C-Series Clinac ®

Enhanced Dynamic Wedge™

Implementation Guide

P/N 1103580-02
January 2002
Abstract The C-Series Clinac, Enhanced Dynamic Wedge Implementation Guide (P/N 1103580-02)
provides information about how to use and measure enhanced dynamic wedges.
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Notice Information in this user guide is subject to change without notice and does not represent a
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incidental or consequential damages in connection with furnishing or use of this material.

This document contains proprietary information protected by copyright. No part of this

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FDA 21 CFR Varian Medical Systems, Oncology Systems products are designed and manufactured in
820 Quality accordance with the requirements specified within this federal regulation.
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Trademarks Clinac is a registered trademark and PortalVision and Enhanced Dynamic Wedge are
trademarks of Varian Medical Systems, Inc. Microsoft and Windows are registered trademarks
of Microsoft Corporation.
© 1996–2002 Varian Medical Systems, Inc.
All rights reserved. Printed in the United States of America.

ii
CHAPTER SUMMARY

Introduction 1

Historical Perspective 2

General Control System Operation 3

Treatment Planning Considerations 4

Measurement Techniques 5

Clinical Operation 6

Quality Assurance 7

EDW Fluence Profiles (Golden STTs) A

STT Computations B

References and Selected Papers C

Glossary D

Index Index

iii
Contents
PREFACE............................................................................................................ V
Who Should Read This Guide....................................................................... v
Visual Cues ................................................................................................... v
Related Publications .................................................................................... vi
How This Guide Is Organized ..................................................................... vii

CHAPTER 1 INTRODUCTION ..................................................................... 1-1

Introduction to Enhanced Dynamic Wedge................................................ 1-1
General Capabilities................................................................................... 1-4
Additional Features .................................................................................... 1-6

CHAPTER 2 HISTORICAL PERSPECTIVE................................................. 2-1

Research and Implementation ................................................................... 2-1
First Clinical Implementation ............................................................. 2-2
Enhanced Dynamic Wedge Feature ................................................. 2-2
Wedge Angle Definition.............................................................................. 2-2
Physical Wedge Definition................................................................. 2-2
Enhanced Dynamic Wedge Definition............................................... 2-4
Key Differences ................................................................................. 2-6

CHAPTER 3 GENERAL CONTROL SYSTEM OPERATION ...................... 3-1

Combined Continuous Dose Delivery And Jaw Motion.............................. 3-2
STT Based ................................................................................................. 3-2
Open Field Phase ............................................................................. 3-2
Jaw Sweep Phase............................................................................. 3-3
Selected Dose Rate Acts as a Dose Rate Ceiling ..................................... 3-5
Beam’s Eye View Collimator Graphic ........................................................ 3-5
Dose Delivered and Jaw Speed Modulation .............................................. 3-6
Dose Rate Versus Jaw Position is the Only Important Parameter .... 3-6
Jaw Velocity, Dose Rate, and Treatment Time ................................. 3-6
Dose and Position Verification .......................................................... 3-6

v
 Description of Segmented Treatment Tables............................................. 3-7
Specifics About the Sample STT....................................................... 3-9
STT as a Dose Versus Jaw Position Function ................................ 3-10
Continuous Dose Delivery or Jaw Motion Model............................. 3-11
More About the Sample STT........................................................... 3-11
STT Generation and Delivery................................................................... 3-12
STT Generation............................................................................... 3-12
STT Delivery.................................................................................... 3-19
Tracking Accuracy Statistics for Dose and Jaw Position ......................... 3-21
Dynalog Files ........................................................................................... 3-23
Date and Time Stamp ..................................................................... 3-27
Treatment Setup.............................................................................. 3-27
Dynamic Beam Statistics................................................................. 3-27
Total Dose Delivered....................................................................... 3-27
Dose Standard Deviation ................................................................ 3-27
Dose Position Standard Deviation................................................... 3-28
Number of Samples......................................................................... 3-28
Segment Boundary Samples........................................................... 3-29

CHAPTER 4 TREATMENT PLANNING CONSIDERATIONS ..................... 4-1

Data Handling Techniques......................................................................... 4-2
EDW Compared to Physical Wedges ........................................................ 4-3
Wedge Distribution ............................................................................ 4-3
Isodose Curves ................................................................................. 4-3
Beam Profiles in the Wedge Direction............................................. 4-16
Beam Profiles in the Nonwedged Direction..................................... 4-16
Effective Wedge Factor............................................................................ 4-17
Physical Wedges............................................................................. 4-19
Variations in Physical Wedge Factors............................................. 4-19
Estimating Effective EDW Factor .................................................... 4-20
Depth Dose .............................................................................................. 4-21
EDW Depth Dose ............................................................................ 4-21
Physical Wedge Depth Dose........................................................... 4-21
Ratio of Wedge Field Depth Dose to Open Field Depth Dose ........ 4-21

vi
 Surface Dose ........................................................................................... 4-23
EDW Surface Dose ......................................................................... 4-23
Physical Wedge Surface Dose........................................................ 4-23
Peripheral Dose ....................................................................................... 4-24
EDW Data in Treatment Planning ............................................................ 4-25
Tabulated Data Sets........................................................................ 4-25
Generated Data Sets....................................................................... 4-26

CHAPTER 5 MEASUREMENT TECHNIQUES ............................................ 5-1

Collimator Field Size Check ....................................................................... 5-1
Verifying Field Size Definitions.......................................................... 5-1
Measuring Data for Treatment Planning ........................................... 5-2
Measurement Devices ............................................................................... 5-3
Ionization Chambers ......................................................................... 5-3
Diodes ............................................................................................... 5-3
Radiographic Verification Film........................................................... 5-3
Thermoluminescent Dosimeters........................................................ 5-3
Depth Dose Measurements ....................................................................... 5-4
Measuring Depth Doses.................................................................... 5-4
Verifying Water Level in the Water Phantom .................................... 5-4
Effective Wedge Factor Measurements ..................................................... 5-6
Beam Profile Measurements...................................................................... 5-6
Film Densitometry ............................................................................. 5-7
Linear Detector Arrays .................................................................... 5-14
Thermoluminescent Arrays ............................................................. 5-18

CHAPTER 6 CLINICAL OPERATION.......................................................... 6-1

EDW Treatment Setup ............................................................................... 6-1
Partial Treatment Setup ............................................................................. 6-8

vii
CHAPTER 7 QUALITY ASSURANCE ......................................................... 7-1
Dynamic Wedge QA Programs .................................................................. 7-2
Assigned Responsibility .................................................................... 7-2
Baseline Standards ........................................................................... 7-3
Plan Simple and Rapid Measurement Techniques ........................... 7-3
Daily Tests......................................................................................... 7-3
Monthly Tests .................................................................................... 7-4
Recommendations ............................................................................ 7-4
Dynamic Wedge Quality Assurance Programs ................................. 7-5
Densitometry or Single Probe Measurements................................... 7-6
Acceptance Testing.................................................................................... 7-7
Initial Measurement ........................................................................... 7-7
Treatment Planning Checks .............................................................. 7-9
Routine Machine Checks ................................................................ 7-10
Checks Specific to Each Treatment ................................................ 7-11
Evolving Technology ................................................................................ 7-12

APPENDIX A EDW FLUENCE PROFILES (GOLDEN STTS)...................... A-1

APPENDIX B STT COMPUTATIONS ........................................................... B-1

Sample Dynalog File ................................................................................. B-1
Sample Computation of a STT.................................................................. B-3
Step 1 - Start from Golden STT........................................................ B-3
Step 2 - Effective Wedge Angle ....................................................... B-4
Step 3 - STT Truncation ................................................................... B-5
Step 4 - STT Normalization to Total Dose........................................ B-6

APPENDIX C REFERENCES AND SELECTED PAPERS........................... C-1

References................................................................................................ C-1
Additional References and Papers............................................................ C-2

APPENDIX D GLOSSARY............................................................................ D-1

INDEX ........................................................................................................ Index-1

viii
Preface
The purpose of this guide is to assist you with implementation of the Enhanced
Dynamic Wedge (EDW) feature. The information in this guide includes
definitions, measurement techniques, and comparative data. All data sets
included in this guide are representative only. Actual machine-specific data
acquisition is the responsibility of the physicist because there are nominal
variations from machine to machine.

Who Should Read This Guide

This manual is for radiotherapy physicist who are responsible for

implementing EDW in the clinic.

Visual Cues

This guide uses the following visual cues to help you locate and identify
information:
Italic text is used for emphasis and book titles.
Bold text identifies menu commands, items you can click or select on the
screen, and keyboard keys.
Monotype font identifies file names, folder names, and text that either
appears on the screen or that you are required to type in.

Note: Describes actions or conditions that can help the user obtain
optimum performance from the equipment or software.

CAUTION: Describes actions or conditions that can result in minor or

moderate injury to personnel or can result in damage to
equipment.

WARNING: Describes actions or conditions that can result in serious injury

or death to personnel.

v
Related Publications

The following Varian publications provide additional information about using

the EDW:
■ C-Series Clinac Clinical User Guide (P/N 1102903)
■ Clinac Safety Manual (P/N 1104957)
■ Dynalog File View Reference Guide (P/N 10007000)

vi Enhanced Dynamic Wedge Implementation Guide

How This Guide Is Organized

This guide includes the following Chapters and Appendices:

■ Chapter 1, Introduction, provides information about the Enhanced
Dynamic Wedge and describes the general capabilities and additional
features.
■ Chapter 2, Historical Perspective, provides the historical perspective of
dynamic wedges and compares Enhanced Dynamic Wedge, dynamic
wedges, and physical wedges.
■ Chapter 3, General Control System Operation, describes the basic
operation of the Enhanced Dynamic Wedge.
■ Chapter 4, Treatment Planning Considerations, describes the
parameters to consider when planning treatments.
■ Chapter 5, Measurement Techniques, describes the techniques used to
measure the required data for treatment planning.
■ Chapter 6, Clinical Operation, describes how to set up the Clinac for an
Enhanced Dynamic Wedge and a partial treatment.
■ Chapter 7, Quality Assurance, describes a comprehensive quality
assurance program.
■ Appendix A, EDW Fluence Profiles (Golden STTs), shows the fluence
profiles (Golden STTs).
■ Appendix B, STT Computations, provides a specific example of the STT
computation.
■ Appendix C, References and Selected Papers, provides a list of
references used to compile this guide.
■ Appendix D, Glossary, provides a glossary for terms used in this guide.

vii
Chapter 1 Introduction

Enhanced Dynamic Wedge is a Clinac treatment that you can use modality to
deliver wedge-shaped photon dose distributions using computer-controlled
dose delivery combined with upper jaw motion.

In This Chapter

Topic Page
Introduction to Enhanced Dynamic Wedge 1-1
General Capabilities 1-4
Additional Features 1-6

Introduction to Enhanced Dynamic Wedge

The Enhanced Dynamic Wedge (EDW) technique differs from the physical
(metal) wedge technique in that no external beam modifier is used to create the
wedged dose profile. Instead, the wedged isodose profile is created by the
sweeping action of the jaw from open to closed position while the beam is on
(see Figure 1-1).

1-1
 Figure 1-1 Jaw Sweeping Action

1-2 Enhanced Dynamic Wedge Implementation Guide

 The wedged isodose profile is created by the integration of the dose deposited
as the jaw sweeps the field from open to closed position. Because of the jaw
motion, different parts of the field are exposed to the primary beam for
different lengths of time. This creates the wedged dose gradient across the
field.

Throughout the treatment, dose is delivered and the jaw is moved under
computer control. The relationship between dose delivered and jaw position is
well-defined within the control system and is accurately followed in order to
create the wedge-shaped field of the desired wedge angle. Computer control
ensures that dose delivered versus jaw position follows the exact precalculated
pattern that produces the prescribed dose distribution.

In general, all EDW treatments start with some portion of the dose being
delivered as an open field (a portion of the total dose is delivered before the jaw
starts moving). After the appropriate fraction of total dose has been delivered,
the jaw starts sweeping the field from open to closed position. The exact
fraction of dose that is delivered as an open field is a function of the selected
energy, field size, and wedge angle. Similarly, the exact relationship between
dose delivered and jaw position during the sweep portion of the treatment is
also a function of selected treatment energy, field size, and wedge angle.

The number of monitor units delivered as the jaw sweeps the field is
continuously adjusted to achieve the desired dose distribution.

The dose rate and jaw speed are also varied during the treatment. This allows
the treatment to be delivered in the shortest possible time.

Introduction 1-3
General Capabilities

Enhanced Dynamic Wedge extends the capabilities of the first clinical

implementation of Dynamic Wedge to allow the following:
■ Both symmetric and asymmetric fields
■ Wedge angles of 10°, 15°, 20°, 25°, 30°, 45°, and 60°
■ Field sizes up to 30 cm wide
■ Effective wedge factor that is a smooth, continuous function of field size
■ Physics mode configurable option to confirm wedge orientation from
inside treatment room using the pendant
■ Significantly fewer STTs (1 per photon energy)
■ Acquisition of PortalVision images during the initial open field portion of
the wedge
■ Automatic logging of dynamic therapy parameters and data for all clinical
treatments (dynalogs)
■ Real time beam’s eye view icon during clinical treatments, showing jaw
movements

1-4 Enhanced Dynamic Wedge Implementation Guide

 Table 1-1 Feature Comparison

Dynamic Wedge Enhanced Dynamic Wedge

Asymmetric Field No Yes

Sizes

Wedge Angles 15°, 30°, 45°, 10°, 15°, 20°, 25°, 30°,
60° 45°, 60°

Field Size Width 4 to 20 cm in 4 to 30 cm in wedge

wedge direction direction

Smooth Wedge No Yes

Factor

Wedge Orientation Mandatory User configurable

Confirmation through Physics mode
Through Pendant

Segmented 132 per photon 1 per photon energy

Treatment Tables energy
(STTs)

Portal Imaging of No Yes

Wedged Fields

Dynamic Data No Yes

Logging (Dynalog)
Capability

Real Time Beam’s No Yes

Eye View Graphic

Introduction 1-5
Additional Features

The following additional features are included with the Enhanced Dynamic
Wedge:
■ Lower peripheral dose outside the treatment field compared to metal
wedges, resulting in lower dose to adjacent sensitive structures.
■ Elimination of beam hardening (as is common with physical wedges), so
that the delivered dose corresponds more closely to the planned dose.
■ STTs that define large (30 cm) field fluence distributions, analogous to
physical wedges. STTs are automatically truncated to the desired field
size, a process that is dosimetrically similar to the use of physical wedges.
■ Treatment times that are comparable to, or in most common clinical cases,
faster than physical wedges.
■ Wedges that are selected with the push of a button. The elimination of
physical wedges allows the operator more opportunity to focus on the
patient, and reduced setup time between fields for the same patient and in
between patients.
■ Use of EDW in conjunction with a multileaf collimator (MLC) and Auto
Field Sequency (AFS) makes it possible to automatically shape and
modulate a set of fields from outside the treatment room.
■ Two wedge orientations, Y1-IN and Y2-OUT, reducing the need for
time-consuming collimator rotation.
■ Unobstructed light field allowing the exact treatment area to be viewed
during setup.
■ Use of a multiple asynchronous parallel processor (MAPP) computer that
can automatically resume treatment at the exact point of interruption when
partial treatments are necessary. The remaining monitor units is the only
extra parameter that must be input into the system to perform a partial
treatment.
■ Incorporation of morning checkout, an embedded quality assurance tool,
allowing easy verification of Dynamic Wedge operation.
■ Availability of several data sources for treatment planning: STTs, detector
arrays, or film.

1-6 Enhanced Dynamic Wedge Implementation Guide

 ■ Wedge angle definitions designed to comply with those recommended by
IEC and ICRU.
■ Computer control that enforces strict adherence to the dose versus jaw
position path required to deliver the operator specified wedge. The DPSN
interlock guarantees that, during an EDW treatment, the position of the
moving jaw cannot deviate more than 0.5 cm from the required path and
dose delivered cannot diverge more than 0.3 MU from the desired
instantaneous dose path, as specified by the STTs. The 0.5 cm and 0.3 MU
(0.45 MU for CD and EX series) are maximum interlock values; actual
deviations are much smaller (typical values are <0.06 MU and <0.03 cm).
■ Dose and jaw position control accuracy statistics are displayed on the
screen and saved to dynalog files after each clinical EDW treatment. These
statistics confirm the precision of treatment delivery.
■ Redundant position readouts on either moving jaw, providing guaranteed
position accuracy.

Introduction 1-7
Chapter 2 Historical Perspective

This chapter describes the historical perspective of the dynamic wedge and
some of the differences among Enhanced Dynamic Wedge, dynamic wedge,
and physical wedges. For the full list of references, see Appendix C.

In This Chapter

Topic Page
Research and Implementation 2-1
Wedge Angle Definition 2-2

Research and Implementation

For many years, a “poor man’s wedge” has been generated by manually
moving a lead block to successive positions across an open treatment field. The
technical literature has also contained reports on the use of
computer-controlled jaw motion to produce wedge-shaped isodose
distributions since 1978 (Ref 1). This particular effort demonstrated proof of
concept, but it was not practical to implement for routine treatments because
computer control was not commercially integrated with the accelerator.

In early 1990, D. Leavitt published a paper that confirmed the earlier published
work (Ref. 2). The major difference in this latter case was that the computer
was commercially integrated with the accelerator control (C-Series). This
made it practical to implement for routine clinical treatments. Each photon
energy required 132 Segmented Treatment Tables (STTs), one for each field
size and wedge angle combination.

2-1
First Clinical Implementation
In 1991, Varian introduced Dynamic Wedge, the first clinical implementation
of this feature. The foundation for this feature was D. Leavitt’s work. This
early implementation was limited to four wedge angles and symmetric fields.

Enhanced Dynamic Wedge Feature

Today, Enhanced Dynamic Wedge (EDW) gives the clinician enhanced
capability while streamlining the commissioning process.

Wedge Angle Definition

This section describes the definitions of physical wedges and Enhanced

Dynamic Wedge, and discusses the key differences in the two types of wedges.

Physical Wedge Definition

The wedge angle definition for Enhanced Dynamic Wedge is different than the
wedge angle definition for physical wedges. The Varian physical wedges are
designed following the convention of D.B. Hughes, C.J. Karzmark, and R.M.
Levy (Ref. 3). Figure 2-1 is taken directly from the reference.

2-2 Enhanced Dynamic Wedge Implementation Guide

 Figure 2-1 Physical Wedge

Historical Perspective 2-3

 The wedge field isodose contours are normalized to 100% on central axis at the
depth of the open field dose maximum.

The nominal wedge angle is defined as the angle through which the 80%
isodose contour has been turned at the central axis. The 80% isodose contour
varies in depth between 5 and 10 cm, depending on the X-ray energy. Because
the isodose contours of a physical wedge are curved, this is generally
interpreted to mean the tangent to the isodose contour at central axis.

The present physical wedges are optimized to produce the desired nominal
wedge angle at the largest field size that the wedge covers (20 cm for the 15°,
30°, and 45° wedges and 15 cm for the 60° wedges).

Enhanced Dynamic Wedge Definition

In contrast to physical wedges, the Enhanced Dynamic Wedge follows the
wedge definition recommended by the IEC report 976 (Ref. 4) and the ICRU
report 24 (Ref. 5). Figure 2-2 is taken directly from the IEC reference to
illustrate the difference between the definition used for physical wedges and
the definition used for the Enhanced Dynamic Wedge feature.

2-4 Enhanced Dynamic Wedge Implementation Guide

 Figure 2-2 Dynamic Wedge

Historical Perspective 2-5

Key Differences
The two key angle definition differences between the two wedge types are the
depth of the wedge angle definition and the wedge angle description.

Table 2-1 Key Differences

Enhanced Dynamic Wedge Physical Wedge

Depth Fixed depth of 10 cm Variable depth

of the 80%
isodose contour

Wedge Line drawn through two Tangent to the

Angle points a quarter of a field 80% isodose
size on either side of central contour on
axis which lie on the isodose central axis
contour that intersects the
central axis at a 10 cm depth

2-6 Enhanced Dynamic Wedge Implementation Guide

Chapter 3 General Control System
Operation

Enhanced Dynamic Wedge (EDW) supports two wedge orientations: Y1-IN

and Y2-OUT. The orientation selection determines which jaw is moved during
the treatment. Therefore, in order to create a wedge with a Y1-IN orientation,
the control system uses the Y1 jaw to sweep the treatment field while the
opposing Y2 jaw is kept stationary. Conversely, to create a wedge with a
Y2-OUT orientation, the control system uses the Y2 jaw to sweep the
treatment field while the opposing Y1 jaw is kept stationary. The resulting
EDW isodose profile corresponds to a physical wedge with its heel oriented
toward the moving jaw and its toe oriented towards the opposing stationary jaw
(see Figure 1-1).

In This Chapter

Topic Page
Combined Continuous Dose Delivery And Jaw Motion 3-2
STT Based 3-2
Selected Dose Rate Acts as a Dose Rate Ceiling 3-5
Beam’s Eye View Collimator Graphic 3-5
Dose Delivered and Jaw Speed Modulation 3-6
Description of Segmented Treatment Tables 3-7
STT Generation and Delivery 3-12
Tracking Accuracy Statistics for Dose and Jaw Position 3-21
Dynalog Files 3-23

3-1
Combined Continuous Dose Delivery And Jaw
Motion

In general, the control system delivers an EDW treatment by moving one of the
two upper jaws while the beam is on. Both dose rate and jaw speed are
modulated according to a precise, precalculated pattern. It is this combination
of dose delivery while the jaw sweeps the field that creates the
operator-selected wedged isodose profile.

STT Based

The dose versus jaw position relationship that is followed during an EDW
treatment is contained in a dose versus position table referred to as Segmented
Treatment Table (STT). STTs are discussed in more detail in Appendix A. The
dose versus jaw position relationship uniquely determines the dose profile.

EDW treatments consist of two phases: an open field phase and a jaw sweep
phase.

Open Field Phase

In general, all EDW treatments start with a fraction of the dose being delivered
to the full field, that is, before the jaw starts moving to sweep the field. This
portion of the treatment is sometimes referred to as the open field phase of the
treatment.

During the open field phase of the treatment, the dose rate is constant and
equals the dose rate selected by the operator for the treatment. The jaws remain
fixed during this phase.

3-2 Enhanced Dynamic Wedge Implementation Guide

Jaw Sweep Phase
Once the open field phase of the beam has been delivered, the jaw starts
sweeping the field towards the stationary jaw to finish the treatment with the
jaws in an almost closed position. The final field size at the end of the sweep
is always 0.5 cm.

After the open field phase of the dose has been delivered, the jaw starts
moving, usually at its maximum speed, while dose rate is reduced. As the
sweep progresses, the jaw speed is typically reduced and the dose rate
gradually increases, but never exceeds the selected dose rate. Figure 3-1 and
Figure 3-2 show example progressions of dose rate and jaw speed during an
EDW treatment. Figure 3-3 shows the dose versus jaw position relationship.

Figure 3-1 Dose Rate Progression

General Control System Operation 3-3

 Figure 3-2 Jaw Speed Progression

Figure 3-3 Dose Versus Jaw Position (Total Dose is 200MU)

In general, the exact progression of dose rate and jaw speed, as well as the
phase of the total dose that is delivered as an open field, depends on the wedge
angle, field size, total monitor units, and beam energy that were selected by the
operator. Therefore, for a given wedge angle, the field size, monitor units, and
beam energy, the progression of dose rate and jaw speed, and consequently, the
dose versus jaw position function, are completely determined and thus always
follow the same precalculated pattern (see Figure 3-3).

3-4 Enhanced Dynamic Wedge Implementation Guide

Selected Dose Rate Acts as a Dose Rate Ceiling

Because of the dose rate modulation, the operator selected dose rate should not
be viewed as an absolute dose rate, but rather as a maximum dose rate or dose
rate ceiling for the EDW treatment.

Beam’s Eye View Collimator Graphic

While the control system is in EDW mode, a beam’s eye view graphic of the
collimator opening is continuously displayed on the control system monitor
(see Figure 6-2 through Figure 6-6). This is a real-time graphic which is
updated several times a second. The sweeping action of the jaw that takes place
during an EDW treatment can be seen on the beam’s eye view collimator
graphic.

Note: The beam’s eye view collimator graphic shows only the
collimator opening. It does not show collimator rotation.

General Control System Operation 3-5

Dose Delivered and Jaw Speed Modulation

During an EDW treatment, dose delivery and jaw motion are continuous,
although jaw speed and dose rate changes according to a precalculated pattern.
The control system calculates the dose rate and jaw speed to be used at each
point in the treatment before the treatment starts. As a result, dose rate and jaw
speed always follow the same pattern for the same EDW setup (that is, for the
same beam energy, monitor units, field size, and wedge angle).

Dose Rate Versus Jaw Position is the Only Important Parameter

From a clinical point of view, the resulting wedged isodose profile depends
only on the dose delivered versus jaw position relationship which is enforced
by the control system (see Figure 3-3). Dose rate, jaw speed, accelerations, and
so on, do not directly affect the dose distribution as long as the system adheres
to the predefined dose delivered versus jaw position relationship.

Jaw Velocity, Dose Rate, and Treatment Time

The control system calculates the dose rate and jaw speed for each segment
individually so that the segment is delivered in the shortest possible time. You
can minimize the treatment time by choosing the maximum jaw velocity for
each field segment that allows delivery of the required monitor units within
that segment. Thus, in segments requiring a small number of monitor units to
be delivered, the maximum jaw velocity is set, while the set dose rate is less
than the maximum you select. For segments requiring a large number of
monitor units, a slower jaw velocity is set, while the set dose rate is changed to
the maximum you select.

Dose and Position Verification

You can verify dose and position by comparing the instantaneous number of
monitor units delivered with the preset values implied by the STT and by
comparing the instantaneous independent jaw position (determined by
precision primary and secondary potentiometer readings) with the preset
position values implied by the STT. A complete printout of actual versus
programmed values is available at completion of treatment.

3-6 Enhanced Dynamic Wedge Implementation Guide

Description of Segmented Treatment Tables

Within the control system, each EDW treatment is associated with an STT. The
STT describes the dose versus jaw position relationship to be followed during
the EDW treatment in order to produce the operator-selected wedged beam
profile. The control system computes the STT after all the relevant EDW
parameters (energy, orientation, field size, and angle) have been specified by
the operator.

Note: The following STT is a theoretical example of an STT: It does

not correspond to an actual STT for a particular energy, angle or
field size. Actual STTs delivered for a specific combination of
energy, angle, and field size are found in the dynalog files which
is created when EDW fields are delivered in clinical mode. For
more information, see “Dynalog Files” on page 3-23.

General Control System Operation 3-7

 Figure 3-4 Sample EDW STT

3-8 Enhanced Dynamic Wedge Implementation Guide

Specifics About the Sample STT
The dose represents cumulative dose in MU, so the sample STT is for an EDW
treatment delivering a total of 100 MU. The following conclusions can be
drawn by examining the STT:
■ Wedge orientation is Y1-IN, as implied by the fact that the Y1 position is
changing for the different dose values while Y2 remains fixed at 4 cm.
■ Field size is asymmetric with Y1 = 12 cm and Y2 = 4 cm.
■ First two rows specify an initial open field dose of 57.25 MU, as implied
by the fact that dose is incremented from 0 to 57.25 MU while the jaws
remain in the same position.
■ Y1 sweeps the field from its starting position at Y1 = 12 cm and closes to
a final position of Y1 = -3.5 cm (final field opening of 0.5 cm) during the
treatment.

General Control System Operation 3-9

STT as a Dose Versus Jaw Position Function
STTs can also be viewed as a tabular representation of a dose versus jaw
position function. Figure 3-5 shows the dose versus jaw position function
implied by the sample STT in Figure 3-4.

Figure 3-5 Graphical Representation of an STT

3-10 Enhanced Dynamic Wedge Implementation Guide

Continuous Dose Delivery or Jaw Motion Model
Notice that successive points on the graph are connected by a line segment.
These line segments represent the true dose versus jaw position path that the
control system enforces. This is the result of the continuous dose delivery and
jaw motion implementation.

While the STT specifies dose and position only at discrete points, the control
system enforces a linear progression of dose and position from one STT row to
the next.

All EDW STTs are generated with 20 segments, regardless of field size. Given
the continuous method of beam delivery with motion, this is more than
adequate to specify a precise dose versus jaw position path. In effect, STT rows
are needed only to describe inflection points, that is, slope changes in the EDW
dose versus position function.

More About the Sample STT

Each point on the graph is a row of the STT in Figure 3-4.

The progression of a treatment can be envisioned as a point traveling the

piece-wise linear function. Between two successive points, dose is delivered
smoothly and the jaw is moved smoothly to keep this imaginary point on the
linear trajectory. Dose rate and jaw speed between two points (that is, within a
segment) is constant.

The slope of each line segment determines the dose rate and jaw speed to be
used for the segment. For each segment, the dose rate and jaw speed are
calculated so that either the dose rate or jaw speed are at maximum. This results
in the shortest possible treatment time. For a particular dose to the target
volume, the treatment time for EDW is, in most cases, shorter than the time
required to deliver the same dose using a physical wedge.

General Control System Operation 3-11

STT Generation and Delivery

The user interface for the EDW option is similar to the interface for the
physical wedge option. If the option is enabled, the correct orientation of the
wedge field must be confirmed inside the treatment room using the hand
pendant before treatment can be given. Pretreatment verification sequences
occur as with other treatments.

Dose delivery commences with the open field segment and ends with the jaws
closed. The jaws remain in this generally asymmetric field position until reset
by the operator, thereby allowing another visual verification of jaw closure.

From a control system point of view, delivery of an EDW treatment consists of

two basic steps:

1. Generation of the STT that applies to a specific EDW setup (see “STT
Generation” on page 3-12).
2. Delivery of the generated STT (see “STT Delivery” on page 3-19).

STT Generation
In the STT generation step, the EDW parameters entered by the operator on the
Clinac console are converted into an STT. The STT generation begins when
the operator finishes entering all the relevant treatment parameters.

The progression of dose rates and jaw speeds to be used during beam-on are
also calculated at this point, that is, before beam-on.

The following mode parameters are used to calculate the STT:

■ Energy
■ Monitor units
■ Wedge orientation
■ Field size
■ Wedge angle
■ Original monitor units value (for partial treatments)

3-12 Enhanced Dynamic Wedge Implementation Guide

 STT generation consists of the following five basic steps:

1. Read fluence for selected energy from disk (“Step 1: Fluence Profiles” on
page 3-14).
2. Derive fluence for selected effective wedge angle (“Step 2: Computation
of Effective Wedge Angles” on page 3-15).
3. Truncate fluence to selected field size (“Step 3: Truncation Process” on
page 3-18).
4. Normalize fluence to total dose (“Step 4: Normalize” on page 3-19).
5. Compute dose rate and jaw speeds for all segments (“Step 5: Compute” on
page 3-19).

Figure 3-6 shows the five steps in STT generation.

Figure 3-6 STT Generation

General Control System Operation 3-13

 Step 1: Fluence Profiles

EDW beam fluence for the selected energy is read from the hard disk. EDW
uses one predefined fluence profile data set for each photon beam energy.
These fluence profiles are stored in files on the Clinac computer hard disk. One
fluence profile is used for high energy, the other for low energy. These fluence
profiles are also referred to as Golden STTs.

Each profile describes the dose fluence required to deliver a full field 60°
EDW. Full field is the 30 cm wide, asymmetric field from 20 cm to -10 cm.

These base fluences are used to numerically derive STTs for any wedge angle
and field size. This method is simpler than dynamic wedge, where separate
fluence profiles were stored on disk for every combination of field size and
wedge angle.

The fluence profile is stored on the computer disk in STT-like structures

because, like an STT, a fluence profile is a tabular representation of a dose
versus jaw position function. One difference between STTs and fluence
profiles is that while the dose column in an STT represents actual dose for a
specific EDW setup, the dose column in a fluence profile represents only
fractional dose. The conversion from fractional dose to actual dose can only be
done after the operator specifies the actual MU value for the specific EDW
treatment. Another difference is that STTs cover the specific field size for the
treatment, while the fluence profiles cover the entire 30 cm field.

Appendix A, “EDW Fluence Profiles (Golden STTs)” lists sample fluence

profiles in the format in which they are stored on the Clinac computer hard
disk.

3-14 Enhanced Dynamic Wedge Implementation Guide

 Step 2: Computation of Effective Wedge Angles

The 60° fluence profile is combined with open field dose to derive the fluence
profile that corresponds to the effective wedge angle.

The open field can be viewed as a 0° wedge.

The effective wedge angle is computed by weighted averaging of the open

field and 60° fluence profiles. The ratio of tangents method is used (Ref. 6).

Two weights, W0° and W60°, are computed based on the effective wedge angle
θ:

tan 60° – tan θ

W0° = -----------------------------------
tan 60°

tan θ
W 60° = -----------------
tan 60°

The effective angle fluence is then computed as the weighted average of the
dose in the 0° and 60° fluences. The following linear combination formula is
used:

(Fluenceθ) = (Fluence 0°) W 0° + (Fluence 60°) W 60°

Figure 3-7 depicts the weighted averaging operation.

Note: In Figure 3-7, the 0° (open field) fluence has a constant

magnitude which is the same as the magnitude of the 60°
fluence on the central axis (0 cm).

General Control System Operation 3-15

Figure 3-7 Weighted Averaging Operation to Derive Effective Wedge Angle Fluence

3-16 Enhanced Dynamic Wedge Implementation Guide

 Table 3-1 lists the two weights (W0° and W60°) for all effective angles.

Table 3-1 Open and Wedged Field Fluence Weights

Open Field Fluence Wedged Field Fluence

Wedge Angle
Weight W0° Weight W60°

10° 0.89820 0.10180

15° 0.84530 0.15470

20° 0.78986 0.21014

25° 0.73078 0.26922

30° 0.66667 0.33333

45° 0.42265 0.57735

60° 0.00000 1.00000

General Control System Operation 3-17

 Step 3: Truncation Process

The effective angle fluence is truncated to the actual field size used in the
specific treatment. Figure 3-8 depicts this truncation process. In this figure, P1
and P2 correspond to the actual field size, as specified by the operator by
means of the COLL Y1 and COLL Y2 EDW parameters.

Figure 3-8 Truncation Process

Note: ■ The truncation process mimics physical wedges. For

physical wedges, the jaws are used to truncate a wedged
full-field fluence through the wedge. The EDW mimics this
behavior by numerically truncating the full-field fluence
down to the actual field size.
■ Fluence is truncated at the P2-0.5 cm point. This is because
the moving jaw does not completely close to a
0 cm field size. The EDW completes with a final field size
of 0.5 cm.

3-18 Enhanced Dynamic Wedge Implementation Guide

 Step 4: Normalize

The truncated dose fluence is normalized to yield the STT specific to the
treatment setup. Normalization is done by proportionally scaling the dose so
that the final dose (dose at P2 in Figure 3-8) is the total dose (MU value)
programmed by the Clinac operator. The treatment-specific STT is completely
defined at the end of this step.

Step 5: Compute

After the STT has been normalized, the dose rate and jaw speed to be used for
each segment of the EDW treatment are calculated.

An example of the computations involved steps 1 through 4 is presented in

“STT Computations” Appendix B.

STT Delivery
STT delivery begins when the operator presses the BEAM ON button. The
control system turns the beam on and starts to follow the dose rate versus jaw
position path specified by the STT.

Dose rated jaw speeds start following the precalculated pattern that was
calculated in the STT generation step.

When the STT for an EDW treatment is computed, it becomes the dose versus
position path that the control system is committed to follow during the
treatment. The control system measures and verifies the delivery, and suspends
or stops treatment if the actual delivery does not follow the STT plan.

Required Starting Jaw Positions

Because an EDW treatment first delivers the open field portion of the dose, the
treatment must start with the actual jaw positions matching COLL Y1 and
COLL Y2.

General Control System Operation 3-19

 IPSN Interlock

An Initial Position Interlock (IPSN) ensures that treatment does not start until
the jaws are placed at their proper starting positions. The IPSN interlock is
cleared when the jaw positions are within 0.1 cm of the COLL Y1 and COLL
Y2 values.

Means of Control During Beam-On

The control system maintains the dose versus position relationship during the
treatment by varying the dose rate and the motor speed from maximum to zero.
The control system compares the actual positions of the jaws to the intended
positions 20 times per second. A jaw is in the hot window when it is within 0.15
cm of its intended position. If a jaw moves out of this window, the control
system suspends the beam while trying to recover the jaw position.

A cold window, when the beam is off and the jaws are more than 0.15 cm and
less than 0.5 cm outside their intended positions, allows the jaw 3 seconds to
regain its position before the treatment is interrupted by an interlock. When the
jaws are again in the hot window, the control system resumes the beam and the
STT segment from the point treatment was suspended.

DPSN Interlock

The Dynamic Position Interlock (DPSN) terminates the treatment if the dose
versus position relationship implied by the STT is not accurately followed.

The DPSN interlock terminates treatment if:

■ Jaw is in the cold window for more than 3 seconds
■ Jaw position is more than 0.5 cm (exceeding cold window) away from its
intended position
■ Delivered dose exceeds the intended dose by more than 0.30 MU (0.45
MU for models 2100CD, 2300CD and EX series) at any point

3-20 Enhanced Dynamic Wedge Implementation Guide

Tracking Accuracy Statistics for Dose and Jaw
Position

The control system gathers dose and position accuracy statistics for each EDW
treatment. The statistics are displayed to the operator and logged to disk files
at the end of every clinical EDW treatment.

The purpose of the statistics is to provide a measure of the actual deviation.

Dose and position deviation statistics are the information the control system
uses to verify a hot window, set a cold window, and set the IPSN and DPSN
interlocks. Error values during treatments are typically much smaller than
those required to set a DPSN interlock or a cold window. Typical deviations
are in the 0.01–0.03 cm range for jaw position and 0.03–0.07 MU range for
dose.

The control system tracks the actual dose and position throughout the EDW
treatment in real time. Samples of the data and any deviations from the plan are
logged at regular intervals. Typically, hundreds of samples are taken
throughout an EDW treatment. The actual number of samples is proportional
to treatment duration.

At the end of the treatment, standard deviations for the dose and the
dose-weighted position are computed and displayed to the operator in the
Treatment Complete message.

Dose weighting of the position deviation reflects the fact that position
deviations are irrelevant unless dose is being delivered.

The two standard deviations are also logged onto the control system hard disk.

These two statistics are the most informative representation of how closely a
specific EDW treatment followed the STT specified dose and position path.

General Control System Operation 3-21

 i=N 2
Σ i = 0 ( D i, plan – D i ,act )
σP = -----------------------------------------------------------------
-
N

Dose Standard Deviation Formula

i=N 2
Σ i = 1 ( ( D i, act – D i – 1 ,act ) ( P i, plan – P i ,act ) )
σ DP = ---------------------------------------------------------------------------------------------------------------
-
D

Dose Weighted Position Standard Deviation Formula

Table 3-2 Standard Deviation Formula Variables

Variable Meaning

N Number of samples taken

Di, plan Desired dose at sample i (dose implied by

the STT)

Di, act Actual dose at sample i

Di-1, act Actual dose at sample i-1

Pi, plan Planned jaw position at sample i (position

implied by the STT)

Pi, act Actual jaw position at sample i

D Total dose delivered for the treatment

3-22 Enhanced Dynamic Wedge Implementation Guide

Dynalog Files

Whenever you perform an EDW treatment, information about the dynamic

treatment is stored in a special file, called a Dynalog file. Dynalog files are also
generated for all clinical dynamic arc treatments. Dynalog files contain the
following information:
■ Date and time the treatment was performed
■ Treatment setup parameters (treatment type, energy, MU, orientation, and
so on)
■ Tracking accuracy statistics described in “Tracking Accuracy Statistics for
Dose and Jaw Position” on page 3-21
■ Treatment specific STT, that is, the STT that was generated and used for
the particular treatment
■ Real-time dose and position snapshots for each row in the STT, that is, for
all segment boundaries

Note: ■ The control system and its interlocks guarantee the accurate
delivery of an EDW treatment. The Clinac operator need
not be concerned with dynalog files. Dynalog files are just
records containing more detailed information about the
EDW treatment performed.
■ This sample dynalog is included for illustration only. The
actual dose and jaw position values are not of any
significance.

General Control System Operation 3-23

 The following is a sample dynalog file for a typical EDW treatment:

CLINAC 2300C/D - S/N 1

DATE......................: 06/23/2001

TIME......................: 10:58:23

DYNAMIC BEAM DELIVERY LOG FILE

**TREATMENT SETUP

TREATMENT TYPE: ENHANCED DYNAMIC WEDGE X-RAYS

ENERGY : 6X
MU : 300

ORIENTATION : Y1-IN

COLL Y1 : 10.00 (cm)

COLL Y2 : 5.00 (cm)

WEDGE ANGLE : 45

TIME : 1.02 (min)

ACCESSORY : NO ACCESSORY

** DYNAMIC BEAM STATISTICS **

TOTAL DOSE DELIVERED : 300 (MU)

DOSE STANDARD DEVIATION : 0.03 (MU)

DOSE-POSITION STANDARD DEVIATION : 0.01 (cm)

NUMBER OF SAMPLES : 929

3-24 Enhanced Dynamic Wedge Implementation Guide

 -- STT --

INSTANCE# DOSE COLL Y1 COLL Y2

(MU) (CM) (cm)

1 0.00 10.00 5.00

2 144.41 10.00 5.00

3 148.92 9.23 5.00

4 153.54 8.48 5.00

5 158.59 7.70 5.00

6 163.74 6.95 5.00

7 169.49 6.18 5.00

8 175.41 5.43 5.00

9 181.89 4.65 5.00

10 188.51 39.0 5.00

11 195.86 3.13 5.00

12 203.48 2.38 5.00

13 211.81 1.60 5.00

14 220.34 0.85 5.00

15 229.76 0.08 5.00

16 239.58 -0.68 5.00

17 250.33 -1.45 5.00

18 261.34 -2.20 5.00

19 273.43 -2.98 5.00

20 286.12 -3.73 5.00

21 300.00 -4.50 5.00

General Control System Operation 3-25

 -- SEGMENT BOUNDARY SAMPLES (ACTUAL) --

INSTANCE# DOSE COLL Y1 COLL Y2

(MU) (cm) (cm)

1 0.00 9.98 5.00

2 144.43 9.98 5.00

3 148.96 9.25 5.00

4 153.56 8.48 5.00

5 158.60 7.70 5.00

6 163.75 6.98 5.00

7 169.51 6.20 5.00

8 175.43 5.45 5.00

9 181.92 4.68 5.00

10 188.54 3.93 5.00

11 195.87 3.15 5.00

12 203.49 2.40 5.00

13 211.82 1.63 5.00

14 220.35 0.88 5.00

15 229.78 0.10 5.00

16 239.58 -0.65 5.00

17 250.34 -1.43 5.00

18 261.37 -2.18 5.00

19 273.44 -2.95 5.00

20 286.13 -3.70 5.00

21 300.03 -4.48 5.00

3-26 Enhanced Dynamic Wedge Implementation Guide

Date and Time Stamp
The date and time stamp reflect the date and time that the dynalog was
generated, that is, the date and time the treatment was performed. The date and
time stamp help associate the dynalog with the treatment.

Treatment Setup
Treatment setup information is essentially a duplicate of the treatment setup
information displayed in the treatment summary box of the Clinac console
screen at the time of the treatment. This section lists the treatment setup
parameters selected by the operator, that is, treatment type, beam energy, dose,
wedge orientation, field size, wedge angle, time, and accessory (if any).

Dynamic Beam Statistics

The dynamic beam statistics area contains the tracking accuracy statistics
described in “Tracking Accuracy Statistics for Dose and Jaw Position” on
page 3-21: total dose delivered, dose standard deviation, and dose-position
standard deviation.

Total Dose Delivered

This field is primarily for incomplete treatments. For treatments that are run to
normal completion, the total dose delivered equals the total dose prescribed.
For incomplete treatments, the total dose delivered is less than the prescribed
dose.

Dose Standard Deviation

Dose standard deviation is the standard deviation of the difference between
actual and planned (STT) dose as recorded at each sample (snapshot) during
the treatment. See “Tracking Accuracy Statistics for Dose and Jaw Position”
on page 3-21 for the exact formula used to compute this value.

General Control System Operation 3-27

Dose Position Standard Deviation
Dose position standard deviation is the standard deviation of the difference
between the actual and planned (STT) jaw position as recorded at each sample
(snapshot) during the treatment. The position difference at each sample is
weighted by the dose delivered between two successive samples. This dose
weighting reflects the fact that differences between actual and planned jaw
position are relevant only when dose is actually being delivered. See “Tracking
Accuracy Statistics for Dose and Jaw Position” on page 3-21 for the exact
formula used to compute this value.

Number of Samples
The number of samples is the total number of samples (snapshots) upon which
the two standard deviation values are based.

Note: The dynamic beam statistics are a comprehensive

representation of how closely the STT prescribed dose versus
position relationship was followed during the treatment.
Typically, the dose standard deviation is less than 0.07 MU. Its
value is photon energy dependent. In general, the lower the
energy, the lower the value. The dose weighted (jaw) position
standard deviation is typically less than 0.03 cm (0.3 mm).

The STT area lists the treatment-specific STT that was generated and used for
the particular EDW treatment (see “STT Generation” on page 3-12).

3-28 Enhanced Dynamic Wedge Implementation Guide

Segment Boundary Samples
The segment boundary samples (actual) area lists 21 actual dose and actual
position snapshots taken in the course of the treatment. Each snapshot
corresponds to a row in the STT table. Actual dose and position snapshots
match planned dose and position closely, as guaranteed by the DPSN interlock
(see “DPSN Interlock” on page 3-20).

Note: The previous 21 samples listed in the dynalog file may be

helpful in visualizing how the actual treatment followed the
STT prescription. However, as with all the information
contained in the dynalog file, the intent is not to display these
samples for verification purposes. The control algorithm and
ultimately the DPSN (and IPSN) interlocks are responsible for
guaranteeing the accuracy of dose versus position. Also
remember that, in terms of verifying the accuracy of dose versus
position, the EDW treatment statistics provide a much more
comprehensive and thorough measure of how closely the actual
dose and position match planned dose and position throughout
the entire treatment. This is because the dose and dose-position
error standard deviation values are computed using data from
all the samples taken throughout the EDW treatment, not just
the 21 listed snapshots. As mentioned earlier, hundreds of
samples are typically logged throughout an EDW treatment.
The exact number of samples taken for every EDW treatment is
included in the dynalog file (see “Number of Samples” on
page 3-28).

If a treatment is not run to completion, the segment boundary samples (actual)

area lists only those segments that were completed plus a final snapshot
showing the dose and position at the exact point of interruption.

Dynalog files are stored on the Clinac computer hard disk under the directory
C:\VARIAN\DYNALOG. Dynalog files for the most recent 199 EDW and arc
treatments are stored. After 199 dynalog files have been logged, every new
dynalog file overwrites the oldest dynalog file.

General Control System Operation 3-29

Chapter 4 Treatment Planning
Considerations

Enhanced Dynamic Wedge (EDW) can be evaluated in terms of the dosimetric

and data manipulation requirements of both manual and computerized
treatment planning. Dosimetric parameters for evaluation include:
■ Wedge factor versus field size and wedge angle (page 4-17)
■ Depth dose versus field size and wedge angle (page 4-21)
■ Surface dose versus field size and wedge angle (page 4-23)
■ Peripheral dose beyond the geometric field limits (page 4-24)

In This Chapter

Topic Page
Data Handling Techniques 4-2
EDW Compared to Physical Wedges 4-2
Effective Wedge Factor 4-17
Depth Dose 4-21
Surface Dose 4-23
Peripheral Dose 4-24
EDW Data in Treatment Planning 4-25

4-1
Data Handling Techniques

Data handling techniques must address the general requirements of different

types of computerized treatment planning systems for incorporation of EDW
treatment planning. These requirements may include a description or
tabulation of:
■ Central axis depth doses
■ Beam profiles for multiple depths for each field size and wedge angle
■ Wedge factors versus field width and wedge angle
■ Effective wedge intensity (fluence) profile for each wedge angle
■ Conversion of Segmented Treatment Tables (STTs) into fractional
field-weighting factors for the sequence of asymmetric fields forming the
EDW

4-2 Enhanced Dynamic Wedge Implementation Guide

EDW Compared to Physical Wedges

The EDW was designed to perform as closely as possible to the physical

wedges. This section compares the two wedge types for the following criteria:
■ Wedge distribution
■ Isodose curves
■ Beam profiles in wedge direction
■ Beam profiles in the nonwedged direction

Wedge Distribution
EDW STTs are designed to deliver the prescribed wedge angle over as large a
fraction of the field as possible. In contrast, the physical wedge angle is defined
by the attenuation through the physical wedge.

Isodose Curves
The side-by-side comparison of isodose curves in Figure 4-1 through
Figure 4-4, Figure 4-5 through Figure 4-8, Figure 4-9 through Figure 4-12,
and Figure 4-13 through Figure 4-15 demonstrate the major differences
between EDW and physical wedge distributions. The figures show wedge
angles of 15°, 30°, 45°, and 60°, respectively. The physical wedge is to the left
and the EDW is to the right in each comparison. Isodoses are adjusted to 100
percent at 10 cm depth on central axis.

Treatment Planning Considerations 4-3

 Figure 4-1 Comparison of 15° Physical Wedge and EDW (5 cm Wide Field)

4-4 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-2 Comparison of 30° Physical Wedge and EDW (5 cm Wide Field)

Treatment Planning Considerations 4-5

 Figure 4-3 Comparison of 45° Physical Wedge and EDW (5 cm Wide Field)

4-6 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-4 Comparison of 60° Physical Wedge and EDW (5 cm Wide Field)

Treatment Planning Considerations 4-7

 Figure 4-5 Comparison of 15° Physical Wedge and EDW (10 cm Wide Field)

4-8 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-6 Comparison of 30° Physical Wedge and EDW (10 cm Wide Field)

Treatment Planning Considerations 4-9

 Figure 4-7 Comparison of 45° Physical Wedge and EDW (10 cm Wide Field)

4-10 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-8 Comparison of 60° Physical Wedge and EDW (10 cm Wide Field)

Treatment Planning Considerations 4-11

 Figure 4-9 Comparison of 15° Physical Wedge and EDW (15 cm Wide Field)

Figure 4-10 Comparison of 30° Physical Wedge and EDW (15 cm Wide Field)

4-12 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-11 Comparison of 45° Physical Wedge and EDW (15 cm Wide Field)

Figure 4-12 Comparison of 60° Physical Wedge and EDW (15 cm Wide Field)

Treatment Planning Considerations 4-13

 Figure 4-13 Comparison of 15° Physical Wedge and EDW (20 cm Wide Field)

Figure 4-14 Comparison of 30° Physical Wedge and EDW (20 cm Wide Field)

4-14 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-15 Comparison of 45° Physical Wedge and EDW (20 cm Wide Field)

Treatment Planning Considerations 4-15

Beam Profiles in the Wedge Direction
The immediately obvious differences in the isodose curves are:
■ Wedge angle is preserved over a greater fraction of the field width
■ Penumbra appears to be decreased by EDW
■ Maximum dose (hot spot) within the field is greater for EDW

The greatest differences are shown in the larger field sizes and wedge angles,
where the defined isodose line covers a greater fraction of the field. For the
smaller fields, the shape of the isodose lines are more alike. This effect has
been achieved by allowing some convexity into the isodose shape, rather than
forcing the isodose line to maintain the wedge angle to the extreme of the field.

Beam Profiles in the Nonwedged Direction

Beam profiles for EDW in the direction perpendicular to the main axis of the
wedge are similar to beam profiles for open fields. This differs from the
physical wedges, where the attenuation of the beam across the wedge in the
direction perpendicular to the main axis of the wedge changes the beam profile,
compared to the open field. The implication for EDW is that the open-field
profiles can be used to calculate off-axis effects in the direction perpendicular
to the main axis of the wedge.

4-16 Enhanced Dynamic Wedge Implementation Guide

Effective Wedge Factor

The effective wedge factor must be carefully considered in using EDW.

WARNING: Unlike conventional physical wedges, with EDW, there is a

strong dependency between field size and wedge factor.

Effective wedge factor for EDW is defined as the ratio of the ion chamber
integrated reading at a depth of 10 cm on the central axis, compared to the
integrated reading for open field for the same number of monitor units. In
EDW, this ratio changes drastically with field width and wedge angle.

Figure 4-16 illustrates the effective wedge factor versus field size and wedge
angle for fields to 20 cm wide.

Treatment Planning Considerations 4-17

 Figure 4-16 Wedge Factors for Symmetric EDW Fields

WARNING: These effects should be carefully noted when calculating the

monitor units required for prescribed dose delivery. As is
obvious from the figure, failure to correctly apply this effective
wedge factor could introduce significant error in delivered dose.

As you can see, the wedge factor is a smooth and continuous function of field
size.

4-18 Enhanced Dynamic Wedge Implementation Guide

 WARNING: The effective field size method used by some treatment
planning systems to calculate wedge factors for physical
wedges should not be applied to EDW.

Physical Wedges
The Varian physical wedges used to modify radiation field dose distributions
lock into position in the accessory tray of the Varian linear accelerators such
that the central axis of the photon beam always intersects the same point on the
wedge.

This configuration allows measurement of a wedge transmission factor that

changes only marginally with field width, because the central axis ray along
which the transmission factor is measured penetrates the same thickness of
wedge for all field widths.

The difference in wedge transmission factor between wedge angles is then

related to the thickness and composition of the wedge on central axis.

Variations in Physical Wedge Factors

The variation in wedge transmission factor for the Varian physical wedges was
measured versus field size under similar conditions to those used to determine
the EDW factors.

The ratio of ion chamber readings at 10 cm depth on central axis with wedge
in field versus open field was measured for 45° and 60° wedges for 6 MV
photons.

The ratio of the wedge factors for the largest field to the smallest field were
1.012 for the 45° wedge and 1.008 for the 60° wedge, indicating the small
variation in wedge factor with field size for the Varian physical wedges.

Treatment Planning Considerations 4-19

Estimating Effective EDW Factor

Note: One simple rule of thumb for estimating the effective wedge
factor for EDW fields is to divide the total number of monitor
units delivered at the time that the moving jaw crosses the
central axis by the total number of monitor units delivered at the
completion of treatment.

4-20 Enhanced Dynamic Wedge Implementation Guide

Depth Dose

This section describes the depth dose factors as they relate to EDW and
physical wedges.

EDW Depth Dose

Depth doses for EDW are similar to the depth doses for open field.

Careful measurement of depth doses for open field and EDW show agreement
to within 2% for depths from dmax to 30 cm for nearly every field. For example,
measurements in a phantom for a 20 cm by 20 cm 60° EDW indicate a
progressive increase with depth in the ratio of central axis dose in the wedge
field compared to the open, nonwedged field.

Note: This ratio approaches 1.02 at a depth of 30 cm. This confirms

that depth doses measured for open fields can also be used for
EDW field dose calculations.

Physical Wedge Depth Dose

Depth doses using physical wedge filters differ because the introduction of the
wedge filter into the beam may also change the spectrum of photons incident
on the phantom. For example, measurement of dose values versus depth were
compared for 6 MV photons for 15 cm by 15 cm open field and 60° wedge.
The wedge dose versus open field dose ratio showed a progressive increase to
greater than 10% at a depth of 30 cm, compared to the 2% effect seen in similar
EDW measurements.

Ratio of Wedge Field Depth Dose to Open Field Depth Dose

Figure 4-17 illustrates the change in ratio of wedge dose to open field dose
versus depth for a 60° EDW and physical wedge.

Treatment Planning Considerations 4-21

Figure 4-17 Change in Ratio of Wedge Field Depth Dose to Open Field Depth Dose

4-22 Enhanced Dynamic Wedge Implementation Guide

Surface Dose

This section discusses the surface dose of EDW and physical wedges.

EDW Surface Dose

Surface doses for EDW appear to be slightly higher (up to 3%) than the
corresponding doses for open fields.

Surface dose and dose in the build-up region for 6 MV was measured using
integrated ionization readings from an energy-compensated diode and repeated
using a parallel plate ion chamber. These readings showed increases in the
surface dose for EDW relative to open field ranging from less than 1% for the
small fields and small wedge angles to approximately 2% for the largest field
and wedge angle.

Physical Wedge Surface Dose

By comparison, surface doses for the physical wedge were reduced 7–12%
compared to the open field data, indicating the filtration effects of the physical
wedge beam modifier.

Treatment Planning Considerations 4-23

Peripheral Dose

Peripheral doses for EDW are reduced by a factor of two compared to the
corresponding values for physical wedge fields (Figure 4-18).

Figure 4-18 Ratio of Dose Outside Field Edge to Central Axis Dose

The peripheral dose for physical wedge fields is higher due to the scatter out of
the field generated by the interactions of the primary photon beam with the
physical wedge.

The peripheral doses for EDW are only slightly higher than those for the
corresponding open field. This is a clinical advantage for EDW; for example,
the minimization of dose to the contra lateral breast is a prime concern in
radiation treatment of breast cancer.

4-24 Enhanced Dynamic Wedge Implementation Guide

EDW Data in Treatment Planning

Some treatment planning systems are limited to one wedge factor per wedge
angle. For these systems, implementation of the EDW factor, which varies
with both field width and wedge angle, may pose a problem. Until this
limitation can be overcome within these systems, a manual correction to the
wedge factor output may be required. You should work closely with the
treatment planning computer vendor to resolve this problem.

The ideas in this section are suggested to help you get started using EDW for
treatment planning. Before using EDW for treatment planning, you are
encouraged to discuss the techniques most suitable for your system with the
treatment planning system vendor.

Treatment planning data sets can be divided into two general groups:
■ Tabulated
■ Generated

Tabulated Data Sets

Tabulated data sets generally describe the radiation field distribution as dose
matrix points along a series of fan-lines and depth-lines and interpolate the
dose distribution onto the patient contour using these data sets.

Acquiring Dose Profiles

Systems requiring tabulated data generally require a few dose profiles for each
field size and wedge angle. These profiles are acquired using a water phantom
dosimetry system. The profiles can usually be fed directly into the treatment
planning system. The same technique can be applied to EDW. Dose
measurements should be made using a linear detector array of diodes or ion
chambers in a water phantom (“Linear Detector Arrays” on page 5-14) or
through film densitometry (“Film Densitometry” on page 5-7).

Treatment Planning Considerations 4-25

 Alternative methods

The required tabular data can also be generated by:

■ Using beam generator programs, which create an effective wedge shape
that matches the measured intensity profiles (see “Using Primary Intensity
Profiles” on page 4-27).
■ Summing the series of asymmetric fields created as the moving jaw
sweeps across the field and weighting each asymmetric field according to
the monitor units delivered to that field (see “Using STTs” on page 4-27).

Generated Data Sets

Generated data sets generally start with a reduced information set, such as the
intensity profile of the primary photon beam after passing through the wedge,
to calculate the dose distribution within the patient using Tissue Air Ratio
(TAR), Tissue Maximum Ratio (TMR), convolution, or pencil beam
calculation techniques. These techniques require less measured or stored data,
and are generally used on the newer treatment planning systems.

Using a Wedge Generator Program

Implementation of generated data may take many forms. Klein (Ref. 7) created
an effective wedge for each wedge angle, and then generated the required
fields using the physical wedge generator program resident in their treatment
planning systems.

These hypothetical physical wedges were defined by a table of attenuation

factors versus distance off central axis, or were defined using the geometric
coordinates of the wedge which would create the required beam intensity
profile.

The wedges were determined iteratively.

4-26 Enhanced Dynamic Wedge Implementation Guide

 Using Primary Intensity Profiles

The primary intensity profile for the widest EDW can be measured for each
wedge angle. Typically, this measurement is made at a depth of dose build-up,
dmax.

These primary intensity profiles are then used as a primary wedge profile.

The specific profiles for narrower wedges are then created by multiplying the
primary wedge profile by an edge function that defines the penumbra and
includes the transmission through the jaws.

As with the hypothetical physical wedge, the dose distribution is then

calculated using physical primary plus secondary dose summation techniques.

Using STTs

The required wedge fields can be generated using the STTs.

Boyer (Ref. 8) has converted the table of integral monitor units delivered into
an intensity table by factoring the output factor versus field size into the
monitor unit table, then applying this intensity function to the open field dose
distribution to create the EDW dose distribution. This method appears to work
well as a technique to modify existing open field data to predict EDW field
data.

Leavitt has used the STTs to calculate the EDW dose distribution as the
summation of a series of asymmetric fields weighted according to the monitor
unit values in the STTs and corrected for the relative change in output per
monitor unit versus field size. This summated field distribution can then be
used directly in treatment planning. This same technique can be applied to
treatment planning systems using pencil beam dose calculation algorithms.

The most promising application of STTs is to use them to generate primary

intensity functions. From these primary intensity functions, the required wedge
field isodose distribution can be created as a single field, without the
intermediate step of summing the contributions from the series of fields that
together make up the wedge field. Narrower fields can then be created by
applying an edge function to the primary intensity function. Figure 4-19
through Figure 4-22 shows the primary intensity function for four wedge
angles for a field width of 30 cm. The intensity profiles for narrower fields are
superimposed as well, indicating the wealth of data that can be created from
the initial intensity profiles. This technique is readily applicable to all
treatment planning systems that generate isodose distributions.

Treatment Planning Considerations 4-27

 Figure 4-19 6 MV 15° EDW Profiles at 1.5 cm Depth

4-28 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-20 6 MV 30° EDW Profiles at 1.5 cm Depth

Treatment Planning Considerations 4-29

 Figure 4-21 6 MV 45° EDW Profiles at 1.5 cm Depth

4-30 Enhanced Dynamic Wedge Implementation Guide

 Figure 4-22 6 MV 60° EDW Profiles at 1.5 cm Depth

Treatment Planning Considerations 4-31

Chapter 5 Measurement Techniques

This chapter covers measurement techniques that you can use to:
■ Verify jaw motions, field size definitions, and wedge field shapes
■ Measure the data required for computerized or manual treatment planning

In This Chapter

Topic Page
Collimator Field Size Check 5-1
Measurement Devices 5-3
Depth Dose Measurements 5-4
Effective Wedge Factor Measurements 5-6
Beam Profile Measurements 5-6

Collimator Field Size Check

Prior to dose measurements, you should make proper adjustments to collimator

field size.

Verifying Field Size Definitions

You should perform a series of symmetric and asymmetric field size
verifications.

A simple calculation in which the positioning of the independent jaw created

fields from 2 mm wider than expected to 2 mm narrower than expected showed
that the effective wedge angle changed by +1° due to this integrated error in
field width. Simultaneously, the dose on central axis at 10 cm depth changed
by as much as +2%.

5-1
 To verify field sizes, position one movable jaw in a fixed location, then move
the second independent jaw to a series of asymmetric settings and measure the
width of the X-ray field. The agreement should be to within 1 mm across the
entire range of measurements. Typically, radiographic verification film is used
to perform this X-ray field size check.

In addition, you should verify the coincidence of the crosshairs with the center
of the field. An offset error in the location of the crosshairs introduces small
errors in all positional measurements conducted for dynamic wedge.

Measuring Data for Treatment Planning

For systems that use tabular beam profile data directly you can take beam
profile measurements from film densitometry or from integrated ion chamber
or diode readings using linear detector arrays.

For systems that require effective wedge filter transmission factors you can
determine beam profile measurements from measured dynamic wedge profile
data.

5-2 Enhanced Dynamic Wedge Implementation Guide

Measurement Devices

Several devices are available to take dynamic wedge measurements. Each

device has some advantage for one or more of the required measurements.
Devices for dynamic wedge measurements include:
■ Ionization chambers
■ Diodes
■ Radiographic verification film
■ Thermoluminescent dosimeters (TLDs)

Ionization Chambers
Both parallel-plate and cylindrical ionization chambers are commonly used in
radiation therapy measurements.

Diodes
Energy-compensated diodes are similar in energy response to ionization
chambers, but offer a smaller measurement cross section and thinner depth.
These characteristics make it possible to measure dose in the build-up region.

Radiographic Verification Film

Radiographic verification film is commonly used in radiation therapy
departments and is supported by several commercial film densitometry
systems.

Thermoluminescent Dosimeters
Thermoluminescent dosimeters (TLDs) are available in reusable rods, chips,
and discs. TLDs can be used in vivo and in anthropomorphic phantom studies.
In addition, TLD rods of 1-mm diameter have been used in solid-water
phantoms to measure depth doses, build-up doses, and beam profiles. Newer
TLD readers can sequentially process up to 50 TLD rods without intervention,
making the process more efficient than previously.

Measurement Techniques 5-3

Depth Dose Measurements

Ion chamber measurements can be used to confirm the central axis depth doses.
The small-volume ion chambers used in water phantom dosimetry systems
work well for these measurements. Newer water phantom systems allow
integration of dose at programmed points.

Measuring Depth Doses

To measure depth doses, record the integrated reading of both the movable
scanning ion chamber and the fixed-position reference chamber for each
dynamic wedge exposure. Then, calculate the ratios to determine the depth
doses. Using the reference chamber for these measurements allows correction
for any change in machine output over time.

Because each depth dose measurement requires integration of a complete

dynamic wedge treatment, you can abbreviate the number of depths at which
doses are measured and interpolate the intermediate values.

Typically, measurements at dmax, 2.5 cm, 5 cm, and additional depths in

increments of 5 cm to a depth of 30 or 40 cm are adequate to construct the depth
dose curve.

Verifying Water Level in the Water Phantom

For measurements that extend over a period of time, the water in the water
phantom can evaporate. An independent indicator, such as a front pointer
attached near the edge of the tank, can be used to verify the water level. Failure
to keep the water level constant leads to errors in depth dose measurements.

Water Phantom Alignment

Water phantom alignment with the central axis of the radiation field
(registration) is critically important. If water phantom alignment deviates from
the central axis of the field with depth, the ion chamber may view a different
effective wedge transmission. Therefore, minor angular misalignment may
introduce larger errors in depth dose measurements for wedge fields.

5-4 Enhanced Dynamic Wedge Implementation Guide

 Minimizing Misalignment Errors

To minimize misalignment errors, measure the depth doses twice, then average
the measurements. Measure once with the collimator at 90° and a second time
with the collimator at 270°.

Water Phantom Alignment Tips

To align the phantom, perform the following steps:

1. Place the water phantom on a leveling device, such as a 3-point system that
allows adjustment of the plane on which the tank rests.

Note: This device may be part of the cart provided with the water
phantom or it could be a separate device attached to the bottom
of the phantom and resting on the treatment couch or some other
fixed device.

2. Place a circular bubble level in the bottom of the phantom.

3. Adjust the vertical adjustments of the leveling device until the bubble is
centered in the circle.
4. Place a bubble level on the flat face of the accessory mount and check the
angular alignment of the gantry.
There may be an offset error in the digital or analog readout of the gantry
angle on the face of the linear accelerator.
5. Center the detector in the crosshairs of the light field.
6. Move the detector across the extended range of depths through which the
measurements are being made and verify that the crosshairs remain
centered on the detector.
Any deviation of the crosshair projection means the verticality of the water
phantom, detector track, and linear accelerator are not aligned.
7. Verify the motion of the detector again after the phantom is filled with
water.
Misalignment can occur due to settling or flex after the tank is filled.

Measurement Techniques 5-5

Effective Wedge Factor Measurements

Varian recommends that you perform ion chamber measurements to verify the
effective wedge factor.

With the ion chamber positioned at 10 cm depth in a phantom on central axis,

record the reading for each dynamic wedge angle for a fixed number of
monitor units. Then, record the reading for the open field for the same number
of monitor units. The ratio of readings is the effective wedge factor. This
procedure is repeated for all square fields from 4 cm wide to 30 cm wide.

Beam Profile Measurements

Film densitometry has long been used in radiation measurement. More

recently, direct measurement of radiation dose distributions using a linear array
of ion chambers or energy-compensated diode detectors has been introduced.
The primary advantage of linear detector arrays is that the measurements made
in a physical water phantom apply directly in profile determination with no
additional corrections. The primary disadvantage is that you must complete a
large number of sequential exposures to define the beam profile at the number
of depths typically required by treatment planning systems.

The following three techniques are currently available to measure dynamic

wedge beam profiles:
■ Film densitometry (page 5-7)
■ Linear detector arrays (page 5-14)
■ Thermoluminescent arrays (page 5-18)

5-6 Enhanced Dynamic Wedge Implementation Guide

Film Densitometry
Film densitometry offers the advantage that a complete field being defined in
one exposure. You can measure two-dimensional profiles by mounting a single
film parallel to the central axis of the beam. You can accumulate
three-dimensional profile data by mounting individual films perpendicular to
the central axis of the field at the depths in phantom required by the treatment
planning data acquisition system. Mark the central axis with a thin solder wire
to properly index the film.

The primary disadvantages of film are:

■ To achieve reliable results, you must determine and apply depth and
energy spectrum corrections to the film density measurements in addition
to the normal density-to-dose conversion factors.
■ You must exercise care with film processor quality control and positioning
techniques of film in the phantom.

Commercially Available Services

Some companies and individuals now offer film densitometry services that
include reading processed film and reporting the dosimetry data in a form
compatible with the treatment planning system requirements. Therefore,
institutions without an on-site film densitometry system can still use this
technique for dose measurement.

Measurement Techniques 5-7

 Film Dosimetry Cassettes

Although commercial cassettes are available in which bare film can be

exposed, using them is time-consuming. Before each exposure, you must load
the bare film in a darkroom, then unload the film in a darkroom after each
exposure.

Several institutions have made all exposures using the radiation therapy
verification film in its paper envelope. To make the film edge coincident with
the leading edge of the phantom, fold over the paper lip of the envelope above
the film edge. Pierce each film envelope with a pin to evacuate any air in the
envelope during compression into the phantom. This technique delivers good
results.

Processing Radiographic Films

Extreme care must be taken when processing radiographic film for dynamic
wedge measurements.The low-volume film processors commonly used in
radiation therapy departments are not designed to process large numbers of
films rapidly. The processor temperature rises if a large number of films are fed
through the processor. The rise in temperature changes the film density to dose
response.

In addition, the processor rollers often introduce streak artifacts to the film.

Because of these problems, Varian recommends that you use a high-volume

film processor that is subject to strict quality control to process dynamic wedge
films. Such processors are readily available in diagnostic radiology
departments and are typically used to process mammographic films where high
detail is required. The softer rollers on these processors minimize streak
artifacts.

5-8 Enhanced Dynamic Wedge Implementation Guide

 Film Measurement Technique 1

One film is required for each field size and wedge angle.

To derive a standard two-dimensional isodose distribution from the film,

perform the following steps:

1. Sandwich the radiation therapy verification film (XV2) between

polystyrene or solid water sheets.
2. Place the film parallel to the central axis of the radiation field.
3. Adjust the dose delivered to the film so that the maximum dose near the tip
of the wedge remains within the dose range of the film.
Typically, 75 cGy delivered at 10 cm depth satisfies this requirement.
4. For smooth apposition of film and phantom, insert sheets of superflab
between the film and the solid phantom sheets.
Superflab expands laterally under compression, thus avoiding pressure
artifacts and air cavity artifacts.

Film Measurement Technique 2

The beam’s eye view arrangement of the film requires multiple films for each
field size and wedge. For typical fan-line or grid-line tabular data treatment
planning systems, five or six films are needed for each field size and wedge
angle, with the films placed at dmax and at equal depth increments beyond
dmax.

To evaluate three-dimensional dose distributions for each wedge field, perform

the following steps:

1. Sandwich the radiation therapy verification film (XV2) between

polystyrene or solid water sheets.
2. Place the film perpendicular to the central axis of the radiation field.
3. Adjust the dose delivered to the film so that the maximum dose near the tip
of the wedge remains within the dose range of the film.

Note: Typically, 75 cGy delivered at 10 cm depth satisfies this

requirement.

Measurement Techniques 5-9

 Comparison of Film Techniques

Beam profiles have been measured and compared for the two film
measurement techniques. These comparisons show that the measured profiles
are in agreement at all depths if reasonable care is taken in the film processing.

Problems With Film Densitometry

Two specific problems are associated with the use of film densitometry:
■ Film alignment verification (page 5-10)
■ Film density-to-dose conversion (page 5-11)

Film Alignment Verification

To help verify proper film alignment (registration), you can use:

■ Thin solder wire
Place a thin solder wire across the film edge along the crosshair shadow
defining the perpendicular bisectors of the light field on the phantom
surface. The wire creates a narrow line along the entire length of the film
corresponding to the central axis of the field. Use the line to align the
center of each scanned profile.
■ Alignment jig
Build an alignment jig into the film cassette. The jig can consist of pins
embedded in one-half of the cassette that correspond to the position of the
central axis just below the entrance surface of the phantom and just above
the exit edge of the film. To center the field crosshairs on the phantom, use
a mark on the entrance surface of the cassette that corresponds to the
position of the pinprick in the film. The pinprick at the bottom of the film
then allows alignment of the central axis of the field relative to the film,
and accounts for any skewing of the film during placement in the cassette.
These pinpricks show up on the film as localized dark spots and can be
aligned with the film densitometer template. Alternatively, you can place
the pinpricks at the edges of the film and match them with positions on the
film densitometer template to ensure proper alignment of the film for
scanning.

5-10 Enhanced Dynamic Wedge Implementation Guide

 Film Density-to-Dose Conversion

Use of a single density-to-dose conversion curve (H&D curve) does not

account for change in film response due to energy change with depth.
Similarly, film response in the penumbra region may change due to the change
in the energy spectrum of the scattered radiation. These effects can be studied
using techniques such as those described by Williamson, Khan, and Sharma
(Med. Phys. 8:94-98).

Measuring the H&D Curve

To measure the H&D curve, you can use film placed in the phantom in the
same orientation used to expose the Dynamic Wedge fields. That is, if the
wedge films are exposed using the film parallel to the central axis of the field,
then determine the H&D curve using a series of films exposed parallel to the
central axis of the field.

Use a fixed, open field size of 10 cm by 10 cm for a series of exposures up to

200 cGy.

To determine the density-to-dose relationship, search for the maximum on

each film and relate that to the delivered dose. Most newer film densitometry
systems have an option to automatically perform this step.

To achieve maximum differentiation of dose from the film densities, adjust the
maximum dose delivered downward so that the maximum film density is still
within the steeply ascending portion of the H&D curve.

Measurement Techniques 5-11

 Film Sensitivity Versus Depth

Film sensitivity versus depth is dependent on photon energy. The two curves
to the left in Figure 5-1 compare the film densitometer output signal versus
dose at dmax and at 30 cm depth on central axis. Similar measurements were
made at intermediate depths in 5 cm increments. These curves suggest an
increased film sensitivity of approximately 4.2% at 25 cm for 6 MV photons
while showing no increase in film sensitivity for 18 MV photons.

Figure 5-1 Film Sensitivity Versus Depth

5-12 Enhanced Dynamic Wedge Implementation Guide

 Dose Modifier

The film sensitivity versus depth effect can be folded into film densitometry
scanning by including a simple dose modifier that corrects the densitometer
reading by the inverse of the sensitivity factor versus depth. This dose modifier
can be represented as:

Table 5-1 Dose Modifier

Variable Description

D (d, R) Corrected dose

R Film densitometer reading

H/D Film density-to-dose conversion

b Film sensitivity coefficient

determined by least squares fit to
measured sensitivity data

Example of Film Sensitivity Coefficient

Evaluation of data for 6 MV suggests a value of 0.0018 cm-1 for the film
sensitivity coefficient (b).

Measurement Techniques 5-13

 Dose Correction Factor Reference

If you ignore the small correction due to energy changes off-axis, this
sensitivity effect is linear with depth. Therefore, you can modify the entire film
density profile at any given depth by this single correction factor. The addition
(and magnitude) of a small correction factor for energy changes off-axis is
reported by Clewlow, Waggener, Feldmeier and Bice, “Film Dosimetry of a
Varian Dynamic Wedge”. (Poster Session S-7, AAPM Annual Meeting,
Calgary, CAN., l992).

Linear Detector Arrays

Linear diode arrays are composed of 11 or 25 energy-compensated p-type
diodes spaced 2.5 cm apart (11 diodes) or 2 cm apart (25 diodes) with an option
to fold the array inward to decrease the diode spacing to 1 cm. In this way, you
can integrate narrow fields in fewer steps, or integrate wider fields in a larger
number of steps.

Ion Chamber Arrays

Ion chamber arrays consist of 41 ionization chambers spaced l cm apart.

Comparison of Arrays

Recent dosimetry comparisons show nearly identical response of diode and

ionization chamber arrays in measurement of open field and dynamic wedge
beam profiles (Figure 5-2).

5-14 Enhanced Dynamic Wedge Implementation Guide

 Figure 5-2 Comparison of Diode and Ion Chamber Measurements

Measurement Techniques 5-15

 Verifying Relative Depth of Arrays

In addition to other alignment checks, you must verify the depth of each linear
detector array relative to the others. Although each detector may have a fixed
position relative to the rest of the array, the entire array may be skewed relative
to water surface when mounted in the water tank. Typically, shims are
provided to adjust the entire array to achieve the desired coincidence with the
water surface.

Monitoring Relative Sensitivity

Because the sensitivity of individual diodes change with dose absorbed by the
diode, you must carefully monitor the relative sensitivity from detector to
detector during dose measurement. Although these sensitivities vary relatively
slowly, you must account for them in the measurements.

Note: When EDW fields are measured, the individual diodes are
exposed to different dose levels. These dose levels vary by
orders of magnitude, depending on the location of the diode. For
example, the diodes near the tip of the wedge receive roughly
twice the dose received by diodes on the central axis while
diodes near the heel of the wedge receive only half of the
central-axis dose.

Diodes outside the geometric limits of the radiation field receive only a small
percentage of the central-axis dose.

5-16 Enhanced Dynamic Wedge Implementation Guide

 Calibration Techniques

Calibration techniques are recommended by the system manufacturers for

careful cross-comparison of individual detector sensitivity. To determine the
relative sensitivity of each detector in the array, perform the following
techniques:
■ In the smaller arrays that can be moved across the water phantom,
sequentially position each diode at the central axis of the radiation field
and deliver a fixed dose in that configuration. Repeat this procedure for
each diode in the array to allow an exact comparison of every diode.
■ Alternatively, set the largest possible field to irradiate the water tank so
that all detectors are simultaneously in the radiation field. For the same
exposure, record the reading for each detector. Then, shift the detector
array a distance equal to the spacing between detectors and repeat the
exposure. The relative sensitivity of each detector can be determined by
evaluating the ratios of readings between neighboring detectors.

Evaluating Measurements in the Build-Up Region

Linear detector arrays can measure dynamic wedge dose profiles at any depth
in a phantom. However, you must exercise care in evaluating measurements in
the build-up region.

The ionization chamber array mounts the individual detectors such that the
long axis of the detector is parallel to the central axis of the beam. This
compromises the ability of the detectors to measure dose in the build-up region
where the dose gradient is changing rapidly across the length of the detector.

The linear diode array has an active thickness for each detector of less than l
mm. This allows you to measure dose in the build-up region. However, you
must verify the mechanical placement of each diode. Otherwise, large
differences in reported surface dose and superficial doses are noted from
detector to detector.

Measurement Techniques 5-17

Thermoluminescent Arrays
Newly available, you can use reusable LiF rods for dynamic wedge
measurements. These rods are 1 mm in diameter and approximately 4 mm in
length.

The rods have a higher LiF content than previous versions, and so are more
consistent in response.

In combination with the new detectors that can process up to 50 TLDs without
intervention, these rods may be useful in determining build-up doses, depth
doses, and beam profiles at various depths.

Note: They have not yet been proven a viable alternative to other
radiation measurement devices.

5-18 Enhanced Dynamic Wedge Implementation Guide

Chapter 6 Clinical Operation

This chapter describes how to set up an Enhanced Dynamic Wedge (EDW)

treatment and a partial treatment.

EDW Treatment Setup

To set up an EDW treatment, perform the following steps:

1. From the SELECT MAJOR MODE screen, select CLINICAL.

2. Press ENTER.
The Clinac mode screen opens with the SELECT TREATMENT menu
box (Figure 6-1).

Figure 6-1 Select Treatment Box

6-1
 3. From the SELECT TREATMENT menu box, select ENHANCED
D-WEDGE X-RAYS.
4. Press ENTER.
The SELECT ENERGY menu box opens (Figure 6-2) if this is a
high-energy Clinac; otherwise, skip to step 7.

Figure 6-2 Select Energy Box

5. Select the appropriate energy.

6. Press ENTER.
The SELECT MONITOR UNITS menu box opens (Figure 6-3).

6-2 Enhanced Dynamic Wedge Implementation Guide

 Figure 6-3 Select Monitor Units Box

7. Type the appropriate monitor units.

8. Press ENTER.
The SELECT ENHANCED DWEDGE PARAMETERS menu box opens
(Figure 6-4).

Clinical Operation 6-3

 Figure 6-4 Select Enhanced DWedge Parameters Box

9. Press F3 to select the wedge ORIENTATION (Y1-IN or Y2-OUT).

10. Press ENTER.
Orientation is accepted and cursor moves to COLL Y1.
11. Type the desired initial position for COLL Y1.
12. Press ENTER.
Position is accepted and cursor moves to COLL Y2.
13. Type the desired position for COLL Y2.
14. Press ENTER.
Position is accepted and cursor moves to WEDGE ANGLE.
15. Use the numeric keypad to type the desired WEDGE ANGLE (10°, 15°,
20°, 25°, 30°, 45°, or 60°).
16. Press ENTER.
The WEDGE ANGLE is accepted and the cursor moves to TIME.

6-4 Enhanced Dynamic Wedge Implementation Guide

 17. Press ENTER to accept the displayed precalculated time.
The SELECT WEDGE menu box appears.
18. From the SELECT WEDGE menu box, select NO ACCY.
19. Press ENTER.
The VERIFY OR MODIFY SETUP menu box appears (not shown).
20. Select VERIFY SELECTIONS.
21. Press ENTER.
The Cal Check message appears, after the Calibration And Check Cycle is
completed, the KEY interlock is active.
22. If you have an active IPSN interlock, press F2 COLL POS to correct
position of collimator jaws.
23. Press the MOTION ENABLE and the >> keys simultaneously.
After the motions are complete, the KEY interlock appears.
24. Turn the ENABLE/DISABLE keyswitch to ENABLE.
The KEY interlock is cleared and the system is in the ready state. The
READY message appears (Figure 6-5).

Clinical Operation 6-5

 Figure 6-5 Ready Message

25. Press BEAM ON to start treatment.

A beam-on message appears. When the treatment is complete, the
NORMAL TREATMENT COMPLETE message appears (Figure 6-6).

6-6 Enhanced Dynamic Wedge Implementation Guide

 Figure 6-6 Normal Treatment Complete Display with Dose and Jaw Position
Accuracy Statistics Box

Clinical Operation 6-7

Partial Treatment Setup

To set up a partial treatment, perform the following steps:

1. At the SELECT TREATMENT menu box (Figure 6-7), select

ENHANCED D-WEDGE X-RAYS.

Figure 6-7 Select Treatment Box

2. Press ENTER.
The SELECT ENERGY menu box opens (Figure 6-8) if this is a high
energy Clinac; otherwise, skip to step 5.

6-8 Enhanced Dynamic Wedge Implementation Guide

 Figure 6-8 Select Energy Box

3. Select the appropriate energy.

4. Press ENTER.
The SELECT MONITOR UNITS menu box opens (Figure 6-9).

Clinical Operation 6-9

 Figure 6-9 Select Monitor Units Box

5. Press F4 PARTIAL.
The SELECT MONITOR UNITS menu box adds the OUT OF
ORIGINAL selection.
6. Type the appropriate monitor units required to complete the treatment.
7. Press ENTER.
The cursor moves to the OUT OF ORIGINAL selection.
8. Type the original monitor units.
9. Press ENTER.
The SELECT ENHANCED DWEDGE PARAMETERS box opens
(Figure 6-10).

6-10 Enhanced Dynamic Wedge Implementation Guide

 Figure 6-10 Select Enhanced DWedge Parameters Box

10. Use the F3 key to select the wedge ORIENTATION (Y1-IN or Y2-OUT).
11. Press ENTER.
Orientation is accepted and cursor moves to COLL Y1.
12. Enter the desired initial position of COLL Y1.
13. Press ENTER.
Position is accepted and cursor moves to COLL Y2.
14. Enter the desired position of COLL Y2.
15. Press ENTER.
Position is accepted and cursor moves to WEDGE ANGLE.
16. Use the numeric keypad to enter the desired WEDGE ANGLE (10°, 15°,
20°, 25°, 30°, 45°, or 60°).
17. Press ENTER.
The WEDGE ANGLE is accepted and the cursor moves to TIME.

Clinical Operation 6-11

 18. Press ENTER to accept the displayed precalculated time.
The SELECT WEDGE box opens.
19. From the SELECT WEDGE menu box, select NO ACCY.
20. Press ENTER.
The VERIFY OR MODIFY SETUP menu box opens (not shown).
21. Select VERIFY SELECTIONS.
22. Press ENTER.
The Cal Check message appears after the Calibration And Check Cycle is
completed, the KEY interlock is active.
23. If you have an active IPSN interlock, press F2 COLL POS to adjust
collimator jaws position.
24. Press the MOTION ENABLE and the >> keys simultaneously.
After the motions are complete, the KEY interlock appears.
25. Turn the ENABLE/DISABLE keyswitch to ENABLE.
The KEY interlock is cleared and the system is in the ready state. The
READY message appears (Figure 6-11).

6-12 Enhanced Dynamic Wedge Implementation Guide

 Figure 6-11 Ready Message

26. Press BEAM ON to start treatment.

A beam-on message appears. When the treatment is complete, the
NORMAL TREATMENT COMPLETE message appears (Figure 6-12).

Clinical Operation 6-13

 Figure 6-12 Normal Treatment Complete Display with Dose and Jaw Position
Accuracy Statistics Box

6-14 Enhanced Dynamic Wedge Implementation Guide

Chapter 7 Quality Assurance

Quality assurance of Enhanced Dynamic Wedges (EDW) should be part of a

comprehensive quality assurance (QA) program for the linear accelerator.

The key parameters in EDW are the same parameters that determine the
consistent functioning of the linear accelerator. Therefore, important EDW
parameters are as follows:
■ Output versus field size, depth dose
■ Light field versus radiation field coincidence
■ Light field versus jaw setting

You should check these parameters routinely as part of an ongoing QA

program. You can add other parameters, such as measured intensity profile
versus wedge angle, to the ongoing routine measurement of field flatness.
Similarly, you can add daily documentation of performance of the EDW on
specific fields to the routine daily morning checkout procedures. A
well-designed QA program for EDW can merge seamlessly with the existing
general QA program, thereby minimizing the additional effort required to
support this procedure.

In This Chapter

Topic Page
Dynamic Wedge QA Programs 7-2
Acceptance Testing 7-7
Evolving Technology 7-12

7-1
Dynamic Wedge QA Programs

Quality assurance of radiation therapy equipment is primarily an ongoing

evaluation of functional performance characteristics. These characteristics
ultimately influence the geometrical and dosimetric accuracy of the applied
dose to the patient. The functional performance of radiotherapy equipment can
change slowly due to deterioration and aging of the components, or can change
suddenly due to the following:
■ Electronic malfunction
■ Component failure
■ Mechanical breakdown

Therefore, two essential requirements emerge:

■ QA measurements should be performed periodically on all radiotherapy
equipment, including the dosimetry and other QA measurement devices
themselves.
■ There should be regular preventive maintenance monitoring (PMM) and
correction of the performance of the therapy machines and measurement
equipment.

The goal of these procedures is to ensure that the performance characteristics,

defined by physical parameters and established during commissioning of the
equipment, demonstrate no serious deviations.

Assigned Responsibility
A QA program for radiation therapy equipment is very much a team effort, and
the responsibilities of performing various tasks may be divided among the
following:
■ Physicists
■ Dosimetrists
■ Therapists
■ Accelerator engineers

7-2 Enhanced Dynamic Wedge Implementation Guide

Baseline Standards
You should base the QA program on a thorough investigation for baseline
standards at the time of the acceptance and commissioning of the equipment
for clinical use. Refer to the following, which describe procedures and
conditions for acceptance tests:
■ American Association of Physicists in Medicine (AAPM), 1993a
■ International Electrotechnical Commission (IEC), 1989a, b
■ American Association of Physicists in Medicine (AAPM), 1984, 1993a
■ American College of Medical Physics (ACMP), 1986

You should follow these procedures to verify manufacturer’s specifications

and to establish baseline performance values for new or refurbished equipment
or for equipment following major repair.

Once you have established a baseline standard, you should develop a protocol
of periodic QA tests to monitor the reference performance values.

Plan Simple and Rapid Measurement Techniques

In designing a machine QA program, explore measurement techniques which
are simple, rapid, and reproducible. The test procedures should be able to
distinguish parameter changes smaller than tolerance or action levels. Within
these limits, the test should also be developed to minimize test time.

Daily Tests
Include the following daily measurements of equipment that seriously affect
patient positioning, and therefore the registration of the radiation field and
target volume:
■ Lasers
■ Optical Distance Indicator (ODI)
■ Patient dose consistency
■ Door interlocks
■ Audiovisual contact

Quality Assurance 7-3

Monthly Tests
For the monthly tests include more refined testing of parameters which either
have a smaller impact on the patient, such as treatment couch indicators, or
have a lower likelihood of changing over a month, such as the following:
■ Light field
■ Radiation field
■ Beam flatness

Recommendations
Adhere to the program outlined unless there is demonstrable reason to modify
it. For example, parameters which show large deviations from their baseline
values should be given special attention and checked more frequently.
Alternatively, if careful and extended monitoring demonstrates that a
parameter does not change, or hardly changes at all, then the frequency for
monitoring it could be reduced. Although it is difficult to recommend how long
to monitor a parameter before decreasing the test frequency (the reverse case
is usually obvious). You should assess the QA data over an appreciable history
of equipment performance (for example, 1 year or more), and also assess the
clinical implications of any modification in test frequency. The best guidance
at the present is to design the QA program to be flexible enough to take the
following into account (Ref. 9):
■ Quality
■ Costs
■ Equipment condition
■ Institutional needs

7-4 Enhanced Dynamic Wedge Implementation Guide

Dynamic Wedge Quality Assurance Programs
The QA program for EDW begins with the initial commissioning and
acceptance procedures. All QA following the initial acceptance is designed to
verify the functional performance characteristics of EDW. Therefore, you
should perform the initial commissioning and acceptance in such a manner that
the vital performance characteristics can be documented for routine
comparison against results of ongoing QA checks. If you plan a routine check
as part of the QA program, that check should first be documented during the
acceptance procedures. The instrument you use during the routine checks
should also be used during the initial measurements. For example, the effective
wedge factor versus wedge angle and field size is generally measured using a
Farmer-type cylindrical ionization chamber placed in-phantom on central axis
at the desired measurement depth. Because this is the same instrument that is
used for routine output verification checks, the verification of an effective
wedge factor for one or more EDW can easily be added to the routine output
check procedure.

In many clinics, field flatness is measured using a linear detector array which
simultaneously measures fluence at multiple points along a principal axis of
the field. These measurements are then plotted on a display as a beam profile,
and can be saved for comparison with later beam profile measurements. These
devices are available commercially from several companies.

You can use these same devices to measure the integrated beam profile for
EDW. These EDW beam profiles can then be saved for comparison with
profile measurements at a later date. In this manner, you can accumulate and
evaluate a log file of saved profiles in order to detect any long-term shift in the
Enhanced Dynamic Wedge profiles. Use of such a device for field flatness
checks allows the inclusion of beam profile checks for EDW in a simple and
straightforward manner. If you use such a beam profile check device, an
asymmetry detected in the open field should be duplicated in the EDW field
profile as well, because the EDW is the summation of a continuous sequence
of reduced width asymmetric fields. Figure 7-1 illustrates the display of a
wedge profile of two fields using a typical display device.

Quality Assurance 7-5

 Figure 7-1 Beam Profile for 30° Wedge Using a Typical Display Device

Densitometry or Single Probe Measurements

Other techniques for verification of flatness and symmetry can also be used for
EDW. For example, the wedge profile can be determined using film
densitometry or by making multiple single-probe measurements in a water
phantom.

The shortcoming of these two devices are as follows:

■ Film measurements require determination of a film density-to-dose
conversion for each film exposure
■ Single-probe measurements are more time consuming

You can make he single-probe measurements using either a standard phantom

and moving the entire phantom to different locations relative to the central axis
of the field, by constructing a special phantom with several predrilled positions
to insert the probe, or by setting up a full-function water phantom and moving
the probe to preselected positions within the water tank, under computer
control. Once a routine is established, you can use any of these techniques
effectively.

7-6 Enhanced Dynamic Wedge Implementation Guide

Acceptance Testing
Quality assurance begins with the initial acceptance testing of the linear
accelerator and continues through every EDW treatment. All parts of the QA
program are interrelated, and the entire radiation therapy treatment team,
including physician, therapist, and physicist should be conversant with the
work conducted to guarantee good quality control. QA procedures are
described in the following categories:
■ Initial measurements
■ Treatment planning checks
■ Routine machine checks
■ Checks specific to each treatment

Initial Measurement
Initial measurement becomes a standard against which future checks are
compared, and should include the following measurements:
■ Measure full-field beam profiles at dmax for the Golden STT of 60°.
■ Measure full-field beam profiles at dmax for the following STT angles: 10°,
15°, 20°, 25°, 30°, 45°, and 60°.
You can then use these to verify intermediate angle interpolations.
■ Measure beam profiles for a series of field widths.
For example, measure profiles for field widths of 5 cm, 10 cm, 15 cm, and
20 cm at dmax, and two to four additional depths for comparison against
profiles generated by a treatment planning computer.
The philosophy adopted here, from discussions with representatives of
treatment planning system vendors, is that the treatment planning systems
are able to generate the required EDW isodose distributions based on a
small subset of measurements, and do not require explicit measurement of
every field width and wedge angle. The required measurements may vary
from vendor-to-vendor, but a subset of measurements as suggested here
should be maintained as a standard against which the computed EDW
beam profiles, central axis depth doses, wedge factors, and other treatment
planning parameters, must compare.

Quality Assurance 7-7

 ■ Verify depth doses.
You can make these measurements in a water phantom by positioning the
scanning probe at a sequence of depths on central axis. You must make all
measurements in the integrate mode. Carefully verify alignment of the
water phantom to guarantee coincidence of the scanning probe and central
axis of the radiation field versus depth.
■ Measure field sizes in the following manner:
 After positioning the probe at the measurement position, set up an
open field and record the measurements for a fixed number of monitor
units.
 Sequentially type in each of the allowed Enhanced Dynamic Wedge
angles for the same field size and repeat the measurements. After
readings have been made for all wedge angles, repeat the open field
measurement.
 Rotate the collimator 180° and repeat the measurement sequence.
 Average the reading to account for any misalignment of probe,
phantom, or gantry angle.
 Repeat this process for a series of depths, for example use 5 cm, 10 cm,
15 cm, 20 cm, 25 cm, and 30 cm. These measurements can be repeated
for a series of field sizes such as 5 cm, 10 cm, 15 cm, and 20 cm wide.
The results of these measurements should show only small deviations
from the open field depth doses.
■ Verify effective wedge factors.
The effective wedge factor varies smoothly with field width and wedge
angle for the field sizes from 4 cm to 20 cm wide. Measure the wedge
factor by placing the probe on central axis at 10 cm depth and recording
the ratio of reading for EDW exposure divided by the reading for open
field exposure for the same number of monitor units. (Although this
definition specifies 10 cm depth, the measurements can be done at any
depth required by the treatment planning system. Again, in order to
minimize the effects of any misalignment of probe with central axis of the
radiation field and gantry angle, the measurements should be repeated with
the collimator rotated 180°.

7-8 Enhanced Dynamic Wedge Implementation Guide

Treatment Planning Checks
The implementation of EDW into the treatment planning systems runs the
gamut from storage of measured data for every field width and wedge angle to
explicit generation of wedge dose distributions from a minimum data set.

New Modality

Because EDW represents a new modality for a number of centers, treatment

planning checks should be a routine part of QA procedures. There are some
minor differences in results between planning systems, based on the technique
used to calculate the EDW dose distributions. For example, the older dose
calculation algorithms which store a single set of tabulated beam profiles for a
given field width and wedge angle are not able to predict the small variation in
beam profile for a fixed field width as the length of the field in the direction
perpendicular to the wedge plane is changed. You should document the
magnitude of this effect by comparing EDW profiles which share a common
width in the wedge direction, while differing in the nonwedge length.

In all treatment plans in which EDW fields are applied, Varian suggests that
you verify the individual EDW field by plotting it as a single field incident on
a rectangular phantom. This ensures that the field width, wedge angle and dose
per monitor unit are consistent with the data measured at acceptance. This
provides a valuable visual check that you are applying the EDW data properly
in the treatment planning system.

Nonstandard Treatment Setup

You should evaluate the influence of nonstandard treatment setup. You can
check this by measuring the ratio of EDW dose to open field dose at a series of
extended and compressed target-to-phantom distances. Consistency of this
ratio with distance across the clinically usable range verifies the simple
relationship of wedge factor versus field size and wedge angle.

Quality Assurance 7-9

 Use wedges in conjunction with field shaping by cerrobend blocks or multileaf
collimation. You should also check the validity of the computer treatment
planning algorithm to correct for changes in scatter dose with secondary
blocking of EDW fields by cerrobend blocks or multileaf collimation. You can
make this simple check using a probe in phantom at a fixed position on central
axis of the field. Using a fixed number of monitor units, you can repeat a series
of measurements in which an increasing fraction of the field is blocked by
secondary blocking. You should duplicate the reduction in reading in the
computer dose calculation. If the calculations are not in agreement with the
relative measurements, investigate the computer algorithm further. You can
repeat the same test by using a nonwedge field, and simply repeating the
sequence of field blocking.

Routine Machine Checks

Each Clinac has a set of checkouts that you should perform periodically. You
should perform some checks daily, while others can be performed weekly or
monthly.

Daily Checkout

A daily checkout procedure is in place for every C-Series Clinac. The daily
printout from this checkout is generally stored in a binder for quality
maintenance verification. You should add the EDW fields in current use to the
daily checkout log and automatically exercise them as part of the morning
checkout. You can store the STT calculated versus actual printout as part of the
patient dose verification notes. You can visually verify the initial and final
position of the independent moving jaw and compare it with the printout.

Weekly Checkout

During the weekly output checks when an ionization chamber and phantom are
already in use, you can measure an optional check of the effective wedge factor
for any selected field, generally choosing one or more wedge fields currently
in treatment use.

7-10 Enhanced Dynamic Wedge Implementation Guide

 Monthly Checkout

You can measure the EDW profile at a single depth for one or more fields and
wedge angles, during the monthly check of field flatness, using one of the
devices described previously, such as a linear detector array, film
densitometer, or a series of readings using a movable probe in a phantom. Then
you can superimpose these profiles over the previously measured profiles for
the same field width and wedge angle, as stored in a computer data file. Any
deviation between the profiles indicates a change in the EDW dose delivery
with time, or a difference in the setup and measurement procedure. In order to
eliminate placement errors in the setup of the measurement device, you can
construct a calibration jig which mounts into the accessory tray in a
reproducible manner. These measurements, repeated regularly with time,
constitute a chronological documentation of the performance of the EDW.

Checks Specific to Each Treatment

Each treatment has a set of checks to be performed before beam-on. For
example:
■ Patient checks
■ Final verification

Patient Checks

Checks specific to each patient are designed to ensure that the radiation
therapist has set the patient up correctly for using the EDW. Therefore, you can
set fields X and Y, with Y representing the plane in which the EDW defines.
The therapist should carefully verify the proper assignment of Y1-IN or
Y2-OUT to define the direction of jaw travel to define the wedge field. This is
illustrated in the logos on the side of the accelerator head. Similarly, before the
patient is positioned in the room, you can set up and deliver the EDW field to
verify that the wedge is properly defined. After actual treatment, the therapist
should verify that the light field defines only a narrow strip corresponding to
the tip of the wedge. This should be in agreement with the EDW icon drawn
on the treatment control monitor.

All involved in the treatment should be aware that the EDW is not a four-way
wedge, as are the type III accessory wedges. You can achieve orthogonal
wedge directions by rotating the collimator 90°.

Quality Assurance 7-11

 Final Verification

Varian recommends that you perform a final independent verification of the

EDW field treatment. Patient monitoring diodes having a build-up equivalent
thickness are available to monitor dose to patient for every treatment. You can
place this diode immediately on the patient at the center of the treatment field,
or it can be mounted it the accessory tray in a reproducible position. The
consistency of diode reading daily during the patient treatment is then an
independent verification of the EDW treatment. As with other measurement
devices, you can store these readings in a chronological file and keep them as
an integral part of the patient’s treatment QA procedures.

Evolving Technology

In summary, the QA procedures for EDW need to be no more complex than

those employed in the routine evaluation and verification of the C-Series
Clinac. The EDW simply represents one of several innovative uses of the
evolving technology aiding in the treatment of cancer. The combination of
technical competence in the design and implementation of the linear
accelerator and its accessories, the technical competence of the physicist in
measuring the EDW characteristics and entering them into the treatment
planning system, the technical competence of the physician in evaluating the
potential improvements in treatment technique using EDW, and the careful
verification and execution of radiation therapy plans by the radiation therapist,
join together to make EDW another valuable treatment tool.

7-12 Enhanced Dynamic Wedge Implementation Guide

Appendix A EDW Fluence Profiles (Golden
STTs)

This appendix shows the EDW fluence profiles. These Segmented Treatment
Tables (STTs) are referred to as the Golden STTs because all other wedges
(both field size and wedge angle) are formed from these reference STTs.

A-1
A-2 Enhanced Dynamic Wedge Implementation Guide
EDW Fluence Profiles (Golden STTs) A-3
A-4 Enhanced Dynamic Wedge Implementation Guide
EDW Fluence Profiles (Golden STTs) A-5
A-6 Enhanced Dynamic Wedge Implementation Guide
EDW Fluence Profiles (Golden STTs) A-7
A-8 Enhanced Dynamic Wedge Implementation Guide
Appendix B STT Computations

This appendix gives a specific example of the STT computation described in

“STT Generation and Delivery” on page 3-12. Remember that the actual STT
delivered for a particular EDW field can always be found in the corresponding
dynalog file. The dynalog file is created every time an EDW field is delivered
in Clinical mode (see “Dynalog Files” on page 3-23).

Sample Dynalog File

The following is a portion of a sample dynalog file from a Clinac 2100C:

CLINAC 2100C - SN 1

DATE.......................: 04/24/1997

TIME.......................: 10:00:57

D Y N A M I C B E A M D E L I V E R Y L O G F I L E

** T R E A T M E N T S E T U P **

TREATMENT TYPE : ENHANCED DYNAMIC WEDGE X-RAYS

ENERGY : 6 X

MU : 300

ORIENTATION : Y1-IN

COLL Y1 : 10.00 (cm)

COLL Y2 : 5.00 (cm)

WEDGE ANGLE : 45 (deg)

TIME : 1.02 (min)

ACCESSORY : NO ACCESSORY

B-1
 ** D Y N A M I C B E A M S T A T I S T I C S **

TOTAL DOSE DELIVERED : 300 (MU)

DOSE STANDARD DEVIATION : 0.03 (MU)

DOSE-POSITION STANDARD DEVIATION : 0.01 (cm)

NUMBER OF SAMPLES : 300

-- STT --

INSTANCE# DOSE COLL Y1 COLL Y2

(MU) (cm) (cm)

1 0.00 10.00 5.00
2 147.06 10.00 5.00
3 151.15 9.23 5.00
4 155.38 8.48 5.00
5 160.04 7.70 5.00
6 164.85 6.95 5.00
7 170.26 6.18 5.00
8 175.88 5.43 5.00
9 182.08 4.65 5.00
10 188.45 3.90 5.00
11 195.58 3.13 5.00
12 203.02 2.38 5.00
13 211.21 1.60 5.00
14 219.64 0.85 5.00
15 228.99 0.08 5.00
16 238.81 -0.68 5.00
17 249.60 -1.45 5.00
18 260.70 -2.20 5.00
19 272.93 -2.98 5.00
20 285.83 -3.73 5.00
21 300.00 -4.50 5.00

B-2 Enhanced Dynamic Wedge Implementation Guide

Sample Computation of a STT

To derive the dose and position values for instances 2, 5, and 18 (bolded in the
proceeding table), use their Y1 positions of 10.00 cm, 7.70 cm, and 2.20 cm.

Step 1 - Start from Golden STT

Start from the original Golden STT (see “Step 1: Fluence Profiles” on
page 3-14) for 6 MV (see Figure B-1, which is a copy of the table in
Appendix A).

Figure B-1 Golden STT for 6 MV

STT Computations B-3

 The degenerate open file Golden STT (the 0° angle STT) has a dose value of
1.145205 for all Y1 positions. This is the same value that the Golden 60° STT
has for Y1 = 0.00 cm at central axis.

Step 2 - Effective Wedge Angle

The effective wedge angle in our example is 45°, so the ratio of tangents
weights are (see “Step 2: Computation of Effective Wedge Angles” on
page 3-15):

W0° = 0.42265, W60° = 0.57735

Apply these weights to derive the Golden STT for the effective wedge angle
(45°).

Golden STT for effective wedge angle (45°):

Dose Position

0.732543 -10.00 cm

0.787736 -8.00 cm
0.819441 -7.00 cm

1.282903 2.00 cm
1.361538 3.00 cm

1.447478 4.00 cm
1.541369 5.00 cm

That is, for Y1 = -8.00 cm the weights were applied as follows:

1.145205 * 0.42265 + 0.526050 * 0.57735 = 0.787736

B-4 Enhanced Dynamic Wedge Implementation Guide

Step 3 - STT Truncation
The field size in the dynalog file is Y1 = 10 cm, Y2 = 5 cm (that is, -10 cm to
5.00 cm in Golden STT coordinates). The jaw, however, moves only to 4.5 cm,
leaving a small 0.5 cm open field at the end. So the portion of the effective
wedge angle STT that is used is from -10.00 cm to 4.50 cm.

The dose value at -4.50 cm becomes the normalization value which

corresponds to the total dose of the 300 MU. We derive the dose normalization
value by interpolating the dose value for 4.50 cm in the effective wedge angle
STT derived in step 2:

Similarly, we derive interpolated dose values for the other 3 sample points in
our computation where Y1 = 10.00 cm, 7.70 cm, and -2.20 cm (the 10.00 cm
value does not require interpolation).

Note: The Y coordinates are inverted in the Golden STTs.

Y1 Dose

10.00 cm 0.732543

7.70 cm 0.797247

-2.20 cm 1.29863

-4.50 cm 1.494424

STT Computations B-5

Step 4 - STT Normalization to Total Dose
By normalizing the values in step 3 so that the -4.50 cm dose value corresponds
to 300 MU, we get the final MU dose values that match the dynalog file:
Y1 Dose

10.00 cm 147.06 MU

7.70 cm 160.04 MU

-2.20 cm 260.70 MU

-4.50 cm 300.00 MU

That is for 7.70 cm, the normalization was calculated as follows:

B-6 Enhanced Dynamic Wedge Implementation Guide

Appendix C References and Selected
Papers

References

Within this guide, there are specified papers and references that correspond to
these numbers:

1. Kijewski PK, Chin LM, Bjarngard, BE

Wedge-Shaped Dose Distributions by Computer-Controlled Motion
Med Phys 1978 Feb; 5(5):426
2. Leavitt DD, Martin M, Moeller JH, Lee WL.
Dynamic Wedge Field Techniques Through Computer-Controlled
Collimator Motion and Dose Delivery.
Med Phys 1990 Jan-Feb; 17(1):87-91
3. Hughes DB, Karznarj CJ, Levy RM
Conventions for Wedge Filter Specifications
Br J Radiol 1972; 45:868
4. International Electrotechnical Commission
Medical Electron Accelerators- Functional Performance Characteristics
IEC Performance Standard 976, Geneva 1989 October
5. International Commission on Radiation Units and Measurements
Determination of Absorbed Dose in a Patient Irradiated by Beams of X or
Gamma Rays in Radiotherapy Procedures
ICRU Report 24 1976 September
6. Petti PL, Siddon RL
Effective Wedge Angles with a Universal Wedge
Phys Med Biol 1985; 30(9):985-91

C-1
 7. Klein E, Low D, Durbin C, Meigooni A, Purdy J
Dosimetry for Clinical Implementation of Dynamic Wedge on a
CL-2100C
Med Phys 1993 May-Jun
8. Boyer A, Waldron T, Wells N
Calculation of Dynamically-Wedged Isodose Distributions from
Segmented Treatment Tables and Open-Field Measurements
Med Phys 1994 May-Jun
9. AAPM
Task Group 40 Report; Comprehensive QA for Radiation Oncology
Med Phys 1994; 24:587-8

Additional References and Papers

In addition to the specified references within the guide, here is a list of

references and papers for additional reading on this subject matter.

Ackerly T, Todd S, Williams I, Geso M, Cramb J.

Comparative Evaluation of Wellhofer Ion Chamber Array and
Scanditronix Diode Array for Dynamic Wedge Dosimetry.
Australas Phys Eng Sci Med 1997 Jun; 20(2):71-83

Avadhani JS, Pradhan AS, Sankar A, Viswanathan PS.

Dosimetric Aspects of Physical and Dynamic Wedge of Clinac 2100C
Linear Accelerator.
Strahlenther Onkol 1997 Oct; 173(10):524-8

Beavis AW.
Implementation of Enhanced Dynamic Wedge Into the Multidata DSS
Radiotherapy Treatment Planning System.
Med Dosim 1997 Fall; 22(3):219-25

C-2 Enhanced Dynamic Wedge Implementation Guide

 Beavis AW.
Implementation of Enhanced Dynamic Wedge Into the Multidata DSS
Radiotherapy Treatment Planning System.
Med Dosim 1997 Fall; 22(3):219-25

Beavis AW, Weston SJ, Whitton VJ.

Implementation of the Varian EDW Into a Commercial RTP System.
Phys Med Biol 1996 Sep; 41(9):1691-704

Bidmead AM, Garton AJ, Childs PJ.

Beam Data Measurements for Dynamic Wedges On Varian 600C (6 MV)
and 2100C (6 and 10 MV) Linear Accelerators.
Phys Med Biol 1995 Mar; 40(3):393-411

Cramb JA, Ackerly TL.

Implementation of Enhanced Dynamic Wedge Using Theraplan.
Med Dosim 1997 Fall; 22(3):237-40

Earley L.
Larger Field Sizes: An Advantage of the Dynamic Wedge.
Med Dosim 1997 Fall; 22(3):193-5

Edlund TL.
Treatment Planning of Oblique Wedge Fields Comparing Enhanced
Dynamic Wedge and Standard 60 Degree Wedge for Parotid Type
Treatments.
Med Dosim 1997 Fall; 22(3):197-9

Edlund TL, Leavitt DD, Gibbs Fa Jr.

Dosimetric Advantages of Enhanced Dynamic Wedge in Small Field
Irradiation for the Treatment of Macular Degeneration.
Med Dosim 1999 Spring; 24(1):21-6

References and Selected Papers C-3

 Gibbons JP.
Calculation of Enhanced Dynamic Wedge Factors for Symmetric and
Asymmetric Photon Fields.
Med Phys 1998 Aug; 25(8):1411-8

Gibbs G, Leavitt DD.

Commissioning the Varian Enhanced Dynamic Wedge Using the RAHD
Treatment Planning System.
Med Dosim 1997 Fall; 22(3):227-9

Karlsson M.
Implementation of Varian's EDW 5.2 On a Clinac 2300C/D for Use With
Helax TMS 3.1 Dose Planning System.
Med Dosim 1997 Fall; 22(3):215-8

Kim S, Liu CR, Zhu TC, Palta JR

Photon Beam Skin Dose Analyses for Different Clinical Setups.
Med Phys 1998 Jun; 25(6):860-6

Klein EE.
Treatment Planning for Enhanced Dynamic Wedge With the CMS
Focus/Modulex Treatment Planning System.
Med Dosim 1997 Fall; 22(3):213-4

Klein EE, Gerber R, Zhu XR, Oehmke F, Purdy JA.

Multiple Machine Implementation of Enhanced Dynamic Wedge.
Int J Radiat Oncol Biol Phys 1998 Mar 1; 40(4):977-85

Klein EE, Low DA, Maag D, Purdy JA.

A Quality Assurance Program for Ancillary High Technology Devices On
a Dual-Energy Accelerator.
Radiother Oncol 1996 Jan; 38(1):51-60

Klein EE, Low DA, Meigooni AS, Purdy JA.

Dosimetry and Clinical Implementation of Dynamic Wedge.
Int J Radiat Oncol Biol Phys 1995 Feb 1; 31(3):583-92

C-4 Enhanced Dynamic Wedge Implementation Guide

 Kubo HD, Wang L.
Compatibility of Varian 2100C Gated Operations with Enhanced Dynamic
Wedge and IMRT Dose Delivery.
Med Phys 2000 Aug; 27(8):1732-8

Lamb A, Blake S.
Investigation and Modelling of the Surface Dose From Linear Accelerator
Produced 6 and 10 MV Photon Beams.
Phys Med Biol 1998 May; 43(5):1133-46

Leavitt DD
New Application of Enhanced Dynamic Wedge for Tangent Breast
Irradiation.
Med Dosim 1997 Fall; 22(3):247-51

Leavitt DD, Huntzinger C, Etmektzoglou T.

Dynamic Collimator and Dose Rate Control: Enabling Technology for
Enhanced Dynamic Wedge.
Med Dosim 1997 Fall; 22(3):167-70

Leavitt DD, Klein E.

Dosimetry Measurement Tools for Commissioning Enhanced Dynamic
Wedge.
Med Dosim 1997 Fall; 22(3):171-6

Leavitt DD, Larsson L.

Evaluation of a Diode Detector Array for Measurement of Dynamic
Wedge Dose Distributions.
Med Phys 1993 Mar-Apr; 20(2 Pt 1):381-2

Leavitt DD, Lee WL, Gaffney DK, Moeller JH, O'Rear JH.
Dosimetric Parameters of Enhanced Dynamic Wedge for Treatment
Planning and Verification.
Med Dosim 1997 Fall; 22(3):177-83

References and Selected Papers C-5

 Leavitt DD, Williams G, Tobler M, Moeller JH, Gibbs Fa Jr, Gaffney DK.
Application of Enhanced Dynamic Wedge to Stereotactic Radiotherapy.
Med Dosim 2000 Summer; 25(2):61-9

Li Z, Klein EE.
Surface and Peripheral Doses of Dynamic and Physical Wedges.
Int J Radiat Oncol Biol Phys 1997 Mar 1; 37(4):921-5

Liu C, Li Z, Palta JR.

Characterizing Output for the Varian Enhanced Dynamic Wedge Field.
Med Phys 1998 Jan; 25(1):64-70

Liu C, Waugh B, Li Z, Zhu TC, Palta JR.

Commissioning of Enhanced Dynamic Wedge On a ROCS RTP System.
Med Dosim 1997 Fall; 22(3):231-6

Liu C, Zhu TC, Palta JR.

Characterizing Output for Dynamic Wedges.
Med Phys 1996 Jul; 23(7):1213-8

Liu HH, McCullough EC, Mackie TR.

Calculating Dose Distributions and Wedge Factors for Photon Treatment
Fields With Dynamic Wedges Based On a Convolution/Superposition
Method.
Med Phys 1998 Jan; 25(1):56-63

Lydon JM, Rykers KL.

Beam Profiles in the Nonwedged Direction for Dynamic Wedges.
Phys Med Biol 1996 Jul; 41(7):1217-25

Miften M, Wiesmeyer M, Beavis A, Takahashi K, Broad S.

Implementation of Enhanced Dynamic Wedge in the Focus RTP System.
Med Dosim 2000 Summer; 25(2):81-6

C-6 Enhanced Dynamic Wedge Implementation Guide

 Moeller JH, Leavitt DD, Klein E.
The Quality Assurance of Enhanced Dynamic Wedges.
Med Dosim 1997 Fall; 22(3):241-6

Papatheodorou S, Zefkili S, Rosenwald JC.

The 'Equivalent Wedge' Implementation of the Varian Enhanced Dynamic
Wedge (EDW) Into a Treatment Planning System.
Phys Med Biol 1999 Feb; 44(2):509-24

Rykers K, Geso M, Brown G.

Dynamic Wedge Factors for a Comprehensive Range of Fields.
Australas Phys Eng Sci Med 1995 Sep; 18(3):146-50

Samuelsson A, Johansson KA, Mattsson O, Palm A, Puurunen H, Sernbo G.

Practical Implementation of Enhanced Dynamic Wedge in the Cadplan
Treatment Planning System.
Med Dosim 1997 Fall; 22(3):207-11

Sidhu NP.
Interfacing a Linear Diode Array to a Conventional Water Scanner for the
Measurement of Dynamic Dose Distributions and Comparison With a
Linear Ion Chamber Array.
Med Dosim 1999 Spring; 24(1):57-60

Thomas SJ, Foster KR.

Radiotherapy Treatment Planning With Dynamic Wedges--An Algorithm
for Generating Wedge Factors and Beam Data.
Phys Med Biol 1995 Sep; 40(9):1421-33

Tobler M, Leavitt DD.

Clinical Application of Enhanced Dynamic Wedge in Three-Dimensional
Treatment Planning: a Case Report.
Med Dosim 1997 Fall; 22(3):201-6

References and Selected Papers C-7

 Verhaegen F, Liu HH.
Incorporating Dynamic Collimator Motion in Monte Carlo Simulations:
An Application in Modelling a Dynamic Wedge.
Phys Med Biol 2001 Feb; 46(2):287-96

Warlick WB, O'Rear JH, Earley L, Moeller JH, Gaffney DK, Leavitt DD.
Dose to the Contralateral Breast: a Comparison of Two Techniques Using
the Enhanced Dynamic Wedge Versus a Standard Wedge.
Med Dosim 1997 Fall; 22(3):185-91

Weber L, Ahnesjo A, Nilsson P, Saxner M, Knoos T.

Verification and Implementation of Dynamic Wedge Calculations in a
Treatment Planning System Based On a Dose-To-Energy-Fluence
Formalism.
Med Phys 1996 Mar; 23(3):307-16

Weides CD, Mok EC, Chang WC, Findley DO, Shostak CA.
Evaluating the Dose to the Contralateral Breast When Using a Dynamic
Wedge Versus a Regular Wedge.
Med Dosim 1995 Winter; 20(4):287-93

Zhu TC, Ding L, Liu CR, Palta JR, Simon WE, Shi J.
Performance Evaluation of a Diode Array for Enhanced Dynamic Wedge
Dosimetry.
Med Phys 1997 Jul; 24(7):1173-80

C-8 Enhanced Dynamic Wedge Implementation Guide

Appendix D Glossary

calibration Determination of the relative accuracy of a measuring

instrument by comparing it to a standard to discover the
necessary correction factors.

calibration cycle Internally programmed test routine in which the controller

verifies that the calibrated dosimetry values are reasonable
for the energy selected. Occurs prior to beam-on after
verification of the treatment parameters. See also Check
cycle.

check cycle Internally programmed test routine in which the controller

tests the operation of the dose counters and verifies that the
dosimetry interlocks can be activated. Occurs immediately
after the calibration cycle. See also Calibration cycle.

collimator Sets of metal blocks, fixed and movable, in the treatment

head that limit the treatment field to a specific size.

compensator A piece of material placed in the treatment beam to

compensate for unevenness of machine output or body
contour.

Dynamic Beam An application in which an axis moves and dose is varied

Delivery (DBD) during beam-on. Arc therapy, in which the gantry is rotated
and dynamic wedge, in which an upper collimator jaw
moves, are both DBD applications. In DBD applications,
the dose is coordinated with the speed and position of the
dynamic axis.

D-1
default Standby data the computer uses when a parameter (or
program) is not specified.

disk A magnetic storage medium used for storing files on a

computer. May be a floppy (removable) or hard
(nonremovable) disk.

dosimetry Identifies a machine condition in which the ability of the

interlock Clinac to deliver or measure dose may be impaired. Beam
is terminated immediately and remains inhibited until a
special password is entered.

dynamic arc Radiation therapy in which the source of radiation is moved

therapy through a limited arc about the patient during treatment. In
this way, a larger dose is built up at the center of rotation
within the patient’s body than on any area of the skin.
Multiple arcs may be used. Synonymous with arc treatment
and rotation therapy.

dynamic A treatment during which the collimator or gantry moves

treatment while the beam is on and both the dose rate and the speed of
the axis are continually adjusted by the control system.
dynamic wedge and arc treatments are dynamic treatments.

dynamic wedge An application which produces wedged distributions by

moving a jaw across a treatment field rather than by placing
a physical wedge-shaped material in the beam. Fields must
be symmetric and the simulated wedge angles include 15°,
30°, 45°, and 60°. See also DBD.

D-2 Enhanced Dynamic Wedge Implementation Guide

Enhanced An application which produces wedged distributions by
Dynamic Wedge moving a jaw across a treatment field rather than by placing
a physical wedge-shaped material in the beam. Fields may
be symmetric or asymmetric and it is possible for the
simulated wedge angles to include any angle between 10°
and 60°. See also DBD and dynamic wedge.

field A plane section of the beam perpendicular to the beam axis.

field size The size of an area irradiated by a given beam, usually

measured by one of the following conventions: geometric
field size, which measures the geometric projection on a
plane perpendicular to the central axis, or physical field
size, which measures the area included within the 50%
maximum dose isodose curve at the depth of maximum
dose.

interlock An electrical, software, or mechanical function that

prevents the operation of the Clinac or the application of
power to its primary systems until one or more preliminary
conditions have been met.

minor interlock Identifies a machine malfunction that prevents beam-on.

Minor interlocks are self-clearing before beam-on when the
condition has been corrected.

monitor unit (MU) A unit of radiation exposure. A table for the conversion of
monitor units into units of absorbed dose (gray or rad) can
be generated by a dose calibration of the machine by a
qualified physicist.

motion enable A safety switch that allows motion of certain motorized

switch functions only so long as the operator continues to press the
switch.

Glossary D-3
override To go around an automatic control system (like the
interlock system) intentionally. To bridge a functional stage
of the control system.

parameter Any of a set of physical properties whose values determine

the characteristics or behavior of something. An operating
value or coefficient entered in a data space on the console
screen that falls within the range of acceptable values.

partial treatment A treatment set up to complete a dynamic treatment (arc or

dynamic wedge) that was terminated before completion.
Other treatments may have been given in the interim.
During a partial treatment, the dynamic axis travels the
complete path planned for the treatment, but the beam is not
turned on until the axis reaches the position where the
original exposure was previously interrupted. The system
uses all the original treatment parameters, plus the monitor
units for the current treatment (MU remaining from the
interrupted treatment) to compute the point in the path
where dose delivery is to be resumed.

password A number or word used to gain entry to a certain program

or a restricted part of a program. Passwords are required for
performing HDTSe- treatments, for clearing dosimetry
interlocks and for entering service and physics mode.

PRO (Position Read Out) Digital display of Clinac motor axis

positions, especially those of the gantry and collimator.
Values are displayed in various scale conventions,
including IEC and Varian. Also the system of
position-sensing potentiometers read by an
analog-to-digital converter in the console electronics
cabinet.

Source-Axis (SAD) Synonymous with target-axis distance.

Distance

D-4 Enhanced Dynamic Wedge Implementation Guide

Source-Surface (SSD) Synonymous with target-skin distance.
Distance

target A metal plate placed in the beam of high-speed electrons to

produce X-rays. For electron therapy, the target is retracted
from the beam.

Target-Axis (TAD) The distance measured along the central axis from
Distance the center of the front surface of the target to the isocenter.

Target-Skin (TSD) The distance measured along the central axis from
Distance the center of the front surface of the target to the surface of
the irradiated object.

X axis Dimension of the treatment field formed by the opening

between the lower (X) collimator jaws. Lower jaw X1 is the
jaw located to the right of the rangefinder assembly.

Y axis Dimension of the treatment field formed by the opening

between the upper (Y) collimator jaws. Upper jaw Y2 is the
jaw located directly above the rangefinder assembly when
the jaws are closed on the collimator centerline.

Glossary D-5
Index

A data
generating sets, 4-26
acceptance testing, 7-7
acquiring dose profiles, 4-25 handling techniques, 4-2
alternative methods, 4-26 measuring, 5-2
arrays date stamp, 3-27
comparison, 5-14 defining
ion chamber, 5-14 cold window, 3-20
linear detector, 5-14 dose rate ceiling, 3-5
relative depth, 5-15 dynalog files, 3-23
thermoluminescent, 5-18 Enhanced Dynamic Wedge (EDW), 1-1, 2-4
auto field sequency (AFS), 1-6 field size, 5-1
Golden STTs, 3-14
B hot window, 3-20
physical wedge, 2-2
baseline standards, 7-3
beam sample STT, 3-9
profile (figure), 7-6 Segmented Treatment Tables (STTs), 3-2,
profile measurements, 5-6 3-7
profiles, 4-16 wedge angle, 2-2, 2-6
beam’s eye view collimator graphic, 3-5 delivering
dose, 1-3
STT, 3-19
C total dose, 3-27
calibration techniques, 5-17 densitometry
capabilities, EDW, 1-4 film, 5-7
cold window defined, 3-20
collimator measurements, 7-6
beam’s eye view graphic, 3-5 depth dose, 4-21
field size check, 5-1 (figure), 4-22
comparing EDW, 4-21
arrays, 5-14 measuring, 5-4
film techniques, 5-10 open field, 4-21
computation, 3-19 physical wedge, 4-21
effective wedge angles, 3-15 wedge field, 4-21
sample STTs, B-3 diodes, 5-3
STTs, B-1 distribution, wedge, 4-3
continuous dose delivery, 3-2 dose
converting film density-to-dose, 5-11 acquiring profiles, 4-25
continuous delivery, 3-2, 3-11
correction factor, 5-14
D delivery, 1-3
daily depth, 4-21
checkout, 7-10
fraction, 1-3
tests, 7-3
modifier, 5-13
peripheral, 4-24

Index-1
dose (continued) Enhanced Dynamic Wedge (continued)
position standard deviation, 3-28 profiles, 4-28 to 4-31
position standard deviation formula, 3-22 sample STT, 3-8
profile, 3-2 surface dose, 4-23
rate treatment setup, 6-1
ceiling defined, 3-5 estimating effective EDW factor, 4-20
progression (figure), 3-3 evaluating measurements in build-up region,
versus jaw position, 3-6 5-17
evolving technology, 7-12
standard deviation, 3-27
standard deviation formula, 3-22
surface, 4-23 F
total delivered, 3-27 field
tracking accuracy, 3-21 open phase, 3-2
verification, 3-6 size check, 5-1
versus jaw position, 1-7, 3-2 size defined, 5-1
(figure), 3-4 size width, 1-5
STT, 3-10 film
densitometry, 5-7
dosimetry, film cassettes, 5-8
DPSN interlock, 1-7, 3-20, 3-29 densitometry, problems, 5-10
dynalog files, 1-5, 1-7 density-to-dose conversion, 5-11
defined, 3-23 dosimetry cassettes, 5-8
location, 3-29 radiographic, 5-8
sample, 3-24, B-1 sensitivity
dynamic beam statistics, 3-27 coefficient, 5-13
dynamic wedge versus depth, 5-12
(figure), 2-5 versus depth (figure), 5-12
quality assurance, 7-2 techniques compared, 5-10
quality assurance program, 7-5 verifying alignment, 5-10
final verification, 7-12
E first clinical implementation, 2-2
fluence profiles, 3-14
effective wedge factor, 4-17 formula
Enhanced Dynamic Wedge (EDW) dose modifier, 5-13
additional features, 1-6
dose standard deviation, 3-22
capabilities, 1-4
dose weighted position standard deviation,
compared to physical wedge, 4-3
3-22
data in treatment planning, 4-25
standard deviation variables (table), 3-22
defined, 1-1, 2-4
fraction, dose, 1-3
depth dose, 4-21
dose and jaw motion, 3-2
estimating effective factor, 4-20 G
feature, 2-2 generating
feature comparison to dynamic wedge, 1-5 data sets, 4-26
fluence profiles, A-1 STTs, 3-12
Golden STTs, A-1 STTs (figure), 3-13
key difference to dynamic wedge, 2-6 Golden STTs
(table), A-1
key parameters, 7-1
defined, 3-14

Index-2
H L
H&D curve, 5-11 linear detector arrays, 5-14
historical perspective, 2-1
hot window defined, 3-20
M
measurement
I densitometry, 7-6
ICRU report, 2-4 devices, 5-3
IEC report, 2-4 diodes, 5-3
implementation, 2-1
implementation, first clinical, 2-2 ionization chamber, 5-3
initial measurement, 7-7 thermoluminescent dosimeters (TLDs),
interlock 5-3
DPSN, 1-7, 3-20, 3-29 verification film, 5-3
IPSN, 3-20, 3-29 initial, 7-7
ion chamber array, 5-14 single probe, 7-6
ionization chamber, 5-3 techniques, 7-3
IPSN interlock, 3-20, 3-29
isodose measuring
curves, 4-3 to 4-15 data, 5-2
profile, 3-2 H&D curve, 5-11
minimizing misalignment errors, 5-5
MLC, 1-6
J monitoring relative sensitivity, 5-16
jaw monthly
motion, 3-2 checkout, 7-11
motion model, 3-11 tests, 7-4
position
tracking accuracy, 3-21 N
verification, 3-6 new modality, 7-9
position versus dose, 1-7, 3-2 normalize, 3-19
(figure), 3-4
rate, 3-6 O
STT, 3-10 open field
speed depth dose, 4-21
modulation, 3-6 fluence weights, 3-17
progression (figure), 3-4 phase, 3-2
sweep, 1-3 orientation
action (figure), 1-2 Y1-IN, 3-1
phase, 3-3 Y2-OUT, 3-1
velocity, 3-6
P
K partial treatment, 1-6
key differences partial treatment setup, 6-8
(table), 2-6 patient checks, 7-11
dynamic versus EDW, 2-6 pendant, confirm wedge orientation, 1-5
peripheral dose, 4-24
key parameters, EDW, 7-1

Index-3
phase Segmented Treatment Tables (STTs), 1-5, 2-1
jaw sweep, 3-2 computations, B-1
open field, 3-2 defined, 3-2, 3-7
physical wedge, 4-19 delivery, 3-19
(figure), 2-3 dose versus jaw position, 3-10
compared to EDW, 4-3 EDW, sample (figure), 3-8
defined, 2-2 generation, 3-12
depth dose, 4-21 (figure), 3-13
factor variations, 4-19 Step 1 - fluence profiles, 3-14
surface dose, 4-23 Step 2 - computation of effective wedge
portal imaging, 1-5 angles, 3-15
primary intensity profiles, 4-27 Step 3 - truncation process, 3-18
processing radiographic film, 5-8
profile Step 4 - normalize, 3-19
acquiring dose, 4-25 Step 5 - compute, 3-19
beam, 4-16 Golden STTs
beam (figure), 7-6 (table), A-1
beam measurements, 5-6 defined, 3-14
dose, 3-2 sample computations, B-3
EDW, 4-28 to 4-31 using, 4-27
EDW fluence, A-1 single probe measurements, 7-6
fluence, 3-14 surface dose, 4-23
EDW, 4-23
Golden STTs, A-1
physical wedge, 4-23
primary intensity, 4-27
sweep phase, jaw, 3-3

R T
radiographic film, 5-8 tabulated data sets, 4-25
recommendations, 7-4 thermoluminescent
redundant position readouts, 1-7 arrays, 5-18
references, C-1
related publications, vi dosimeters (TLDs), 5-3
reports time stamp, 3-27
ICRU, 2-4 total dose delivered, 3-27
IEC, 2-4 tracking accuracy statistics, 3-21
treatment
research, 2-1 EDW setup, 6-1
routine machine checks, 7-10
nonstandard setup, 7-9
partial setup, 6-8
S planning, 4-25, 5-2
sample planning checks, 7-9
computation of STTs, B-3 setup, 3-27
dynalog file, B-1 specific checks, 7-11
STT, 3-8 time, 3-6
segment boundary samples, 3-29 truncation process, 3-18
truncation process (figure), 3-18

Index-4
U Y
using STTs, 4-27 Y1-IN orientation, 3-1
Y2-OUT orientation, 3-1
V
verification, final, 7-12
verifying
field size definitions, 5-1
film alignment, 5-10
relative depth of arrays, 5-16
water level in phantom, 5-4
visual cues, v

W
water phantom
aligning, 5-4
aligning tips, 5-5
verifying water level, 5-4
wedge
angle, 1-5
computing effective, 3-15
defined, 2-2, 2-6
distribution, 4-3
dynamic
(figure), 2-5
quality assurance, 7-2
quality assurance programs, 7-5
effective factor, 4-17
factor (figure), 4-18
factor measurements, 5-6
field depth dose, 4-21
fluence weights, 3-17
generated program, 4-26
key differences, dynamic versus EDW, 2-6
orientation, 3-1
orientation confirm through pendant, 1-5
physical, 4-19
(figure), 2-3
defined, 2-2
depth dose, 4-21
factor variations, 4-19
surface dose, 4-23
weekly checkout, 7-10

Index-5