Clinical Implementation of

Varian Enhanced Dynamic

Wedges
Nathan L. Childress, Ph.D.
January 27, 2004

Overview
An introduction to enhanced dynamic
wedges (EDWs)
Comparing EDWs to physical wedges
why bother switching?
EDW dosimetry
Using RadCalc and Pinnacle to perform
calculations

When are we getting EDWs?

Soon (around March)
RadCalc must be clinically implemented
before we can clinically use EDWs

EDW introduction

What is a wedge?
A wedge is a device used to modify how
radiation is delivered to the patient
Wedges make one side of the beam deliver
more radiation than the other
Wedges are used when there is less tissue
on one side of the beam (breast, neck) or a
patient is treated with two beams that are
tilted towards each other

Physical wedge

60 wedge vs. no wedge

What is a dynamic wedge?

Traditionally, physical wedges are inserted
into the linac to create a wedged distribution
They are large chunks of metal that block one
side of the beam more than the other
Dynamic wedges do not require anything
placed in the beam. Instead, one jaw moves
towards the opposing jaw during treatment to
create a wedged distribution.

The history of dynamic wedges

1978 Theorized
1991 Varian implemented Dynamic Wedges on its
machines
1996 Varian upgraded to Enhanced Dynamic
Wedges. EDWs can use asymmetric field sizes up
to 30 cm long and have more wedge angles than
DWs.
1997 Siemens introduced Virtual Wedges. No one
has been able to get a machine to run long enough to
measure them.

EDW properties
Maximum field size: X=40 cm, Y=30 cm
for all wedge angles
Allowed wedge angles: 10, 15, 20, 25,
30, 45, and 60
Either Y jaw can move across the field to
create a wedge, but it can only go 10 cm
past the center (this is why the maximum Y
size is 30 cm)

How EDWs work

MUs are delivered to an open field during
the open field phase
Y1 or Y2 starts closing and the dose rate is
modulated during the jaw sweep phase
When delivery is complete, Y1 or Y2 stops
0.5 cm away from the opposing jaw

EDW example
Y1

Y1

Y1

Y1

Y2
Y2
Y2

Y2

MU = 0

100

125

150

How EDWs work

Varian has a Golden STT table that is
used with the wedge angle to calculate
where the Y jaw should be at each MU
The dose rate and the jaw speed are both
modulated during treatment
Pinnacle and RadCalc use this Golden STT
table to calculate dose for EDWs

EDW screenshots

Entering an EDW field

EDW delivery

EDW delivery

EDW delivery

Advantages and disadvantages of

EDWs

Advantages of EDWs
Therapists will not have to walk into the
treatment room to add or change wedges
Management will make more money, as
more efficient treatments mean more
patients per day
Dosimetrists will be able to choose more
wedge angles with larger field sizes to
produce better plans

More advantages of EDWs

Port films can be automatically acquired
during the start of the EDW field
Both Y1 and Y2 can be used to create a
wedge, so opposed fields do not require
collimator rotation
The light field is undisturbed in EDW fields
EDW performance is monitored, recorded,
and displayed automatically

Even more advantages of EDWs

Doctors (the real ones) can sleep easier
knowing that patients are receiving slightly
less total body dose (less MU required)
Physicists dont have to listen to everyone
complain that we dont use dynamic wedges
There is no chance of an EDW falling off
and hitting a patient

Disadvantages of EDWs
Wedges can only be delivered by the Y
jaws, which is perpendicular to the MLC
Field in field or physical wedge techniques
work best with breast treatments

There is a greater possibility of an interlock

interrupting or preventing a EDW treatment

Current MLC breast block

Disadvantages of EDWs
Surface doses are ~2% higher than open
fields, and ~10% higher than physical
wedges
Using a dynamic treatment means that
breathing or other patient motion may alter
dose

EDW dosimetry

60 wedges, 10 cm depth

EDW dose differences

EDWs need 20%-50% less MUs to deliver the
same dose as a physical wedge
EDWs generate about half as much dose outside
the field, because physical wedges act as a source
of scattered photons
Both EDWs and physical wedges deliver the same
dose distribution on different Varian linear
accelerators, so 21EX plans may be temporarily
used to treat patients on a 6EX

EDW dose gradients

30 wedge 0.5%/mm
60 wedge 1%/mm
Just like physical wedges, small setup errors can
translate to large errors in tumor dose
Changing the SSD by 5 mm changes the dose by
1%
As long as these errors are not systematic, the
average dose over the whole treatment will be
correct

How Varian monitors EDWs

After each treatment is delivered, Varian
reports MU and jaw position statistics
Varian also generates Dynalog files with
more detailed information for nerdy
physicists

EDW statistics

Expected EDW accuracy

Standard deviations are typically around
0.01-0.03 cm and 0.03-0.07 MU
Physics should be notified if higher
standard deviations are noticed

New EDW interlocks

IPSN Initial position The current jaw
positions do not correspond with the EDW
field size
DPSN Dynamic position During
treatment, the jaws deviated more than
0.5 cm or the MUs deviated more than 0.3
from from their expected values. The beam
is shut off automatically.

Resuming EDW treatments

If an interlock occurs in the middle of a
EDW treatment, it must be resumed rather
than restarted
The Varian console has a partial treatment
function, just like its IMRT partial treatment

Partial treatments

EDW partial treatment delivery

EDW partial treatment delivery

EDW partial treatment delivery

EDW calculations

Pinnacle EDW calculations

MU calculations are based on measurements
Profile and depth dose calculations are based on
open field measurements plus the Golden STT
table
MU calculations are within ~1% of measured data,
even for large and asymmetric fields
Profiles are within ~1% of the measured data

RadCalc introduction
RadCalc will completely replace the in-house MU
check programs developed by John McGary and
David Bellezza
Plans are transferred from Pinnacle to RadCalc in
one click
Any mistake made in Pinnacle will be made in
RadCalc due to its automatic transmission
RadCalc keeps an electronic database of all MU
calculations

RadCalc screenshot

RadCalc EDW calculations

RadCalc calculates EDW doses using open
field data and the Golden STT table
It does not use EDW measurements, and is
completely independent from Pinnacle
calculations
Its calculations are not perfect they are
accurate within ~3% for large, asymmetric
fields

Total dose uncertainty

2% - Machine calibration
2% - Pinnacle calculations
2% - Patient setup errors
2% - Intrafractional motion
3% - Machine daily output fluctuations
3% - Interfractional motion
Average tumor dose uncertainty over the course of
a full treatment 5% (???)

Conclusions
EDWs have a wide range of advantages
over physical wedges
MU checks must change to RadCalc
Patients will receive better, faster treatments
and less total body dose with EDWs

The End