1

Christina Ong
March 4, 2018
Attenuation Project
TrueBeam Treatment Couch Transmission Factor Calculation
Objective: To determine the transmission factor for a TrueBeam treatment couch and apply it to
a patient treatment monitor unit (MU) calculation.
Purpose: In radiation therapy, linear accelerators use monitor units (MU) to deliver accurate
dose during treatment. MU is calculated as dose (cGy) divided by the calibration condition (e.g.
1cGy/1MU). Factors that change the calibration condition must be accounted for in MU
calculation.1
A radiation beam is attenuated as it passes through objects placed in the path of the beam.
Such objects include but are not limited to: the body, immobilization devices, and treatment
couch with/without rails. The dose delivered to patient is altered as a result of beam attenuation.
To correct for the variation in dose, a transmission factor for each object in the path of the beam
is applied during MU calculation, as mentioned above. The transmission factor is defined as the
ratio of dose with an object in the path of a radiation beam to the dose without the object in the
path of a radiation beam:1
𝐷𝑜𝑠𝑒 𝑤𝑖𝑡ℎ 𝑜𝑏𝑗𝑒𝑐𝑡 𝑖𝑛 𝑡ℎ𝑒 𝑏𝑒𝑎𝑚 𝑝𝑎𝑡ℎ
𝑇𝑟𝑎𝑛𝑠𝑚𝑖𝑠𝑠𝑖𝑜𝑛 𝐹𝑎𝑐𝑡𝑜𝑟 =
Dose without object in the beam path
For this project, the TrueBeam treatment couch is selected as the object in the beam path and
measurements are taken to determine the transmission factor then MU calculation is computed
based off that.
Methods and Materials: A TrueBeam linear accelerator was used to deliver photon energies of
6MV, 10MV, and 15MV. The following parameters were set for each radiation beam: 100cm
source to axis distance (SAD), 10cm x 10cm field size, 180° gantry rotation, 600MU, and a dose
rate of 600MU/min. Two brass build-up caps were used; a smaller one for 6MV-8MV and a
large one for 10MV-18MV (Figure 1). A cylindrical thimble type ion chamber (Figure 2) is
connected to a PTW Unidos E electrometer (Figure 3) with cable from the treatment room to
outside to measure beam output. Readings were taken with (Figures 4, 5) and without (Figures 6,
7) the TrueBeam treatment couch for 6MV, 10MV, and 15MV.
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Figure 1. Brass Build-Up Caps for 10MV-18MV (Top) and 6MV-8MV (Bottom)

Figure 2. Cylindrical Thimble Type Ion Chamber

Figure 3. PTW Unidos E Electrometer

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Figure 4. 180° Gantry Rotation With TrueBeam Treatment Couch

Figure 5. Close Up of Ion Chamber With TrueBeam Treatment Couch

The radiation beam from the gantry head is going through the treatment couch to the ion
chamber positioned on top of the treatment couch.
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Figure 6. 180° Gantry Rotation Without TrueBeam Treatment Couch

Figure 7. Close Up of Ion Chamber Without TrueBeam Treatment Couch

The ion chamber is positioned in free space (air).
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Results:
Table 1. Electrometer Reading Data
Energy Readings with Couch (nC) Readings without Couch (nC)
6MV 1.880 1.900
1.880 1.900
1.899
10MV 2.121 2.169
2.120 2.168
2.168
15MV 2.374 2.420
2.373 2.419
2.419
Readings were taken with and without the TrueBeam treatment couch at 180° for 6MV, 10MV,
and 15MV. Two measurements were taken for each energy with the treatment couch. Three
measurements were taken for each energy without the treatment couch.
Table 2. Average Reading Calculations
Energy Average Readings with Couch (nC) Average Readings without Couch (nC)
6MV 1.880 1.899
10MV 2.121 2.168
15MV 2.374 2.419
The average reading for each energy was determined with and without the TrueBeam treatment
couch at 180° for 6MV, 10MV, and 15MV. The average reading for each energy with the
treatment couch was determined by adding the two values measured and dividing the sum by 2.
The average reading for each energy without the treatment couch was determined by adding the
three values measured and dividing the sum by 3.
Table 3. Transmission Factor Calculations
Energy Transmission Factor Percent Attenuation
6MV 0.990 1%
10MV 0.978 2.2%
15MV 0.981 1.9%
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The transmission factor for each energy is calculated by the formula below:
𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝑜𝑓 𝑟𝑒𝑎𝑑𝑖𝑛𝑔𝑠 𝑤𝑖𝑡ℎ 𝑡ℎ𝑒 𝑐𝑜𝑢𝑐ℎ
𝐴𝑣𝑒𝑟𝑎𝑔𝑒 𝑜𝑓 𝑟𝑒𝑎𝑑𝑖𝑛𝑔𝑠 𝑤𝑖𝑡ℎ𝑜𝑢𝑡 𝑡ℎ𝑒 𝑐𝑜𝑢𝑐ℎ
The percent attenuation for each energy is calculated by: (1 − 𝑇𝑟𝑎𝑛𝑠𝑚𝑖𝑠𝑠𝑖𝑜𝑛 𝐹𝑎𝑐𝑡𝑜𝑟) ∗ 100
Discussion: The transmission factor is 0.990 for 6MV, 0.978 for 10MV, and 0.981 for 15MV.
The data collected demonstrates that the TrueBeam treatment couch attenuates 1% for 6MV
photon energy, 2.2% for 10MV photon energy, and 1.9% for 15MV photon energy. The percent
attenuation specifies the necessary increase in MU per field to deliver the prescribed dose to the
target volume for any field that goes through the TrueBeam treatment couch at 180°.
The results contradict with the principle of attenuation of radiation beam energies and the
American Association of Physicists in Medicine Task Group 176 (AAPM TG 176) Report for
“Dosimetric effects caused by couch tops and immobilization devices”.2 Generally, lower-energy
photon beams interact with matter at superficial depth more than higher-energy photon beams,
causing lower transmission factor and higher percent attenuation. In the AAPM TG 176 Report,
the attenuation for Varian’s IGRT tabletop (TrueBeam) is 3.1% for 6MV and 2.0% for 15MV;
no values were provided for 10MV.2 Hence the 1% attenuation for 6MV collected for the
purpose of this project may be erroneous due to the 6MV-8MV build-up cap and a second trial
should be conducted to verify the numbers in future research at the clinical site.
Clinical Application: A palliative treatment to T10 – L3. The dose and fractionation regimen is
3000cGy in 10 fractions = 300cGy per fraction. Two equally weighted opposing fields were
created anteriorly and posteriorly to treat the patient in a prone position. In this specific treatment
plan, the gantry was rotated 6° counterclockwise for each field to avoid the kidneys as both
kidneys were tilted to the left on the CT dataset, shown in Figure 8.
Figure 8. A Transverse Slice Presenting Kidneys Anatomical Position
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For the purpose of this project, I rotated the gantry to 0° for the “AP” field and 180° for the “PA”
field and recalculated with and without the treatment couch (Figure 9). Monitor units (MU) hand
calculation is only shown for the AP field that goes through the treatment couch as the patient is
positioned and treated prone. The PA field does not go through the treatment couch and MU
does not change based on the transmission factor of the treatment couch. The dosimetric factors
necessary to calculate MU for the AP field are shown in Table 4.
Figure 9. Plan Comparison Screenshot of With and Without TrueBeam Treatment Couch
with Adjusted Gantry Rotations

Table 4a. Hand Calculation Form for Field AP (Gantry Rotation 180°)
Field AP
Energy 15MV
Field Size 9.1cm x 17.7cm
Treatment Area 12.0cm2
(Equivalent Square)
Depth 13.3cm
Collimator Scatter Factor (Sc) 1.011cGy/MU
Phantom Scatter Factor (Sp) 1.003cGy/MU
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Table 4b. Continuation of Table 4a

Tissue Maximum Ratio (TMR) 0.815
Isodose Line (IDL) 1
Inverse Square Factor (ISF) 1.057
Prescribed Dose (per field per fraction) 150cGy
The MU hand calculation for the AP field is shown as follows with and without the treatment
couch transmission factor.
With treatment couch – AP: MU = 175
𝑃𝑟𝑒𝑠𝑐𝑟𝑖𝑏𝑒𝑑 𝐷𝑜𝑠𝑒
𝑀𝑈 =
𝑆𝑐 𝑥 𝑆𝑝 𝑥 𝑇𝑀𝑅 𝑥 𝐼𝐷𝐿 𝑥 𝐼𝑆𝐹 𝑥 𝑻𝒓𝒆𝒂𝒕𝒎𝒆𝒏𝒕 𝑪𝒐𝒖𝒄𝒉 𝑻𝒓𝒂𝒏𝒔𝒎𝒊𝒔𝒔𝒊𝒐𝒏 𝑭𝒂𝒄𝒕𝒐𝒓

150𝑐𝐺𝑦
𝑀𝑈 =
1.011𝑐𝐺𝑦/𝑀𝑈 𝑥1.003𝑐𝐺𝑦/𝑀𝑈 𝑥 0.815 𝑥 1 𝑥 1.057 𝑥 0.981
𝑀𝑈 = 175
Without treatment couch – AP: MU = 172
𝑃𝑟𝑒𝑠𝑐𝑟𝑖𝑏𝑒𝑑 𝐷𝑜𝑠𝑒
𝑀𝑈 =
𝑆𝑐 𝑥 𝑆𝑝 𝑥 𝑇𝑀𝑅 𝑥 𝐼𝐷𝐿 𝑥 𝐼𝑆𝐹

150𝑐𝐺𝑦
𝑀𝑈 =
1.011𝑐𝐺𝑦/𝑀𝑈 𝑥1.003𝑐𝐺𝑦/𝑀𝑈 𝑥 0.815 𝑥 1 𝑥 1.057
𝑀𝑈 = 172
Percent attenuation of the TrueBeam treatment couch from MU hand calculation: 1.7%
175 − 172
( ) ∗ 100 = 1.7
175
The MU calculation from the treatment planning system (TPS) is as follows with and without
treatment couch.
With treatment couch – AP: MU = 172

Without treatment couch – AP: MU = 169

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Percent attenuation of the TrueBeam treatment couch from MU TPS calculation: 1.7%
172 − 169
( ) ∗ 100 = 1.7
172
The gantry angle also comes into play in beam attenuation from the TrueBeam treatment couch.
The gantry angles with the most beam attenuation are 135° and 225°, 45° from 180°
counterclowise and clockwise respectively.2 For demonstration purposes, below are the MU
calculated from TPS with the original treatment plan with a RAO field of 174° and LPO field of
354° with and without treatment couch. Notice the MU for LPO, the field that does not go
through the treatment couch before reaching the atient, stayed the same.
With treatment couch – RAO: MU = 170

Without treatment couch – RAO: MU = 167

The percent attenuation of the TrueBeam treatment couch from MU TPS calculation at 174° is
1.8%; 0.1% more than it is at 180°, which is minimal; nevertheless, it discloses that the
transmission factor differs from degree to degree of gantry rotation angles.
As shown by the MU calculations in the Clinical Application section of this project, the percent
attenuation from the TrueBeam treatment couch at 180°for a 15MV photon beam is about 1.7%.
This value represents the beam attenuation attributed to the TrueBeam treatment couch at 180°
for a 15MV photon beam. The dose delivered will be reduced by the percent attenuation if the
transmission factor was not applied in the MU calculations. Both MU hand calculation and MU
TPS calculation support this value. Although the percent attenuation is within standard deviation
acceptance ~3%-5%, it indicates that the TPS takes into account the transmission factor of the
TrueBeam treatment couch. Thus the TrueBeam linear acceleration is delivering and patients are
receiving accurate radiation dose to the target volume.
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Conclusion: It is inevitable for treatment plans to have radiation beams going through the
treatment couch. To account for the attenuation of the beams through the treatment couch and
deliver accurate dose, the transmission factor of the treatment couch must be considered in
monitor units (MU) calculations. As demonstrated in this project, the patient is underdosed
without the transmission factor and the transmission factor of the TrueBeam treatment couch
varies with photon energy and gantry rotation.
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References
1. Bentel GC. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996.
2. Olch AJ, Gerig L, Li H, et al. TG-176: Dosimetric effects caused by couch tops and
immobilization devices. Med Phys. 2014;41(6): 2228-2258.
http://dx.doi.org/10.1118/1.4876299