JANUARY, 1973

A METHOD FOR THE CALCULATION OF DOSE

IN THE RADIATION TREATMENT OF
HODGKIN’S DISEASE’
J.
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By H. CUNDIF’F,2J. R. CUNNINGHAM,’ R. GOLDEN,’L. H. LANZL,4 M. L. MEURK,5J. OVA I)IA,#{176}

V. PAGE LAST,7 R. A. POPE,8 V. A. SAMPIERE,’ W. L. SAYLOR,’#{176} R. J. SHALEK,2
and N. SUNTHARALINGHAM”
HOUSTON, TEXAS

T HE calculation of dose at depth for considerations of dose to the spinal cord,

large, i rregularlv shaped treatrnen t the gonads, and between adjacent fields,
fields, such as mantle fields in the radiation and the construction of lung blocks were
treatment of Hodgkin’s disease, is complex presented at a Hodgkin’s Disease Dosime-
and is usuillv accomplished by approxima- try Workshop on June 26, i 969, at Chicago.
tions based upon, or corroborated by, mea- The workshop was sponsored by the Coop-
surements in phantoms.’1””6 The validity erative Hodgkin’s Disease Clinical Trial
of an approximation is limited to the type Steering Committee and conducted through
of radiation machine, the points chosen for the American Association of Physicists in

calculation, and other parameters such as Medicine by the Radiological Physics

field shape used during measurement. A Center (RPC) and a task group of the
general calculative method described here Scientific Committee. The instructors and
utilizes standard tabular data together collaborators at the workshop appear as

with a few measurements on the therapy authors here, and this paper is intended to
machine. The dose is separated into pni- present the essentials of the discussions at
mary and scatter contributions, as has been the workshop.
described by Clarkson,’16 with allowances Another method of dose calculation
for the variation of exposure across the utilizing the tissue maximum ratio (TMR)
field and non-nominal source-skin distance definition of the dose at depth has been
(SSD) in parts of the field. A computer developed at the Memorial Hospital in
method embodying the same principles has New York.’4 This method is designed to be
been in use at the Princess Margaret Hos- independent of energy and is in use at a
pital, Toronto.5 The method described here number of institutions; however, it will
can be used to calculate the dose at any not be presented in the discussions here.
point in the patient within or outside the
useful beam except near the edges of the CONSIDERATIONS IN CALCULATION
field. It may be considered a standard of
IHE I’ROII.EM
comparison for approxirn ation methods
without further experimental verification. In the treatment of Hodgkin’s disease,
These discussions of calculative methods, large fields with outside borders of up to

I 5upported in part b National Cancer Institute Grants CA 08971, Cooperative Hodgkin’s I)isease Clinical Trial, and CA ioc,
1’he Radiological Physics Center.
2The Radiological Physics Center, The University ofTexas at Houston, NI. I). Anderson Hospital and Tumor Institute, Houston,
lexas. R. Golden now at Youngstown Hospital Association, Youngstown, Ohio.
3 The Princess Margaret Hospital, Toronto, Ontario, Canada.
I Argonne Cancer Research Hospital, The University ofChicago, Chicago, Illinois.
I Saroni Tumor Institute, Mount Zion Hospital, San F rancisco, California.
S Michael Reese Hospital, Chicago, Illinois; now at Milwaukee County General Hospital, Milwaukee, Wisconsin.
7 Stanford University Medical School, Palo Alto, California; now at Prince ofWales Hospital, Randwick, Australia.
‘Memorial Hospital, New York, New York; now at Wessex Regional Department of Nuclear Medicine, Southampton General
Hospital, England.
‘The University of Texas at Houston, M. D. Anderson Hospital and Tumor Institute, Houston, Texas.
10 Walter Reed Hospital, Bethesda, Maryland; now at the School of Medicine, The University of North Carolina, Chapel Hill, North
Carolina.
11 Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

30
 \OL. 117, No. I Calculation of Dose in Hodgkin’s Disease 3’
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0 5 0 IS 20
1111111111! 1111111111

cm.

l’Ic. 1. Typical mantle field for radiation treatnient of the neck and thorax. + = positions on surface of pa-
tient; 0 = the projection at mid-depth.

4o Xo cm. are blocked to shield regions radiations usually are used, including
where the radiation is not desired, such as cobalt 6o gamma rays and 2, 4,6, or 8 MV
the lungs. The resulting treatment field will roentgen rays, with SSD of 8o to o cm.
differ in shape from patient to patient; \Vith highei’ energy photons, there is
thus, it is not practical to have isodose danger of underdosing superficial regions
curves available for each field shape and in which electronic build-up has not been
patient contour. An example in Figure i achieved, and some clinicians question the
shows the outline of a field and a number use of 6 and 8 MV roentgen ra\-s for this
of points chosen for calculation. A cross- reason. This danger may be more apparent
sectional view of the same treatment plan than real, since with 8 MV roentgen rays
which includes the central axis is shown in the dose at 0.5 cm. depth is 90% of the
Figure 2. The departure from nominal maximum with a 30 X3o cm. field, and 8o%
SSD (g), relating to a point of calculation of maximum with a ioXio cm. field.’
(A), at depth (d), is illustrated. For treat- With 6 MV roentgen rays, the dose at 0.5
ments of this type, high energy photon cm. depth is 92% of the maximum with a
 J. H. Cundiff et al. JANUARY, 1973

central axis in a cobalt 6o beam may have

[Titl
an exposure of 8 or 9% less than the center.
Shadow Tray
l As is shown in the third column for cobalt
6o, this effect can be diminished by utiliz-
ing the central part of a larger field with
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FIELDBOUNDARY AT s beam definition by secondary blocking, or

SURFACE OF PATIENT g
alternatively by using a compensator to
flatten the field, as is illustrated for 6 MV
roentgen rays. Off-axis diminution may be
measured in air with a detector having a
wall of sufficient thickness to provide elec-
FIG. 2. Cross section through the patient in the axil- tronic equilibrium. Measurements across
lary region at the level of the point of calculation, the unblocked field at the treatment dis-
A. tance on perpendicular axes and diagonals
are usually sufficient. If the shadow tray is
25 X 25 cm. field and 86% of the maximum in place during the measurements, oblique
with a loXto cm. field.24 attenuation near the edges of the field
OFF-AXIS DIMINUTION OF THE BEAM
is taken into account.

With large, irregularly shaped fields, it is NON-NOMINAL SOURCE-SKIN DISTANCE

necessary to take account of beam charac- The variation of SSD within the field of
teristics, just as with smaller fields of treatment is a source of error in the cal-
regular shape. With the latter, the off-axis culation considered. If the nominal SSD is
diminution of the beam is implicit in the 130 cm. and a portion of the skin is 4 cm.
isodose curves; for the calculation of dose more distant, then an error of about 6% is
to the points in an irregular field for which introduced if the patient is considered flat
isodose curves do not exist, however, the at 130 cm.
diminution across the beam must be al-
INFLUENCE OF COLLIMATORS AND BLOCKING
lowed for explicitly. In Table i, some

typical beam profiles in air are shown for The setting of the primary collimators
large fields, indicating that points off the influences the exposure rate significantly,

TABLE I
BEAM PROFILE IN AIR, RELATIVE TO THE CENTRAL AXIS FOR LARGE FIELDS*

2 MV 6 MV
Co’#{176} Co#{176}#{176} Roentgen Rays Roentgen Rays
Distance from
Side of Field
ioo cm. SSD 130 cm. SSD
(cm.) 150 cm. TSD 160 cm. TSD
35X35 cm. Trim- 53X52 cm. Blocked
35X35 cm. 40X40 cm.
mers 6 cm. to 34X34 cm.

(Center of field) 1.00 1.00 1.00 1.00

12 .99 1.00 1.00 1.00
10 .99 .99 .99 1.00
8 .98 .98 .98 1.00
6 .97 .98 .97 1.00
5 .96 .97 .96 1.00
4 .95 .97 .95 1.00
3 .94 .96 .94 1.00
2 .92 .96 .92 1.00
I .91 .95 .91

* Measurements were in air on particular machines. The results are not applicable generally to other similar machines.
 ROL. 117, No. I Calculation of Dose in Hodgkin’s Disease 33

but the presence of secondary blocking, mary and scattered radiation with al-
such as for the lungs, may increase or de- lowance for the off-axis diminution and
crease the exposure rate slightly-usually non-nominal SSD. The primary radiation
less than I %. This occurs because of the to a point of interest is calculated using the
large contribution ofscatter radiation from tissue-air ratio (TAR) for zero field size,
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the collimating parts near the source and and the scatter radiation is calculated from
the relatively small contribution of scatter scatter-air ratios (SAR). The TAR is de-
from secondary collimators at a distance fined as the ratio of the absorbed dose at a
from the source. Therefore, it is sufficient given point in a phantom to the absorbed
that the exposure rate in air or absorbed dose which would be measured at the same
dose rate in free space’#{176}from a machine be point in free air within a volume of the
known or calculated with the primary phantom material just large enough to
collimators as they are set in treatment provide the maximum electronic buildup at
prior to the addition of secondary blocking. the point of measurement.1’ The SAR is
defined as the difference between the TAR
for a given field and the TAR at the same
GENERAL METHOD
depth for zero field size.’3 The data for
The general method consists of a sum- these calculations are given in Table ii.

mation at each point of interest of the pri- The absorbed dose at an arbitrary point

TABLE hA
TISSUE-AIR RATIOS AND SCATTER-AIR RATIOS

11. Cobalt 60

Depth Tissue-Air Ratio* Scatter-Air Ratios for Field Radiust

(cm.) 0 cm.2 100 cm.2 2 cm. cm. 6 cm. 8 cm. io cm. 15 cm. 20 cm. 25 cm.

0.5 1.000 1.036 .014 .026 .037 .048 .o8 .076 .085 .089
I . 965 I . 028 . 025 . 048 . o66 . 078 . 089 . 107 . I I8 . i 23
2 .905 1.002 .045 .o8o .102 .ii6 .127 .149 .160 .167
3 .845 .97I .061 .103 .130 .147 .i6i .184 .198 .205
4 .792 .938 .071 .121 .151 .170 .i86 .210 .228 .239
S .742 .902 .076 .134 .i66 .189 .206 .235 .255 .266

6 .694 .864 .o8o .14I .176 .201 .219 .252 .272 .284
7 .6o .825 .o8i .143 .181 .209 .229 .267 .290 .304
8 .6o8 .785 .o8o .142 .i8 .214 .236 .278 .301 .315
9 .570 .746 .078 .140 .183 .216 .240 .284 .312 .327
10 .534 .707 .075 .136 .i8i .215 .242 .288 .318 .336

II .501 .671 .071 .132 .178 .213 .241 .289 .322 .339
12 .469 .635 .069 .128 .174 .210 .239 .290 .324 .342
13 .440 .602 .o66 .124 .170 .207 .237 .290 .325 .345
‘4 .412 .570 .063 .120 .i68 .204 .235 .288 .326 .347
Is .386 .539 .060 .ii6 .162 .200 .231 .286 .325 .347

i6 .361 .511 .o8 .112 .157 .196 .227 .283 .322 .346
‘7 .338 .484 .o6 .io8 .153 .191 .223 .279 .318 .343
i8 .317 .459 .054 .104 .148 .i86 .218 .275 .313 .339
‘9 .297 .433 .052 .101 .144 .181 .213 .270 .309 .335
20 .278 .409 .049 .097 .139 .176 .207 .265 .305 .329

* Bria’. 7. Radio!., 1968.

t Gupta and cunthham, i66.
 34 J. H. Cundiff et al. JANUARY, 1973

TABLE JIB
TISSUE-AIR RATIOS AND SCATTER-AIR RATIOS

11. MI Roentgen Rays: Varian C/inac- (Lead Flatness Filter)

i)epth Tissue-Air Ratio Scatter-Air Ratios for Field Radius

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(cm.) 0 cm.2 100 cm.2 2 cm. 4 cm. 6 cm. 8 cm. 10 cm. 15 cm. 20 cm.* 25 cm.*

J2 1.000 1.037 .013 .026 .039 .052 .062 .073 .077 .079
2.0 .952 1.021 .035 .055 .073 .o88 .098 .110 .115 .ii8
3.0 .899 .998 .048 .081 .102 .ii8 .130 .143 .150 .154
4.0 .847 .966 .o58 .097 .125 .145 .157 .174 .i88 .195
5.0 .799 .933 .063 .110 .141 .i6 .179 .200 .214 .222

6.o .753 .900 .067 .119 .155 .181 .196 .220 .237 .24#{244}
7.0 .7I0 .866 .o68 .125 .163 .193 .2II .237 .257 .268
8.o .670 .832 .069 .128 .170 .201 .222 .252 .272 .28
9.0 .632 .800 .069 .131 .174 .207 .230 .263 .283 .296
10.0 .598 .764 .o68 .132 .177 .210 .236 .271 .291 .30

11.0 .564 .7I .067 .II .178 .213 .240 .278 .300 .I5
12.0 .529 .698 .o66 .130 .178 .215 .242 .283 .308 .I8

13.0 .500 .666 .o6 .128 .177 .214 .243 .288 .325
14.0 .471 .636 .063 .125 .175 .212 .24 .289 .I6
15.0 .444 .6og .062 .122 .171 .210 .241 .290 .316

i6.o .419 .576 .o6o .118 .168 .206 .239 .289 .316 .325
17.0 .395 .549 .059 .114 .163 .202 .235 .287 .314 .323
18.0 .373 .42I .057 .110 .159 .197 .230 .284 .312 .320
19.0 .351 .496 .o6 .107 .154 .19’ .226 .28! .310 .318
20.0 .331 .47 .054 .104 .150 .188 .221 .276 .306 .3i

S Extrapolated data.
Notes: (I) Table by Mary Peterson ofRosewood General Hospital and Robert Golden ofthe AAPM Radiological Physics Center fronT
measurements at Wadley Institute, Dallas, Texas.
(21 This machine produced a depth dose of 6o.8 per cent at io cm. depth for a ioX so cm. field at 8o cm. target-skin distance
and a tissue-maximum rato ofo.738 at io cm. depth for a loX 10 cm. field at 8c cm. target-axis distance.

A, as shown in Figures i and , is calcu- Symbolically, with the brackets having the
lated as follows: same meaning as above, the absorbed dose

Absorbed dose at point A =

Iabsorbed dose in phantom for calibration conditions]

x [transition to absorbed dose in a small mass of tissue for treatment field sizej

x (transition to absorbed dose in a small mass of tissue at point A]

r (absorbed dose due to primary radiation to point A in patient)

x + (absorbed dose due to scatter radiation to point A in patient)
absorbed dose in asmall mass of tissue at point A
 \OL. 117, No. 1 Calculation of Dose in Hodgkin’s Disease 35

TABLE IIC
TISSUE-AIR RATIOS AND SCATTER-AIR RATIOS

C. 6 MV Roentgen Rays: Varian Clinac-6

Depth Tissue-Air Ratio Scatter-Air Ratios for Field Radius

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(cm.) 0 cm.2 100 cm.2 2 cm. cm. 6 cm. 8 cm. 10 cm. 15 cm. 20 cm. 25 cm.

1.5 1.000 I .029 .010 .021 .031 .042 .05I .o6 .069 .071
2 . 997 I .027 .011 .02I .032 .043 .052 .064 .069 .071

3 . 965 I .009 .016 .032 .047 .o8 .067 .o8; .089 .oco
4 .926 .981 .020 .040 .057 .071 .082 .099 .io8 .111

5 .88 . 952 . 024 .049 .071 .087 .100 .117 .126 .I0

6 . 924 . 030 .o6o .o8 .io .ii8 .i; .147 .151

7 . 802 . 895 . 035 .070 .og8 .120 .14 I .155 .ib6 .171

8 .76 I . 866 . 040 .0’79 .111 .I34 .149 .172 .184 .189

9 .722 . 837 . 043 .087 .121 .145 .162 .i88 .200 .206

I0 .687 . 8o8 . 046 .091 .127 .151 .170 .199 .212 .217

II . .779 . 047 .09 .I3I .157 .178 .207 .221 .227

12 .624 . 750 . 047 .093 . I 33 . I 62 . I 84 . 2 I 3 .228 . 26

I 3 .596 . 722 . 047 .093 .i;; .163 .i8 .218 .2#{231} .245

14 .567 . 694 . 047 .09.; .134 .i6 .187 .224 .241 .254

15 . 540 . 668 . 047 .094 .i;6 .i68 .191 .226 .247 .262

16 .513 . 642 . 048 .095 .137 .171 .19 .229 .252 .269

17 .488 . 618 . 048 .096 .138 .171 .194 .22 .256 .274
18 . 464 .593 . 048 .o#{231}6 . I37 . 170 . 194 . 234 . 259 . 278
19 . 443 . 570 .048 .094 .134 .167 .192 .22 .259 .278
20 .422 . 546 . 047 .091 .130 .164 .189 .230 .258 .278

Notes: (I) l’ablebyj. H.CundiffandR.GoldenoftheAAPMRadiologicalPhysicsCenterwith thecollaborationofL. H. Deiterman,

verified on the 6 MV Varian Clinac X-ray machine at Scott and White Clinic, Temple, Texas.
(2) This machine produced a depth dose of 67.5 per cent at 10 cm. depth for a loX io cm. field at ioo cm. target-skin distance
and a tissur-maximum ratio of 0.785 at 10 cm. depth for a loX io cm. tield at ioo cm. target-axis distance.

at point A can be calculated for source-skin

DA [D1 X B][T’R) x G]
on isocentnic techniques.

Fixed
phantom.
source-skin distance; calibration in
. [ ( )I SAD’
SPD [TAR)d + Sd].
(2)

ri Fixed source-skin distance; cobalt #{243}o

or 2
DA=IDeXBJI XG]
LTAR)C MV x-ray, calibration in air.
The rationale with in-air calibration is the
.[P x (_±-e--Y1 (I)
same as for equation (i), except the factor,
L \SSD+g+d/J
TAR)C is not required.
. [TAR)d + Sd]
DA [D X B][G]

Isocentric technique; calibration in pliantoni. .

r[I) X
I
---------)
SSD+e ‘‘-l
_I

The rationale for an isocentnic technique is

the same. ITAR)d + SJ.
 J. H. Cundiff et al. JANUARY, 1973

DA absorbed dose at arbitrary point Sd average scatter-air ratio for point

A. A at depth d for the treatment
D=absorbed dose in phantom for field.
same SSD as used in treatment at
In a strict implementation of Equations
depth of dose maximum (mea-
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(I), (2), and (,), the field size at the depth

sured at or corrected to this
of calculation should be employed for
depth) for the calibration field
scatter-air calculations, and the TAR)d for
size.
zero field size should be for the slant dis-
D = absorbed dose in phantom at
tance on the ray from the patient’s surface
depth of calibration at source-
to A. In practice, however, it is acceptable
tumor distance (or SAD) for the
that the field size at the surface of the pa-
calibration field size.
tient and also the vertical tissue depth for
D5=absorbed dose in small mass of
tissue, just sufficient for elec-
TAR)d be used in calculation. This recom-
tronic equilibrium, in-air at nom-
mendation leads to 2 errors which are al-
most mutually compensatory. The use of
inal SSD+e, for the calibration
field size. the field size at the nominal SSD instead of
that at the depth of calculation can lead
B = fractional transmission of gamma
rays through tray supporting sec- to an underestimation ofdose by i% or so,
while utilizing the vertical depth instead of
ondary blocking for field size
the slant depth overestimates the dose by
utilized.
about o.%. It is thus recommended that
TAR). = tissue-air ratio for the calibration
field size at depth of dose maxi-
the field size at the nominal SSD and the
vertical depth of tissue oven a point of cal-
mum (this is the backscatter
culation be utilized.
factor).
The average scatter-air ratio (Sd) at a
TAR) = tissue-air ratio for the calibration
given point off-axis is calculated by sum-
field size at the depth of calibra-
ming the contributions from a number of
tion.
sectors with equal angles, as shown in
G = relative field size dependence
Figure 3. The scatter-air ratios for various
(measured in-air at the center of
circular field sizes for the depth (d) may
the large unblocked field to be
be marked on a transparent ruler for direct
employed; at calibration field
reading. Different rulers must be prepared
size in-air, G is i.oo).
for each depth. Scatter-air ratios are in-
P=beam diminution off-axis in-air
at the nominal SSD or SAD over dependent of SSD, and the same tables
may be used at different distances from
the point to be calculated, for the
the source. The sum of the contributions
large unblocked field; central axis
from all the sectors is divided by the num-
is 1.00.
ber of sectors (36 in Fig. 3) to obtain the
SSD = nominal source-skin distance for
treatment with the irregular field.
average.
e=depth of dose maximum. Example of calculation at axilla for cobalt #{243}o
g = vertical distance between skin
Point A in Figure 2 and Figure 3.
surface over A and nominal SSD
(beam vertical). SSD= 130 cm.
d=vertical depth, skin surface to A. e=0.5 cm.

SAD = source-axis distance. D0= absorbed dose at 130.5 cm. (io

SPD=distance, source to point of cal- Xiocm. field at 130 cm.)
culation (such as point A). TAR)C = I .036 (io X io cm. field, 0.5 cm.
TAR)d = tissue-air ratio at depth d for depth)
zero field size. B=o.9
 VOL. 117, No. I Calculation of Dose in Hodgkin’s Disease 37
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23.

l’ic. . The method of obtaining the average scatter-air ratio from equal sectors centering on point A.
Regions under heavy blocking are considered as contributing no scatter.

G=I.o5 (36X36 cm. field at 130 cm. From Equation (I):

relative to a ioXio cm. field at

130 cm.)
1)A = JD. X 0.951 [2 x i.o]
P=o.96 (#{231}
cm. inside field boundary 1.036

defined by primary collimators)

g=.o cm. rI 0.96 X
1
I 130+0.5 2

d=8.o cm. L \I3o+4.o+8.o

TAR)d=o.6o8 (zero field size, 8 cm. depth)
Sd=o.200 (from average scatter-air {o.6o8 +10.200]

ratio calculation outlined in Table

iii) DA = 0.63! D.
 38 J. H. Cundiff et al. J ANUARY, 1973

TABLE 111
CALCULATION OF AVERAGE SCATTER-AIR RATIO TO POiNT A IN FIGURES 2 AND 3

Sector Scatter-Air Ratio (SAR) Net SAR

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I + . 208 +.208
2 + .218 +.218
3 + . 306 +.238 - .26) +.275
4 + . 297 +.297
5 + .316 +.280 - .302 +.294

6 +.310 +.266 -.292 +.284

7 + .310 +.263 - . 284 +.289
8 +.32I +.i58 - .228 +.251
9 + .321 +.288 +.I34 - . - . 227 +.208
JO + .322 +.289 +125 - .311 - . 228 +.I97
II + .323 +.292 +121 - 314 -.231 +.191
12 +300 +122 - .239 +.I83
‘3 + . 307 +.I27 - .249 +.185
‘4 +137 - .266 +.i86
‘5 + . 308 +.I50 - . 289 +.I69
i6 + . i8o +.I80
‘7 +.223 +.223
i8 + .238 +.238
19 + . 240 +.240
20 +242 +.242
21 + . 228 +.228
22 +219 +.219
23 +.I92 +.I92
24 + . 165 +.i6
25 + . I 49 +.I49
26 + . I 40 +.140
27 +.I32 +.I32
28 + . 130 +.I30
29 + . 130 +.‘30

30 +132 +.132
31 +.138 +.138
32 + . 149 +.‘49
33 + . 164 +.164
34 +.,88 7.216 +.188
35 +.200 Average SAR = = .200 +.200
36 + . 202 36 +.202

Total +7. 216

Corn itients on the calculation. exaggerated off-axis correction factor (P)

The above calculations are not valid can be derived and applied. One would
near the edges of the open fields as defined expect a lower accuracy in this region.
by the secondary blocking, since the beam
APPROXIMATE METHODS
penumbra will reduce the dose there. At
distances of i. cm. and greater from the Some institutions utilizing similar field
edges of the beam, the effects due to shapes from patient to patient use an effec-
penumbra are usually small. If one wishes tive area for each point of calculation to
to calculate within the penumbra near the choose an appropriate backscatter factor
edges of the secondary blocking, it is and per cent depth dose. The general
possible to measure in-air across the field method described above is useful in check-
with the secondary blocks in place. An ing the validity of an equivalent area ap-
 OL. 117, No. I Calculation of Dose in Hodgkin’s Disease 39

proximation. The best choice of effective TABLE V

area is that area which gives the same TAR UNCERTAINTIES IN THE GENERAL METHOD
as the general method. The equivalent
area is irr2, where r, the radius, is selected Measured/
Calculated
from Table ii to give the scatter-air ratio
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calculated by the general method. In Table Effect on scattered radiation of:

Iv, the equivalent radii and areas are I. Lesser density of lung be-
listed for the points noted in Figure i. neath block I .OI

As an aid in selecting equivalent areas 2. Non-nominal SSD 0.99-I .01

3. Limited phantom 0. 98-I. 00*
for calculation, some institutions have
4. Transmission through blocks 1.01*
evolved rules-of-thumb which are very
helpful. The reader is cautioned against 1.00±0.03

using rules-of-thumb unless he has checked

Estimated.
their validity by the general method for
his machine and his method of treatment.

COMPARISON OF CALCULATIONS
ofthe field such as point A. The low density
AND MEASUREMENTS
of lung beneath the lung blocks does not
fully attenuate the scatter from distant
The general method of calculation is parts ofthe open field, as indicated in Item
proposed as a definitive method, not re- I of this table. Item 2 arises because of the
quining further experimental verification. assumption tables
in that
scatter-air all
Accordingly, 3 approaches have been taken parts of the field are at the same SSD; the
to challenge the calculative method: (i)
general method allows for the effect of non-
uncertainties in the general method; (2)
nominal SSD for the primary radiation but
measurements in an idealized phantom; not for the scattered radiation. Item 3 is an
and (,) measurements in an anatomic estimate of the effect of the limited thick-
phantom. ness of scattering media beneath or ad-
jacent to such the neck or axilla,
areas as
UNCERTAINTIES IN THE GENERAL METHOD
which fail to provide full scatter to the
A summary of types of known uncer- point of calculation. Some transmission of
tainties in the general calculative method, primary radiation occurs through the lung
together with a measurement or estimate blocks with subsequent
scatter to points
of each, appears in Table v. These entries of calculation. Since lung blocks usually
are appropriate to points in the open parts attenuate the primary beam to about 5%
transmission, it is estimated that scattered
TABLE IV radiation contni buted by non-zero primary
under shielding contributes on the order
EQUIVALENT RADII AND AREAS FOR THE POINTS NOTED
IN FIGURE I DERIVED BY THE GENERAL METHOD of I % of the total absorbed dose at a point
in the open field (Item ). These uncer-
. Equivalent Radius* Equivalent Area* tainties are estimates, or partial estimates,
I olnt
(cm.) (cm.2) and they are added to obtain an oven-all
uncertainty of about ±3% in the correct-
A 7.00 154
ness of the calculation. In this context,
B 9.19 265
C 8.43 223 “uncertainty” does not have a rigorous
D 5.76 104 definition, but it is likely that errors due
E 5.20 85 to the above causes would fall within the
F 8.00 20I
stated range 95% of the time; if this is so,
#{149}
These values are applicable only to the example presented in the standard error due to the above causes
Figure 1. would be less than ±2%.
 40 J. H. Cundiff et al. JANUARY, 1973

TABLE VI average agreement between calculation

COMPARISON OF THE GENERAL METHOD OF and measurement in this idealized case
CALCULATION AND MEASUREMENTS was i%. The standard error is estimated
ii. Idealized Phantom (Grant, I970) at 2%.
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MEASUREMENTS IN AN ANATOMIC PHANTOM

Depth Dose Calculated’
Point
(cm.) Dose Measured An Alderson phantom loaded with
lithium fluoride dosimeters was exposed in
A o.o .98
6 experiments to cobalt 6o gamma rays
B 10.0 1.00

C 10.0 1.00
utilizing the field shape and points of mea-
1) io.o .97 surement indicated in Figure i . The dose at
F . 5.2 .98 mid-depth was compared with the dose
F o. 1.00
calculated by the general method of cal-
G 10.0 1.00
culation. The first column in Table V1B12
H io.o .97
is the ratio of the dose calculated to that
Average 0.99±0.02 measured, considering as muscle density
the pants of the phantom exposed to the
B. .lnatomic Phantom (Grant, 1970)
open radiation field; the second column
corrects the scatter calculations for in-
Dose CalculatedDose Measured
cursions of lung (at density 0.33) into the
Point Phantom Phantom exposed area. This correction was neces-
. i nhomogenei ties i nhomogenei ties sar’ in this experiment because the Alder-
not considered considered son phantom used had abnormally large
lungs resulting in incomplete shielding of
1.04± .02 1 .02± .02
13 1.02± .0! 1 .00± .01 the lung area with lead. One should not
C 1 .05 ± .03 I .03± .03 need to make this correction for a clinical
I) .96± .o .95±0 situation since the lung normally is com-
F 1.02± .01 1.02± .01

1.00±01 .97± .01

pletely shielded. Thus, the second column
is a more correct comparison of the general
calculative method and measurement. The
MEASUREMENTS IN AN IDEALIZED PHANTOM experimental errors indicated are the
Measurements were made with a standard deviations derived from variabil-
Farmer-Baldwin, o.6 cc. ionization cham- ity of the data.
ber and a Keithlev 6o2 electrometer in a In the view of the authors, these lines
rectangular water tank utilizing cobalt 6o of experiment and reasoning support the
gamma rays and the field shape and points general method of calculation.
of measurement indicated in Figure i.
LUNG BLOCKS
Thus, the entrance surface of the phantom
POSITION
was flat at the nominal SSD (100 cm.) and
no inhomogeneities were present beneath The support trays for lung blocks and
the surface. Lung blocks of cm. lead to other secondary blocking are usually lo-
shape the field were employed at a dis- cated i 5 cm. or more from the surface of
tance of 20 cm. from the water surface. the patient. The closer the blocks are to
The results shown in Table VIA are ex- the patient, the less the penumbra cast by
pressed as the ratio of dose calculated/dose the edges of the blocks, but also the greater
measured.” The method of calculation was the surface dose due to secondary electrons
the general method described above. For ejected blocks
from and the
tray.’ If the
point G, the off-axis correction factor was field size is large, the skin sparing charac-
measured in air with the lung blocks in teristics of the beam will he reduced, even
place, since the point is near the edge of with a 15 cm. skin distance. For example,
the field. For the points considered, the for cobalt 6o radiation through a plastic
 \oi.. 117, No. I Calculation of Dose in Hodgkin’s Disease 4’

tray, the skin dose is 5% of the sub- lead shot, No. 7, to fill a styrofoam cavity
cutaneous dose at maximum for a field size 7.5 cm. deep. This thickness is equivalent
of I2X12 cm. and a skin-to-tray distance to more than cm. of solid lead. The
of 5 cm. ;18 however,
I for a 30 X3o cm. field, cavity is cut in the styrofoam at the tray
the skin dose is about 70% that at maxi- distance with a hot electrical wire sup-
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mum.27 The relative skin dose depends not ported at the target distance, as the other
only on field size and distance but also end of the taut wire is made to trace the
upon the material and type of shadow lung outline on the roentgenogram at the
tray. For any given field size on skin-to- film distance.7 In the latter method, the
tray distance, a solid plastic tray gives the edges of the blocking are parallel to the
greatest dose to the skin. The use of plastic rays, but since the styrofoam holding the
or metal trays in the form of an open mesh shot is opaque to light, the outline of the
may improve skin sparing somewhat; how- lung blocks is not seen upon the skin. A
even, in those instances where optimum method which utilizes lead shot, but per-
skin sparing is desired, a material of inter- mits visualization of the light field upon
mediate atomic number may be placed on the patient, has been described.’9”0 The
the side of the shadow tray nearest the shot is glued together in a thermoplastic
patient. For a 30X30 cm. field at i cm. material using polyethylene foam as a form
distance, the dose to the skin is reduced to cut with divergent sides in a manner sim-
about o% of that at the maximum by the ilar to that described above. Alternatively,
addition of copper, tin, or leaded glass on a low melting point alloy molded into a
the underside of the shadow tray.27 solid block may be used.6

CONSTRUCTION OF BLOCKS DOSE UNIFORMITY BETWEEN

The attenuation of the beam to about ADJACENT FIELDS

5% is desired under the lung blocks. Gen- It is possible to achieve uniformity of

erally 5 cm. of lead is used for this purpose, dose at the junction of 2 fields from geo-
both for cobalt 6o gamma rays and 6 MV metric considerations, providing the light
roentgen rays. A shape to shield the lung beam defines the dose which is o% of the
may be achieved by building with general central axis dose of the penetrating beam.
blocks, by cutting from a lead slab for in- On most therapy machines, the edges of
dividual patients, or by building the the light field define the position of 50% of
proper shape from lead shot or low melting the exposure in air or absorbed dose in
alloy. free space at the central axis. At depth, the
Several techniques exist for determining extension of the light edge approximates
the shape of blocks for individual patients. o% of the dose on the central axis; the
Meunk22 utilizes a pantograph and the method described here is based on that
chest roentgenognam to produce a tem- assumption. The separation of the light
plate for the cutting of lead blocks (with a fields at the skin is that necessary to
4 TPI skiptooth blade on a handsaw). An achieve junction of the light fields at the
alloy of lead containing 2 to #{231}%antimony chosen depth. This situation is illustrated
is more easily cut than pure lead. The in Figure and is related to the length of
pantograph minification is related to the the fields, L1 and L,, the SSD, and the
source-film and source-block distance. In depth beneath the surface where uni-
another method, a roentgen-nay simulator fonmity is to be achieved. By similar tn-
with a tray at the proper distance permits angles, the separation S on the surface is
the sketching of the block outline at the calculated as shown. In practice, it is more
tray to cast a light shadow over the lungs difficult to achieve matching if the radia-
in the roentgenognam.’5 In both of the above tion field edge has a small penumbra;
methods, the height of the blocks must be therefore, it is advisable not to use trim-
taken into account. A third method utilizes mers on the edges that are being matched,
 42 J. H. Cundiffeta/. JANUARY, 1973

shielding of the entire spinal cord from the

posterior for half the treatment;2’ however,
from the latter, the reduction of tumor dose
to the mediastinum might be an undesir-
able consequence. In Figure , the dose
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with 2 MV roentgen rays to the spinal

cord in an Alderson phantom is compared
to that delivered to the mediastinum with
anterior and posterior mantle fields. The
effect of shielding the upper part of the
spine also shown.
is

There will be differences in the dose to

the spinal cord if the tumor dose is stated
at or near the suprasternal notch or if it is
stated lower in the mediastinum. Generally,
o: /2 L1 L1 and L2 ‘ Fifid Lengths
the patient is thicker at the lower medias-
d : Depth Of Dose
Specification tinum and will therefore require a greater
62: /2 L2 SSD Source-Skin Dist.
exposure to the anteroposterior and pos-
and 62 Field Half_Separations
S:t11+ 62 teroantenion fields, with a resulting higher
$ ‘ Field Separation
dose to the spinal cord. From a review of
FIG. 4. Diagram illustrating the required field sepa- measurements at 12 institutions with
ration at the surface to achieve dose uniformity at lithium fluoride thermoluminescent dosime-
depth between adjacent fields.
ters in an Alderson anatomic phantom, the
average ratio of the maximum dose to the
Similarly, it is advisable to shift the region spinal cord to the prescribed dose in the
of matching on different days of treatment, mediastinum is 1.14 (range 0.93 to 1.36).”
so that if errors are occurring, they will be The beams included 2 MV roentgen rays,
spread over a distance. A more precise cobalt 6o gamma rays, 6 MV roentgen
method based on decrement lines and ex- rays, 22 MV roentgen rays, and 33 MV
perimental results has been given.”0 roentgen rays. Although there have been
If the fields are being treated over dif- few reports of neurologic symptoms in pa-
ferent periods of time, it may be advisable tients, some institutions may be very close
to treat the junction to a somewhat higher to administering the maximum dose that
radiation dose in order to compensate ra- can safely be delivered to the spinal cord.
diobiologically for the longer total time of Perhaps the best way of reducing the
treatment. Johnso&7 treats the junction possibility of overdose to the spinal cord
area to a dose I .2 times greaten than at the is by the use of compensating filters to
central axis when the courses of treatment attenuate those parts of the beam which
to the adjacent fields occur at different will be treating thinner parts of the
times. This type ofcalculation is more com- anatomy, such as the neck. The method
plex than the one described above.’0 proposed by Faw et al.9 compensates in the
craniocaudad and lateral dimensions of the
DOSE TO SPINAL CORD
patient, thus equalizing the doses in the
With parallel opposing fields, all parts axillary region as well as in the spinal cord.
between the surfaces are raised to nearly Another simpler method, which com-
the same dose. If some sections are thinner, pensates only in the craniocaudad dimen-
such as near the neck, then this region will sion and thus reduces the dose to the
receive a higher radiation dose than spinal cord, has been reported.2’ In this
thicker body sections. The spinal cord may latter method, the tissue compensator is
be protected by partial shielding of the employed together with a beam-flattening
upper portion down to about T2, or by filter for cobalt 6o.
 \oi.. 117, No. i Calculation of Dose in Hodgkin’s Disease 43

1.14 / Posterior Irradiation Only

/
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a: 9
. 1.c
#{149} #{149}0

.8

F
Toward
Cranium

Dose Relative to Mediastirnar

Mid
Cervical Shield Upper
0 0 0 0 0 No Shielding
Anterior

vel of Dose Noalization

at Mediastintai
Posterior Upper Mid

t I
T9
C-2 C- C- C-es C-7 T-1 T-3 T-5 T-5T-T-( ‘10 T’U
* 5 7 T-1 2 VERTEBRAL
BODY

I’!G. 5. The dose to the spinal cord from equally weighted anterior and posterior mantle treatment fields. The
dotted lines are normalized to 1.00 at the mid-thickness of the mid-mediastinum (such as point C in Fig.
I); the solid lines are normalized to 1.00 at the mid-thickness of the upper mediastinum (such as point B
in Fig. I). The circles are a continuation of the solid lines, measured with no cervical shielding in place.
Measurements were with 2 MV roentgen rays in an Alderson phantom at 150 cm. SSD.

DOSE TO GONADS OR FETUS

distances from 6 MV roentgen rays and
The dose to the gonads or to a fetus will cobalt 6o gamma rays. A summary of their
depend on the particular field arrangement results is shown in Table vii.
and distances. It is possible, however, to
SUMMARY
make some general statements about the
doses. Usually it is possible to shield by A general method is given for the cal-
blocking toward a cobalt 6o irradiator to TABLE VII
reduce the radiation dose to the fetus or DOSE AT VARIOUS DISTANCES OUTSIDE THE EDGE OF A
female gonads to approximately 20 rads MANTLE FIELD AS A PER CENT OF THE DOSE AT

from an upper mantle treatment delivering MID-DEPTH IN THE CENTER OF THE FIELD

4,000 rads to the mediastinum. Similarly,

the male gonads can be protected to a large Distance from 6 MV
EdgeofField Roentgen Rays
CoSo
extent by exclusion from the radiation field.
Without additional blocking, however, 5 cm. 3.7% 4.4%
Meurk and co-authors2’ indicate that ap- 10 cm. 1.6% 2.2%
proximately 6 nads are delivered to the 15 cm. o.8% 1.4%

ovaries from the mantle treatment with a 20 cm. i.o%

25 cm. 0.3% 0.7%
mediastinal dose of 4,000 rads. Covington
and Baker4 investigated the dose at various From Covington and Raker, 1969.
 44 J. H. Cundiff et al. JANUARY, 1973

culation of absorbed dose to an arbitrary portal radiation therapy. AM. J. ROENTGENOL.,

point in an irregularly shaped radiation RAD. THERAPY & NUCLEAR MED., 1968, 102,
199-206.
field. This method is recommended either I I. GOLDEN, R. Dose to the Spinal Cord in Mantle
as a routine method or as a standard Treatments at Various institutions
Reviewed
method against which more rapid approxi- by the RPC. Included in Hodgkin’s
Workshop
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mate methods may be judged for correct- Notebook, September 17, 1970, as paper H.
This book is available upon request to the
ness.
Radiological Physics Center, M. D. Anderson
In addition, limited consideration is
Hospital & Tumor Institute, Houston, Texas.
given to the problems of secondary block- 12. GRANT, W. H. Unpublished data, 1970.
ing, matching adjacent fields, dose to 13. GUPTA, S. K., and CUNNINGHAM, J. R. Measure-
spinal cord, and dose to the gonads or ment of tissue-air ratios and scatter functions
for large field sizes, for cobalt-6o gamma radia-
fetus.
tion. Brit. 7. Radio!., 1966, 39, 7-I I.
Robert J. Shalek, Ph.D. 14. HOLT, J. G., LAUGHLIN, J. S., and MORONEY,
Radiological Physics Center
J. P. Extension of concept of tissue-air ratios
TAR to high energy x-ray beams. Radiology,
The University ofTexas M. D. Anderson Hospital
and Tumor Institute at Houston
1970, 96, 437446.
15. ICRU. International Commission of Radiologi-
6723 Bertner Avenue
Houston, Texas 77025
cal Units and Measurements, Report iod,
Handbook 87, 1963, U. S. National Bureau of
Standards.
REFERENCES
i6. JOHNS, H. E., and CUNNINGHAM, J. R. The
I. ANDERSON, R. E., D’ANGIO, G. J., and KAHN, Physics of Radiology. Third edition. Charles
F. M. Dosimetry of irregularly shaped radia- C Thomas, Publisher, Springfield, Ill., 1969.
tion therapy fields. Parts 1 and II. Radiology, 17. JOHNSON, R. E. Private communication, 1970.
1969, 92, 1092-I 100. 18. LANZL, L. H. Unpublished data, 1969.
2. A review ofSuppl. No. 10. Depth dose tables for 19. MARUYAMA, Y., MOORE, V. C., BURNS, D., and
use in radiotherapy. Brit. 7. Radiol., 1968, i, HILGER, M. T. Individualized lung shields
932936. constructed from lead shot embedded in plas-
3. CLARKSON, J. R. Note on depth doses in fields of tic. Radiology, 1969, 92, 634-635.
irregular shape. Brit. 7. Radiol., I 941 , 14, 20. MARUYAMA, Y., WREDE, D., VAN ARSDALE, E.,
265-268. SAYEG, J., and ENGLES, E. P. Comments on
4. COVINGTON, E., and BAKER, A. S. Dosimetry of shielding by lead shot method. Radiology,
scattered radiation to fetus. 7A.M.il., 1969, 1972, 102, 445.
209, 414415. 21. MEURK, M. L., GREEN, J. P., NUSSBAUM, H.,
5. CUNNINGHAM, J. R. Calculation of dose due to and VAETH, J. M. Phantom dosimetry study
irregular fields by computer. To be published. of shaped cobalt-6o fields in treatment of
6. DEMIDECKI, A. J., FELDMAN, A., BRADFIELD, Hodgkin’s disease. Radiology, 1968, 9!, 554-
J. S., KINZIE, J. J., and POWERS, W. E. Evolu- 558.
tion ofsystem for field-shaping in radiotherapy 22. MEURK, M. L. Unpublished data, 1969.
utilizing low-melting alloys. Phys. Med. Biol., 23. MEURK, M. L. Unpublished data, 1970.

(Abstract), 1972, 17, 129. 24. OVADIA, J. Unpublished data, 1970.

7. EDLAND, R. W., and HANSEN, H. Irregular field- 25. PAGE, V., GARDNER, A., and KARZMARK, C. J.
shaping for cobalt-6o teletherapy. Radiology, Physical and dosimetric aspects of radiother-
1969, 92, 1567-1569. apy of malignant lymphomas. I. Mantle tech-
8. FAW, F. L., and GLENN, D. W. Further inves- nique. Radiology, 1970, 96, 609-618.
tigations on physical aspects of multiple field 26. PAGE, V., GARDNER, A., and KARZMARK, C. J.
radiation therapy. AM. J. ROENTGENOL., RAD. Physical and dosimetric aspects of radiother-
THERAPY & NUCLEAR MED., 1970, io8, 184- apy of malignant lymphomas. II. Inverted Y
192. technique. Radiology, 1970, 96, 619-626.
9. FAW, F. L.,JOHNSON, R., and GLENN, D. W. 27. SAYLOR, W. L., and QUILLIN, R. M. Methods for
Standard set of individualized compensating enhancement of skin sparing in cobalt 60
filters for mantle field radiotherapy of Hodg- teletherapy. AM. J. ROENTGENOL., RAD.
kin’s disease. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1971, III, 174-

THERAPY & NUCLEAR MED., 1971, III, 376- 179.

381. 28. SVAHN-TAPPER, G., and LAUDBERG, T. Mantle
10. GLENN, D. W., FAW, F. L., KAGAN, A. R., and treatment of Hodgkin’s disease with cobalt 6o.
JOHNSON, R. E. Field separation in multiple ilcta radio!. (Ther.), 1970, 9, 190-204.