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1 Dustin Melancon February 21, 2012 Transmission Factor Calculation Couch Transmission Objective: To determine the transmission factor

for a Varian TrueBeam treatment couch. Purpose: In radiation therapy, the beams interactions with matter must be determined to deliver accurate doses. The beam undergoes attenuation as it passes through matter, which is a gradual reduction in the number of photons or exposure rate.1 The Varian TrueBeam carbon fiber couch prevents my clinic site from performing more traditional posterior to anterior (PA) treatment fields. Attenuation factors must be accounted for to deliver an accurate dose. The transmission factor (TF), is determined by the following equation:2 TF = Dose with the object in the beam path Dose without the object in the beam path Specifically, the treatment couch transmission factor is calculated as follows: TF = Dose with the treatment couch in the beam path Dose without the treatment couch in the beam path. Methods and Materials: Couch transmission measurements were made for all three thickness levels using the following parameters: 132 centimeter (cm) source to skin distance (SSD), 10x10 field size, 0 gantry, and 200 monitor units (MU). The carbon fiber couch top from computed tomography (CT) simulation was suspended from ladders on each side of the TrueBeam gantry. A solid water phantom was placed on top of the couch top with an ion chamber inside of it. The beams path passed through the solid water phantom and was measured by an ion chamber (Figure 1). The TrueBeam couch top was then moved over top of the solid water phantom so that the treatment beam would pass through the TrueBeam couch before being measured again by the ion chamber (Figure 2). The ion chamber readings were used to determine the attenuation of the radiation beam as it passed through the treatment couch. For example, with a 6 megavolts (MV) beam, if the ion chambers reading is 18.805 with no couch and 18.483 with the couch, the transmission factor calculation would be: 18.483/18.805 = 0.983 These measured values were then used to compare the accuracy of the attenuation calculation for couch structures in the Varian Eclipse 10.0 treatment planning system (TPS).

2 Eclipse was used to find the maximum difference between the transmission calculated in the TPS and the measured transmission for each couch thickness. Two plans were made in Eclipse, one with the couch contour and another without it. The MU were compared to observe differences in the attenuation. These results were compared with the actual measurements on the linear accelerator.

Figure 1: The carbon fiber couch top from computed tomography (CT) simulation was suspended from ladders on each side of the TrueBeam gantry. The picture shows the solid water phantom on top of the CT simulation couch top to obtain readings without the TrueBeam treatment table.

Figure 2: The carbon fiber couch top from CT simulation was suspended from ladders on each side of the TrueBeam gantry. The picture shows the solid water phantom on top of the couch top to obtain readings with the TrueBeam treatment couch in the beam. Results: The measured values were used to test the accuracy of the transmission values of the couch structures in Eclipse. The Varian TrueBeam couch transmission values for various photon energies are shown in the tables below:

4 Table 1: Ion chamber (IC) readings taken with and without the treatment couch in the 6MV beam path. 6MV No Couch Thin Medium Thick IC Reading Transmission 18.805 18.483 18.413 18.353 1.000 0.983 0.979 0.976

Table 2: Ion chamber (IC) readings taken with and without the treatment couch in the 10MV beam path. 10MV No Couch Thin Medium Thick IC Reading Transmission 19.720 19.465 19.445 19.388 1.000 0.987 0.986 0.983

Table 3: Ion chamber (IC) readings taken with and without the treatment couch in the 10MV Flattening Filter Free (FFF) mode beam path. 10FFF No Couch Thin Medium Thick IC Reading Transmission 19.583 19.257 19.218 19.135 1.000 0.983 0.981 0.977

5 Table 4: Average of ion chamber readings for the couchs various thicknesses in different energies. Energy 6MV 10MV 10FFF Transmission 0.984 0.987 0.985

Discussion: The difference between the transmission calculated in the TPS and the measured transmission for each couch thickness is a maximum of 0.8%. Since the difference was less than 1%, it is negligible for intensity-modulated radiotherapy (IMRT) and the TPSs default attenuation value is used. These measured values would be used if my clinic site decided to treat posterior to anterior (PA) fields on the TrueBeam using a clinical setup and hand calculations. For example, if we were forced to treat with a PA beam on the TrueBeam, we would have to increase our MU by the transmission factor. If we are treating 100 MU without the couch, a transmission factor of 0.984 increases the output to 102 MU if the couch was there. 100 MU = 102 MU 0.984 If these values were not accounted for in a hypothetical treatment situation with PA fields, we would not be giving our patients the prescribed dose. In another discussion, the TrueBeam couch has three different thicknesses over the entire length of the couch. The thinnest part of the couch is at the end closest to the gantry where the head would normally be positioned. The medium thickness is located over the portion of the couch where the chest and abdomen would normally be positioned. The thickest part of the couch is the remainder of the couch from where the pelvis is usually positioned down through the end of the couch away from the gantry. In Eclipse, the three different couches can be inserted into a TrueBeam plan, one representing each of the three different couch thicknesses. However, it was discovered that all three of the virtual couches in Eclipse are programmed with the same transmission factor. In other words, it doesnt matter where the patient is lying on the table as far as Eclipse is concerned.

6 Clinical Application: Since the TrueBeam couch has very little attenuation, we can continue to use Eclipses attenuation factor in the standard couch contour for IMRT planning (Figure 3). These differences come into play clinically by choosing which machine we use for specific patients. Three other linear accelerators in the department with tennis racket-like treatment couches attenuate the beam less than TrueBeam; therefore, we treat patients with simple PA fields on the other linear accelerators.

Figure 3: RapidArc plan with treatment couch contour structure. Conclusion: The TPS takes into account the attenuation of the treatment couch. Inserting a couch contour allows us to calculate dose that actually reaches the patient. My clinic site avoids treating PA fields through the TrueBeam treatment couch, if possible. Three other linear accelerators in the department with tennis racket-like treatment couches treat patients with PA fields.

References 1. Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010. 2. Stanton R, Stinson D. Applied Physics for Radiation Oncology. Madison, Wisconsin: Medical Physics Publishing; 1996.