4.
Combination of Basic Data and Patient Data
As pointed out in Section 3, a patient differs from
an homogeneous phantom in size, shape and composi-
tion. In this section, methods are discussed for adjust-
ing the basic data to take account of these differences.
4.1 Contour Shape
In obtaining basic absorbed dose distribution data,
the beam is usually directed at a right angle to the
surface of the phantom. During treatment, however,
the beam is directed through a body surface that may
be at an angle differing appreciably from a right
angle and, in addition, the surface may be curved in a
complex way. Two consequences arise from this;
points below the surface may have altered thick-
nesses of absorbing material between them and the
source, and they may be near to different volumes of
scattering material.
Alteration in the absorbed dose due to both of the
above factors may be avoided by the use of tissue
equivalent bolus as discussed in Section 6. This, in
fact, is the preferred method for use with x rays
generated by potentials of 200-400 kV, but for higher
energy rays, the skin sparing advantage would be
lost. For such radiations, it is frequently desirable to
alter the incident beam by the imposition of a com-
pensating filter which approximates the role of the
bolus and is also discussed in Section 6.
Under some circumstances it is also permissible, or
even advantageous, to accept the beam as it is and,
by calculation, to determine the resultant actual dose
distribution. The most convenient manual procedure
for doing this involves starting with the basic isodose
data and calculating correction factors. The following
three methods produce satisfactory results for angles
of incidence of up to about 45° for 6OCO gamma rays or
high-energy x rays, and of up to about 30° from the
surface normal for 200-400 k V x rays.
4.1.1 The Tissue-Air Ratio Method
This method can be explained with the help of Fig.
4.1. This diagram shows isodose curves taken in a
plane containing the central ray of the beam. The
solid line isodose curves represent the basic data that
were obtained in a phantom with its surface coincid-
ing with the line S' -S'. The line S-S represents the
19
curved surface of a patient. Two points are indicated,
A and B. Consider first point A. The surface location
(along a ray line) above it is unaltered and the pri-
mary absorbed dose contribution to it would be un-
changed. For moderate skin obliquity, the scattered
component also would not be changed appreciably.
This would be especially true for HOCO and high-en-
ergy radiation and the absorbed dose at point A,
therefore, can be considered as unaltered by surface
shape. Point B, on the other hand, has a considerably
reduced amount of material above it and both the
primary and scattered components of the radiation
beam will be altered. The primary component would
be increased and the scatter slightly decreased. A
good value for the correction factor required can be
obtained by the ratio of tissue-air ratios for depths (d-
h) em and d cm.
T(d - h, Wd )
CF = T(d, Wd ) (4.1)
With d = 7, h = 3, and Wd = 10, from Fig. 4.1, and
with data for 60CO radiation from Cohen et ai . (1972),
this becomes
F _ T(4, 10) _ 0.938 _
C - T(7, 10) - 0.825 - 1.137
5
Fig. 4.1 Diagram showing correction of isodose curves under
a sloping and curved surface such as S-S. The solid isodose curves
are from an isodose chart for which the phantom surface was
located at S'-S'. They would apply if the space between S-S and
S'-S' were filled in with tissue-like material but, because of the
air gap, the absorbed dose at points such as B is increased. The
line S"-S" and the dashed isodose lines represent the isodose chart
moved down a distance h . The relative dose at B can be read off
and multiplied by an inverse square factor to make allowance for
the distance change h .
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20 . . . 4. Basic Data and Patient Data
If the uncorrected relative absorbed dose at point B is
68%, the corrected value becomes
P'B = P B x CF = 68.0 x 1.137 = 77.3%
This method takes both the beam dimensions and the
depth of concern into account and is essentially an
application of a method known as the "effective atten-
uation coefficient method" (ICRU, 1963). It can be
applied equally well for fixed SSD and isocentric
techniques.
4.1.2 The Effective SSD Method
An alternative method, which also allows for beam
dimensions and depth, is as follows. Consider again
Fig. 4.1. and the two points A and B. The dose to
point A, as before, will not be altered. The air gap
(tissue-deficit) above point B is h cm and the tissue
thickness above it is (d - h). The absorbed dose, at
the point of maximum, at depth d m , along the ray line
through B, will be altered by an inverse square rela-
tion. If we also note that the percentage depth dose
does not change rapidly with distance from the source
(provided that this distance is not less than 50 cm or
so), the relative dose at point B can be obtained by
sliding down the isodose chart the distance h, so that
its surface is at S' -S', reading off the new value and
multiplying it by the inverse square law factor to give
the corrected percentage depth dose value:
P'
B
= p' x ( s+dm
B s+h+dm
)2 (4.2)
With s = 80 cm (the distance from the source to the
surface S'-S'), d m = 0.5 cm, h = 3 cm and pII B = 81
(the relative dose read off the relocated isodose
chart), the corrected relative dose value at point B is
80.5)2
P'B = 81.0 x ( 83.5 = 75.3%
This compares fairly well with the previous method.
4.1.3 The Isodose Shift Method
The foregoing methods are convenient for making
point calculations. Frequently, however, one wishes
to construct an entire isodose chart for the actual
contour shape, in which case the following procedure
can be used with quite satisfactory results. Consider
the ray through point B in Fig. 4.2. If the isodose
chart is slid down along this ray by an amount k x h,
where k is a factor less than 1, the altered intersec-
tion of the isodose lines with this ray can be read off
directly as shown. For 60CO radiation, k is usually
s
s'- - - - - - - - - - s'
s
Fig. 4.2. Diagram showing the "isodose shift" method of con-
structing isodose curves under a sloping surface. The isodose
chart is moved down a distance k x h along lines such as that
through point B and the intersections of the isodose curves with
the lines noted to construct the new isodose curves. The beam is
the same as that of Fig. 4.1.
taken to be 2/3 and this is used in the example of Fig.
4.2. The relative dose estimated at point B by this
method is 78%, which again is in fairly good agree-
ment with the above two methods.
The factor k is different for each radiation quality
and, strictly speaking, for each beam size, depth of
interest and SSD. Satisfactory values for a few radia-
tion energies for commonly used conditions are
given in Table 4.1. A discussion of these values is
given by van der Giessen (1973). The method is fast
and useful, but less accurate than either of the two
previously discussed. It should be used with great
caution for points near the surface.
The method is equally applicable for both fixed
SSD and isocentric techniques although in this latter
case the reference surface becomes a virtual surface
and will not, in general, coincide with that for which
the isodose curves were drawn. The procedure is il-
lustrated in Fig. 4.3. The reference surface, S'-S', is
located at the point of intersection of the central ray
of the beam with the patients contour. Doses at points
such as A on the central ray will not be changed since
they are normalized to be 100 at the isocenter, C.
Doses along a ray such as that through point B will
be altered. A good value for the corrected dose may be
obtained by shifting the isodose chart along this ray a
distance k x h as described above. The direction of
the shift may be either up or down, depending on the
displacement between S'-S' and S-S.
Of the three methods, the tissue-air ratio method
gives the most accurate results over a wide range of
depths since it does implicitly take both the beam size
and depth into consideration. Its use is recommended
for the estimation of doses at points of special inter-
est. The first two methods of correction lend them-
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 4.3 Effect of Body Inhomogeneities . • . 21
TABLE 4.1-Isodose shift factors for different radiation energies TABLE 4.2 -Correction factors for determination of absorbed dose
Type of radiation with lack of underlying tissue (HVL 1.5 to 2 .5 mm Cu; valid depth
5-15 em )
x rays from 150 k V to 1 MV 0.8
T hickness of Area of fi e ld /cm ~
xrays from 1 to 5 MV 0.7 underlying
0.6 t issue/em 25 50 100 150 200 400
x rays from 5 to 15 MV
x rays from 15 to 30 MV 0.5 0 0.81 0.76 0.72 0.70 0.68 0.66
x rays above 30 MV 0.4 1 .89 .86 .82 .80 .78 .75
2 .93 .91 .87 .85 .84 .82
3 .95 .93 .91 .89 .88 .85
5 .98 .97 .95 .94 .93 .92
8 1.00 1.00 1.00 .99 .99 .99

beam receives the fraction 0.91 of the dose predicted

by basic data and other corrections so far mentioned.
For 60CO gamma-ray energies and higher, the cor-
rections due to lack of backscatter can be estimated
from the reciprocal of the backscatter factor, but it is
now small, less than 5%. Frequently, the material of
the couch is sufficient to provide backscatter and, in
these cases, this correction should be ignored.

4.3 Effect of Body Inhomogeneities

The presence of tissues of different compositions or

Fig. 4.3. Diagram showing the "isodose shift" method of con-
structing isodose curves under a sloping surface for an isocentric
setup. The procedure is the same as that used in Fig. 4.2, but the
reference surface S'-S' must be taken at the intersection of the
contour with the central ray . The shift at the central ray will thus
be zero and may have positive or negative values on either side of
it.
selves to dose data representation by ray line coordi-
nates, since all values along a ray line would be
modified by the same factor. This is particularly use-
ful in computer applications.
4.2 Effect of Patient Size
Near the exit surface of the patient there may be
insufficient material to provide full scattering condi-
tions. At the exit surface, provided there is a com-
plete absence of back scattering material, the ab-
sorbed dose, obtained from the basic data, will be high
by a factor which is approximately equal to the recip-
rocal of the backscatter factor for the beam in use
(Legare, 1964). For points in the patient remote from
the exit surface, the correction factor approaches un-
ity. Table 4.2. shows corrections which should be
applied for radiation having HVL in the range from
1.2 to 2.5 mm Cu for various thicknesses of tissue (or
tissue-equivalent material) below the point of inter-
est and for different field sizes. Thus, for example, a
point 3 em above the exit point in a 10 cm x 10 em
density will cause the absorbed-dose distribution
within the patient to differ from that obtained in the
water-equivalent body. The deviations caused will
vary widely, depending on the amount and type of
non-water-equivalent material present and on the
radiation quality. The effects may be considered as
arising from alterations in the attenuation and ab-
sorption of the primary beam and from the associated
pattern of scattered photons and effects arising from
alterations in the fluence of secondary electrons.
An alteration in the attenuation of the primary
component ofthe radiation beam affects the absorbed
dose at points which lie beyond the non-water-equiv-
alent region, while an alteration in the pattern of
scattered photons affects the absorbed dose at points
which are relatively close to the non-water-equiva-
lent material, but need not be directly beyond it.
Alterations in the fluence of secondary electrons
affect the tissues within or very close to the non-
water-equivalent region . For x rays generated by
potentials of less than 400 kV, the increased fluence
of secondary electrons in bone will result in an in-
crease in the absorbed dose received by soft tissues
within the bone, or immediately adjacent to it. The
actual dose may indeed be several times the uncor-
rected dose. For high energy beams in which the
higher effective atomic number of bone is of less
significance, this effect is small or virtually absent.
However, in the case of high energy radiation, there
may be a loss of electron equilibrium in very low
density materials or in air cavities which results in a
reduction in the absorbed dose received by the tissues

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 22· . . 4. Basic Data and Patient Data
just beyond the cavity and this decreased dose may
extend an appreciable distance into the tissues.
4.3.1 Methods of Correction for Effects Arising
from Alterations in the Absorption of the Primary
Beam and the Associated Pattern of Scattered
Photons
For all methods of correction discussed, it is first
necessary to obtain the standard or basic absorbed
dose values by the application of standard depth-dose
data, isodose charts, etc., valid for water-equivalent
bodies and corrected for body shape. The correction
factors for inhomogeneities are adjustments made to
these values. For each method discussed, it is neces-
sary to determine the water-equivalent thickness of
material lying between the point of calculation and
the beam entrance point. This is taken to be the
thickness which would attenuate the primary beam
by the same amount as the actual tissues of the body.
This may be illustrated by reference to Fig. 4.4,
where a very stylized arrangement is depicted. Cal-
culation is to be made at point P, a distance d = 10 cm
below the surface. This distance is made up of3 cm of
material with a relative density of 1, followed by 5 cm
of low density material. The relative density is given
as 0.3 and since lung tissue differs from water equiva-
lence only in density, the equivalent water thickness
of the lung traversed is 0.3 x 5 cm = 1.5 cm. This
layer is followed by another layer (2 cm) of unit
relative density material. The total thickness, d, is 10
cm. The equivalent water thickness d', is 3 + 1.5 + 2
= 6.5 cm. d' is greater than d, when a high density
material such as bone is involved.
Fig. 4.4. Schematic diagram showing an inhomogeneity of
relative density 0.3 in a water equivalent phantom. Its thickness
is 5 cm and a large lateral extent is assumed. The alteration in
dose. due to the inhomogeneity. is to be calculated at point P.
Three methods of arriving at a correction factor are
presented. They are arranged in order of increasing
number of parameters that are taken into account.
There is considerable similarity with the corrections
for surface shape discussed in section 4.1.
(aJ Tissue-Air Ratio Method. A correction factor
may be obtained by using a ratio of two tissue-air
ratios.
(4.3)
where d' is the equivalent water thickness and d is
the actual thickness of material between the point of
calculation and the skin along a ray passing through
the point. W d is the dimension of the cross section of
the beam at point P.
To obtain the correction factor for the above exam-
ple for 60CO y rays, it is necessary to know the beam
dimensions. As an example, assume the beam to be
square with side Wd = 10 cm and use tissue-air ratio
data from Cohen et al. (1972) for depths of 6.5 and 10
cm to give
CF = T(6.5, 10) = .847 = 1.19
T(10, 10) .709
This correction factor takes account of both the beam
size and the depth of the point of calculation. It does
not, however, take account of the distance between
point P and the material with density different from
water, nor does it take account of the lateral extent of
the inhomogeneity.
The so-called "effective attenuation method" is very
similar in principle to the tissue-air ratio method.
However, now the correction factor, CF, would be
obtained from CF = e~d-d'), where again d is the
actual thickness of material and d' the equivalent
water thickness. Here [J., is the effective linear atten-
uation coefficient which is empirically determined.
For example, [J. could be taken as a standard value of
0.050 cm- I (5% per cm) or obtained from the rate of
change of the tissue-air ratio for the 10 cm x 10 cm
beam which would be [J. = 0.049 cm- I for 60CO radia-
tion (obtained by plotting tissue-air ratios with re-
spect to depth on semi-logarithmic paper). In this
case
CF = eO. 049 (10-6.S) = 1.19
To increase the accuracy of this type of correction, a
"position correction factor" CP, may be introduced
such that
CF' = CF x CP
This correction has been determined experimen-
tally by a number of authors (Dutreix et al., 1960;
Massey, 1962) for 60CO gamma radiation and 4 MV x
rays in the case of the lung and by O'Connor (1957)
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for x rays generated by potentials in the neighbor-
hood of 200 kV. CP is a function of the distance d l
from the point of calculation to the inhomogeneity.
The following values give an idea of the size of the
correction and are recommended:
dt/cm o 2 5 > 10
CP 0.92 0.95 0.97 1.0
In the example used here , the amended value CF' =
1.19 x 0.95 = 1.13. For very high x ray energies, the
correction factor becomes independent of the distance
dt .
( b) The Isodose Shift Method . A method of correc-
tion, similar to the method of the same name dis-
cussed in Section 4.1.3, was proposed by Greene and
Stewart (1965) and Sundbom (1965c). These authors
propose to move the isodose lines by an amount equal
to n times the thickness of the inhomogeneity as
measured along a line parallel to the central axis and
passing through the point of interest. The isodose
lines should be moved toward the skin for bone and
away from the skin for lung or air cavities. The
values of n given below were determined experimen-
tally and are independent of the field size; they are
valid for 60CO radiation and 4 MV x rays and should
be lower for higher energies.
Inhomogeneity
air cavity -0.6
lung tissue -0.4
hard bone 0.5
spongy bone 0.25
In the previous example, a shift of - 0.4 x 5 cm =
- 2 cm would be indicated. It would correspond to a
correction factor of 64.1/55.6 = 1.15 (data taken from
percentage depth dose tables, Cohen et at ., 1972, for
depths of 8 cm and 10 cm).
(c) The Power Law Tissue-Air Ratio M ethod .
Batho (1964) and Young and Gaylord (1970) have
shown, at least in the case of 60CO gamma rays, that
tissue-air ratios may also be used to calculate a cor-
rection factor which accounts for not only the magni-
tude and nature of the heterogeneity but also its
position, by raising a ratio of tissue-air ratios to a
power as follows; referring again to Fig. 4.4, the
correction factor for point P is
CF = (T(d 2, W d))(P,-1l
(4.4)
T(dl> W d )
where d I is the distance from point P to the non-
water-equivalent material and d 2 is the distance from
point P to the front (source side) of the non-water-
equivalent material. Wd is the beam dimension (ef-
fective) at the depth ofP, although, since ratios only
are used, little loss in accuracy results from taking a
constant beam size whatever be the depth of calcula-
4.3 Effect of Body Inhomogeneities • . • 23
tion, Pe is the ratio of the number of electrons per cm3
in the heterogeneity to the number of electrons per
cm3 in soft tissue . The correction factor so derived is
independent of the thickness of water-equivalent ma-
terial overlying the non-water-equivalent material,
but it does depend on the thickness ofthe heterogene-
ity and its position with respect to point P . This
expression is derived theoretically assuming Comp-
ton interaction only. It is not valid in the buildup
region nor within the non-unit-density material.
The calculated correction factor for the example of
Fig. 4.4 would be
= (T(7, 10))<0.3-1) = ( .827 )-0.7 = 1.145
CF T(2, 10) 1.004
This value is slightly lower than those given by the
other methods except where the position correction
factor was included. It can, in general , be considered
the most accurate , except for very high energy x rays
where the simple tissue-air ratio method should be
used.
4.3.2 Effects Arising from Alterations in the Flu-
ence of Secondary Electrons
(a) Bone . For x rays generated at potentials less
than about 250 kV, the electron fluence in the soft
tissues adjacent to or surrounded by bone is increased
by the electrons arising from the photoelectric ab-
sorption in the mineral contents of bone. The increase
of the absorbed dose in these regions has been com-
prehensively studied by Spiers (ICRU, 1963).
For radiation from 60CO, the absorbed dose at the
interface between bone and soft tissues varies be-
tween 95% and 108% of the dose to soft tissues, de-
pending on the direction of the photons. These varia-
tions are still smaller at higher energies.
(b) Air Cavities . For high energy photons, elec-
tronic equilibrium may be partially lost at the sur-
faces of the cavity and the actual dose to tissue be-
yond and even in front of the cavity may be apprecia-
bly lower than expected. Epp et al. (1958), for 60Co y
rays, and Nilsson and Schnell (1976), for 6OCO y rays,
6 MV and 42 MV x rays, have comprehensively stud-
ied the buildup of the absorbed dose for different
geometric conditions. The relative absorbed dose at
the surface beyond the cavity is smaller for 60CO
radiation than for higher energies, but the maximum
of the buildup curve occurs at greater depths for
higher energies. The most important decrease of the
absorbed dose at the surface is observed for the larg-
est cavities (4 cm deep) and the smallest fields (4 cm x
4 cm) tested. For those conditions, the ratio of the
absorbed dose at the surface to the maximum ab-
sorbed dose is as low as 0.64 for 6OCO y rays, 0.72 for 6
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24 . . . 4. Basic Data and Patient Data
MV and 0.76 for 42 MV x rays. For a cavity depth of 9
mm, this ratio is about 0.9 for the three beam quali-
ties. For larger field sizes, this ratio approaches un-
ity. A slight decrease of the dose at the surface of the
cavity on the side of the source is also observed owing
to a lack of back scattered electrons. This decrease of
the dose is less important than that beyond the cavity
and it occurs in a smaller thickness of tissue.
(c) Lung Tissue. In a similar way, on account of
the low density of the lung, a loss of secondary elec-
trons is observed in the first layers of soft tissue
beyond a large thickness of lung, when it is irradi-
ated by high energy photons, especially with a nar-
row beam. In common clinical conditions, this de-
crease of the absorbed dose could be as great as five
percent, but is normally ignored (Leung et at., 1970).
4.4 Input of Data for Manual and Computer Calcu-
lations
4.4.1 Manual Calculations
The basic data required for manual calculation of a
dose distribution are tables of depth-dose data and/or
tissue-air ratios, a set of isodose charts for the treat-
ment machine being used and a tracing, on a piece of
paper, of the contour of the patient. This contour is
normally taken in the plane that will contain the
central rays of the radiation beams that will be used .
Methods for obtaining this contour are discussed in
section 3.2.1. If corrections for tissue heterogeneities
are required, their locations and shapes must be
added to the diagram of the contour. Manual calcula-
tions will normally be restricted to the plane contain-
ing the central ray. It is also usually assumed that
the contour shape in other planes has no influence on
the dosage pattern in this plane. With this assump-
tion, information on other planes is not required.
This is an assumption, however, that one should be
conscious of and one which, at times, should be made
with caution.
4.4.2 Computer Calculations
The isodose chart, used in manual calculations, is
essentially an analogue device and is not particularly
suited to use with computers. It is more convenient
either to store the beam data in digital form as a
matrix of numbers or to generate the beam data as it
is required. The diagram of the patients' contour is
also analogue and this too must be entered in digital
form. The digitization can take place manually, point
by point, or by digitizing devices such as the "rho-
theta" device used in the Programmed Console (Cun-
ningham and Milan, 1969; and Holmes, 1970) or,
more recently, the "sonic digitizer". 6 These devices
could be used to take the contour directly from the
patient, thus eliminating the step of producing the
diagram on paper. The advisability of this, however,
is not established and it is likely that the operators
interaction with the paper diagram during the proc-
ess of radiation treatment planning is valuable.
Tomograms and other radiographs can be read and
digitized for computer input with a curve follower on
a light table and the magnification corrections and
other desired processing can be performed directly by
the computer. At the present time, however, such
equipment is not widespread and so, in many cases,
the shapes, the location and nature of internal struc-
tures and inhomogeneities are entered first onto a
paper diagram and then digitized for the computer.
As for manual calculations, it is most commonly as-
sumed that the two-dimensional description of the
contour, in the plane of calculation, is sufficient. The
use of the computer, nevertheless, makes it possible
to consider an extension to three dimensional treat-
ment planning.
Computer calculations will, in general, be more
accurate than hand calculations. However, they
should always be at least spot-checked by a manual
calculation. If there is significant disagreement, both
should be questioned.
An important distinction should be made between
computer programs which carry out absorbed dose
calculations and those which are called treatment
planning programs. The former carry out calcula-
tions after the beam positions have been decided.
They form a set of tools with which an operator can do
treatment planning. The latter attempts to take over
part of the decision-making process and either them-
selves arrive at values for beam settings, or more or
less directly assist the operator in doing so. The core
of both are the absorbed dose calculations and it is
essential that these be correct.
4.5 Use of Anatomical Phantoms for
Checking Procedures
Water tanks are routinely used as phantoms for
measurement of basic radiation data. It can also be
useful to measure radiation absorbed in or transmit-
ted through anatomical phantoms. In these phan-
toms the lungs should have the same atomic composi-
tion as water, but a lower density. Sawdust or cork,
after a careful check of density, can be used. Phantom
material representing bone is much more difficult to
" An example is the GRAF/PEN produced by Science Accesso-
ries Corp. of Southport, Connecticut, U.S.A.
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constitute although some plastics loaded with min-
eral compounds have been proposed (Surmont and
Gest, 1957). The best bone phantoms are made of real
bones, dried and injected with paraffin or plastic in
vacuum. Dry skeleton pieces cannot be used directly.
Realistic phantoms including skeleton and lung in-
serts are now commercially available although very
expensive. These are useful when one wants to check
4.5 Anatomical Phantoms . . . 25
a treatment procedure or a new method of calcula-
tion, for instance to take account of body heterogenei-
ties. They can be used to check the accuracy of a new
technique such as use of simulators, transverse tom-
ography or ultrasonic procedures. However, they can-
not be recommended for dosimetry of actual patients
because the variations in anatomy among patients
are far too great.
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set-up, that is, positioning the patient on the couch
outside the treatment room, prior to each session, in
order to conserve time within the treatment room.
This mode of use must be regarded as still in the
experimental stage.
6.2 Beam Compensating Devices
6.2.1 Bolus
The effect of the shape of the patient's surface in
distorting the dose distribution was discussed in sec-
tion 4.1. Fig. 6.1(a) shows, schematically, isodose
curves under a sloping surface. The dotted region
represents a target volume and it can be seen that the
absorbed dose is not uniform across it. This distortion
can be avoided by the use of tissue-equivalent bolus
material placed on the surface so that it fills in the air
gap and presents a plane surface to the beam. This is
shown in Fig. 6.l(b). The use of such material is the
preferred method for use with x rays generated by
potentials of 200-400 k V, but for higher energy rays
the skin sparing advantage would be lost. For such
radiations it is frequently desirable to alter the inci-
dent beam by the imposition of a compensating filter
which approximates the role of the bolus. There are
some circumstances when the maximum dose is, in
fact, desired at the surface, even when high energy
radiation is used. In these cases it is necessary to add
a layer of bolus material to the surface. Its thickness
should be equal to the electron buildup distance. The
use of bolus is easiest and most common with fixed
SSD set-ups although it is also possible when isocen-
tric techniques are used.
6.2.2 Compensating Filters
In order to preserve the skin sparing properties of
high energy radiation beams, and yet have the effect
produced by the bolus, it is convenient to place, away
from the patient's skin, a compensating filter so de-
signed that it duplicates, as nearly as possible, the
role of the bolus material. This is illustrated in Fig.
6.1(c). For convenience, the compensator is fre-
quently made of heavy material and it should be at
least 15 cm or so away from the skin. Its dimensions
therefore must be reduced (compared to the bolus) in
the lateral directions to allow for the diverging rays
and, in thickness, to allow for the higher attenuation
in the filter. This is shown in Fig. 6.1(d).
Compensators are not easily applicable to isocen-
tric techniques because the SSD is not fixed while the
location for the compensator usually is. It is thus not
possible to maintain a fixed geometrical ratio for the
6.2 Beam Compensating Devices • • • 39
No bolus Bolus Compensated
- - -~-- ---t---
, high I
density
I, I,
I I
(a) (b) (e) (d)
Fig. 6.1. Schematic diagrams illustrating the use of bolus
and compensating filters (From Johns, H. E. and Cunningham,
J. R. THE PHYSICS OF RADIOLOGY 3rd Ed., 1969. Courtesy
of Charles C Thomas, Publisher, Springfield, Illinois.)
lateral reduction and appreciable errors may result.
A compensating filter may be used to allow for the
effects of: (i) beam obliquity; (ii) curvature of the
entry surface of the body; (iii) body heterogeneity;
(iv) in the case of large, irregularly shaped beams,
variations in local scatter and SSD. A given filter
may be designed to allow for one or more of these
effects, the most common application being for a com-
bination of beam obliquity and body curvature. Com-
pensation may be thought of as an alternative to the
calculation procedures (section 4.1) which correct the
dose distribution for obliquity and curvature. Insofar
as correction procedures are readily available, partic-
ularly as part of an overall calculation method car-
ried out with the aid of a computer, the use of com-
pensators may be regarded as redundant. It must be
borne in mind, however, that most calculation meth-
ods are essentially two-dimensional, the body being
assumed to be a cylinder or quasi-cylinder, although
in several regions of the body (e.g., the neck andjawl
the surface curvature involves steep slopes in three
dimensions. Compensation may frequently be a bet-
ter solution. On the other hand, exact compensation
can be achieved only for the dose at a single depth,
whereas (in those situations where calculation is ap-
plicable), the dose may be corrected at all depths. It
must also be borne in mind that a dose distribution,
although fully corrected, may still be unsatisfactory
and compensation may be the only method of provid-
ing an acceptable treatment plan. An individual case
may even require both calculated corrections and
compensation (Leung et al., 1974).
The compensating filter method is constrained by
the fact that compensation can be made only for
insufficient attenuation in body tissues. For this rea-
son, when a compensating filter is used, the "nominal
surface" of the body, for purposes of applying normal
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40· . . 6. Planning and Delil/ery of Radiation Therapy
isodose curves, must be taken, as in Fig. 6.1, at the
highest point of the surface.
An analogous problem occurs when compensation
is attempted for body heterogeneity, since the atten-
uation of bone is greater than that of soft tissue to
which the normal isodose curves apply. Ellis and
Lescrenier (1973) designed compensators of minimum
thickness along those rays which include bone, the
thickness along other rays being sufficient to equal-
ize the transmission throughout the body. Thus the
compensator "matches" the body, not to a "standard"
phantom (density 1 g/cm 3 ) but to a phantom of in-
creased density (or of equivalent increased thickness)
corresponding to the pathway of maximum attenua-
tion. The method therefore involves a considerable
reduction in the useful beam intensity.
A compensating filter is intended, in the first in-
stance, to provide the primary beam attenuation
which would otherwise occur in the "missing" tissue
when the body surface is curved and/or the incident
beam is oblique (Fig. 6.1). Such a filter must, there-
fore, take account of: (a) the relative mass attenua-
tion coefficients of the filter material and soft tissue
(or water), for the radiation concerned; (b) the geo-
metrical change in lateral dimensions needed when
the attenuating material is moved nearer the source
of a divergent radiation beam; (c) the reduction in
build-up in the skin if the filter is placed near to the
surface: this reduction is negligible for 60CO 'Y rays
and other high energy radiation, if the compensating
filter is separated from the skin by at least 15 cm.
A compensating filter which allows for primary
beam attenuation only will overcompensate, i.e., the
dose at a given point in the patient will be lower than
that indicated by "standard" isodose curves, owing to
the absence of scatter reaching the point from the
'missing' tissue. The attenuation of the filter must
therefore be less than that required for primary ra-
diation only. This problem has been treated theoreti-
cally for plane parallel layers of "missing" tissue
(Sundbom, 1964; van de Geijn, 1965; Khan et al.,
1970) but the more complex practical situation, in-
volving body curvature and beam obliquity, is best
dealt with experimentally by direct measurement of
the relationship between the compensating and
'missing' material. Such experimental studies have
been carried out by the authors already cited and by
several other workers (Ellis et at., 1959; Cohen et at.,
1960; Hall and Oliver, 1961; Wilks and Casebow,
1969).
The contribution of scattered radiation to the dose
at any point in a phantom depends on the type and
energy of the radiation, the field size and the depth
and position of the point. It follows that a compensat-
ing filter must take account of all these factors, in
addition to those mentioned above in relation to the
primary radiation. Furthermore, even for a given
radiation and field size, it is impossible to design a
filter which will make absorbed dose compensation
exact at all depths in the patient. The filter is there-
fore designed either to minimize the absorbed dose
errors in the radiation field as a whole (van de Geijn,
1965) or to achieve exact compensation at a selected
depth. Most authors have chosen the second ap-
proach, and are prepared to accept the errors occur-
ing at depths other than the "compensation depth".
These errors are usually small for points within a few
centimeters of the "compensation depth" but may be-
come appreciable at more distant points. For exam-
ple, Wilks and Casebow (1969) investigated the use of
lead compensators in cobalt-60 therapy and showed
that, for a compensation depth of 5 cm below the
nominal surface, the error is within ±3% for depths
up to 8 cm but can be -10% at 15 cm depth (data for
12 cm x 12 cm field at 100 cm SSD).
Compensating filters may be constructed of wax,
acrylic material, or metal. Wax compensators (Cohen
et at., 1960) may be molded directly on the skin of a
patient, or on a plaster cast, but this method makes
no allowance for beam divergence. The errors result-
ing from the technique have been investigated by
Jackson (1970), who concluded that the errors are
acceptable for small field sizes and retraction dis-
tances, i.e., distance between the filter and the skin;
however, the retraction distance is dictated by the
need to preserve skin-sparing and must be at least 15
cm if no reduction in skin sparing is to be seen. The
fabrication of wax or plastic compensators, with al-
lowance for beam divergence, has been described by
Beck et at. (1971), Boge et at. (1974), and Khan et al.
(1968, 1970). The latter authors used a mixture of an
acrylic plastic and glass bubble beads, the density of
the final solid being controlled by the proportions of
the mixture. In this way the effective attenuation
coefficient of the filter could be varied to suit the
needs of the individual case.
Compensating filters may also be fabricated in
metal. The original filters described by Ellis et at.
(1959) were constructed of aluminum alloy blocks, the
cross-section of each block being such as to allow for
beam divergence. Brass has been advocated by Khan
et at. (1970) since this material gives minimum elec-
tron contamination at the skin for a given distance.
Probably the most useful material of all is lead (Wilks
and Casebow, 1969); such filters are laminated and
sheet lead is well suited to semi-automatic mechani-
cal design techniques.
A user adopting a system for compensating filters
is strongly urged to make a few experimental com-
parisons of predicted doses with careful measure-
ments.
Compensating filters were originally developed for
fixed SSD techniques. They may, however, be used
for isocentric techniques provided that a separate
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filter is constructed and used (if required) for each
beam: since the SSD is likely to change with each
field while the position of the filter remains fixed,
both the lateral correction for beam divergence and
the "compensation depth," i.e., the depth of the iso-
center, will be individual to each beam. A design and
fabrication technique is therefore essential which al-
lows for variation in both the divergence and the
effective attenuation coefficient; several of the meth-
ods described in the literature can provide this facil-
ity.
Other AppZications of Compensation Filters. As
already indicated, filters can also be designed to com-
pensate for the heterogeneity of the human body, in
particular the presence of bone and lung. Ellis (1960)
and Ellis et aZ. (1964) proposed a system of compensa-
tion based on a knowledge of the cross-sectional com-
position of the body obtained by transaxial tomogra-
phy. More recently Ellis and Lescrenier (1973) have
described compensators which equalize the transmis-
sion through a body section, on the basis of measure-
ments with photographic film. This method, which,
corrects for body contours as well as for heterogene-
ity, is used in practical dosimetry only for irradia-
tions with parallel opposed beams.
A further application of compensating filters is to
allow for the increase in SSD which occurs towards
the edges of a large field. In addition, if the field is ir-
regular, with narrow "limbs" protruding from a cen-
tral area, there will be a local decrease in dose when-
ever the scattered radiation is less than in the main
part of the field. These irregularities may also be
associated with dips or other changes in the body
surface. An example of such a filter, for use in the
treatment of medulloblastoma by orthovoltage x
rays, was described by Bottrill et aZ. (1965). More
recently, Leung et aZ. (1974) have discussed the de-
sign of such filters for use in high energy radiother-
apy, for example, the mantle technique for the treat-
ment of Hodgkin's Disease. In this method the com-
pensator is designed on the basis of a calculated dose
distribution in the absence of a compensator.
Svahn-Tapper and Landberg (1971) reported on an
examination of dose uniformity in mantle treatments
of patients with Hodgkin's disease. They found that
filters were not required to compensate for patient
shape in the lateral direction but that they were
useful in the craniocaudal direction of the sagittal
section. Dose calculations were verified with in vivo
measurements (see Sec. 6.5).
6.3 Methods of Optimization
It should be possible, in principle, to program a
computer so as to optimize choices of radiation beam
arrangements as part of radiation treatment plan-
6.4 Patient and Radiation Beams • • • 41
ning. The computer is given a series of constraints,
specifying upper and lower limits of doses at chosen
locations and is asked to find the best beam arrange-
ment to meet these criteria. Hope and Orr (1965)
pioneered this subject and assigned "score functions"
or relative importance to such criteria as dose uni-
formity and integral dose as well as dose maxima and
minima at specified locations. A number of other
workers have used linear programming techniques
(Bahr et aZ., 1970; Jameson and Trevelyan, 1969;
Bourgat et aZ., 1974) to arrive at choices of beam
arrangements. The main difficulty encountered in
satisfactory achievement of optimization is with the
choice of input criteria. Certainly a consideration of
radiation dose alone is not enough as dose fractiona-
tion is known to be important. Calculation of doses
with allowance for tissue inhomogeneities has al-
ready been discussed (section 4.3) and shown to be
difficult in itself although such considerations should
certainly be included in optimization procedures.
Very large and well controlled statistical studies,
especially for the purpose, would be required to eval-
uate the criteria systematically. Although there is
much current interest in the topic of computer opti-
mization, it has not as yet been satisfactorily carried
out.
6.4 Setting-Up of the Patient and the Radiation
Beams
The accurate planning of a radiation treatment
should be followed by corresponding accuracy in the
setting-up of the patient and the radiation beam.
Accurate calculation of the dose distribution is possi-
ble and pertinent only if the patient is irradiated in a
well defined position. This is usually the supine posi-
tion since patient movement during irradiation is
less probable when the patient is comfortable.
The treatment couch should allow irradiation from
any direction around the patient. Most modern treat-
ment couches are designed to make this possible
without also losing the skin sparing effect or causing
beam attenuation through heavy supporting struc-
tures of the couch.
Various techniques have been developed to guar-
antee accurate positioning of the patient on the couch
and to restrict movement as much as possible during
irradiation. The most convenient device is a cast
which is made to fit the individual patient. Casts are
made of plaster of Paris, plastics or other material
and can be supplied with beam alignment indicators
and portals to ensure the desired locations of the
entrance of the beams.
When the beam is collimated by an adjustable
diaphragm, beam position is usually checked by
means of a light localizer. The accuracy of this system
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