dose difference due to couch attenuation in IMRT and VMAT.

Evaluation of two-dimensional bolus effect of immobilization/support devices on skin doses: a radiochromic EBT film dosimetry study in phantom

PURPOSE

In this study, the authors have quantified the two-dimensional (2D) perspective of skin dose increase using EBT film dosimetry in phantom in the presence of patient immobilization devices during conventional and IMRT treatments.

METHODS

For 6 MV conventional photon field, the authors evaluated and quantified the 2D bolus effect on skin doses for six different common patient immobilization/support devices, including carbon fiber grid with Mylar sheet, Orfit carbon fiber base plate, balsa wood board, Styrofoam, perforated AquaPlast sheet, and alpha-cradle. For 6 and 15 MV IMRT fields, a stack of two film layers positioned above a solid phantom was exposed at the air interface or in the presence of a patient alpha-cradle. All the films were scanned and the pixel values were converted to doses based on an established calibration curve. The authors determined the 2D skin dose distributions, isodose curves, and cross-sectional profiles at the surface layers with or without the immobilization/support device. The authors also generated and compared the dose area histograms (DAHs) and dose area products from the 2D skin dose distributions.

RESULTS

In contrast with 20% relative dose [(RD) dose relative to dmax on central axis] at 0.0153 cm in the film layer for 6 MV 10 x 10 cm2 open field, the average RDs at the same depth in the film layer were 71%, 69%, 55%, and 57% for Orfit, balsa wood, Styrofoam, and alpha-cradle, respectively. At the same depth, the RDs were 54% under a strut and 26% between neighboring struts of a carbon fiber grid with Mylar sheet, and between 34% and 56% for stretched perforated AquaPlast sheet. In the presence of the alpha-cradle for the 6 MV (15 MV) IMRT fields, the hot spot doses at the effective measurement depths of 0.0153 and 0.0459 cm were 140% and 150%, (83% and 89%), respectively, of the isocenter dose. The enhancement factor was defined as the ratio of a given DAH parameter (minimum dose received in a given area) with and without the support device. For 6 MV conventional 10 x 10 cm2 field, the enhancement factor was the highest (3.4) for the Orfit carbon fiber plate. As for the IMRT field, the enhancement factors varied with the size of the area of interest and were as high as 3.8 (4.3) at the hot spot of 5 cm2 area in the top film layer (0.0153 cm) for 6 MV (15 MV) beams.

CONCLUSIONS

Significant 2D bolus effect on skin dose in the presence of patient support and immobilization devices was confirmed and quantified with EBT film dosimetry. Furthermore, the EBT film has potential application for in vivo monitoring of the 2D skin dose distributions during patient treatments.

Determination of the photon beam attenuation by the Brainlab imaging couch: angular and field size dependence

Highly attenuating radiation treatment couches are no longer useful in the present era of radiotherapy utilizing IMRT and IGRT. Carbon fibers couch tops with its high tensile strength and low density present a useful alternative. The objective of the current study was to quantify the attenuation of megavoltage photons through a Brainlab imaging couch top and headrest at various angles and field sizes. At normal incidence, the couch attenuated 6 MV photons by 4.9% and 3.4% for 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. The headrest on the other hand only attenuated 6 MV photons by 2.5% and 1.6% respectively. There was no significant attenuation of the 18 MV beam by either the couch or the headrest. We found the attenuation to be dependent on the gantry angle, with the highest attenuation recorded at 1200. At this angle, the couch attenuated the 6 MV photon beam by 10% and 8.3% for the 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. Similarly, 18 MV photon beam was attenuated by 3.6% and 3.4% for the 5 x 5 cm(2) and 10 x 10 cm(2) field sizes at 1200 gantry angle. The highest attenuation for the headrest on the other hand occurred at 110 degrees gantry angle. For the 6 MV photon beam the headrest attenuation at this angle was 6.3% and 5.6% for the 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. Similarly for the 18 MV the attenuation was 2.3% and 2.1% 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. It apparent that the use of the Brainlab imaging couch and headrest in IMRT with posterior beams will results in significant decrease in the dose delivered to the target.

Investigating treatment dose error due to beam attenuation by a carbon fiber tabletop

Carbon fiber is commonly used in radiation therapy for treatment tabletops and various immobilization and support devices, partially because it is generally perceived to be almost radiotransparent to high-energy photons. To avoid exposure to normal tissue during modern radiation therapy, one must deliver the radiation from all gantry angles; hence, beams often transit the couch proximal to the patient. The effects of the beam attenuation by the support structure of the couch are often neglected in the planning process. In this study, we investigate the attenuation of 6-MV and 18-MV photon beams by a Medtec (Orange City, IA) carbon fiber couch. We have determined that neglecting the attenuation of oblique treatment fields by the carbon fiber couch can result in localized dose reduction from 4% to 16%, depending on energy, field size, and geometry. Further, we investigate the ability of a commercial treatment-planning system (Theraplan Plus v3.8) to account for the attenuation by the treatment couch. Results show that incorporating the carbon fiber couch in the patient model reduces the dose error to less than 2%. The variation in dose reduction as a function of longitudinal couch position was also measured. In the triangular strut region of the couch, the attenuation varied +/- 0.5% following the periodic nature of the support structure. Based on these findings, we propose the routine incorporation of the treatment tabletop into patient treatment planning dose calculations.

The effect of gantry angle on megavoltage photon beam attenuation by a carbon fiber couch insert

The use of rigid carbon fiber couch inserts in radiotherapy treatment couches is a well-established method of reducing patient set-up errors associated with couch sag. Several published studies have described such inserts as radiotranslucent with negligible attenuation of the radiation field. Most of these studies were conducted with the radiation field normally incident on the couch and there appears to be no evidence in the literature of the effect of the gantry angle on the extent of beam attenuation by the carbon fiber insert alone during external beam radiotherapy. In this study we examined the magnitude of this effect over a range of posterior oblique gantry angles using a cylindrical solid water phantom containing an ionization chamber placed isocentrically. It was found that a 6 MV photon beam, field size 10 x 5 cm, was attenuated significantly as the gantry angle approached the plane of the couch, from 2% at normal incidence and reaching 9% attenuation at angle of incidence 70 degrees. This could have serious implications regarding dose to the treatment volume for treatments requiring posterior oblique angles of incidence with a possible correction factor necessary in monitor unit calculations.

Effects of immobilization mask material on surface dose

This work investigates the increase in surface dose caused by thermoplastic masks used for patient positioning and immobilization. A thermoplastic mask is custom fit by stretching a heated mask over the patient at the time of treatment simulation. This mask is then used at treatment to increase the reproducibility of the patient position. The skin sparing effect of mega‐voltage X‐ray beams can be reduced when the patient's skin surface is under the mask material. The sheet of thermoplastic mask has holes to reduce this effect and is available from one manufacturer with two different sizes of holes, one larger than the other. This work investigates the increase in surface dose caused by the mask material and quantifies the difference between the two samples of masks available. The change in the dose buildup was measured using an Attix parallel plate chamber by measuring tissue maximum ratios (TMRs) using solid water. Measurements were made with and without the mask material on the surface of the solid water for 6‐MV and 15‐MV X‐ray beams. The effective thickness of equivalent water was estimated from the TMR curves, and the increase in surface dose was estimated. The buildup effect was measured to be equivalent to 2.2 mm to 0.6 mm for masks that have been stretched by different amounts. The surface dose was estimated to change from 16% and 12% for 6 MV and 15 MV, respectively, to 27% to 61% for 6 MV and 18% to 40% for 15 MV with the mask samples.

PACS number: 87.53.Dq

Two-dimensional measurement of photon beam attenuation by the treatment couch and immobilization devices using an electronic portal imaging device

In our institution, an individualized dosimetric quality assurance protocol for intensity modulated radiotherapy (IMRT) is being implemented. This protocol includes dosimetric measurements with a fluoroscopic electronic portal imaging device (EPID) for all IMRT fields while the patient is being irradiated. For some of the first patients enrolled in this protocol, significant beam attenuation by (carbon fiber) components of the treatment couch was observed. To study this beam attenuation in two-dimensional, EPID images were also acquired in absence of the patient, both with and without treatment couch and immobilization devices, as positioned during treatment. For treatments of head and neck cancer patients with a 6 MV photon beam, attenuation of up to 15% was detected. These findings led to the development of new tools and procedures for planning and treatment delivery to avoid underdosages in the tumor.