Ashley Coffey

Beam Attenuation: TrueBeam Couch

Objective: To determine the amount of dose attenuated by the Varian TrueBeam standard table
and to incorporate this factor into a treatment plan calculation.
Purpose: When treating a patient, many angles within the 360 range can be utilized to deliver
appropriate dose to the target. However, objects in the way of the beam can affect the dose
delivered. With the Varian TrueBeam, it was noticed that the table can attenuate dose and affect
the path of the beam. IMRT and Arc treatments often have to treat through the table during a
portion of the treatment; being that the TrueBeam is a newer piece of technology with huge
advancements in imaging, it is utilized most for these precise treatment methods. A transmission
factor must be generated in order to account for the table attenuation and to correct dose
calculations.
Transmission Factor = Dose with object in beam path
Dose without object in beam path
Method/Materials: The readings were performed on a Varian TrueBeam accelerator with the
accompanying TrueBeam table. The table is made of carbon fiber material and does not include
the Six Degrees of Freedom feature that some Varian tables utilize. A 6MV energy beam at 600
MU/minute dose rate with 10x10cm field and 100cm SSD were used to acquire the data. Solid
water blocks with 1.5cm of buildup and a backscatter block were placed on the floor under the
head of the gantry with an ion chamber placed in the center of the solid water opening at a depth
of 1.5cm (Dmax for 6MV). The central axis labeled on the block was lined up with the central
axis of the field. The ion chamber was then connected to an electrometer. Three readings were
taken without and with the table in the way with 100 MU delivered each time. On the TrueBeam
table, there are thin, medium, and thick parts of the table; the superior of the table is the thinnest
and the thickest is at the most inferior portion. The readings were performed at the thinnest part
of the table.

Results:
Reading without table (nC)
3.88
3.88
3.89

Reading with table (nC)

3.79
3.79
3.78

Average reading without table- 3.88nC

Average reading with table- 3.79nC

Transmission Factor = Dose with object in beam path

Dose without object in beam path
3.79nC/ 3.88nC = 0.976

Discussion: The transmission factor for 6MV through the couch is 0.976 which means that the
beam attenuates 2.4%. The photons from the beam hit the couch and that 2.4% scatter out
through the material used to design the couch. When incorporating this factor into the MU
calculations (or the treatment planning program), the total MUs will increase due to making up
for the percentage that is attenuated.
The use of only 6MV measurements served a purpose in this experiment. When treating at the
most superior end of the table (which is also the thinnest section), the most common treatments
will be head, neck, and thorax area.1 For these variation of treatments, 6MV energy is the most
standard energy that would be used; IMRT treatments are most common in the neck region and
AP/PA commonly for lung or spine of the upper body. Therefore, only 6MV was measured due
to reasonable deduction and mindfulness of the experiment.
Clinical Application: If treating an AP/PA spine with 150cGy per field with an 8x8cm field size
at 8cm depth, the follow calculations demonstrate the differences with and without the
transmission factor of the table.
Without transmission factor:
MU =

dose
(output)(TMR)(Fc)(Fp)(ISL)

MU =

150cGy
(1 cGy/MU)(0.857)(0.985)(0.993)(1.03)

= 174 MU
With transmission factor:
MU =

dose
(output)(TMR)(Fc)(Fp)(ISL)(TF)

MU =

150cGy

(1 cGy/MU)(0.857)(0.985)(0.993)(1.03)(0.976)

= 178 MU

Percent difference in MU:

MU without transmission factor/ MU with transmission factor (correct MUs)
174 MU/ 178 MU = .978 or 97.8% of dose delivered
2.2% under dose per treatment
Conclusion: Table attenuation causes a change in dose distribution throughout a patients
treatment. With the transmission factor not being accounted for in calculations, the scatter dose
produced will add dose to the surface of the patient due to lack of penetration. Although only
2.4% attenuation, that dose will add up over the course of treatment and cause skin reactions.
The target will also be under dosed by more than 2% with each treatment. It common for
metastatic spine to be treated AP/PA to 30Gy in ten treatments2; if the transmission factor is left
out, the total dose would be 2934cGy instead of 3000cGy. At Massey Cancer Center, there are
TrueBeam options for thin, medium, and thick table contours in Pinnacle; this automatically
corrects for the attenuation when the program calculates MUs as well as isodose lines. The
transmission factor must be utilized during patient planning in order to reduce the skin reaction
and receive an accurate dose distribution on the planning program.

References
1. Wen N, Zhao B, Kim J, et al. IMRT and RapidArc commissioning of a TrueBeam linear
accelerator using TG-119 protocol cases. J Appl Clin Med Phys. 2014;15(5).
doi:10.1120/jacmp.v15i5.4843.
2. Sejpal SV, Bhate A, Small W. Palliative Radiation Therapy in the Management of Brain
Metastases, Spinal Cord Compression, and Bone Metastases.Seminars in Interventional
Radiology. 2007;24(4):363-374. doi:10.1055/s-2007-992324.