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Medical Dosimetry, Vol. 23, No. 4, pp.

267270, 1998
Copyright 1998 American Association of Medical Dosimetrists
Printed in the USA. All rights reserved
0958-3947/98/$see front matter

PII 50958-3947(98)00030-2

Original Contribution

CLINICAL CONSIDERATIONS IN THE USE OF


MISSING TISSUE COMPENSATORS FOR
HEAD AND NECK CASES
S. C. SHARMA and M. W. JOHNSON
Department of Radiation Oncology E. W. Sparrow Hospital,
Lansing, MI 48909
AbstractThe irregular shape or contour of the patients surface in the treatment field can alter the dose
distribution resulting in non-uniformity of dose in the treatment volume. Missing tissue compensators have been
most commonly used to improve this non-uniformity, especially in head & neck, breast, lung and supraclavicular
regions. Two or three dimensional compensators have been typically designed to make the dose uniform at a
specific depth. This compensation shifts the dose distribution within the treatment volume so that some structures
may be under or over compensated. This study will examine how various sites in head and neck cases are affected
by compensators. We have also analyzed the uncertainty in compensated dose due to the daily variations in
patient repositioning. Computer isodose plans using Cobalt-60 gamma rays and 6 and 18 MV x-rays were
generated using coronal contours. Results show that the dose uniformity is improved for the treatment sites,
especially for the thinner sites, like the larynx and the anterior cervical neck nodes. Finally, patient movement
or positioning errors of 61.0 cm will cause a change in dose distribution. 1998 American Association of
Medical Dosimetrists.
Key Words: Tissue compensators, Head and neck, Treatment planning, Positioning errors.

INTRODUCTION

compensator were acquired through Moire fringe photographs of the phantom.2 Each fringe is equivalent to a 1.0
cm change in separation in the phantom and each step of
the compensator is from 1 to 2 cm wide. A custom
polylead step-wedge compensator was constructed from
a technique described by Spicka, et al.3 A standard
nasopharynx field (with blocks) was set-up to analyze
doses for typical treatment sites: larynx, nasopharynx,
cervical spinal cord, and anterior/posterior cervical neck
nodes. Computer isodose plans were generated using the
GE Target treatment planning computer. The energies
studied were from a Theratronics Cobalt-60 gamma ray
teletherapy unit and 6 & 18 MV x-rays from a Varian
Clinac 1800 linear accelerator. These plans were calculated with/without compensators.
In addition, to simulate position errors or patient
movement, the lateral fields were moved anterior/posterior 61.0 cm.

The irregular shape or slope of the patients surface in the


treatment field can alter the dose distribution resulting in
non-uniformity in the treatment volume. Missing tissue
compensators1 are most commonly used in head & neck,
breast, lung and supraclavicular regions. Two or three
dimensional compensators are typically designed to
make the dose uniform at a specific depth. This compensation shifts the dose distribution within the treatment
volume so that other structures may be under or over
compensated. This study examines how various sites of
interest in the head and neck are affected by compensators at several energies. In addition, the uncertainty in
compensated dose due to daily variations in patient repositioning is presented.
MATERIALS AND METHODS
Coronal cross-sections (through the larynx, nasopharynx, and cervical cord) of an Alderson-Rando anthropomorphic phantom were obtained using an Oldelft
Simulix CT-Extension system. The contour data for the

RESULTS
A comparison of isodose plans normalized to isocenter without compensators with the compensated isodose plans for photon energies of Cobalt-60 (Fig. 1), 6
MV (Fig. 2), and 18 MV (Fig. 3) show that, i) the dose
decreases in the thinner laryngeal region, ii) there is a
slight over-compensation seen in most regions, iii) the
hot spot shifts from the larynx region to the anterior neck

Reprint requests to: Dr. S. C. Sharma, Sparrow Hospital, Department of Radiation Oncology, 1215 East Michigan Ave., Lansing MI
48909.
Poster presentation at the 37th annual meeting of ASTRO, Miami, Florida, October 1995.
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Medical Dosimetry

Vol. 23, Number 4, 1998

Fig. 1. Isodose plans for Co-60 uncompensated field (left panel) and compensated field (right panel).

Fig. 2. Isodose plans for 6 MV uncompensated field (left panel) and compensated field (right panel).

Clinical considerations in the use of missing tissue compensators for head & neck cases S. C. SHARMA and M. W. JOHNSON

269

Fig. 3. Isodose plans for 18 MV uncompensated field (left panel) and compensated field (right panel).

node region and decreases from 7.7% for 6 MV to 1% for


18 MV, and iv) as the photon energy increases the dose
variation in the treatment volume decreases. Table I
shows that site doses are less compensated, in general,
for the higher photon energies.
For the patient movement study, the site doses increased an average 4% as the compensator was shifted
anterior/posterior 1.0 cm for Co-60 (Table I).
CONCLUSION
Adding a missing tissue compensator to a head and
neck field does produce the expected dose uniformity. It

not only decreases the Hot Spot, but the overall dose
variation in the treatment volume is decreased. This is
primarily because of the general symmetry of the
treated region, unlike the thorax which can only be
compensated from the anterior and has major organs
of concern that are not in the calculated plane of
compensation.4 With regard to patient movement,
when the incremental shift is about the width of the
compensator step, there is still some change in dose
distribution. Therefore, it is emphasized that reproducible immobilization is necessary when using compensators.

Table 1. Relative site doses


Sites
Description
Cobalt-60
Uncompensated
Compensated
Shifted Field
6 MV x-rays
Uncompensated
Compensated
18 MV x-rays
Uncompensated
Compensated

Larynx

Nasopharynx

Anterior
Neck Nodes

Posterior
Neck Nodes

Cervical
Cord

Hot Spot

Figure
Reference

105
92
65%

93
96
66%

100
97
62%

96
94
65%

94
93
64%

109
105
62%

Figure 1

108
98

98
100

104
99

96
97

99
99

112
104

Figure 2

103
96

98
100

100
94

86
86

99
98

103
102

Figure 3

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Medical Dosimetry

REFERENCES
1. Ellis, F.; Hall, E.J.; Oliver, R. A compensator for variations in
tissue thickness for a high energy beam. British Journal of Radiology 32:421; 1959.
2. Boyer, A.; Goitein, M. Simulator mounted moire tomography for
constructing compensator filters. Medical Physics 7(1):1926; 1980.

Vol. 23, Number 4, 1998


3. Spicka, J.; Fleury, K.; Powers, W. Polyethylene-lead tissue compensators for megavoltage radiotherapy. Medical Dosimetry 13:25
27; 1988.
4. Sharma, S.; Johnson, M. Clinical considerations in the use of
missing tissue compensators for thoracic cases. Medical Dosimetry
22(2):107112; 1997.

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