Q.

1 Explain Different Beam Modification devices used in

radiotherapy? (15 marks)

Beam modification is the modification of the spatial distribution of

radiation within the patient by insertion of material into the beam
path.

Patient surface is not flat or uniform and there is also counter irregularity,
Tissue in-homogeneity so that to modify the iso-dose distribution to get
uniform dose distribution we used beam modification device. There are
four main types of beam modification devices:

1. Wedge filter.

2. Bolus.

3. Tissue Compensator.

4. Shielding blocks.

Shielding: To eliminate radiation dose to some special parts of the zone at

which the beam is directed.

Compensation: To allow normal dose distribution data to be applied to

the treated zone, when the beam enters obliquely through the body or
where different types of tissues are present.

Wedge filtration: Where a special tilt in isodose curves is obtained.

Flattening: Where the spatial distribution of the natural beam is altered

by reducing the central exposure rate relative to the peripheral

Wedge Filter

Wedge is a beam modifying device that causes a progressive decrease in

the intensity across the beam resulting in a tilt of the isodose curves from
their nominal positions.
 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.

Types of wedge

1. Individualizes wedge

2. Universal wedge

3. Motorized wedge

4. Dynamic wedge

5. Enhanced Dynamic Wedge

Individualized wedge

Such a filter is fixed to align the thin end of the wedge with the border of
the light field.

Universal wedge
Universal wedges are designed so that the same wedge can be used with all
field sizes.
Such a filter is fixed centrally in the beam.
Dynamic Wedge and Physical Wedge

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 simulation of a physical wedge by the motion of a collimating jaw, while

beam is on, is called a dynamic (or virtual) wedge.

Enhanced Dynamic Wedge

The enhanced dynamic wedge technique differs from the physical (metal)
wedge technique in that there is no external beam modifier is used to create
the wedge profile. Instead, the wedge isodose profile is created by the
sweeping action of the collimator from open to close position while the beam
is on.
 Wedge Transmission Factor

The presence of a wedge filter decreases the output of the machine, which
must be taken into account in treatment calculations.

Ratio of doses with and without the wedge, at a point in phantom along the
central axis of the beam.

Wedge angle:

Line drawn through two points a quarter of a field size on either side of
central axis which lie on the isodose contour that intersects that central axis at
a 10 cm depth.
Bolus

Bolus is a tissue-equivalent material placed directly on the skin surface to

even out the irregular contours of a patient to present a flat surface normal to
the beam.

Placing bolus directly on the skin surface is satisfactory for orthovoltage

radiation, but for higher-energy beams results in the loss of the skin-sparing
advantage.

Material: Wax, Cotton.

For such radiations, a compensating filter should be used, which approximates

the effect of the bolus as well as preserves the skin-sparing effect.
To preserve the skin-sparing properties of the megavoltage photon beams, the
compensator is placed a suitable distance (≥20 cm) away from the patient's
skin.

Tissue compensator

TC is a “beam modification device” that compensates for missing

tissues. This is because of the different SSD within the field produced by the
irregularities of the patient contour. Through this can be corrected by putting TC.

This technique to produce a homogeneous dose to plane of interest is by inserting a

properly shaped tissue compensator of suitable thickness and material.

Tissue compensators are widely used in radiotherapy to correct the dose

inhomogeneity cased due to the surface irregularities particularly in head and
neck regions where a large variation in tissue thickness is possible. In our
institute, we are using aluminium as the tissue compensators material after
the dosimetric study pertaining to the use of aluminum medium for tissue
compensators.

Material required

 Special jig for measurement at various location

 Recording sheet
 Head rest
Preparation of TC using Al blocks for appropriate missing tissue.
(Aluminium block of 9mm x 9mm and various thicknesses ranging from
2.5mm to 25mm).
Shielding Blocks

Shielding of vital organs within a radiation field is one of the major concerns
of radiation therapy. Considerable time and effort are spent in shaping fields
not only to protect critical organs, but also to avoid unnecessary irradiation of
the surrounding normal tissue.

Block Thickness

Shielding blocks are most commonly made of lead. The thickness of lead
required to provide adequate protection of the shielded areas depends on the
beam quality and the allowed transmission through the block. A primary
beam transmission of 5% through the block is considered acceptable for most
clinical situations.

If n is the number of half-value layers to achieve this transmission:

Low melting point alloy, Lipowitz metal (Cerrobend), which has a density of
9.4 g/cm3 at 20°C (~83% of lead density). This material consists of 50.0%
bismuth, 26.7% lead, and 13.3% tin, and 10.0% cadmium.

The main advantage of Cerrobend over lead is that it melts at about 70°C
(compared with 327°C for lead) and, therefore, can be easily cast into any
shape. Density ratio relative to lead (multiply lead thickness by 1.21).

Megavoltage range of photon beams, the most commonly used thickness is 7.5
cm, which is equivalent to about 6 cm of pure lead.
Write a short note on Gamma knife treatment.
The Gamma Knife is a dedicated radiosurgery unit. It houses 201 radioactive Co-60 sources that
converage the beams at tumor, with source to target distance of 40 cm. It mainly consists of
radiation unit, operating table and sliding couch. The central beam is tilted through an angle of
55 degrees with respect to the horizontal plane. Each of the 201 Co-60 sources is of nominal
activity 30 Ci , therefore, the radiation unit houses the total activity of approximately 6000 Ci.
Beam channels are machined in the central body; these channels provide the primary collimation
of the individual gamma ray beams. Further collimation is provided by the four collimator
helmets provided along with the machine. These helmets are of diameter 4, 8, 14 & 18 mm. The
central axis of all the 201 beams meets at the focus with mechanical precision better than ±0.3
mm. In order to reduce the doses to eye or any other sensitive organ, plugs are provided, the
plugs are made up of 6 cm thick tungsten alloy. Figure 1 and 2 shows the photographs and cross
sectional view of the machine respectively.

In order to localize the target in the brain, the Leksell`s stereotactic frame is attached to the head,
and the brain is imaged with imaging modality like CT, MRI or angiography are used as an
additional imaging modality for fusion with CT images.
 Gamma Knife Unit

Cross sectional view of Gamma Knife unit

 Four Collimator Helmets Collimators

Work Flow in Gamma Knife

Step 1: Frame fixation
Step 2: Patient imaging with fiducial marker box attached to the frame

Step 3: Development of treatment plan

Step 4: The patient head frame is affixed to Gamma Knife`s automatic positioning system
Step 5: Patient is advanced in the treatment unit and treatment is delivered

Treatment Planning in Gamma Knife

Case 1: Spherical target of 3 mm in diameter.
This is one of the simplest cases, since the target is 3 mm in diameter and is spherical in shape,
the 4 mm collimator will be used and it covers the target with the 50% isodose line. Figure 5
below shows the target coverage with the 50% isodose.

Figure 5 Target coverage with the 50% isodose

Case 2 Non spherical lesions of larger diameter

For non-spherical lesions of larger diameter, the treatment planning becomes more complex, it
requires several shots of radiation. It requires experience, that how many shots of radiation are
required, what should be the collimator size, locations and weights. This is achieved through
iterative trial and error process.

Gamma Knife QA
The routine Gamma Knife QA can be divided into the following categories:

Daily QA Weekly QA

(1) Warm up (1) Couch releasing handle

(2) Door Interlock (2) Helmet microswitches

(3) Emergency Off (3) Helmet trunnions

(4) AV communication (4) Automatic Positioning system accuracy

(5) Radiation monitor

Monthly QA Annual QA

(1) Radiation output (1) Relative helmet factors

(2) Computer output Vs measured (2) Isocenter coincdence

(3) Emergency rod release (3) Film Measurements

(4) Medical UPS battery check

(5) Timer constancy linearity and accuracy

Q.3 Explain different steps of 3DCRT planning?

Delivers a conformal dose distribution to the tumour by using uniform beam

intensities within each beam portal. It is based on 3-D anatomic information &
use dose distribution that conforms as closely as possible to the target volume
with adequate dose to the tumor & min. possible dose to normal tissues.

3D view of patients anatomic structures & calculated isodose distribution

throughout the target volume (just a demonstration project).New type of display
beam’s eye view (BEV) .The development of 3D planning systems –DRRs are
displayed with the help of digital CT data. Then, powerful new features like
room’s-eye-view (REV) Introduced.
Aim of 3DCRT planning

 Maximum dose to tumor

 Lowest possible dose to Organs at Risk (OAR
Steps of planning:

 Patient positioning and immobilization

 Image acquisition and input

 Image registration

 Image segmentation

 Dose prescription

 Beam aperture design

 Dose calculation

 Plan evaluation and improvement

 Plan implementation and verification

PATIENT POSITIONING AND IMMOBILIZATION

position is choosen for patient comfort, minimum normal tissue & accessories
in the way of the beam and Reproducibility of the treatment .

Various devices are used for this like that Orfit cast, Vac loc, Breast board etc.

IMAGE ACQUISITION AND INPUT

High image quality CT images for 3D treatment planning (with contrast). They
provide e- density information.

Slice thickness is kept –

 3-5 mm for 3D CRT.

 2-3 mm for IMRT.
IMAGE REGISTRATION

Correlates different image data sets and comparison of images from two or
more studies (CT, MRI , PET)then Matching of the coordinates during fusion
Using various techniques Manual, Automatic, Input data pixel size, slice
thickness, spacing , image orientation (prone/supine , head-foot orientation ,
left-right orientation)

BEAM APERTURE DESIGN

 Beam direction and design beam aperture.

 BEV capability of 3D TPS

 Targets and different critical normal structures can be viewed in different

directions in planes perpendicular to the beam central axis

 Beam aperture are designed taking GTV, CTV , PTV concepts into
consideration.

 Beam direction: To create greater separation between target and critical

structures are preferred.
DOSE CALCULATION

 A rectilinear coordinate system for dose calculation

 Contour points are specified in X , Y and Z coordinates
 Each voxel in 3D CT image matrix is computed relative to the same
coordinate system and electronic density values.
 Select appropriate grid spacing for 3D dose matrices
 PLAN EVALUATION & IMPROVEMENT
 isodose lines superimposed on CT imges slice by slice
 Or using most useful tool-DVH.

DOSE VOLUME HISTOGRAM (DVH)

 DIFFERENTIAL
 CUMULATIVE
 To check inhomogeneous dose distribution.

 Divide the volume into consideration into 3D voxels.

 Voxels are grouped acc. To dose bins.

 Plot no. of voxels (y axis) & bin dose range(x -axis)

PLAN IMPLEMENTATION & TREATMENT VERIFICATION

 Beam parameter (isocentre depth) settings to the t/t machine “record & verify system“,
MLC parameters.
 Match the EPID taken with the DRR.
 Execute the plan.
DOSE REPORTING & PRESCRIPTION

Minimum dose, maximum dose, means dose are used for dose reporting. ICRU
reference dose point pr reporting should be in the central part of PTV.
Reference point is choosen on following criteria:

 Clinically relevant.
 Should be located where dose can be accurately determined.
 Should be located in a region where there are no steep dose
gradients.

Write treatment techniques for the following:

Multileaf collimators

Multileaf collimators are a bank of large number of collimating blocks or leaves

that can be driven automatically independent of each other, to generate a field
of any shape.

TYPICAL MLC

 80 leaves (40 pairs) or more.

 Width of 1 cm or less as projected at the isocenter.

 Thickness along the beam b/w 6 – 7.5 cm

 Made of a tungsten alloy.

 Density of 17 - 18.5 g/cm3.

 MLC system can be double focus or single focus leaves

 Single focus leaves --rounded at end

 Double focus leaves –leaf and leaf size matches with beam divergence and
difficult to manufacture

 Both are designed to ensure sharp beam cut off at the edge

 Time for shaping and inserting of custom blocks is not required.

 It’s a boon for treating large number of multiple fields

 The hardening of beam, scattered radiation, and increase in skin doses and
doses outside the field, as seen with physical compensators is avoided.

 Automation of dynamic reshaping and modulation of beam intensity in3D-

CRT and IMRT.

 MLCs can also be used to as dynamic wedges and electronic

compensators (2D).
 Island blocking is not possible.

 Because the physical penumbra is larger than that produced by Cerrobend

blocks, treatment of smaller fields is difficult, as is the shielding of critical
structures, near the field.

 The jagged boundary of the field makes matching difficult.