DOS 522 Radiation Dose Calculations

Treatment Errors Activity

The following five problems represent realistic, clinical situations that any dosimetrist could encounter
in the clinic. Calculating the correct monitor units, or dose to various points of interest, are one of the
vital roles of a dosimetrist. However, another vital skill is the ability to recognize mistakes as they occur
and how to fix the error; if possible. Use the attached data tables for all calculations.

1. A chest wall patient is treated with two phases; an initial plan with tangent fields and a boost
plan with an electron scar boost. The tangent fields have a prescription of 5000cGy over 25
fractions and the boost is 1400cGy over 7 fractions. The initial treatment is completed
according to the prescription and the patient is doing well. The boost treatment is treated with
an enface 6e electron field which follows the scar contour and uses 1cm bolus to adequately
dose the skin surface. However, the electron field must be treated at 110cm source to bolus
distance (SBD) because of patient clearance concerns from the team.

The field settings for the electron field are as follows: 6e, 10cm cone, 4x7cm custom cutout,
prescribed 200cGy to the 90% isodose line, 1cm bolus, and 110cm SBD.

On the first day of treatment, the radiation therapists can clear the patient’s body and set the
SBD to 100cm and treat the patient. On the second day of treatment, the radiation therapist
treating sets 100cm SBD based on the previous day’s experience. However, the 2nd therapist
notices the SBD should be at 110cm when reviewing the planning document. The medical
dosimetrist is called and notified of the mistake. The physician is consulted and wishes to adjust
the MU on the remaining 6 fractions so the patient has the prescribed 1400cGy delivered for the
boost.

Assuming 299 MU are required to treat the patient at the originally prescribed setup:

a. Calculate the dosimetric error (cGy) by treating the patient at 100cm SBD instead of
110cm SBD.
b. Calculate the new MU required on fractions 2 through 7 to deliver 1400cGy over the
entire 7 fraction boost course.

2. A patient with skin cancer is to be treated with enface electrons; prescribe 250cGy per fraction
at the 90% isodose line, 20 fractions, 9e, 10cm cone, 8x8cm custom cutout, and 100cm SSD. The
physician orders TLDs to verify the skin dose for treatment. The TLDs returned a measured dose
of 225cGy per fraction delivered to the skin surface; a deficit of 25cGy per fraction.
Unfortunately, the TLDs were sent to an outside service and the results were not realized until
fraction number 5. Starting fraction 6 through fraction 20, the MU will need to be adjusted so
the total dose at the skin surface is 5000cGy over 20 fractions. Assuming 275 MU are originally
calculated for the prescribed treatment:
a. How much additional dose per fraction will need to be added for fractions 6 through 20
to make up for the missed dose on fractions 1 through 5 based on the TLD
measurements?
b. What is the new MU per fraction needed for fractions 6 through 20 to both adjust for
the original deficit and make up for the underdose from fractions 1 through 5?
3. You are called in on Saturday along with a therapist and physician to treat an emergent patient
who is bleeding in the pelvis. The physician prescribes 400cGy per fraction for 7 fractions to a
total dose of 2800cGy, at mid-plane depth, 100% isodose line, using an equally weighted AP/PA
technique, 15X and 8x12cm open field, the SSD is 90cm from both AP and PA; the MU for each
field is 217 MU. The patient is treated Saturday and Sunday with this arrangement, and on
Monday the physician wants to change the prescription to 300cGy per fraction (instead of
400cGy per fraction) and a total dose of 3000cGy. The order is not relayed to the appropriate
people and the patient is treated for another two fractions at 400cGy per fraction; for a total
delivered dose of 1600cGy.
a. Calculate the new MU for each field required from fractions 5 through 10 so the total
dose delivered to the patient is 3000cGy.

4. A patient with bone metastases needs her entire femur treated. The physician orders an AP/PA
treatment at 120cm SSD in order to fit the femur in the treatment fields; the prescription is
3000cGy over 10 fractions. On the first day of treatment, the therapist sets the SSD at 100cm as
opposed to 120cm for both fields.
a. Based on the inverse square law alone, what is the percentage in total dosimetric error
and is it an underdose or overdose?
b. If the original MU from each field was 250 MU per fraction, what will the new MU need
to be for each field (per fraction) to correct for the dosimetric error and still deliver
3000cGy over 10 fractions?

5. A patient is being treated for an abdominal tumor. The treatment technique is AP/PA, using 15X,
10cm square fields with no blocking. The patient’s AP/PA thickness is 20cm and the isocenter is
placed midline and mid-depth. The prescription is 6000cGy to isocenter at the 100% isodose line
over 20 fractions; equally weighted fields. The original MU is 162 for each field. Over the course
of treatment, the patient loses weight, but the radiation therapists are not notified and they do
not report the change in AP SSD; which has changed from 90cm to 95cm. Assuming this weight
change occurred from fractions 11 through 15, and the correction is made starting on fraction
16:
a. What was the per fraction total daily dose error on the days where the patient had an
AP SSD of 95cm?
b. How do the MU need to be adjusted starting fraction 16 in order to deliver the
prescribed 6000cGy over the course of 20 fractions; keeping the fields equally
weighted?