Chapter 10 THE INTERACTION OF SINGLE BEAMS . OF X AND GAMMA RAYS WITH A SCATTERING MEDIUM 10.01 INTRODUCTION r radiotherapy, one is concerned with the absorbed dose received by tissues in the irradiated volume. Since it is seldom possible to measure this directly, it must be calculated. Because this calculation must be done on a routine basis, itis further necessary that the calculations be simple and reliable. In this and following chapters we will be concerned with defining and illustrating various concepts that are useful in this dose de- termination In Chapter 7 we described in detail methods for determining the ab- sorbed dose ina phantom. These procedures gave us the dose at a refer. ence point. Functions have been developed to enable us to calculate the dose at any other point once the dose at this reference point is known These functions have been developed as a result of a long series of care ful systematic measurements made by many workers over many years For greater clarity the order of presentation we will follow differs from the historical development. Furthermore, although we recognize the im portance of beams of electrons, our discussions are strongly oriented ae the use of photons. Much of the formalism applies equally well 10.02 PHANTOMS When a patient is placed in a photon beam of known quality and quan- tity,:the photons will be absorbed and scattered nel both the qualiand quantity of the beam will be changed. The changes in quality were dealt with in Chapter 8. In this chapter, the changes in quantity will be dis. cussed. To study these changes, experiments have been performed using phantoms to replace the patient. The phantom should be of a materi that will absorb and scatter photons in the same way as tissue |Spiers ($13) ong ago showed that the phantom material should have the same density as tissue and contain the same number of electrons per gram| Wate and wet tissues absorb photons in almost the same way, and for this reason water has been used in many investigations. Since ionization chambers show troublesome leakage effects when damp, water phantoms 336 Functions Used in Dose Calculations 337 introduce some difficulties; to avoid these, dry phantoms have been de- veloped. White has made by far the most extensive study of phantom ma- terials and his papers (W7, H11) should be referred to. For most pur poses, nonetheless, water remains the most practical phantom material. 10.03, FUNCTIONS USED IN DOSE CALCULATIONS, The right side of Figure 10-1 shows a beam of radiation incident on a phantom and the left side shows the same beam with the phantom re- moved. The size of the beam is usually characterized by stating the di- mensions of the rectangular or square field at some specified distance from the source. In Figure 10-1 the field has a width Wy at distance F, or width Wy, at distance (F + dy), or width Wa at distance (F + d). Con- sider wo points on the beam axis: point Y at depth dy: is the point where the dose is maximum, while point X is a point at any depth d. For radia- tions having a half-value layer less than a few mm of Cu (for example radiation generated up to 250 kV,) point Y is on the surface of the phan- tom while for energies above a few hundred keV the maximum dose is below the surface. For cobalt 60 radiation, which is nearly monoenergetic with an energy of 1.25 MeV, dy = 0.5 cm. The depth of maximum dose increases with energy, reaching a value of about 5 cm for a continuous spectrum with peak energy 25 MeV. The points Y’ and X” shown in the left side of Figure 10-1 are at the same positions in space as Y and X but are “in air,” that is, with no phantom present,/To make a statement] about dose in air the points in air must be considered to be s by enough phantom-like material to establish electro: 7.11). After a given irradiation the doses delivered to a small mass of phantom material at these points will be referred to as Dy: (dose at Y") Dy dose at X’), while Dy and Dy are the corresponding doses in the phantom. Four functions—the tissue-air ratio, the backscatter factor, the percentage depth dose, and the inverse square law—may be used to interre- late the doses at these four points. An additional function, tissue-phantom ratio, is specially useful for high energy radiation. The tissue-ai 3) is the ratio of the dose at X to the dose at and is represented b F,(d,Wg he) = Dx/Dx (10-1) It depends on the depth d below the surface of the phantom, the size Wa of the beam measured at depth d, and on the quality of the radiation, represented here by hv. The dependence on these variables is indicated by including them within parentheses after the symbol Ty. At times we are interested in the area of the field at depth d and could then refer to the tissue-air ratio as T,(d,Aq,h»).338 The Physics of Radiology The backscatter factor (B) is the tissue-air ratio for the special case when the depth d is equal to the depth of maximum dose, that is dj. We repre- sent it by B(Wa hy) = Ta(dn,Wauhv) = Dy/Dy , (10-2) The backscatter function gives the factor by which the radiation dose is increased by radiation scattered back from the phantom. The concept was first developed for low energy radiation, where the depth, di, was for all practical purposes equal to zero, so the maximum dose was on the surface. The term has been carried over to high energy radiation even though the point, Y, is no longer on the surface. Since the backscatter factor is a function of field size and quality, we represent it by B(Wm,hv). The percentage depth dose (P) is the ratio of the dose at X to the dose at Y, both points being within the phantom. It is expressed as a percen- tage thus: P(d,Wp,Fhv) = 100 Dx/Dy (10-3) The percentage depth dose depends on the depth d, the width of the beam Wa, the distance F from the source to the surface of the phantom, and on the quality of the radiation hv. Usually the field size is specified at the depth of the reference point, although frequently the surface is also used and W,, in equation 10-3 becomes W,. Since a number of different conventions are used, it is es- sential that the user be aware of the convention that applies to a specific set of data before it is used, otherwise errors in dose calculations will be made. At times it is convenient to relate doses in the phantom to a reference point other than Y—for example Y,, which might be at a depth of 10.0 cm. When this is done, percentage depth doses can exceed 100 and are often referred to as “relative depth doses.” The Inverse Square Law (1): Points X’ and Y' are in air and if there is no attenuating or scattering material between them or near to them, the dose at one point will be related to the dose at the other inversely as the square of their distances from the source (see also section 9.07). That is: F4+dy)* ( tas) (10-4) I(F.d.dy) Dy: iensions of the This function The inverse square relationship is valid provided the source of radiation are small compared to the distance F is independent of beam quality. RELATIONSHIP BerweEN THE FuNcTioNs: The square insert between the two halves of Figure 10-1 illustrate how the doses are related. For example the dose at Y can be obtained from the dose at Y’ by muliply- Functions Used in Dose Calculations 339 Figure 10-1. Diagram to illustrate the meaning of functions that facilitate the calculation. of absorbed dose in a patient or in a phantom, ing by the backscatter factor B along the arrow B. The dose at X can be obtained from that at Y by multiplying by P along the arrow P. Ina simi- lar way the dose at X' is related to that at Y' through the inverse square factor I (vertical arrow 1). Finally the dose at X is related to that at X" by the tissue-air ratio, Ty. By going clockwise around the rectangle we may relate Dx to Dy: thus: Dy. B-P and by going counterclockwise we obtain: Dividing the second equation by the first we obtain the relation between B, P, Ty, and I for a given radiation quality thus: T.(d,Wa) (F + do)? Pd,WaF) (ott 100 = see ( FE 2) (10-5) ‘This is an important relation between the four functions. Before discuss- ing the properties of each of these functions in detail, we will introduce the tissue-phantom ratio. Tissue-Phantom Ratio (,). For high energy radiation, measurements in air such as at point X’ are not practical and tissue-air-ratios are not used. This is chiefly because it would be necessary to supply the dosime- ter with such a large buildup cap that it would not be fully irradiated by340 The Physics of Radiology small area beams. As an alternative, the arrangement shown in Figure 10-2 is used. The right side of this diagram is the same as the right side of Figure 10-1 but only point X is shown. The left side shows a phantom arranged so that point X”, which is the same distance from the source, is at a depth d, below the surface. The tissue-phantom ratio is tHe ratio of the dose at X to the dose at X” thus: . T)(d.d,, Wash) = Dy/Dx- (10-6) This quantity, like T,, depends on the depth d, the field size W,, and on the radiation quality hv. Like tissue-air ratio it does not depend on distance from the source. We have also included dj, the reference depth, within the parentheses because the ratio would also depend on this quan: tity. The field size, Wa, is designated at the position of the point and the same for the two configurations of Figure 10-2. ‘Tissue-phantom ratios may be related to tissue-air ratios through the dose in air, Dy:. Dx = Dy: + Tad, Wash) Dx: = Dy - Ta(d;,Wa,hv) and hence: (10-7) This relation can be seen to be like equ but without the inverse square term. Tissue-phantom ratio can be thought of either as an extension of tis- sue-air ratio where the reference dose in air, Dx., is replaced by one at a reference depth in a phantom, Dy, or as an extension of percent depth ‘ion 10-5 for percent depth dose, Figure 10-2. Diagram to illustrate the meaning of tissue phantom ratio, useful for the Calculation of absorbed dose ina patient ora phantom. ‘Tissue-Aw Ratio ahead doses where the distance to the source is infinite and the inverse square term of equation 10-5 becomes unity. 10.04 TISSUE-AIR RATIO ‘Tissue-air ratio was originally introduced by Johns (J10) in 1953 as “tumour-air ratio.” It was at that time specifically intended to simpl calculations for rotation therapy. In this type of treatment, the patient is located so that the tumor is on the axis of rotation of the machine and the source moves in a circle about this point. The source-to-axis distance isa constant quantity in such motion and so is the size of the beam at the axis. Attention is thereby focused on this point for calculations. Since the time of its introduction it has become more and more widely used, es in dosimetry involving isocentric units. JBecause it is perhaps the radiotherapy calculations, it is intro- ciall {simplest of all the functions used duced first Tissue-air ratio was defined by equation 10-1. Its meaning, as applied to a patient, is illustrated in Figure 10-3. The left side of this diagram shows a circular beam of radiation having cross-sectional area Ay at a distance F, from the source. The beam is in air, and F, is the distance from source to axis. After a given irradiation let the dose to a small mass of tissue on the axis be Dy ‘The solid line contour in Figure 10-3b represents a patient in place being irradiated by the same beam. The depth of tissue overlying the axis is d and the dose at this point, Dx, may be calculated directly by the relation: Dg = Dy: Ta(d,W, hr) (10-1ay Tables of tissue-air ratios for rectangular beams are given in Appendix Figure 10-3, (a and b) Schematic diagram to illustrate the use of tissue-air ratio in dose calculations. (c) The scattering to point X from the cylindrical block of phantom material is the same as from the conical-shaped section when the two beams have the same area at depth d and receive the same primary radiation at X.a The Physics of Radiology B-5d. We illustrate their use by an example. Example 10-1. An isocentric cobalt 60 unit delivers a dose of 1.00 Gy in one minute to a small mass of tissue in air on the axis of the machine at point X’, A patient is introduced into the beam with the center of the tumor at the point X’, The tumor is 10 cm below the skin and, the field size at the point X’ is 10 x 10 cm, Determine the dose to the tumor, ir ratio = 0.709 for a 100 cm? field at From Table B-5d, the tissue- depth 10 cm Hence Dx (eq. 10-1a) = 1.00 Gy x .709 = .709 Gy This calculation makes no mention of rotation therapy, but it is clear how the concept can be used in this context. Suppose at a later instant the position of the patient is as indicated by the dotted contour of Figure 10-3b, so that the overlying tissue is 6.0 cm thick. Table B-5d shows that now T, = 0.867 so that for the same irradiation time the dose delivered to the center of the tumor is .867 Gy. For rotation therapy one would merely average all such dose values. A more usual approach today is t0 direct the beam to the tumor for a few discrete directions and then add up the doses. It should also be noted that in these calculations no mention is made of the source-to-axis distance; this will be discussed in the next section. When tissue-air ratio was first introduced, it was defined in terms of a ratio of exposures: the exposure in the phantom divided by the exposure at the same point in the absence of the phantom. ‘This is certainly a valid procedure but has the disadvantage that it could not be used for high energy radiation since for these the use of exposure is not recommended. ‘The use of absorbed dose also makes tissue-air ratios conveniently con- ‘ent with other functions used for dose calculation, such as percent depth dose. It is also in line with recommendations of the ICRU (17). Effect of Distance from the Source on the Tissue-Air Ratio Experimentally it has been shown that tissue-air ratios are independent of the distance from the source (Fy of Figs. 10-1 and 10-3) at least for di tances of 50cm or mord Figure 10-3c shows two beams, one parallel and the other diverging, which have the same cross-sectional area, Ay, at depth d below the surface of the phantom, They will both deliver the same primary dose since both will be attenuated by the same amount of tissue. If, in addition, the scattered doses to X were the same in both cases, the tissue-air ratio would be the same for both configurations, To test this Johns et al. (J11), using the Klein-Nishina formula, compared the once scattered radiation to point X by the cylindrical block of tissue from the parallel beam to that from the cone-shaped block of tissue from Tissue-Air Ratio 343, the diverging beam. ‘The once scattered radiation proved to be the same to within about 2% for radiations from 100 keV to 1.25 MeV. Since higher orders of scattered radiation would be expected to depend direct- ly on first scattered rad total dos X should be very neatly independent of the distance F fratios can be used for all source distances Variation of Tissue-Air Ratio with Field Size and Depth Typical tissue-air ratio data for cobalt 60 are shown in Figure 10-4 as a function of depth for a selection of field sizes. It should be empha- sized that the field sizes are specified at the depth in question. For exam- ple, point G (Fig. 10-4) is for a field size of 400 em* at 10 cm depth while point H is for a field of 400 cm? at a depth of 20 cm. The curves are near- ly straight lines when plotted on a log scale, showing the variation with depth is essentially exponential 3 cer Pls Sl ae 8 : 05) 400 em? 3 oa 100 : 0 Figure 10-4. Tissue-air ratios ° for “Co as a funcion of depth fora selection of circu lar fields, The areas of these fields are measured at the oey 4 e 1 6 20 24 depth a oesindiom 7 The steepest curve of Figure 10-4 is for zero area. For this case the dose received at a depth d below the surface is due entirely to primary radiation, since the volume that can scatter radiation is zero. If the radia- tion were monoenergetic, or nearly so, like that from cobalt 60, the de- pendence on depth of the tissue-air ratio would be the simple expons tial e~#4=¢») where jis the linear attenuation coefficient for the radiation and the phantom material, and (d — dy) is the thickness of material in the path of the beam in the phantom that is in addition to that in its344 The Physics of Radiology path in free space.* The curve thus starts at depth da, which for cobalt 60 is 0.5 cm and isa straight line (see Fig. 10-4). As the area of the beam is increased, scatter increases, the tissue-air ratio increases, and the curves are no longer straight The dependence of the tissue-air ratio on field size for arconstant depth is shown in Figure 10-5 for “Co. The curves show that the tissue- air ratio increases continuously with field size at all depths. The increase is relatively rapid at first and gradually levels off for very large field sizes The form of this variation is similar for beams of other qualities. os ten Soe em Sar een 8 doe aoen a Figure 10-5. Tissue-air ratio for Co asa function of the field size for a number of depths. The effect of scattered radiation may be demonstrated by calculating the ratio of the total dose at a point to the primary dose. For a cobalt 60 beam and a depth of 20 cm T, = 0.278 for a zero area field and T,, 0.508 for a 20 x 20 cm field (Table B-5c). For this field the primary dose 0.278 and the total dose is 0.503 so the ratio of total to primary in- creases from 1.0 to 0.503/0.278 = 1.8 as the field size is increased. In contrast, for radiation with HVL 1,0 mm Cu, scattering is much more important and the student may show using Table B-5a that the ratio for the same conditions is now over 9.0. Tissue-Air Ratios for Rectangular or Irregular Fields Tables of tissue-air ratios for a wide range of beam sizes and shapes can be prepared from relatively few measurements by using data for cir- cular beams, Such data can be measured direcily as was done by Johns in determining the dose in free space at point X" (Fig. 10-1) we require a mass of tissue that has a radius dy to give maximum elecron buildup, hence the extra tissue thickness in the beam in the phantom i (d = da). (See see. 7.11.) Tissue-Air Ratio 345 (J10) or may be obtained from measurements made in square beams as discussed in section 10.08. Tissue-air ratios for rectangular beams can then be obtained from data for circular beams by the sector integration procedure first introduced by Clarkson (C7). The method will be il- Justrated by determining the tissue-air ratio for a 4 x 15 cm field of co- balt radiation at a depth of 10 cm. Figure 10-6 shows tissue-air ratios for ‘a depth of 10 cm (Table B-5c) plotted as a function of beam radius. The insert shows the 4 x 15 cm field, and radii have been drawn from its center at angles of 5°, 15°, 25°, to 85° so that the rectangular field may be replaced by a series of sectors of circular fields as indicated. The angles, radii, and corresponding tissue-air ratios, read from the graph in Figure 10-6, are shown in Table 10-1. The tissue-air ratio for the rec- tangular field is 0.660. The area of the rectangular field is 4 x 15 = 60 can®, A circular field with this area has a radius of 4.36 cm and gives a tisstie-air ratio of 0.681 for 10 cm depth whereas that for the rectangular field is only 0.660. The rectangular field contributes less scatter to its center than would a circular field of equal area because some of its scat- ter, coming from points near the ends of the rectangle, must travel further than from points near the edge of the circle, The scatter coming from farther away will be attenuated more. Figure 10-6. Diagram to illustrate how a rectangular field can be broken up into a num= ber of sectors allowing one to caleulate the tissue-air ratio, T,, or the percentage depth dose, P, for a rectangular field from the corresponding data from circular fields TABLE 10-1 culation of Tissue-Air Ratio For a4 X 15 Field at Depth 10 cm for Co Radiat Te ee Radius,r, 201 207 221 244 283 349° 478 7.73 7,58 Tal0n), 612 61S G18 62663868690 745 TAB total = 5.942 “Tissue-air ratio for 4 15 em field = 5.942 % 4/86 = 0.660346, The Physics of Radiology A rectangular field, and in fact even a field having an irregular out- line, can be resolved into sectors of circular beams, The tissue-air ratio for a rectangular or irregular beam having a field area A at depth d can be calculated from the equation: taday=4 3 Tyan) ‘C0 where n is the number of sectors in 360°, r, are the radii from the center to the edge of the field at the center of each sector, and ‘T,(d,r,) are the issue-air ratios for circular fields of radius r, at depth d. In Table 10-1 the sectors have an angular width of 10°. Although there are 36 such sectors in 360° only 9 of them need be considered in this example be- cause of symmetry. The accuracy of the calculation is improved by using more sectors with smaller angular widths, but little gain is achieved by going below 10°. Measurement of Tissue-Air Ratios To obtain a tissue-air ratio it is necessary to determine the dose at pairs of points such as X’ and X of Figure 10-1. Both points must be the same distance from the source and be irradiated with beams having the same field size (G10). The most reliable way to make such measurements is by using ionization chambers. Considerations that need to be taken for such measurements are discussed in sections 7.16 and 9.13. It is convenient to clamp the ion chamber in air on the axis of the radiation beam and with the source of radiation turned on for a fixed time note the reading of the instrument, Let it be My:. For the second reading the dosimeter, still at the same point in space, is surrounded by water so that the depth of water above the chamber is d. A new reading, My, is taken for the same exposure time. The tissue-air for that depth and field size is as- sumed to be Mx/Mx:. This is not quite correct since strictly speaking both the numerator and denominator should be multiplied by factors di cussed in sections 7.1] and 7.12. It is usually assumed, however, that these factors cancel, so the ratio of the two readings is considered to be the tissue-air ratio. Readings, Mx, for other depths can be taken by changing the level of the water surface. For a new field size the reading in air must be taken again, since My varies in an unpredictable way with field size. Some additional special precautions must be taken with respect to the reading in air, It is necessary that there be no material in the beam that might contribute scattered radiation to the dosimeter, For some situa- tions, particularly for large field sizes, it is necessary to be surprisingly far from walls or floors that might scatter radiation back to the dosim- eter (V6). L Backscatter Factor 347 Although the above method of measuring tissue-air ratios is direct, they can also be obtained from measured percent depth doses and back- scatter factors using the relations between these quantities given in equa- tion 10-5. All of the early “tumour-air ratios” (J10) were in fact derived in this manner. 10.05 BACKSCATTER FACTOR When the depth, d, of Figure 10-1 is made equal to the depth of maxi- mum dose, the tissue-air ratio reduces to the backscatter factor and is defined by equation 10-2. The top curve of Figure 10-5 (depth dy = 0.5 cm ina beam of cobalt radiation) is also the backscatter factor, Our atten- tion is now focused upon a special reference point within the phantom, and some detailed discussion about this point is in order. The depth at which electronic equilibrium occurs increases from a fraction of a milli- meter for 200 kV radiation to about 5 mm for Co radiation and to about 5 em for 25 MV radiation. The depth, dy, is frequently also thought of as the depth at which electronic equilibrium (see sec. 7.03) occurs. In some situations this is not true. For example, in the 200 kV range the path lengths of electrons set into motion are so small that dj, must be thought of as zero and we can consider the reference point to be on the surface of the phantom (or the skin of the patient). At these energies, however, because of the great amount of scattered radiation (photons rather than electrons) the maximum dose may actually occur about 1 em below the surface for a large field. This is because the increase in scat- tered radiation may, for a short distance, more than compensate for the attenuation of the primary component of the beam. An analogous but very different situation may occur for very high energy radiation. For ex- ample, for a 25 MV beam, for a small field size, the maximum dose may be found experimentally to be at a depth of 4-5 cm while for a large field it may be closer to the surface, perhaps 3 cm. This occurs because for large fields a large component of low energy photons and high energy electrons may be scattered from the inner surfaces of the collimator and cause a dose buildup near the surface. This same behavior can also be observed in “Co beams (L2). The depth of electronic equilibrium cannot, therefore, easily be determined experimentally. ‘The above discussion illustrates that the reference depth, dy, for high energy radiation has a somewhat arbitrary character. When used, there- fore, its magnitude should be stated clearly. ‘The term “backscatter factor” is applied to the tissue-air ratio for depth, da, largely for historical reasons, Backscatter factor was proposed and measured for radiations in the so-called orthovoltage range long before tissue-air ratios were thought of. For these beams, since dm = 0.0, the scatter to the surface is truly backscatter. At high energies, where348 The Physics of Radiology dm > 0, not all photons reachii , ‘ons reaching the reference point are scatter but the term sil continues t0 be used. Pot APE scattered back Backscatter and Beam Quality ‘The variation of backscatter with half-va laye il i ure 10-7. With soft radavon the hathacattes koe ee oF maximum ata half-value layer of about 1.0 mm Cu and then falls slow. ly zero for cobalt 60 (HVL 14.8 mm Cu). Figure 10-7 show: ie variat mn of backscatter with quality for five field sizes ranginy rf a a small eld 7 = ) to a large one (400 cm*). The quality at which the Jax 1m backscatter occurs dey Is on ares large fi Oi imum is shifted slightly towards andes raion Re the max Figure 10-7. Variation of backscatter factor with the quality of the radiation for a number of circular field sizes 05 08081024 8 40 Po Ha oer a o This complicated variation of backscatter with qualit ‘ood by reference to Chapter andthe Klein Nishina formals, Ac love caergies as many tone are scatered forward as backward snd exacty , ingles. This type of scattering is called cla . tering. For soft radiation, the region that can effectively seater radiation {0 a point on the surface is very small because this radiation i quick absorbed in the medium, {The backscatter from low energy xrays thus aoe im and high energies the same amount is scattered for- ward asin the casa case but es an less scattered at right sings on backwards as the energy is increased. At medium energies, although the amount scattered back is small, the region that can effectively scatter to the point i large because of the greater penetrating power of the scat tered radiation, and maximum backscatter is obtained, At high energies, amount scattered backwards is negligible but the reference depth for Percentage Depth Dose 349 “backscatter” is no longer zero and some of the foreward scattered pho- tons can contribute to it. The net scatter is, however, relatively small. 10.06 PERCENTAGE DEPTH DOSE Percentage depth dose interrelates doses at points within a phantom. For example, in equation 10-3 the dose at points such as X (of Fig. 10-1) are related to the dose at the reference point Y. Point Y is often at the depth of maximum dose but can in fact be any chosen point. This func- tion can be applied equally well to high or low energy radiations, depth d Ds 49, Spe arde 7 100° By 108) Pid, Wa, F, hv) = 100 - 228 Example 10-2. A patient is irradiated with a 200 kV (HV 2.0 mm Cu) beam at a source-to-skin distance of 50 cm using a circular 400 cm* field. If the patient's skin is given a dose of 2.00 Gy, determine the doses at depths of 10 em and 1.0 em. P (depth 10, area 400, 50, HVL 2.0) = 46.7 (Table B-2c) P (depth 1, area 400, 50, HVL 2.0) = 102.4 P= Dy _ 46.7 x 2.00 Dyo(eq. 10-3) = “155° = Too 934 Gy gy _ 102-4 x 2.00 D, (eq. 10-3) = F565 2.05 Gy It should be noted that for this particular quality scattering is severe and the dose at 1 cm depth is slightly larger than the surface dose. Dependence of Depth Dose on Depth and Photon Energy Figures 10-8 and 10-9 show the variation of depth dose with depth for a variety of radiations, Figure 10-8 shows the variation for depths up to 16 mm, while Figure 10-9 shows it for depths up to 25 cm. We will first examine the depth dose near the surface. With low energy radiation, as shown by curve A of Figure 10-8 (140 kV), the depth dose decreases with depth from the surface reaching about 80% at 6 mm. The dose from slightly harder radiation (curve B, 200 kV) is almost constant over the depth range shown, More energetic radiation, in the megavoltage range as exemplified by curve C for ®Co, exhibits a rise in depth dose for the first few mm and then reaches a broad maximum that extends over several nm. As the energy is increased still further the surface dose be- comes smaller and the maximum occurs at greater and greater depths. With 22 MV betatron radiation (curve E) the surface dose is less than 20% and the maximum occurs some 4 to 6 cm below the surface. The350 The Physics of Radiology reason for this general behavior was explained in_terms!of electronic buildup” discussed in detail in Chapter 7. With high energy radiation the electrons set in motion by the photon interactions are projected pri- marily in the forward direction; hence, the number of electron tracks will increase with depth until a depth equal to the clectron range i$ reached. From this point on, the dose decreases with depth due to the attenuation lof the photon radiation. The result is that the dose first increases and then decreases. With low energy radiation the range of the electrons is so small that this effect is not observed and the dose falls continuall, with increase in dej Percent segth dose ieee . Depinmm) a Figure 10-8, Percentage depth dose plotted against depth for the region near the surface for a range of photon beam energies. The dosage buildup with cobalt 60 occurs in the first few mm and Jost_ partially or completely if electron contamination is present\ It might be argued that since all the effect occurs in I to 2 mm, it cannot be of importance clinically. However, there is clinical evidence that a real skin sparing effect is achieved if care is taken to preserve this buildup (B12). The whole effect will obviously be lost if the patient's skin is cov- ered by bolus, a cast, or the end of a treatment cone. Figure 10-9 shows the percentage depth dose that may be obtained for low, medium, high, and very high energy photon radiation plotted on a semilogarithmic scale. For all radiation qualities shown,[the curves are straight Tines for points well beyond the position of maximum ndicating that primary attenuation, buildup of scatter, and fall off with inverse square law combine to ‘A useful quantity to use as an index of the penetration of the radia- tion is the depth at which the dose falls to 50% of its peak value. For 22 MV betatron radiation (curve A), this depth is over 22 cm. This curve and this large half-value depth is representative of very high energy Percentage Depth Dose 351 Wage radiation. Curve B, for 8 MV radiation, is considerably less penetrating reaching 50% at a depth of 17 cm. Curves G and D, for 4 MV and Co radiation respectively, have a half-value depth of from 12 to 14 cm. Curve E is typical of the depth doses that may be obtained from a 200 to 250 kV x ray machine and yields a depth dose of 50% at a depth of some 7 to 8 cm. Curve F is typical of the depth dose from a 100 to 140 KV x ray machine giving 50% at a depth of only 1 or 2 cm. Figure 10-9. Graph showing the variation of depth dose with depth: (a) 22 MeV radia tion with copper compensat- ing filer, 10x 10 em field, SSD 70 cm; (b) 8 MV radi tion from a linear accelerator 10x 10 cin field, SSD. 100 cm; (¢) 4 MV radiation from a linear accelerator, 10 x 10 cm field, SSD 100 em; (d) co- balt 60,"10 10 em; (e) 200 kV, 10°x 10 «m field, HVL. 1.5 mm Gu, SSD 50 em; (f) 120 kV, HVL 20 mm Al Area 100 em#, SSD 15 em, Depth Dose Dependence on Field Area When the area of the field is very small the dose Dx (of Fig. 10-1) received at a point below the surface is due entirely to primary radiation, since the volume that can scatter radiation is small. As the area of the field is increased, both Dx, and Dy, at the reference point Y, will increase due to scattered radiation but_the increase will be greater at_greater The variation of percentage depth dose with area depends upon the quality of radiation. This is illustrated in Figure 10-10 where the 10 cm depth dose is plotted against the radius of the field for qualities typical of low, medium, and high energy radiation. The depth dose for zero area is due to primary radiati With large areas the depth dose is due to primary plus scattered radiation. In the case of 25 MV radiation, scatter is very small and the depth dose n alon352 The Physics of Radiology dose rising from 12 to 46% over the range of field sizes shown.|From Figure 10-10, it is evident that high energy radiation offers a big advan- tage over lower energy radiation especially with small fields, 25. MV X10y2,SS0:100em_ : a so} Ri Rim inssorcin | Figure 10-10. Variation of percentage depth dose with area and radius of field for three types of radiation, Depth 10 em, Percentage Depth Dose for Rectangular Fields Percent depth doses for rectangular fields can be obtained from per- cent depth doses for circular fields by the same sector integration pro- cedure described in section 10.04 for tissue-air ratios. The percentage depth dose for a rectangular field of area A can be obtained from: Paar) = 2S Pint) (10-9) where Fis the source-surface distance, P(d,r,,F) is the percent depth dose for a circular field of radius r;, and n is the number of sectors in a com- plete circle. Percent depth dose for circular beams of cobalt 60 radiation, for a depth of 10 cm at an SSD of 80 cm, were plotted in Figure 10-10 against radius. It is left as an exercise for the student to show that the percent depth dose for a4 x 15 cm field using the percent depth doses for circular fields given in Table B-2d and the radii given in Table 10-1 is 52.2%. This value appears in Table B-2e (in the appendix) Percent depth doses are dependent on source-to-surface distance and beam quality and a separate table is required for each of the distances and qualities that are to be used. The method described by equation i Percentage Depth Dose 353 10-9 was used for the preparation of the depth dose tables for rectangu- lar fields given in appendix B-2e and for much of the data tabled in Supplement 11 of the British Journal of Radiology (B13). Percent Depth Dose for Isocentric Machines have isocentric Most modern linear accelerators and cobalt unit mounts and the patient is positioned with the tumor on the axis of rota- tion of the machine. Beams are directed at the tumor from different directions and the source-surface distance and field size at the surface may be different for each beam. The percentage depth dose data di cussed above is not convenient for making dose calculations in such beams. The problem is illustrated by the following example. Example 10-3. A beam from an isocentric cobalt unit is used to irradi- ate a patient as shown in Figure 10-11, Point Y is on the axis of rotation and is a distance of 80.0 cm from the source. The field size at the axis is 10 x 10 cm and this point is at a depth of 12 cm below the surface. Dur- ing a course of treatment point Y receives a dose of 2.5 Gy. Determine the dose at point X that is at a depth of 4 cm 636 (Table B-3d) 510.636 = 3.93 Gy dose in air at point X = 3.93 (80.0/72.0)' = 4.85 Gy Field size at point X = 10.0 (72.0/80.0) = 9.0 em T,(4, 9 x 9), at point X = 0.932 (Table B-5d by interpolation) Dose at point X = 4.85 x 0.932 = 4.52 G: T, for point Y= dose in air at isocenter = Figure 10-11. Diagram show ing two points in a patient ir . radiated by a 10 10 cm beam from an isocentric treatment unit L In solving this problem we made use of two tissue-air Fatios and the inverse square law and combined them in the manner described in sec- tion 10.03. Although this is an accurate and useful way to solve this prob-354 The Physics of Radiology lem, it is not really practical for routine radiation treatment planning purposes where a more direct method is desirable. A direct method using percentage depth doses as discussed earlier in this section requires tables of depth doses for every field size and source-surface distance that might be encountered. This, clearly, is not practical. We can obtain approxi- mate answers using relative depth doses as illustrated in Figure 10-12 where percentage depth doses for 10 x 10 cm fields at a source-axis distance of 80 cm have been computed by the method of example 10-3 for three different source-surface distances. Curve A is for an SSD of 7: cm and the reference point Y is at a depth of 5 cm and thus coincides with the axis of rotation. The abscissa in this diagram is distance along the axis of the beam measured from the axis of the treatment unit. Thus the surface for curve A is 5 cm above the axis of rotation, for curve B it is 10 em above, and so on. Relotve depth dose & AA ee oan A wool i wrens Ai WNT” lc BF sho | t is ‘Rolotve depth dose Figure 10-12. Graph of rela tive depth doses for an iso: ‘centric cobalt unit. Field size is 10 x 10 cm, source axis dis. tance is 80.0 em, Curve A is for SSD =75 cm, B is for eS SSD = 70.cMm, Cis for SSD = Diane trom SAD,em S= 654m, Dis for SSD = 60 cm. We can approximate these curves by a single curve, labelled D, which is within 2% of the accurate curve except for points very near to the sur- face. Their use can be illustrated by again solving the problem of exam- ple 10- Percentage Depth Dose ee Example 10-4. Use the relative depth dose data of Figure 10-12 to solve the problem of example 10-3. Distance from isocenter to point X = 8 cm Relative depth dose = 184% (Fig. 10-12) Dose at point X = 2.5 x 184/100 = 4.60 Gy The answer given in example 10-4 is 1.8% higher than the more ac- curate value given in example 10-3. Relative depth dose data represented by Figure 10-12 are very useful for answering questions like that of ex- ample 10-3 in practical situations. The data are accurate for points 4 to 5 ‘cm below the surface but are less so for points near it, Where there is disagreement, the dose is always overestimated for points nearer to the surface than the reference point and slightly underestimated for points below it. Relative depth dose data for cobalt, SAD SAD = 100 cm, are given in Appendix B-3. 80 cm, and 25 MV data, Measurement of Depth Dose Percentage depth dose may be measured in a number of different s. One way is to move a probe detector along the axis of the beam and record the reading at a number of depths. These readings are then con pared with the reading taken at the reference point to yield the pe centage depth dose. This is a straightforward method but is inaccurate because in most treatment units (other than cobalt) there are random fluctuations of dose rate with time. Under these circumstances, the dose at the depth and the dose at the reference point will be measured at different times and the ratio may be inaccurate. This inaccuracy may be avoided if some comparison chamber or monitor is placed at a fixed position in the beam and simultaneous readings are taken on it and on the probe detector. The probe detector readings are first corrected to constant monitor readings, and a comparison is then made between the dose at the depth and the dose at the reference point. A number of automatic methods have been developed to correct for random fluctuations in dose rate. In one such method, the outputs from the probe detector and the monitor are connected to a ratio circuit and the ratio is recorded directly The depth dose measurements from different workers often do not agree too well. This is partly due to fluctuations in output, differences in response of detectors, the use of different phantom materials, and a number of factors difficult to control. The tables presented in this book are those obtained by the authors and collaborators and taken from the excellent summary of depth dose measurements, found in Sup- plement No. 11 of the British Journal of Radiology (B13)356 The Physics of Radiology 10.07 TISSUE-PHANTOM RATIOS Tissue-phantom ratios were introduced in section 10.08 with the aid of Figure 10-2 as a replacement for tissue-air ratios for high energy ra- diation, The main reason tissue-air ratios do not lend themselves 10 use with high energy radiation has to do with the determination of the (refer- ence) absorbed dose in air. The electrons that are set into motion by ery high energy photons may travel distances of several cm; in order to make the dose determination in air, a very large buildup cap must be added to the dosimeter. The cap may in fact be so large that notall of i will be irradiated by small field sizes. This has led Karzmark (K6), among others, to suggest that the reference dose in air should be replaced by a dose determined in a phantom at a specified depth. A tissue-phantom ratio is therefore the ratio of the dose determined in a phantom for a chosen depth and field size to the dose determined in the same phantom and same field size but at some reference depth. Like tissue-air ratio, the dosimeter should be at the same distance from the source for both these measurements and the field size should be specified at that same distance. There is no universal agreement on the reference depth to be used but it is reasonable to use the values recommended by the ICRU (17) for absorbed dose calibrations. These are given in Table 10-2 TABLE 10.2 Depths Recommended for Tissue-Phantom Ratios and Absorbed Dose Calibrations Depth in em 150KV to 1OMV xrays 3 Cs and “Co y rays 5 1M 1025 MV xrays 7 Above 25 MV x rays 0 From IGRU Report 24 (17) 10.08 EQUIVALENT SQUARES AND CIRCLES FOR RECTANGULAR AND IRREGULAR FIELDS In section 10.06 a precise method for obtaining the depth dose for a rectangular field was given. The same method was applied to tissue-air ratios in section 10.04, We have seen that a rectangular field gives a smaller depth dose and tissue-air ratio than does a circular or square field of the same area. Day et al. (B13), however, have shown that it is possible to choose a circular field that has the same depth dose as a given rect- angular field. Such a field is called an equivalent circular field, Radii for equivalent circular fields are given in Table 10-3. It has been taken Equivalent Fields 357 from Supplement 11 of the British Journal of Radiology (B13). Ina more formal way, one could state that the circular field equivalent to a rectangular field would be the one that satisfied the following equa- tion: : Tadisho) = 4S Taldsn, he) (10-10) where fis the radius of the equivalent circular field, The data given in Table 10-3 were derived from backscatter factors for x rays in the energy region of 200 to 250 KV,. More recent studies (V7) have indicated that this table is satisfactory for clinical purposes for all depths and other beam qualities. Ina similar way equivalent squares for rectangular fields have been determined and are presented in Table 10-4. We will now illustrate the usefulness of this data. Example 10-5. Obtain the 10 cm depth dose for a 4 x 20 cm field for Co by finding the equivalent square and using appendix B-2e. Compare the answer with the percentage depth dose given for this rectangular field in the same table. Equivalent square field = 6.7 cm (Table 10-4) Percent depth dose for 6 x 6 field = 52.0 (Table B-26) Percent depth dose for 8 x 8 field = 54.0 (Table B-2e) Percent depth dose for 6.7 x 6.7 field = 52.7 by interpolation Percent depth dose for 4 x 20 field = 52.5 (‘Table B-26) ‘The data for rectangular fields in Table B-2e were obtained from care- ful measurements made using both square and circular fields (B13) and an application of equation 10-9. The percent depth dose (52.7) found by using the equivalent square method is within 0.4% of the value listed in the table for this field. This is representative of the precision that may be expected from this procedure and also illustrates how data for a small number of square fields may be used to produce useful data for any rect- angular field chosen for treatment. A simple rule of thumb method for finding the equivalent square of a rectangular field has been suggested by Sterling (S14). Square fields and rectangular fields are equivalent if the ratios formed by dividing area by perimeter are the same. For the beam of example 10-5, the area is 4x 20 = 80, the perimeter is 2 x (4 + 20) = 48. The ratio is 80/48 = 1.67. The student may show that the square field giving this ratio is 6.67, in very good agreement with the value 6.7 found in Table 10-4.358 ‘The Physics of Radiology TABLE 103 Radi of Gircular Fields Equivalent w Rectangular Fields ‘Short Axis em) 46 8 © BH w Bw B 2 28 30 Lis . 150 2.26 175 270 335 1.90 30. 3.85. 200 325 420 495 5.60 210 340 445 535 6.10 6.70 25 355 4.55 220 305 4.85 220 370 4.95 225 375 5.05 225 380 510 225 340 5.15 650 720 7.80 680 760 830 8.90 705 795 870 9.40 100 725 830 905 985 105 113 240 840 035 102 110 116 122 730 860 955 105 113 121 127 133 225 985 520 645 760 870 970 107 116 124 131 138 144 290 385 525 650 770 880 985 109 11S 127 155 142 149 158 290 385 525 655 775 89) 100 110 120 129 138 146 153 159 159 rom British Journal of Radiology, Supplement 11 (B13), TABLE 10-4 Side Lengths of Square Fields Equivalent to Rectangular Fields ee Long Short Axis em) Axis (em) 46 8 0 2B MW mw 1B 2 Bw 2% mB 90 2 [ao 4 [27 6 far 8 isa 80 wo | 36 89 100 2/57 61 80 96 109 120 M38 63 84 nl 116 129 160 16 |59 65 86 105 122 187 149 160 Is |40 66 39 lox 127 143 157 169 IO. 20 |40 67 90 111 130 147 163 177 189 200 2 |40 68 91 113 133 151 168 183 197 209 220 24 |41 68 92 115 135 154 172 188 203 217 229 240 2% [41 69 98 116 137 157 175 192 209 224 287 249 60 28 [41 69 94 117 138 159 178 196 213 229 244 25.7 B70 B80 30 ]41 69 94 117 139 160 180 199 217 235 249 B64 27.7 200 500 From British Journal of Radiology, Supplement 11 (B13) 10.09 PATIENT DOSE CALCULATIONS The functions defined in section 10.03 and described in subsequent sections were all introduced for the purpose of calculating relative doses, In this section we show how they can be combined with machine cali- brations so that the dose given to any point in a patient may be known. Patient Dose Calculations 359 he use of tissue-phantom ratios and calibration in a phantom is the most straightforward and will be discussed first Tissue Phantom Ratios ‘The reference dose for the use of tissue-phantom ratios is Dy- of Figure 10-2. Procedures for determining absorbed dose in a phantom are discussed in Chapter 7. The depth, d,, should be chosen according to the beam energy and the phantom should be set up so that the dosime- ter is located on the isocenter of the machine at a depth recommended ‘Table 10-2. The dose should then be determined as a function either of time or of machine monitor units for field sizes covering the range that will be used for treatment. The measurements must include square and rectangular fields as the output from the machine may be strongly dependent on collimator opening. It cannot be assumed that the equiva- lent squares discussed in the previous section apply. An example set of output data for a high energy linear accelerator is shown in Figure 10-13. Field sizes vary from 4 x 4 cm to 25 x 25 cm. As can be scen, the radia- tion output of such a machine may be strongly dependent on the col- limator opening. In this case it is 30% greater for a large field than for a small field. The reasons for this large variation are not clear. Radiation scattered within the phantom can only be a small part of it and therefore the greater part must be due to radiation scattered from the collimator or other structures. The importance of the collimator jaws is illustrated by the dashed lines and the solid line near to it. Both are for the same field sizes. ‘The difference is due to the fact that for one line the short side of the field is defined by the lower set of collimator jaws and for the other line it is defined by the upper jaws. The data shown in Figure 10-13 is plotted as relative dose. The actual dose would be given by the relatio’ Dye = M+ Nx: Gy. (10-11) where M is the dosimeter reading, Nx is its exposure calibration factor for cobalt 60 radiation, and G, is the factor discussed in section 7.16. ‘The dose in a patient, calculated using tissue-phantom ratios, is then given by: D = Dy. = Ty(d,Washv) » Fav/p ian (10-12) where d is the depth from the surface of the patient to the isocenter and We is the (equivalent) field size. (7lay/p)u has been introduced in order toconvert the absorbed dose from water to its value for tissue. This quan- tity is the ratio of mass energy absorption coefficients for tissue to water averaged over the photon spectrum as discussed in section 7.05. Numeri- cal values for this factor can be taken from columns 6 and 7 of Table 7-4.360 The Physics of Radiology g B sos : £ oss é s 0 is 20 25 Figure 10-13, Relative output data for a 25 MV linear accelerator, The outputs were ‘measured at a depth of 7 cm in a water phantom and are expressed as fractions of the ‘output for a 10 x 10 em field. The factor is very nearly unity (0.99 for beam energies commonly used in radiotherapy) and is frequently neglected. The reference dose, Dx-, includes a number of factors that are dis- cussed in sections 7.12 and 7.13. These include an exposure calibration factor for the dosimeter, ratios of averaged stopping powers, ratios of averaged absorption coefficients, and displacement factors. Calibration procedures are discussed in section 9.13. The tissue-phantom ratio is by definition a ratio of two absorbed doses, and it too must include these factors. They will appear, however, both in its numerator and denominator; it is reasonable to assume that cancellation will take place so that the tissue-phantom ratio is taken as the ratio of two dosimeter readings. This is an approximation. The dose at other depths in the patient may be calculated from D, by using percent depth doses or relative depth doses. Percent depth doses ‘The reference dose, Dy, of Figure 10-1 may be measured directly in a phantom. The phantom in this case is set up with its surface at the specified source-surface distance. As discussed above, measurements should be made as a function of time or monitor units for a selection of field sizes. Again it cannot be assumed that equivalent squares can be used for these calibrations. The dose in a patient at the reference depth, dy, is given by: D = Dy - (an/p)is (10-13) Patient Dose Calculations 361 where (ZEan/p)ith is as discussed above for tissue-phantom ratios. The dose at another depth in the patient is then given by multiplying D by the appropriate percentage depth dose. Tissue-Air Ratios ‘The reference dose to be used with tissue-air ratios is Dy. of Figure 10-1 and is the dose “in space” to a small mass of phantom-like material located at the appropriate point in air. The principles for determining this dose from a dosimeter reading are the same as those for determining dose in phantom and are discussed in section 7.11. In calibrating a treatment machine for use with tissue-air ratios, mea- surements should be made at the isocenter for a selection of fields. A set of such data for a cobalt unit is shown in Figure 10-14 where th sponse, M, of the dosimeter is plotted against the length of one the field for a range of values of the other side. The data have been nor- malized to 1.00 for a 10 x 10 cm beam, and this diagram illustrates the way the output in air may change with field size and shape. This may be due to a variety of reasons, including alteration in the amount of scat- tered radiation from the inside surfaces of the collimator and other structures. : Figure 10-14. Relative output data for a cobalt unit, The output is measured in air and ex- pressed relative to the value for a 10 x 10 field, ‘The dose in the patient, calculated using tissue-air ratios, is then given by: Da = Dy: Ta(d, Wa he) (Han/o)itar (10-14)362 The Physics of Radiology where, as for equation 10-12, d is the depth in the patient and We is the field size. (Zay/p)ia converts the dose from water to tissue. Tissue-air ratios, like tissue-phantom ratios and depth doses, are de- fined as the ratio of two doses. They are usually determined éxperimen- tally by making measurements with ion chambers. To convert the read- ings into doses, both numerator and denominator must by implication contain factors like those appearing in equation 7-30. It has generally been assumed that all factors except the instrument readings will cancel. This is usually a good approximation. 10.10 ‘TABULAR DATA IN THE APPENDIX Because extensive tables of tissue-air ratios, percentage depth doses, etc. are available elsewhere, we have restricted the tabular material in the appendix of this book to data that is representative of the field. It will enable the student to solve problems that cover the expected range of experience. It is not, however, intended to serve as source material for the practice of radiation therapy. We feel this is particularly impor- tant, since for the high energy equipment that is now in such common use the data is specific to the machine, Fach user must therefore either measure or acquire the proper data For low energy radiations we have supplied percentage depth doses and backscatter factors for circular, square and rectangular fields for typical source surface distances. They are given in Tables B-1 to B-2. We have included more extensive tables for cobalt radiation, since this type of radiation is so widely available and is so convenient for experi- mental work because of its freedom from random variations in time. ‘Tables B-2 to B-5 for cobalt radiation includes percentage depth doses and tissue-air ratios for circular, square, and rectangular fields. We have included data for three high energy radiations, 6, 10, and 26 MV, for square and circular fields in the form of tissue-phantom ratios and per- centage depth doses for source-axis distance of 1 meter. The latter data are given in Tables B-2 to B-4. They are examples only and should not be assumed to apply to any particular machine without thorough testing, 10.11 ISODOSE CURVES In the preceding sections of this chapter we have confined our atten- tion to the dose at points on the axis of the beam. In any actual treatment wwe are interested in knowing the dose at many other points in the patient. These may be compared with the dose received at the reference point. When points that have the same dose are joined together, an isodose curve is obtained. A set of isodose curves, for a range of dose values, can be combined to form an isodose chart or isodose distribution. Such Isodose Curves ‘363 a distribution gives a map of the dose pattern in one plane in a radiation beam. ‘Three typical isodose distributions are shown in Figure 10-15 for low energy, high energy, and very high energy radiation. The 200 kV distri- bution is typical of the isodose curves obtained in the HVL range from 0.5 to 3.0 mm Cu for a source-to-skin distance of 50 cm. The cobalt 60 curve is typical of the distributions obtainable with cobalt and low energy linear accelerators used at source-to-skin distances from 80 to 120 cm. The 25 MV distribution is typical of super-voltage machines in the range 15 to 50 MV. Study of these three distributions may emphasize some previous observations. Consider first the depth dose along the axis. With 200 kV, the dose falls continuously, reaching about 25% at 10 cm depth. With cobalt 60, the dose rises rapidly to the maximum of 100 at a depth of about 5 mm and then falls slowly to reach some 52% at 10 em depth. With 25 MV the buildup region that extends to about 4 em is evident, after which the dose falls to some 83% at 10 cm depth, L__ Figure 10-15, Isodose distributions: left, 200 kV, HVL 1.5 mm Gu, SSD 50 em, field size 5X 7 cm; middle, Co, SSD 80 cm, field size 6 x 6 cm; right, 25 MV, SSD 100 cm, 6x 6em The three sets of curves of Figure 10-15 are quite different near the edge of the beam. For the low energy radiation a sharp discontinuity can be seen. This discontinuity may be easily demonstrated by moving a small probe dosimeter across the beam along a path such as shown by the line AB in the diagram. Such an experiment measures the dose pro- file; the properties of such profiles are discussed in detail in section364 The Physics of Radiology 10.13. The sharp edge of such a beam may also be demonstrated with photographic film. If the focal spot of the x ray tube were large and the limiting diaphragm some distance from the surface of the phantom, the discontinuity would disappear. \ ‘The cobalt 60 isodose curves do not show a sharp discontinuity be- cause of the penumbra effects due to the finite size of the source. The 26 MV radiation shows a somewhat sharper demarcation between the region of high dose and low dose but no discontinuity as with 200 kV radiation, At cobalt 60 and 26 MV energies, no single diaphragm can completely absorb the beam of radiation because of its penetrating power and some radiation always passes through the edge of the diaphragm, ‘The sharpness of the beam is further degraded by the flattening filter. The three sets of curves of Figure 10-15 are quite different in the re- gion outside the beam. With 200 kV, there is a large amount of side scatter, while with the other two, side scatter is low, ‘The 26 MV distribution was obtained using a carefully designed and precisely placed beam flattening filter. Without this filter to reduce the beam intensity along the axis, the isodose curves are quite pointed in the forward direction and useless for most radiotherapy. To give the flat isodose curves, the filter must be carefully aligned in the beam. Isodose Curves with Other Reference Points Figure 10-16 shows two isodose charts drawn with the reference point at different locations. Both are for 6 x 6 cm beams of cobalt 60 radiatis ‘The chart on the left is for fixed source-surface distance (SSD = 80 cm) use and the reference point is at the position of maximum electronic buildup (see the discussion of depth dose in section 10.06), For this chart the field size is defined at the surface and 100% appears just below it at a depth of 0.5 cm. Percent depth doses are tabulations of the doses along the axis of the beam, and data for this beam are given in Table B-2e and plotted in Figures 10-8 and 10-9. The chart on the right in Figure 10-16 is for use with an isocentric (or rotational) mounted ma- chine. The reference point is chosen to coincide with the axis of rotation (isocenter) and for this chart is located at a depth of 15 cm below the surface (SAD = 80 cm). The field size is defined at the isocenter and 100% appears at this location. Alll other doses in the beam are expressed as a percentage of the dose at this point Percent depth dose data for this beam are plotted as curve C of Figure 10-12. In normal use with an isocentric machine the patient would be placed so the center of the tumor was at the isocenter; using the isodose distribution one can easily compare the dose at other points to the dose at the tumor. { Figure 10-16, Left; Isodose pattern for fixed SSD with percentages referred to the i Ce point of maximum electronic t buildup, Rights odose pate | ; terms for isocentrie use with i percentages and fiekd sizes 7; referred to the axis of ro- i tation, Both beams are for "Co radiation and are 6 em square. Isodose Surfaces —Isodose Curves in Three Dimensions The isodose curves shown in Figures 10-15 and 10-16 give the distri- bution of radiation in a plane containing the axis of the beam. This plane is known as the principal plane. It is important to remember, however, that the isodose distribution is three-dimensional in nature and one should think of isodose surfaces rather than isodose curves. It is very difficult to display isodose surfaces, and it is customary to show the dis- tribution in two principal planes at right angles to one another. These principal planes also contain the central ray of the beam. This is illus~ trated in Figure 10-17, where two distributions for a 15 x 10 cobalt 60 field are shown in perspective at right angles to one another. The isodose curves in the two planes give the intersection of the isodose surfaces with these planes. The three-dimensional nature of the isodose pattern is further illustrated in Figure 10-18 where isodose curves for four differ- ent planes are shown for a 6 X 15 beam of cobalt radiation. Figures 10-18a and b are for the principal planes and c is for a plane that is parallel to the plane of b but is 3 cm away from it. Diagram d is for a cross section of the beam taken at a depth of 10 cm. The positions of the inte sections of the planes are indicated by the dashed lines in the diagram, The production of these isodose curves requires a computer. The dia- grams of Figure 10-18 were produced by methods discussed later in this chapter.