Mantle Lab Handout

Introduction
The purpose of this activity is to understand how to calculate the off-axis dose points for a
mantle field beam arrangement. This handout will you take you through some of the calculation
steps and provide you with the tools to answer the questions in Canvas.
Throughout this handout you will see references to questions you will have to answer. All these
references will be bolded.
A patient with Hodgkin’s Lymphoma to be treated with full mantle irradiation. The physician
prescribes 20Gy to be treated in 10 fractions. The field arrangement will be equally weighted
AP/PA, 6X, prescribed at the isocenter to the 100% isodose line. The linear accelerator is
calibrated to deliver 1.0 cGy per MU at 100 cm SSD, 10x10 cm2, and 1.5cm depth. The field
arrangement and beam geometry (X/Y jaws) are stated below in Figure 1, and the blocked field
can be evaluated using Figure 3 and Figure 4 for the anterior and posterior fields; respectively.
MLCs cannot be used for the blocks, and physical blocks must be used to account for the
irregular nature of the blocking required. The photon blocks block out 25% of each field’s area.
The blocking tray factor is 0.97. The SSDs and depths for each calculation point is shown in
Table 2. The off-axis distances are in Figure 5. Use the data tables attached, along with the
supplemental figures, for your calculation.

Calculation Methods
Let’s begin by writing out what we are given.
Table 1. Given problem information.

Known:
Beam Energy 6MV
Field Width 35.2cm
Field Length 22cm
Blocked area % 25%
𝑇𝐹 0.97
𝑆𝑆𝐷0 100cm
𝑑0 1.5cm
𝐷0 1.0 cGy/MU

To start we will find the MU required to deliver 200 cGy to CAX given the field and patient
parameters. Given it is a rectangular field we will start by calculating the equivalent square using
sterling’s approximation Eq ( 1 ).
4 ∗ 𝐴𝑟𝑒𝑎 4∗𝑙∗𝑤
𝐸𝑞 𝑆𝑞 = =
𝑃𝑒𝑟𝑖𝑚𝑒𝑡𝑒𝑟 2 ∗ 𝑙 + 2 ∗ 𝑤
Eq ( 1 )
Let’s plug in our measurements which is 35.2cm by 22cm.

4 ∗ 35.2𝑐𝑚 ∗ 22𝑐𝑚
𝐸𝑞 𝑆𝑞 =
2 ∗ 35.2𝑐𝑚 + 2 ∗ 22𝑐𝑚

3097.6𝑐𝑚2
𝐸𝑞 𝑆𝑞 = = 27.08𝑐𝑚
114.4𝑐𝑚

Now that we have the equivalent square, we can account for the blocking using Eq ( 2 ). This
method is an approximation.

𝐵𝑙𝑜𝑐𝑘𝑒𝑑 𝐸𝑞 𝑆𝑞 ≈ 𝐸𝑞 𝑆𝑞 ∗ √%𝑜𝑝𝑒𝑛
Eq ( 2 )

We are given the blocks account for about 25% of the field’s area. Therefore, we can deduce
that 75% of the field is open.

𝐵𝑙𝑜𝑐𝑘𝑒𝑑 𝐸𝑞 𝑆𝑞 = 27.08𝑐𝑚 ∗ √0.75 = 23.5𝑐𝑚

Let’s look at the MU equation Eq ( 3 ). The source to point distance 𝑆𝑃𝐷 is 𝑆𝐴𝐷 when on central
axis, however, if you go deeper or shallower than CAX there is a possibility the 𝑆𝑃𝐷 could be
greater or less than 100 cm. Now that we have the blocked equivalent square field size this will
lead to a difference in the field size used to calculate the collimator scatter 𝑆𝑐 and phantom
scatter 𝑆𝑝 . The collimator scatter factor is a function of the primary collimator system (e.g., x and
y jaws). The field size used to calculate 𝑆𝑐 is 27.08cm and the field size which will be used to
calculate 𝑆𝑝 and 𝑇𝑀𝑅 is 23.5 cm.
𝐷
𝑀𝑈 =
𝑆𝑆𝐷0 + 𝑑0 2
𝐷0 ∗ 𝑆𝑐 ∗ 𝑆𝑝 ∗ 𝑇𝑀𝑅 ∗ 𝑂𝐴𝑅 ∗ 𝑇𝐹 ∗ ( 𝑆𝑃𝐷 )
Eq ( 3 )

Let’s utilize the data provided in Table 2. We will use linear interpolation equation Eq ( 4 ) to
determine the unknown quantities 𝑆𝑐 , 𝑆𝑝 , 𝑇𝑀𝑅, and 𝑂𝐴𝑅. We know the depth at central axis is
9.5 cm and the SSD is 90.5 cm.
𝑦2 − 𝑦0
𝑦1 = 𝑦0 + (𝑥1 − 𝑥0 )
𝑥2 − 𝑥0
Eq ( 4 )

The values for 𝑆𝑐 at 25x25 cm2 and 30x30 cm2 is 1.035 and 1.036 respectively. We are
interested in the 𝑆𝑐 value at a 27.08x27.08 cm2 field size.
 1.036 − 1.035
𝑆𝑐 = 1.035 + (27.08 − 25) ∗
30 − 25

𝑆𝑐 = 1.0354

The respective values for 𝑆𝑝 at 20x20 cm2 and 25x25 cm2 are 1.023 and 1.031. We are
interested in the value of 𝑆𝑝 at a 23.5x23.5 cm2 field size.
1.031 − 1.023
𝑆𝑝 = 1.023 + (23.5 − 20) ∗
25 − 20

𝑆𝑝 = 1.0286

The TMR values will require interpolation at the depth of 9.5 cm and the field size of 23.5x23.5
cm2. To keep things clearer I will use the notation 𝑇𝑀𝑅(𝑟𝑑 , 𝑑) where 𝑟𝑑 is the field size at a
specific depth 𝑑.

𝑇𝑀𝑅(20𝑥20 𝑐𝑚2 , 9 𝑐𝑚) = 0.832

𝑇𝑀𝑅(25𝑥25 𝑐𝑚2 , 9 𝑐𝑚) = 0.842

0.842 − 0.832
𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 9.0 𝑐𝑚) = 0.832 + (23.5 − 20) ∗
25 − 20

𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 9.0 𝑐𝑚) = 0.839

Now we will need the TMR of a 23.5x23.5 cm2 field size at 10.0 cm depth.

𝑇𝑀𝑅(20𝑥20 𝑐𝑚2 , 10 𝑐𝑚) = 0.809

𝑇𝑀𝑅(25𝑥25 𝑐𝑚2 , 10𝑐𝑚) = 0.819

0.819 − 0.809
𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 10.0 𝑐𝑚) = 0.809 + (23.5 − 20) ∗
25 − 20

𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 10.0 𝑐𝑚) = 0.816

We will now find the TMR of a 23.5x23.5 cm2 field size at 9.5 cm depth
 0.816 − 0.839
𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 9.5 𝑐𝑚) = 0.839 + (9.5 − 9.0) ∗
10 − 9

𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 9.5 𝑐𝑚) = 0.8275

The off-axis ratio 𝑂𝐴𝑅 will be 1 as we are on CAX. The tray factor according to the table is 0.97.
Now we can plug in all the information into Eq ( 3 ). The desired dose for the AP field is 100 cGy
as they are equally weighted.

𝐷
𝑀𝑈𝐴𝑃 =
𝑆𝑆𝐷0 + 𝑑0 2
𝐷0 ∗ 𝑆𝑐 ∗ 𝑆𝑝 ∗ 𝑇𝑀𝑅 ∗ 𝑂𝐴𝑅 ∗ 𝑇𝐹 ∗ ( 𝑆𝑃𝐷 )

100 𝑐𝐺𝑦
𝑀𝑈𝐴𝑃 =
𝑐𝐺𝑦 100 + 1.5 2
1.0 𝑀𝑈 ∗ 1.0354 ∗ 1.0286 ∗ 0.8275 ∗ 1 ∗ 0.97 ∗ ( 100 )

𝑀𝑈𝐴𝑃 = 113.5 𝑀𝑈 = 114 𝑀𝑈

The same process will be followed to calculate the MU for the PA field. Keep in mind the depth
slightly changes from 9.5 cm to 9.0 cm. The final MU for the PA field is
𝑀𝑈𝑃𝐴 = 112 𝑀𝑈
**In the assignment on Canvas, you will be asked to calculate some of the factors utilized
to get the MU required for the PA field to the CAX point.
Now that we know the MU for each field, we can rearrange Eq ( 3 ) determine the dose to the
off-axis points.

𝑆𝑆𝐷0 + 𝑑0 2
𝐷 = 𝑀𝑈 ∗ 𝐷0 ∗ 𝑆𝑐 ∗ 𝑆𝑝 ∗ 𝑇𝑀𝑅 ∗ 𝑂𝐴𝑅 ∗ 𝑇𝐹 ∗ ( )
𝑆𝑃𝐷
The two factors which will change per point are 𝑇𝑀𝑅 and 𝑂𝐴𝑅. In this problem all the points are
at 100 cm from the source so the 𝑆𝑃𝐷 will be 100 cm.
Let’s start by solving for the Left Axilla point. We are given (Table 2) the depth for the AP and
PA fields are 9.4 cm, and 8.4cm respectively. The only other piece of information we need is the
distance off axis, refer to Figure 5. The distance in the x direction is 13.0 cm from CAX and 3.04
in the y direction. To get the distance from central axis we can use Pythagorean’s Theorem. The
geometry of which is shown in Figure 1.
 C
A

B
Figure 1. Pythagorean’s theorem geometry.

The equation theorem states:

𝐶 2 = 𝐴2 + 𝐵2
Eq ( 5 )

For our problem, we are given 𝐴 and 𝐵. We need to calculate the off-axis distance 𝐶 and
ultimately the 𝑂𝐴𝑅.

𝐶 2 = 132 + 3.042

To solve for 𝐶 we will take the square root of both sides.

𝐶 = √132 + 3.042 = 13.35 𝑐𝑚

The distance from CAX to the Left Axilla point is 13.35 cm. Looking at the data book table we
have attached to the end of this handout, we see the 𝑂𝐴𝑅 values for 12 cm and 15 cm off axis,
therefore, we will have to interpolate Eq ( 4 ) to our distance of 13.35 cm.
𝑂𝐴𝑅(15𝑐𝑚) − 𝑂𝐴𝑅(12𝑐𝑚)
𝑂𝐴𝑅(13.35 𝑐𝑚) = 𝑂𝐴𝑅(12 𝑐𝑚) + (13.35 − 12) ∗
15 − 12

The 𝑂𝐴𝑅 for 12 cm and 15 cm is 1.026 and 1.021. Therefore,

1.021 − 1.026
𝑂𝐴𝑅(13.35 𝑐𝑚) = 1.026 + (13.35 − 12) ∗
15 − 12
𝑂𝐴𝑅(13.35𝑐𝑚) = 1.024

The 𝑇𝑀𝑅 for the AP field is at 9.4 cm depth and the blocked equivalent field size is 23.5x23.5
cm2. We have values at 9 and 10 cm depth for a 20x20 cm2 and 25x25 cm2 field size.
Fortunately, if you look back, we found that the TMR for both 20x20 cm2 and 25x25 cm2 at 9
and 10 cm depth are shown below.

𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 9.0 𝑐𝑚) = 0.839

𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 10.0 𝑐𝑚) = 0.816
We will find the desired value by performing interpolation.
0.816 − 0.839
𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 9.4 𝑐𝑚) = 0.839 + (9.4 − 9.0) ∗
10 − 9
𝑇𝑀𝑅(23.5𝑥23.5 𝑐𝑚2 , 9.4 𝑐𝑚) = 0.8298

Now we can solve for the dose to the Left Axilla from the AP field.

𝑆𝑆𝐷0 + 𝑑0 2
𝐷𝐴𝑃 = 𝑀𝑈𝐴𝑃 ∗ 𝐷0 ∗ 𝑆𝑐 ∗ 𝑆𝑝 ∗ 𝑇𝑀𝑅𝐴𝑃 ∗ 𝑂𝐴𝑅 ∗ 𝑇𝐹 ∗ ( )
𝑆𝑃𝐷𝐴𝑃

We will use the collimator and phantom scatter factors we calculated earlier, 𝑆𝑐 = 1.0354 and
𝑆𝑝 = 1.0286.

𝑐𝐺𝑦 100 + 1.5 2

𝐷𝐴𝑃 = 114 𝑀𝑈 ∗ 1.0 ∗ 1.0354 ∗ 1.0286 ∗ 0.8298 ∗ 1.024 ∗ 0.97 ∗ ( )
𝑀𝑈 100

𝐷𝐴𝑃 = 103.1 𝑐𝐺𝑦 = 103 𝑐𝐺𝑦

Once you arrive at this answer, I would often ask myself intuitively does it make sense? The
dose to CAX is 100 cGy from the AP field. The Left Axilla point is less deep in the patient from
the AP perspective and the OAR is greater than 1. Therefore, we would expect the dose to the
Left Axilla point to be greater than CAX.
The same process will be conducted to calculate the dose to the Left Axilla from the PA field.
**In the assignment on Canvas, you will be asked to calculate some of the factors utilized
to get the dose from the PA field to the Left Axilla calculation point.
Figure 2. Axial, sagittal, coronal and BEV for the full mantle field.
Figure 3. AP beam’s eye view with calculation point location
Figure 4. Posterior beams eye view of the calculation points.
 Table 2. SSD and depth data for calculation points.

Isocenter SSD (cm) Depth (cm)

AP 90.5 9.5
PA 91.0 9.0
Left Axilla
AP 90.6 9.4
PA 91.6 8.4
Left Neck
AP 95.5 4.5
PA 95.5 4.5
Low-Mediastinum
AP 89.9 10.1
PA 90.7 9.3
Mid-Mediastinum
AP 92.5 7.5
PA 90.8 9.2
Rt Supraclav
AP 95.0 5.0
PA 93.0 7.0

Mid-Mediastinum

Figure 5. Off axis distances for the calculation points.