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Brittany Bird
March 12, 2017
Transmission Factor Calculation

Treatment Couch Transmission Factor Calculation

Objective: To determine the transmission factor for the treatment couch, and to incorporate the
determined transmission factor to configure a monitor unit calculation.

Purpose: In radiation therapy, monitor unit calculations or dose corrections must be taken into
account when applying either a wedge factor, tray factor, and block. Oftentimes, the treatment
couch can be overlooked and omitted from the correction calculation. Due to the fact that the
use of carbon fiber tables are becoming widely predominant rather than the tennis racket table,
although the table excels for imaging purposes, it does indeed attenuate a percentage of the
radiation beam.1 An attenuation correction factor needs to be established for the treatment couch
in order to deliver the correct dose to the tumor volume. Every linear accelerator is specifically
calibrated according to a standard set fourth by the AAPM TG-51 protocol encompassing certain
clinical reference dosimetry. The reference dosimetry for a linear accelerator is typically
calibrated at 100 cm SSD, using a 10 cm by 10 cm field at a depth of 10 cm, with a dose rate of 1
cGy/MU. This information is important when performing calculations and referring to data
tables. To determine the transmission factor of the treatment couch, it is necessary to understand
and implement the following equations listed below.

The attenuation correction formula is defined as:2

Cattn = Dose with device in radiation beam path

Dose without device in radiation beam path

The formula specifically for the calculation of the transmission factor for the treatment couch is
given in the following equation:

TF= Dose with the treatment couch in the beam path

Dose without the treatment couch in the beam path
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Methods and Materials: All measurements pertaining to the treatment couch were acquired
using a Varian TrueBeam linear accelerator. A thimble CC13 ionization chamber was placed at
a fixed depth in a tissue equivalent solid water phantom (Gammex, Middleton, WI) within a pre-
measured hole. This particular ion chamber is the standard chamber used for conducting output
measurements and contains 0.13 cm3 of air. When irradiated, the volume of air inside the
chamber becomes ionized. The ion chamber was centralized within a 12 cm thick water
phantom to simulate symmetric geometry. This mimics the radiation source rotating around the
axis of the isocenter when treating a patient. The ionization chamber is then connected to a
coaxial cable that runs through a conduit outside to the treatment console area. When irradiated,
the coaxial cable ensures minimal leakage and allows the potential to travel through and be
collected by an electrometer. In this study, a PTW Unidos electrometer with a high voltage of -
300 volts precisely records the charges measured in nanoCoulombs (nC). The photon energies
measured are 4 megavoltage (MV), 6 MV, 10 MV, and 15 MV using a 15 x 15 cm field size at
100 SSD. A total of 50 monitor units were given for each photon energy and beam angle.
Overall, three trials were conducted for each energy and gantry angle in order for an average to
be approximated and utilized in the transmission factor calculation. The figures shown below
are some of the materials employed.

Figure 1 and 2. Varian TrueBeam linac with ion chamber positioned in a solid water phantom.
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Figure 3. PTW Unidos electrometer.

Results: The table provided below shows values recorded by the PTW Unidos electrometer,
capturing charges measured in nanoCoulombs (nC). Upon the completion of three trials, an
average was calculated for all four photon energies by using the following equation:

Average = Trial 1 + Trial 2 + Trial 3

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Table 1. Average collected data measured in (nC) for different photon energies with
and without the treatment couch.
Readings without the Readings with the
Energy Trials treatment couch treatment couch
AP (0) 45 (LAO) PA (180E) 225 (RPO)
4 MV Trial 1 1.660 1.505 1.619 1.443
Trial 2 1.662 1.504 1.617 1.440
Trial 3 1.661 1.504 1.615 1.439
Average 1.661 1.504 1.617 1.441
6 MV Trial 1 1.740 1.604 1.699 1.547
Trial 2 1.739 1.603 1.696 1.542
Trial 3 1.736 1.600 1.696 1.541
Average 1.738 1.602 1.697 1.543
10 MV Trial 1 1.867 1.755 1.835 1.708
Trial 2 1.865 1.755 1.833 1.707
Trial 3 1.865 1.753 1.833 1.705
Average 1.866 1.754 1.834 1.707
15 MV Trial 1 1.911 1.808 1.882 1.767
Trial 2 1.910 1.806 1.882 1.765
Trial 3 1.908 1.804 1.881 1.765
Average 1.910 1.806 1.882 1.766
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Table 2. Calculation of the transmission factor using averages

obtained from the trials shown in Table 1.
Readings with the treatment couch
Energy Readings without the treatment couch
PA AP RPO LAO
4 MV 1.617 = 0.973 1.441 = 0.958
1.661 1.504
6 MV 1.697 = 0.976 1.543 = 0.963
1.738 1.602
10 MV 1.834 = 0.983 1.707 = 0.973
1.866 1.754
15 MV 1.882 = 0.985 1.766 = 0.978
1.910 1.806

Discussion: I evaluated the transmission factor in regards to an AP/PA (0/180E) beam

arrangement and an oblique LAO/RPO (45/225) beam arrangement. The transmission factor
for an AP/PA beam for the 4 MV photon energy is 0.973, 6 MV is 0.976, 10 MV is 0.983, and
15 MV is 0.985. The transmission factor for an LAO/RPO beam for the 4 MV photon energy is
0.958, 6 MV is 0.963, 10 MV is 0.973, and 15 MV is 0.978. This concludes that the treatment
couch for the AP/PA gantry angle arrangement is attenuating 2.7% of the radiation beam for the
4 MV energy, 2.4% for 6 MV, 1.7% for 10 MV, and 1.5% for 15 MV. The treatment couch for
the LAO/RPO gantry angle arrangement is attenuating 4.2% of the radiation beam for the 4 MV
energy, 3.7% for 6 MV, 2.7% for 10 MV, and 2.2% for 15 MV. The difference measured
reflected a lower transmission factor for the oblique beams traversing the treatment couch, due to
higher attenuation with the beam travelling through a greater portion of the couch. Lower
photon energy ranges demonstrated a higher percent of attenuation due to an increased amount of
photon interactions with the couch. This study shows how important it is to factor in the couch
during treatment planning and the consideration of using a certain number of beams that traverse
through a significant portion of the treatment couch.

Clinical Application: A clinical example applicable to this study would be in an isocentric

thoracic spinal met case. The physician prescribed a dose of 250 cGy per day for 15 fractions at
a total dose of 3,750 cGy. This particular treatment plan shows a 4-field beam arrangement
using a 3D conformal technique. The collimator is turned to 90 and a photon energy of 10 MV
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was used. The monitor unit calculation shown below demonstrates just the AP/PA fields
incorporating the treatment couch attenuation factor and omitting the couch attenuation factor.

Monitor Unit Calculation without the treatment couch attenuation correction factor:

MU = Dose
(cal.)(Sc)(Sp)(TMR)(TF)(*ISF)

AP MU = 62.5 cGy = 62.5 cGy = 68 MU

(1.0)(0.975)(0.983)(0.920)(1.0)(1.049) 0.925

PA MU = 62.5 cGy = 62.5 cGy = 82 MU

(1.0)(0.975)(0.983)(0.755)(1.0)(1.049) 0.759

*Reference data tables were TPR so I had to calculate the TMR as following:
100 + 2
ISF= ( )
+

Monitor Unit Calculation with the treatment couch attenuation correction factor:

AP MU = 62.5 cGy = 62.5 cGy = 69 MU

(1.0)(0.975)(0.983)(0.920)(.983)(1.049) 0.909

PA MU = 62.5 cGy = 62.5 cGy = 84 MU

(1.0)(0.975)(0.983)(0.755)(.983)(1.049) 0.746

Percent Difference in MU

AP = 69 68 x 100% = 1.4% PA = 84 82 x 100% = 2.4%

69 84

It can be concluded that the AP field resulted in a couch attenuation factor of 1.4% and the PA
field 2.4% respectively. These percentages indicate how much the monitor units must increase
to reach the target volume, due to the treatment couch blocking the path of the radiation beam.
The patient would receive insufficient dose if the couch was not accounted for. From this study,
I learned that the Eclipse treatment planning system at our facility does take into account the
treatment couch by designating it certain Hounsfield units and factoring that into the algorithm.
With the increasing use of VMAT and arcs that are going through the table posteriorly, this
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transmission factor is crucial. Every beam adds up, and throughout the accumulation of the
patients treatment it can make a difference in the dose and result they receive.
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Image 1a. An example of a thoracic spinal met treatment plan report.

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Image 1b. A continuation of image 1a.

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Image 1c. A example of an independent check of the treatment planning system with the
incorporation of the transmission factor.
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Image 2a. A plan with the treatment couch added.

Image 2b. A plan with the omission of the treatment couch.

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Conclusion: This study exhibits how important it is to determine the transmission factor if an
object is placed in the radiation beam path to correct for the appropriate dose being delivered to
the patient. With the omission of using a treatment couch attenuation correction factor during
treatment planning, a patient could be underdosed. This study also exhibits how different photon
energies effect the transmission factor and monitor units as well.
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References

1. Olch, A. J., Gerig, L., Li, H., et al. Dosimetric effects caused by couch tops and
immobilization devices: Report of AAPM Task Group 176. Med Phys. 2014:27(5).
http://dx.doi.org/10.1118/1.4876299.

2. Bentel GC. Radiation Therapy Planning. 2nd New York, NY; McGraw-Hill; 1996.