SSD vs. SAD Setup: Write down the MU equations for both setups and describe all variables.

MU SSD = Dose ( Output f ) PDD ( d,E,FS ) Sc ( FSorig ) S p ( FSblocked )( SSD factor )

2 2 2

SSDcalib + d max 100 +1.5 SCD SSD factor = = = =1 SSDT + d max SSDT + d max 100 +1.5 Dose ( Output f ) TMR ( d,E,FS ) Sc ( FSorig ) S p ( FSblocked ) ( SAD factor )
2 2 2

MU SAD =

SCD SSDstandard + d max 100 +1.5 SAD factor = = = = 1.03 SAD SSDT + dT 100

Collimator Scatter Factor, Sc: The beam output measured in air depends on field size. As field size increases, output increases due to the collimator scatter that is added to the primary beam. It is defined as the ratio of the output in air for a given field to that of a reference field (usually 10x10), at the same depth. Sc = Dair ( r ) Dair ( rref

It refers specifically to the original collimator setting, NOT the modified or blocked field dimensions. When actually measuring this ratio, the field must fully encompass the ion chamber buildup cap. For that reason, smaller fields can be measured at extended distances to ensure this. Phantom Scatter Factor, Sp: The phantom scatter factor takes into account the change in scatter radiation originating in the phantom at a reference depth as field size is changed. It is defined as the ratio of the dose rate for a given field size to that of a reference field size (usually 10x10), at the same depth. In practice, Sp is not actually measured, but calculated. Consider the following relationship:

Sp =

Sc , p ( r ) Sc ( r )

One can first measure the total scatter factor, which is defined as the dose rate at a reference depth for a given field size to the dose rate at the same point and depth for a reference field size. This total scatter factor Scp can then be divided by the

collimator scatter factor, which weve already measured above, to isolate the phantom scatter factor, Sp. Percent Depth Dose, PDD: Is a ratio of dose at a given depth to dose at dmax along the central axis, or:
PDD = Dd Ddmax

Tissue Maximum Ratio, TMR: Is a ratio of dose at a given depth to dose at the SAME point at the reference depth of dmax, or:

TPR =

Dd D = d = TMR Dd ref Ddmax

The concept of TMR is based on the assumption that the fractional scatter contribution to the depth dose at a point is independent of the divergence of the beam and depends only on the field size at that point and the depth of the overlying tissue. (As a side note, the whole principle behind finding equivalent squares or equivalent circles is that we are creating a new field such that we have the same PDD, TMR, and scatter contributions; NOT the same area. For a square, we use 4(A/P). For a circle, we use r )
What are the mathematical relationships between TAR, BSF, PDD, and TMR?

Derivations are as follows: Consider the dose at a point in a phantom, say at point Q. We can express this dose in terms of dose in free space at the same point when we multiply it by its tissue air ratio, or:
Dd Q = D fsQ TARd

Tissue-air ratio is defined as the ratio of the dose to water at a given depth to the dose in air measured with a buildup cap. It must be ensured that the ion chamber is placed far away from any scattering sources such as the floor and walls. Measurements for each value are taken with identical source to detector distances and field sizes. We also know that dmax at point P, for instance, can be given by:
DmaxP = D fsP BSFr

The BSF is actually a TAR at the depth of maximum dose. (Note that the BSF increases with beam quality and with field size. The scatter reaching the ion chamber at dmax compared to free space comes from overlying and underlying tissue. However, for high energy beams, the magnitude of the BSF gets much smaller because overall scatter is reduced.) D Since PDD is defined as PDD = dQ , we can substitute the above relations to get: DmaxP PDD = We can finally see that: TARd SSD + d max PDD = BSFr SSD + d Since TMR is actually defined as:
TMR = TARd BSFr
2

DdQ DmaxP

TARd SSD + d max = = D fsP BSFr BSFr SSD + d D fsQ TARd

PDD and TMR can be interchanged via the relation:

SSD + d max PDD = TMR SSD + d
2

From these results, we deduce a very important fact. Whereas TMR only accounts for attenuation and scatter, PDD accounts for attenuation, scatter, AND the inverse square law. That is why PDD values are smaller than TMR values at the same depth.
Which setup causes a higher dmax value, SSD or SAD?

First, let us establish the simple dose relations within a patient for both setups. For an SSD treatment: D2 =
PDD2 D1 PDD1
2

TMR2 SAD For an SAD treatment: D2 = D1 TMR1 SAD - d

Consider treating a lesion 8 cm deep. The prescription dose at the midline is 250 cGy. Let us examine both setups in order to quantify dmax.

For an SSD treatment: PDDdmax D2 = Dmax = PDDd For an SAD treatment:

TMRdmax SAD 80 1.00 D2 = Dmax = D1 = 250 cGy = 366 cGy 0.8 80 - 8 +1.5 TMRd SAD - d + d max
2 2

1.00 D1 = 250 cGy = 357 cGy 0.7

As can be seen, the SAD treatment was 2.6% hotter than its SSD counterpart. Recall that a 6x, SAD treatment will have a hotter dmax than an 18x, SSD treatment.
Visualize the different setups.

Note that the collimator setting is ALWAYS defined at 100 cm, regardless of the type of setup. However, the size of the field at the designated treatment depth must be the same for each setup.