Zachary Casto 1

Zachary Casto

March 13, 2020

DOS 522: Radiation Dose Calculations

45° Dynamic Wedge Transmission Factor Calculation

Objective: To measure and calculate the transmission factor for a 45° dynamic wedge, perform a
hand calculation showing the implementation of the found wedge factor (WF), compare the
wedge monitor unit (MU) calculation to one without a wedge factor, and then apply it to a
clinical scenario.

Purpose: Wedges are a beam modifying device that allows a dosimetrist to further shape the
dose distributions delivered by the treatment machine. Two clinical scenarios where the use of a
wedge would be warranted are: 1) Tissue compensation. A wedge can compensate for tapering
the body contour irregularities leading to a more uniform dose distribution. 2) Multiple fields.
Wedges can help reduce the hotspots caused by adjacent fields overlapping.1

It is important to note that two types of wedges exist, physical wedges (PW) or an
enhanced dynamic wedge (EDW). A physical wedge is a piece of high-density metal, such as
steel or lead, that is mounted to a tray and then inserted into the head of the gantry by a radiation
therapist.1 Physical wedges are also commonly referred to as external wedges. On the contrary,
enhanced dynamic wedges are internal wedges. EDW’s produce the desired dose distribution by
moving one of the jaws across the field while the beam is on. The thick end of the wedge is
called the “heel” and the thin end is called the “toe.” Majority of machines can create/mimic four
wedge angles: 15 degrees, 30 degrees, 45 degrees, and 60 degrees. One must understand that the
wedges angles are not the physical angles of the wedge, but the angle between the slanted
isodose line and a line perpendicular to the central axis of the beam.2

The main purpose of this study will be to evaluate a 45-degree wedges transmission
factor using a 15 MV photon beam. It is crucial to include a wedge transmission factor into a
monitor unit (MU) calculation to ensure the patient is receiving the proper dose prescribed by the
physician due to the wedge's attenuation principles and decreased output of the machine when its
placed in the beams path.3 If the wedge transmission factor is left out of the calculation and a
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wedge is still used for treatment, the patient will be underdosed. Inversely, if the treatment
calculation included a wedge transmission factor but the wedge was left out of the treatment
field, the patient will be overdosed.

Method and Materials: Data was collected using a Varian True Beam linear accelerator
calibrated using a source to axis distance (SAD) technique that delivers 1cGy/1MU to dmax, at a
10cm depth, for a 10x10cm field size. I used a 9cm thick slab of solid water (tissue equivalent)
blocks on top of a 1cm thick slab that encased a farmer ion chamber for adequate electron build
up anteriorly, with 10cm thick solid water slabs posterior to the ion chamber to ensure the
backscatter component was independent of the treatment table. The gantry was set at 0 degrees
of rotation, 100 SSD to the solid water (110cm distance at depth), and a 90-degree collimator
rotation. The farmer ion chamber was plugged into an electrometer that was set to a bias voltage
of 300V in order to collect the charges in nanocoulombs resulting from irradiation. Image one
found below illustrates the in-room setup.

Image 1; In-room setup

Outside of the treatment room, the machine was placed into service mode so that 100 MU
could be delivered at a dose rate of 600 MU per minute. Next, I opened the pc electrometer
application and selected a +300-bias voltage. Prior to exposure, the jaws were confirmed to be
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set for a 10x10cm field size, and the collimator was at 90 degrees. Three reading were conducted
for each photon energy the machine could produce (6MV, 10MV, 15MV), and then the three
readings per energy were averaged to give the average charge collected. This process was
followed for both the open field with no wedge, and then for 45-degree wedged field. This data
was then used to calculate the wedge factor for use in the monitor unit calculations.

Results: The tables below show the data collected by the electrometer for all the trials
conducted. The averages were obtained by summing all three readings per energy and dividing
by the sample size (3). The wedge factor was then obtained for each energy by following the

equation using the averages for the readings. For

Table 2; beam data with a 45-degree out wedge in the field

Discussion: The average wedge factor ratio for 6MV, 10MV, and 15MV beams on a Varian
True Beam linear accelerator were .7678, .8000, and .8117 respectively. The measured wedge
factor ratios are under 2% to those listed in the calibration data tables for this machine found
during commissioning and quality assurance. It is important to see that a percentage of the beam
is attenuated when a wedge is placed into the field. For example, looking at the 6MV beam,
23.22% of the primary beam is attenuated by the 45-degree EDW. If the wedge factor is not
considered in a monitor unit calculation, the patient will be severely underdosed if the wedge is
still being used for treatment. In order to deliver the prescribed dose, an increase in monitor units
will be needed. It is important to also note that the wedge factor ratio increases with increasing
energy, decreases with increasing wedge angles, and decreases with increasing field size due to
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scattering. A wedge too is an example of a beam hardener since it attenuates some of the lower
energy photons.1,2,3

Clinical Application: An isocentric three field prone pelvis (PA, RLat, LLat) treatment plan was
created to illustrate the effects of a wedged pair planning approach. The prescription called for a
total dose of 4500cGy to be delivered over 25 fractions making it 180cGy per fraction. I chose to
use a 45-degree EDW on both the right and left lateral fields, with no wedge on the PA, 15 MV
photon energy, and a weighting scheme of 50% from the PA field, and then 25% each from the
lateral fields. Each field was treated with a standard 10x10cm field size and 100SAD. The
following hand calculations were completed using the above parameters for both a wedged field
and then a non-wedged field (table 3 on the next page), and then they were compared to the
treatment planning systems MU calculations which are found in images 2 and 3. The equivalent
pathlength was found using the TPS script developed by our physicists as well as the TMR and
SCP data tables used for this calculation and the wedge factor was taken from Table 2 above for
a 15MV beam.

The percent differences calculated at the bottom of Table 3 below shows an 18.4%
difference between the monitor units of the right and left lateral fields for a wedged pair vs no
wedge. This indicates that the patient would be underdosed by 18.4% if the wedge factor was not
included in the MU calculation, but the patient was still treated with a wedge due to its
attenuation principles. An underdose of this magnitude is of clinical significance when the goal
is to deliver a therapeutic dose within a 5% tolerance of the prescribed dose.4 One can also see
that there is a difference of 28 MU’s between the wedged fields vs non-wedged fields treatment
plans.
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Table 3; MU Hand Calculation

Image 2; TPS MU Calculation with 45-degree EDW

Image 3; TPS MU Calculation without EDW

Image 4; axial slice of prone patient showing the 45-degree EDW’s and dose distribution

Image 5; axial slice of prone patient with no wedges and dose distribution
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Conclusion: Wedges, both physical and dynamic, are a commonly used beam modifying device
that a dosimetrist will use to optimize the target volume dose distribution. It is important to
remember that whenever a wedge is used for treatment planning, it must be accounted for in the
MU calculation due to its attenuation and beam hardening principles. Should a patient be treated
with a wedge that wasn’t accounted for in the MU calc, the patient would be underdosed. On the
contrary, should a patient be treated without a wedge that was accounted for in the MU calc, the
patient will be overdosed. Also, one must remember that the wedge factor itself is dependent
upon the wedge angle, beam energy, and field size.
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References

1. McDermott PN, Orton CG. The Physics & Technology of Radiation Therapy.
Madison, WI: Medical Physics Publishing; 2010.
2. Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. 4th
ed. St. Louis, MO: Elsevier Mosby; 2016.
3. Khan FM, Gibbons JP. Khans the Physics of Radiation Therapy. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016.
4. “Determination of absorbed dose in a patient irradiated by beams of x- or gamma-
rays in radiotherapy procedures,” International Commission on Radiation Units
and Measurement Bethesda Report 24, 1976.