Medical Electron

Accelerators
 Notice
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Medical Electron
Accelerators
Department of Radiation Oncology
Stanford University School of Medicine
Stanford, California

Craig S. Nunan and Eiji Tanabe

VarianAssociates
Palo Alto, California

McGRAW-HILL, INC.
Health Professions Divisiorz
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Medical Electron Accelerators
Copyright O 1993 by McGraw-Hill, Inc. All rights reserved. Printed in the United States of America.
Except as permitted under the United States Copyright Act of 1976, no part of this publication may be
reproduced or distributed in any form or by any means, or stored in a data base or retrieval system,
without the prior written permission of the publisher.

1234567890 HALHAL 98765432

ISBN 0-07-105410-3

This book was set in Times Roman by Northeastern Graphic Services, Inc.
The editors were Jane Pennington and Steven Melvin;
the production supervisor was Richard Ruzycka;
the cover designer was Marsha Cohenffarallelogram.
Arcata GraphicsMalliday was printer and binder.

Library of Congress Cataloging-in-Publication Data

Karzmark, C. J.
Medical electron accelerators 1 C.J. Karzmark, Craig S. Nunan, and
Eiji Tanabe.
p. cm.
Includes bibliographical references and index.
ISBN 0-07- 105410-3 :
1. Cancer-Radiotherapy. 2. Electron accelerators. 3. Electrons-
Therapeutic use. I. Nunan, Craig S. 11. Tanabe, Eiji.
III. Title.
[DNLM: 1. Electrons. 2. Neoplasms-radiotherapy. 3. Particle
Accelerators. QZ 269 K18mI
RC271.E43K37 1993
6 16.99'40642-dc20
DNLMIDLC
for Library of Congress 9249307
CIP
 Contents

CHAPTER 1 The Medical Electron Accelerator 1

OVERVIEW 1
THE NEED FOR MEDICAL ELECTRON ACCELERATORS 1
OUTLINE OF THIS BOOK 1
GOALS OF RADIOTHERAPY 1
IMPACT OF TREATMENT COURSE FRACTIONATION ON MACHINE
PERFORMANCE REQUIREMENTS 2
USER PREFERENCES FOR BEAM MODE 3
TREATMENT BEAM GENERATION 4
HISTORY OF ELECTRON ACCELERATORS 6
DIRECT ACCELERATORS 6
BETATRONS 6
MICROWAVE ELECTRON LINEAR ACCELERATORS (LINACS) 7
RECIRCULATING ELECTRON ACCELERATORS 13
ELEMENTARY DESCRIPTION OF MEDICAL LINACS 15
MICROWAVE ACCELERATION PRINCIPLE 16
BEAM CURRENT REQUIREMENTS
IN X-RAY MODE 18
MAJOR SUBSYSTEMS AND COMPONENTS 18
SUMMARY OF ENERGY CONVERSION STEPS 20
DESIGN CRITERIA FOR RADIOTHERAPY ACCELERATORS 20
CLINICAL REQUIREMENTS 22
SOME DESIGN CHALLENGES 24
CHANGES IN TECHNOLOGY FROM EARLY-TO-MODERN MACHINES 26
SUMMARY: ACCELERATOR MAJOR SUBSYSTEMS 26
ONE FUTURE DIRECTION OF EQUIPMENT DEVELOPMENT
IN RADIATION THERAPY 27
REFERENCES 29

CHAPTER 2 Radiotherapy Modalities 33

ORTHOVOLTAGE X-RAY THERAPY 33
vi CONTENTS

MEGAVOLTAGE X-RAY THERAPY 34

TOTAL-BODY AND HEMIBODY X-RAY THERAPY (MAGNA-FIELD
THERAPY) 35
MEGAVOLTAGE ELECTRON THERAPY 37
TOTAL SKIN ELECTRON THERAPY 38
INTRAOPERATIVE RADIATION THERAPY 39
ARCTHERAPY 41
DYNAMIC AND CONFORMAL THERAPY AND MULTILEAF
COLLIMATORS 41
STEREOTACTIC RADIOSURGERY 43
REFERENCES 45

CHAPTER. 3 Microwave Principles for Linacs 49

ELEMENTARY LINAC 50
MICROWAVES 50
TRANSMISSION LINES AND WAVEGUIDES 51
IMPEDANCE MATCHING AND VOLTAGE STANDING WAVE RATIO 54
RESONANCE AND RESONANT CAVITIES 55
PHASE VELOCITY AND GROUP VELOCITY 59
PERIODIC STRUCTURES AND COUPLING 59
MODE AND DISPERSION 62
SHUNT IMPEDANCE AND TRANSIT TIME 64
REFERENCES 66

CHAPTER 4 Microwave Accelerator Structures 67

ELECTRON GUNS AND INJECTION 67
CATHODE 67
DESIGN OF AN ELECTRON GUN 68
ELECTRON INTERACTION WITH MICROWAVE FIELD 68
MOTION OF ELECTRONS 68
SPACE HARMONICS 70
TRAVELING-WAVE ACCELERATORS 70
THEORY OF OPERATION 70
STRUCTURES 71
ELECTRON INJECTION AND BUNCHING 72
BEAM LOADING AND LOAD LINE 75
STANDING-WAVEACCELERATORS 76
THEORY OF OPERATION 76
STRUCTURES 78
ELECTRON INJECTION AND BUNCHING 79
 CONTENTS vii

BEAM LOADING AND LOAD LINE 80

TRAVELING-WAVE VERSUS STANDING-WAVE ACCELERATORS 82
DESIGN OF ACCELERATOR CAVITIES 86
REFERENCES 87

CHAPTER 5 Microwave Power Sources and Systems 89

MAGNETRONS 89
KLYSTRONS 91
RADIO FREQUENCY DRIVERS 92
CIRCULATORS 95
OTHER MICROWAVE COMPONENTS 97
WAVEGUIDE BENDS AND TWISTS, AND FLEXIBLE WAVEGUIDES 97
DIRECTIONAL COUPLERS 98
SHUNT, SERIES, AND HYBRID TEES 98
ROTARY JOINTS 99
WAVEGUIDE WINDOWS 100
WATER LOADS 101
AUTOMATIC FREQUENCY CONTROL 102
LOW ENERGY (MAGNETRON) AUTOMATIC FREQUENCY CONTROL 102
HIGH ENERGY (KLYSTRON) AUTOMATIC FREQUENCY CONTROL 103
REFERENCES 104

CHAPTER 6 Pulse Modulators and Auxiliary Systems 105

PULSE MODULATORS 105
VACUUM SYSTEMS 107
WATER COOLING SYSTEM 110
MISCELLANEOUS SYSTEMS 111
GAS DIELECTRIC SYSTEM 111
PNEUMATIC SYSTEM 113
REFERENCES 113

CHAPTER 7 Beam Optics of Magnet Systems 115

OVERVIEW 115
STRAIGHT AHEAD LINACS 115
BENT BEAM LINACS 115
LINAC BEAM CHARACTERISTICS 115
EFFECT OF MAGNET SYSTEM CHOICE ON ISOCENTER HEIGHT 115
ELECTRON MOTION IN MAGNETIC FIELDS 116
ELECTRON MOMENTUM 116
ELECTRON MOTION IN THE DIPOLE MAGNETIC FIELD 116
viii CONTENTS

ELECTRON MOTION IN THE FRINGE FIELD AT THE EDGE OF THE DIPOLE

MAGNET 117
ELECTRON MOTION IN THE QUADRUPOLE MAGNETIC FIELD 119
ELECTRON MOTION IN THE MAGNETIC FIELD OF A SOLENOID 120
BEAM STEERING COILS 122
BEAM TRANSPORT 122
BEAM EMITTANCE 122
NONACHROMATIC BEND
MAGNET SYSTEMS 125
ACHROMATIC BEND MAGNET SYSTEMS 129
SYMMETRICAL270" SINGLE SECTOR HYPERBOLIC POLE GAP 129
SYMMETRICAL270" SINGLE SECTOR LOCALLY TILTED POLE GAP 129
SYMMETRICAL 270" SINGLE SECTOR STEPPED POLE GAP 129
SYMMETRICAL270" THREE SECTOR UNIFORM POLE GAP, TWO Cx
CROSS-OVERS 130
SYMMETRICAL270" THREE SECTOR UNIFORM POLE GAP, ONE Cx
CROSS-OVER 131
ASYMMETRIC 270" TWO SECTOR UNIFORM POLE GAP 133
ASYMMETRIC 112 115" THREE SECTOR UNIFORM POLE GAP 133
SYMMETRICAL 180" FOUR SECTOR UNIFORM POLE
GAP-ISOCHRONOUS 133
REFERENCES 134

CHAPTER. 8 Treatment Beam Production 137

GEOMETRIC RESTRICTIONS OF RADIATION HEAD 138
ANCILLARY COMPONENTS 139
RADIATION SHIELDING 140
BEAM COLLIMATORS 141
FIELD LIGHT AND RANGEFINDER 142
ELECTRON THERAPY 142
ELECTRON SCATTERING SYSTEM 144
ELECTRON SCANNING SYSTEM 144
MICROTRONS VERSUS LINACS FOR ELECTRON THERAPY 145
X-RAYTHERAPY 146
X-RAY TARGET AND FLATTENING FILTER 147
X-RAY SCANNING SYSTEM 148
SCANNED BEAM DOSIMETRY 150
CONTAMINATION OF RADIATION BEAM 150
NEUTRON LEAKAGE AND RADIOACTIVATION 150
REFERENCES 151

CHAPTER. 9 Dose Monitoring and Beam Stabilization 157

IONIZATION CHAMBER 157
 CONTENTS ix

INTEGRATED DOSE AND DOSE RATE 160

FIELD UNIFORMITY CONTROL 161
MONITORING AND CONTROL OF MULTIMODALITY
TREATMENT UNITS 162
TREATMENT BEAM STABILIZATION 164
ELECTRICAL AND MAGNETIC INTERFERENCE 166
REFERENCES 167

CHAPTER 10 Accelerator Control and Safety Interlocking 169

COMPUTER CONTROL 170
MINIATURIZATION 170
SEMICONDUCTOR DEVICES AND ELECTRICAL INTERFERENCE 171
ACCELERATOR OPERATIONAL STATES 173
INTERLOCK SYSTEM 173
PROTECTION AGAINST EXTREME DOSE 176
CONTROL CONSOLE 177
MOTION CONTROL SYSTEM 178
RECORD AND VERIFY SYSTEM 180
PATIENT RECORD KEEPING 181
COMPUTER INTEGRATION OF RADIOTHERAPY 181
REFERENCES 185

CHAPTER 11 Multi-X-Ray Energy Accelerators I89

DESIGN CHALLENGES 189
CLINICAL NEED 189
PERFORMANCE REQUIREMENTS 189
ELECTRON BEAM DURING ACCELERATION 190
ENERGY STABILITY 190
DOSE SPATIAL DISTRIBUTION AND CALIBRATION IN INITIAL
SECONDS 190
EQUIPMENT DESIGN ALTERNATIVES 191
MICROWAVE POWER SOURCE-KLY STRON VERSUS MAGNETRON 191
ELECTRON GUN-TRIODE VERSUS DIODE 191
ACCELERATOR GUIDE-TRAVELING WAVE VERSUS STANDING
WAVE 191
SWITCHING FROM HIGH TO LOW ENERGY IN A TRAVELING
WAVE GUIDE 193
SWITCHING FROM HIGH TO LOW X-RAY ENERGY IN A STANDING WAVE
GUIDE 193
BEAM LOADING 197
NON-CONTACT TYPE SIDE CAVITY ENERGY SWITCH 197
x CONTENTS

SYSTEM FEEDBACK CONTROL PHILOSOPHY 199

REFERENCES 199

CHAPTER .12 Patient Support Assembly and Treatment Accessories 201

PATIENT SUPPORT ASSEMBLY 201
PATIENT TABLE SUPPORT TYPES 201
TABLETOP 203
TREATMENT CHAIR 203
TREATMENT ACCESSORIES 204
FIELD SHAPING SYSTEMS 204
WEDGE FILTERS AND TISSUE COMPENSATORS 205
PATIENT CONTOUR SYSTEMS 207
PATIENT IMMOBILIZATION DEVICES 208
MECHANICAL AND OPTICAL POINTERS 208
PATIENT POSITIONING AND MOTION DETECTION 208
REFERENCES 209

CHAPTER .13 Treatment Simulators, Treatment Planning and Portal Imaging 213
TREATMENT SIMULATORS 213
MECHANICAL FEATURES 2 14
RADIOGRAPHY AND FLUOROSCOPY 216
SIMULATION ACCESSORIES 2 17
OPERATIONAL ORGANIZATION 2 17
REGULATORY REQUIREMENTS 2 17
SIMULATOR USAGE 219
CONTEMPORARY DEVELOPMENTS 219
TREATMENT PLANNING 220
RESOURCES 222
RADIOGRAPHIC (FILM) PORTAL IMAGING 224
PHYSICS OF CONVENTIONAL PORT FILMING 224
PORTAL FILM ENHANCEMENT TECHNIQUES 226
ELECTRONIC PORTAL IMAGING 227
VALUE OF ELECTRONIC IMAGING 227
ONE-DIMENSIONAL VERSUS TWO-DIMENSIONAL DETECTORS 228
SILICON DIODE LINEAR ARRAY-MECHANICALLY SCANNED 230
MULTIWIRE SEQUENTIALLY PULSED (ELECTRONICALLY SCANNED)
LIQUID IONIZATION CHAMBER 230
MECHANICALLY ROTATED MULTICHANNEL IONIZATION CHAMBER
TAPERED FIBER OPTICS TO TV CAMERA 232
LENS TO TV CAMERA 233
TWO-DIMENSIONAL ARRAY OF SILICON DETECTORS 234
TWO-DIMENSIONAL AMORPHOUS SILICON ARRAY 234
MOUNTING A DETECTOR ON A LINAC 235
 CONTENTS xi

PHOTON SPECTRUM IN PORTAL IMAGING 235

DEPENDENCE OF IMAGE CONTRAST ON X-RAY ENERGY 236
OFF-AXIS PORTAL X-RAY TUBE 236
ON-AXIS PORTAL X-RAY TUBE 236
REFERENCES 237

CHAPTER .14 Radiotherapy Accelerator Facilities 241

FACILITY PLANNING AND OPERATIONAL RESOURCES 241
MEGAVOLTAGE THERAPY ACCELERATORS AND TREATMENT
FACILITIES 244
MULTIMODALITY THERAPY INSTALLATION 244
TREATMENT ROOM DESIGN 247
SHIELDING BARRIER DESIGN 247
ENTRY DOORS AND MAZES 25 1
PATIENT OBSERVATION AND COMMUNICATION 25 1
RADIOACTIVE AND TOXIC GAS PRODUCTION 252
RADIOACTIVATION OF PATIENT 252
ACCELERATOR MAINTENANCE AND USAGE 252
CONVENTIONAL MAINTENANCE 252
EXPERT SYSTEMS 254
TEST EQUIPMENT AND INSTRUMENTATION 254
PERIODIC TESTS OF FUNCTIONAL PERFORMANCE 255
USAGE AND DOWNTIME EXPERIENCE 256
SAFETY ASPECTS-FACILITY AND MACHINE INTERLOCKS 256
HUMAN ENGINEERING ASPECTS 257
REFERENCES 258

CHAPTER .15 Medical Microtron Accelerators 261

CIRCULAR MICROTRON 261
CAVITY POWER REQUIREMENTS 26 1
MAGNET SIZE 262
INJECTION METHODS FOR INCREASED ENERGY PER ORBIT 262
PHASE STABILITY 262
BEAM CURRENT AND FOCUSING 263
GANTRY 263
MACHINES FOR RADIOTHERAPY 263
RACETRACK MICROTRON 263
CONFIGURATION 263
FOCUSING 264
ACCELERATOR STRUCTURE POWER 264
INJECTION 264
EXTRACTION 265
ALIGNMENT PRECISION 265
xii CONTENTS

MACHINE FOR RADIOTHERAPY 266

REFERENCES 266

CHAPTER .I6 Other Types of Medical Electron Accelerators 267

HISTORY 267
TRANSFORMER-RECTIFIERUNITS 268
RESONANT TRANSFORMER 270
VAN DE GRAAFF GENERATOR 270
BETATRON AND ELECTRON SYNCHROTRON 271
REFERENCES 274

APPENDIX A Generation of Radiation Beams 275

X-RAY BEAMS 275
PHOTON SPECTRA ON THE AXIS OF AN UNFLATI'ENED LOBE 275
ANGULAR DISTRIBUTION OF PHOTON INTENSITY 275
CHOICE OF TARGET MATEIUAL AND THICKNESS 276
CHOICE OF MATERIALS AND THEIR DISTRIBUTION IN THE X-RAY
FLATI'ENING FILTER 278
ELECTRON BEAMS 278
SPURIOUS SOURCES 278
SCATTERING FOILS 279
EFFECT OF ENERGY SPECTRUM WIDTH ON THE SLOPE OF DEPTH DOSE
CURVE 279
RADIATION INTERACTIONS IN THE PATIENT 279
ADDITIONAL MATERIAL FOR RADIATION CALCULATIONS 281
REFERENCES 281

APPENDIX. B Survey of Medical Linacs 287

HISTORICAL SUMMARY OF MANUFACTURERS' TYPES 287
CONTEMPORARY RADIOTHERAPY ACCELERATORS 287
REFERENCES 287

APPENDIX C Miscellaneous 297

C-1 ABBREVIATIONS 297
C-2 SYMBOLS 298
C-3 GREEK SYMBOLS 299
C-4 UNITS 299
C-5 TERMINOLOGY 300

Index 309

The emphasis in this book is on the design and principles of
operation of microwave electron linear accelerators for the
treatment of cancer. Associated equipment and accessories in
the radiotherapy clinic are described, such as simulators, treat-
mentplanning units, radiotherapy management systems, multi-
leaf collimators, and electronic portal imagers. Other electron
accelerators, including rnicrotrons, betatrons, and direct accel-
erators, are also discussed.
The intended audience for this book includes medical
physicists and engineers, radiation technologists, radiation on-
cologists and residents, hospital and radiology administrators,
design and service engineers, as well as university students in
physics and engineering. A knowledge of the various engineer-
ing tradeoffs in machine design can assist users in the initial
selection of the appropriate machine for their application. An
understanding of the principles of accelerator operation and
their application promotes confidence in their more effective
use.
This book is useful directly as a teaching aid for physicists
and engineers in training, medical residents, and radiation
therapy technologists. The book is particularly designed for
study by persons without extensive knowledge and experience
of accelerator technology. It is also organized to serve as a ready
reference. We have assumed on the part of the reader only a
knowledge of elementary physics and mathematics. Emphasis
is placed on how accelerators function and how they are used
in the treatment of cancer. Illustrations, tables, and analogies
are abundantly used for clarity to the nonspecialist. A solid
theoretical base is provided for the specialist by descriptive text
and illustration.
The subject matter includes a history of development and
application, general theory of acceleration, accelerator sys-
tems, radiation beam systems and associated equipment, per-
formance characteristics, testing, and use. The major modules
of a representative medical accelerator are described, includ-
ing the principles of operation, and how these modules func-
tion collectively to produce electron and x-ray beams for
radiotherapy.
Electron accelerators were initially developed in research
laboratories for use in experimental nuclear physics, and an
Preface
extensive literature exists on that early work. These physics
laboratories subsequently moved on to the development of
much higher energy particle accelerators for elementary parti-
cle physics. Meanwhile, manufacturers have carried on the
development of these more moderate energy accelerators for
pragmatic applications. The formal literature on these develop-
ments by laboratory researchers, manufacturers, and users is
sparse and scattered. The goal of this book is to provide in one
convenient place a lucid description of the design and operation
of medical electron accelerators, together with extensive refer-
ences for a more detailed study of specific areas of the readers'
interest.
Early medical accelerator developments were primarily
concerned with the transition from a supportive physics labo-
ratory environment to reliable operation in the hospital clinic
where the laboratory resources were largely unavailable. Over
a period of time advances in vacuum technology and micro-
wave, electronic, and mechanical systems contributed signifi-
cantly to the precision, reliability, and stability of these
treatment machines, as well as to markedly improved treatment
beam characteristics. In recent years, the number of these
accelerators in use has increased rapidly. Their technology is
continually advancing to meet the developing requirements of
radiotherapy. Present emphasis is on features concerned with
how best to treat the widest possible group of patients safely,
rapidly, and comfortably and on facilitating efficient manage-
ment of equipment operation in the clinic. The application of
computers and imaging technology is being increasingly incor-
porated in this effort.
The preparation of this book would not have been possible
without the valuable assistance of many colleagues: engineers,
physicists, physicians, and technologists in clinics, in industry,
and universities. Often they have provided insight and under-
standing pertaining to specific considerations related to the
design and application of these accelerators. We are grateful
for the contributions from the following individuals at Varian
Associates: David Auerbach, Steve Cheung, Verne Edward-
son, Dan Hardesty, Joseph Jachinowski, Stan Johnsen, Martin
Kandes, Phil LaRiviere, Dick Levy, Ray McIntyre, Stan Mans-
field, David Maurier, David Penning, Niel Pering, Dick
xiv PREFACE
Thompson, and Gene Tochilin, and especially for the technical
assistance of Joyce Lawson and Dee Rust of the Department
of Radiation Oncology, Stanford University School of Medi-
cine. To all of them we extend our heartfelt thanks. We are
particularly grateful to Don Goer of Schonberg Radiation, Inc.,
and Robert Morton of Siemens Medical Laboratories, Inc.,
who read the entire manuscript. We have benefited from their
many incisive comments and suggestions. We also express our
appreciation for the extensive secretarial assistance in prepar-
ing the manuscript and for the drafting assistance in preparing
the line drawings. These include: Connie Allen, Dolan Chan,
Juanita Clack, Harry Lewis, Hisae Liang, Sumiko Oshima,
Sherry Takahashi and Hal Westcott. Finally, we wish to ex-
press our deep appreciation to two organizations for their
assistance, namely, Varian Associates and Stanford University
School of Medicine. They provided facilities for word pro-
cessing, computer graphics, and reproduction as well as moral
support.
Medical Electron
Accelerators
 C H A P T E R 1

The Medical Electron Accelerator

OVERVIEW work, how optimal designs are achieved, how their components
and subsystems are combined to constitute an accelerator, and
THE NEED FOR MEDICAL ELECTRON how the accelerator is integrated into a complete facility and
ACCELERATORS applied in various radiotherapy modalities.
Chapter 1 presents a history of electron accelerators and
Cancer is the second leading cause of death in the United States,
addresses cancer incidence, the goals and rationale of radio-
accounting for one-fourth of all deaths. It is the leading cause
therapy, an elementary description of accelerators, and criteria
of death in the 35-54 age group.' Cancer is not just a disease
for optimal accelerator design. This is followed by a survey
of the elderly. Approximately one-half of all cancers are de-
of isocentric machines that have been introduced by various
tected in people at ages less than 60, and the tumor may have
manufacturers over the past decades and a more extensive
been growing for many years before that. Figure 1-la and b
comparison of contemporary machine types. Chapter 2 de-
shows cancer death rates for a few selected sites.' Lung is now
scribes various radiotherapy modalities. Chapters 3-11 relate
the most prevalent site associated with cancer deaths in the
to the theory and design of accelerator hardware. Chapters 3-6
United States in both males and females. It has been estimated
address fundamental aspects of microwave power generation
that about 30 percent of all cancers in the United States are
and transmission, microwave structures for acceleration of
caused by smoking. Figure 1-2 shows cancer incidence by site
electron beams, and the associated equipment. Chapter 7
for males and females.
discusses the electron beam inside the accelerator, its genera-
About 50 to 60 percent of all cancer patients in the United
tion, acceleration, confinement, bending, and treatment beam
States will receive radiation therapy,56 as definitive therapy, for
formation. Chapters 8-1 1 describe the radiation head, control
palliation, or as an adjunct to surgery. This totals more than
and safety systems, and the design aspects of multi-x-ray
500,000 new radiotherapy patients per year in the United
energy machines. Chapters 12-14 relate to equipment and
States, plus about 150,000 patients returning for retreatment,
facilities to apply the accelerated beam. These include items
for persistent or recurrent disease. In 1986, there were over
in and on the radiation head such as multileaf collimators, the
1,950 radiotherapy machines in the United States treating an
patient support assembly, simulators, treatment planning sys-
average of 230 new patients per year per machine.20 To serve
tems, portal imaging systems, record and verify systems,
a world population of 5 billion with the same incidence of
computer networks, and accelerator usage and maintenance.
cancer and with the same average patient load per machine,
Chapters 15 and 16 describe microtron and other types of
about 20 times as many machines would be required as are in
medical electron accelerators.
use in the United States. About one-half of all radiotherapy
The physics of generation, interaction and application of
patients are treated with curative intent. The remaining one-half
radiation beams is addressed in Appendix A. This is followed
are treated for palliation,l6 that is, for relief or prevention of
by a survey of historical and contemporary accelerators in
specific symptoms. The median course of treatment for pallia-
Appendix B and by a tabulation of systems of units and a
tion is 10fractions of 300cGy in 15 days. The median treatment
summary of symbols and terminology in Appendix C.
for cure is more like 25-35 fractions of 200 cGy in 25 to 35
days for a total of 5000 to 7000 cGy. Of those patients present-
ing with locoregional disease, 56 percent will be cured.56
GOALS OF RADIOTHERAPY
OUTLINE OF THIS BOOK
In addition to trying to save the patient's life, maintaining
This book is primarily about megavoltage microwave electron quality of life is a major goal of radiation therapy. Figure 1-3
linear accelerators in medicine, about their origins, how they compares quality of life outcomes of two cancer patients; one
2 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR
AGE-ADJUSTED CANCER DEATH RATES' FOR
SELECTED SITES, MALES, UNITED STATES, 1930-1988
0 1 1 1 1 1 1 1 1 1 1 1 1 1 1
1930 1940 1950 1960 1970 1980 1990
Year
'Adjusted to the age dtstrlbutlon of the 1970 US Census Populat~on
Sources of Data US National Center for Health Statlstlcs and
US Bureau of the Census.
\ \
FIGURE 1-1 . Cancer death rates (from Ref. 7) (left) Male. (right) Female.
treated by surgery, with gross loss of function; the other treated
by radiation therapy.11 Other examples of the use of radiother-
apy for preservation of function are to conserve the female
breast (for cosmesis); prostate (for better sexual function);
bladder, (for more convenient urination).
Although quality of life is a major factor, other factors are
more widely used to compare efficacy of alternative treatment
protocols. Freedom from recurrent disease is used as a basis for
comparison of efficacy, but the most widely used measure is
survival, the most frequently used being 5-year survival. There
have been improvementslo in 5-year survival over the past
three decades in treatment of some sites, as shown in Table 1-1.
Examples of such sites having relatively high cancer incidence
are breast, bladder, and prostate. Improvements in imaging
equipment and medical training have led to a more rational
selection of patients to treat for cure versus palliation. Although
there have been no clinical trials to demonstrate unequivocally
that choice of equipment affects cure rates, national surveys
2
AGE-ADJUSTED CANCER DEATH RATES* FOR
: SELECTED SITES, FEMALES. UNITED STATES. 1930-1988
Year
'Adjusted to the age distribution of the 1970 US Census Population.
Sources of Data: US National Center for Health Statistics and
US Bureau of the Census.
show that the most experienced medical teams get the best
results and they tend to have the best medical accelerators.
IMPACT OF TREATMENT COURSE
FRACTIONATION ON MACHINE
PERFORMANCE REQUIREMENTS
The standard course of treatment is divided into daily fractions
of about a 200-cGy tumor dose, delivered over a period of, for
example, 6 weeks for a 6000-cGy cumulative dose. Fraction-
ation exploits the difference in response between normal and
cancerous tissue in their recovery from small doses of irradia-
tion. Normal tissue is better organized and regenerates better
than the tumor after a radiation insult. (Think of how quickly
tissue regenerates at a cut in your finger.) Fractionation also
impacts on requirements for machine performance. Some as-
pects of fractionation response are as follows56:
 OVERVIEW 3

\
1989 ESTIMATED CANCER INCIDENCE BY SlTE AND SEX'
Melanoma Melanoma
of Skin 3%
Oral 4%
Lung 18%
Pancreas 2%
Stomach 3% 3% Pancreas
Colon &
Rectum 14% 14% Rectum
Prostate 23%
Urinary 10%
Leukemia &
Lymphomas 9% Leukemia &
All Other 14% 7% Lymphomas
11% All Other
.ExcIudong nonmelanoma s k ~ ncancer and carelnoma on sotu
\ \

1989 ESTIMATED CANCER DEATHS BY SlTE AND SEX -

Melanoma
of Skin 1%
Oral 2%
Lung 34%
Pancreas 4%
Stomach 3%
Colon &
Rectum 11%
Prostate 12%
Urinary 5%
Leukemia &
Lymphomas 9%
All Other 19%
FIGURE 1-2 . Cancer incidence and deaths by site and sex (from
Ref. 7).
1. Repair of sublethal radiation damage to cells occurs in
both normal and cancerous cells. This repair is completed
within a few hours after irradiation. Consequently, about
6000 cGy is required in 30 daily fractions to sterilize the
same number of cells as 2000 cGy in one exposure. An
accidental overdose of say 2000 cGy is far more damaging
than just its 10:l ratio to a 200-cGy dose. The implications
for dose limiting interlocks for patient safety are obvious.
2. Regeneration of tumor cells can result in some tumors
speeding up their growth rate by as much as a factor of 10
after initiation of a course of radiotherapy. This regenera-
tion can require that the course of treatment not be
extended excessively or interrupted unintentionally. Un-
planned extended machine downtimes can be detrimental
to the patient.
3. Redistribution of cells after each irradiation refills the
more radiosensitive phases of the cell division cycle, es-
pecially with the widely varying rates of progression of
tumor cells through the cell cycle. This redistribution
occurs faster in some tumor cells than in normal tissue cells
and can be exploited by treating all portals in each daily
FIGURE 1-3 Surgery versus radiotherapy for cancer of the mouth
(from Ref. l l a , Fig. 7.4b and 7.8b).
Melanoma
fraction and, for some tumors, by hyperfractionation, treat-
ing the patient more than once per day. These procedures
5% Pancreas create a need for ergonomic machine design to facilitate
rapid positioning of the machine and patient so that a large
12% Rectum
daily patient load can be maintained.
4. Reoxygenation of previously hypoxic and hence
radioresistant tumor cells increases their radiosensitivity
Leukemia &
9% Lymphomas by a large factor. Selective loss of radiosensitive cells near
19% All Other the blood supply facilitates diffusion of oxygen
.-
from the
blood vessels to these previously hypoxic tumor cells.
Because of reoxygenation with conventional fractionated
x-ray and electron therapy, improvements in therapeutic
ratio with heavily ionizing radiation (e.g., neutrons) have
not been as dramatic as was once hoped. Hence, accelera-
tors producing megavoltage x-rays and electrons remain
the mainstay of radiotherapy.
USER PREFERENCES FOR BEAM MODE
X-ray energies
Table 1-2 shows the caseload mix for one large metropolitan
area and the percentage of physicians who preferred a partic-
ular modality for treatment of each tumor site. The range of
tumor sites led physicians24 and physicists46 to recommend
use of a low megavoltage x-ray mode for the majority of cases
but a widely separated high energy x-ray mode for about
one-fourth of the patients and an electron mode for about
one-eighth of the patients. As shown in Tables 1-2 and 1-3,
the choice of x-ray energy for particular tumor sites is based
on a number of factors including depth dose, penumbra,
buildup in superficial layers, and buildup at air cavities. Ahigh
energy x-ray mode provides a clear advantage in treating large
tumors in thick sections of the body such as the lateral pelvis,
but also in protecting bone near the skin because of slower
4 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

TABLE 1-1 . Cancer incidence by site-improvements in 5-year survival

New cases in 1987 Five-year survival (whites)

Site Thousands percent 1960-1963(%) 1977-1983(%) Points

Brain and C N S ~
Oral and Pharynx
Breast (fem)
Lung
Esophagus
Stomach
Pancreas
Ovary
Colon
Rectum
Bladder
Prostrate
Leukemia
Other blood and lymph
Other

Total
Average

"Central nervous system (CNS).

buildup of dose versus depth, such as in treating some tumors
of the head. Meredith49 discusses the variation of the shielding
effect of bone and dosage in soft tissue as functions of x-ray
photon energy and the corresponding optimal range of x-ray
beam energy.
Electrons
There are several sites where the tumerous tissue overlies very
radiosensitive normal tissue. An example is the treatment of
chest wall tumors while protecting the lung by irradiating the
patient with electrons of the appropriate energy and hence
limited range. Electrons are also used, for example, to produce
a boost dose after x-ray therapy, such as to a tumor lying near
one side of the head or neck.
TREATMENT BEAM GENERATION
The primary application of electron accelerators in medicine
is in the treatment of cancer. A tumor can be detected by
diagnostic x rays, which are produced by accelerating elec-
trons to about 0.1 MeV (million electron volts) (see Appendix
C for definition and units) and directing them onto a metal
target. X rays of this energy are attenuated by a large factor,
of order 100, in passing through the body, and attenuation
is greater in bone than in flesh. Very small thickness, density,
or atomic number differences produce detectable changes in
x-ray transmission. Thus, anatomical features are readily seen
in the x-ray diagnostic film or other display. However, to
treat the tumor, megavoltage x rays, typically in the range
of 4 to 25 MeV, are used because they are attenuated by
only a factor of about 2 in passing through the body. In
addition, the energy deposition (or absorbed dose) builds up
over the first 1-4 cm of penetration, so the sensitive layers
of the patient's skin receive only a fraction of the dose at
depth. Thus, the megavoltage x-ray beam can be aimed at
the tumor from a number of directions, producing a cross-
over of high radiation dose at the tumor without producing
a harmful dose in the rest of the patient's body. These
megavoltage x rays are produced by accelerating an electron
beam to millions of volts of energy and directing this beam
onto a metal target. For tumors that overlie especially radi-
ation-sensitive tissue, such as the spinal cord, the patient is
treated with the megavoltage electron beam directly, without
converting to x-rays in a metal target.- Electrons penetrate
the patient's body only to a distance in centimeters of about
one-half of their energy in megaelectron volts (e.g., 5 cm
for a 10-MeV electron beam).
In diagnostic x-ray tubes, the electrons are accelerated
to about 0.1 MeV across a single gap. A high-voltage trans-
former at a power line frequency of 50 or 60 Hz (Hertz,
cycles per second), is used to develop the accelerating voltage
(see Fig. 1-4). Since many millions of volts cannot be held
off readily by a single gap, electrons in microwave linear
accelerator type radiotherapy machines are accelerated to
megavoltage energy by passing them through a succession of
gaps (see Fig. 3-3b). Each gap is at the center of a microwave
 OVERVIEW 5

TABLE 1-2 . Caseload and beam preferences-Philadelphia area

Physician's beam preferences

Body area Caseload(%) Low X High X Electrons

Lung 22 35
Pelvis 20
Prostate 17
Cervix 4
Head and neck 7 83
Breast (intact) 7 96
Adomen 5
Pancreas 0
Brain primary 4 74
Chest wall 3 52
Trancheaandesophagus 2 78
Nodes 3
Bone mets 18
Brain CNS mets 3
Other - 6
100
Beam utilization at two multimodality departments

Low X(%) High X(%) Electrons boost(%) Electrons alone(%)

71 23 12 6

resonant cavity (see Fig. 1-5), which is powered at a frequency
of about 3 billion hertz. Because the cavity resonates at this
frequency, the required drive power from the magnetron or
klystron radio frequency (rf) source is only about 0.01% of
the oscillating reactive power in the cavity. In simplified
analogy to the diagnostic x-ray system, each cavity acts like
a small transformer. Oscillating rf current flows on its internal
surface and acts like a single turn primary winding; the
electron beam bunch flowing synchronously across the gap
acts like a single turn secondary winding. Each gap in turn
adds to the energy of the electron beam bunch. For example,
a beam energy of 20 MeV can be obtained in a series of 28
cavities, gaining about 0.7 MeV per cavity (gap). Yet the
entire multicavity structure is at ground potential. The only
high voltages are at the electron gun (15-35 kV), which
initiates and injects the electron beam and at the magnetron
or klystron (50-150 kV), which provides the microwave power
to excite the multicavity accelerator structure (see Fig. 1-6).
A few megawatts (MW) of microwave peak power are re-
quired to excite the accelerator structure to suitably intense

TABLE 1-3 Importance of beam characteristics versus site

Beam characteristics Optimum energy vs. site

Depth Beam Bone

Site dose Build-up penumbra dose Neutron 60Co 4 MV 6 MV 10-15MV ~ 1 8 W

Brain
Head and neck 1
1
1
1
1 . . b

.
.
Breast
Thorax 1
1
1
1
1
1 1
.. •

Lymphoma
Pancreas
Whole pelvis
1
1
1
1 1 1

1
1 +
.
4
b

.
Pelvic cone 1 1 4 b

Down
Pediatrics 1 1 1 +- b
6 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

6 Rectifiers 12 Rectifiers 12 Rectifiers

(6 pulses/cycle) (6 pulseslcycle) (6 pulseslcycle)

A A

X-ray Tube
Voltage +
It--1 cycle ---)I I cycle +

Transformer
Windings:
Seconday

FIGURE 1-4 . Diagnostic x-ray tube high-voltage circuits.

accelerating fields but only a kilowatt (kW) or less of average
power is required to produce adequate intensity in the x-ray
treatment beam. Thus, a pulse modulator is used to pulse the
magnetron or klystron on for a few microseconds (ps) every
few milliseconds (ms) several hundred times per second.
HISTORY OF ELECTRON ACCELERATORS
DIRECT ACCELERATORS
Laughlin47 presents a concise history of the technological
development of radiation therapy. The earliest machines were
direct accelerators, in which the entire voltage was held off over
a long insulating column. Cockroft Walton generators, M a n
generators, resonant transformers12 (Resotrons), Van de
Graaffs, and Dynamitrons are examples of this technique. All
of these machines were large and cumbersome and difficult to
move around a patient. Their energy was also limited to about
2 MeV in orientable machines.

f
i -I
Current

Electric Field
BETATRONS
The betatron44357+".68 was invented in 1940. It employs a trans-
former technique of magnetic induction. The electrons travel
around in a circle, many thousands of times, acting like the
electrical current in the secondary winding of a transformer,
hence multiplying the alternating current primary voltage of
about 10 kV (kilovolts) to perhaps 2 5 4 5 MeV. The electron
beam is confined within an evacuated donut by the weak focus-
ing forces of the betatron magnetic field as it rises in intensity in
synchronism with the rise in electron energy from injection to
FIGURE 1-5 - Microwave accelerator cavity circuit. full energy in one-fourth cycle of a sine wave. The beam current
 HISTORY OF ELECTRON ACCELERATORS 7

Accelerator Structure
f
A

>
Modulator and
High Voltage P.S. E'FLr Accelerator Target
-+Assembly
CO'limatOr --+
Accessories L
F

'..
A h A

Water Collimator
RF Cooling A
t Drives &
Primary Subsystem 4 - Subsystem Position Sensing
Power

A
Distribution

I-
Subsystem Wlfe:~cJe
Y
Dosimetry
4 :
Gantry
Drive 8
Position Sensing
To Accelerator
Y - Structure
Relay
-+ Interlocks
(In Clinacs) ETR (Couch)
Drive &
- Position Sensing

-_
v
Console and
Controller 4
A
7

-
-
FIGURE 1-6 . Block diagram for low-energy machine.

confined by this technique is relatively small, so the x-ray
intensity and flattened field size of betatrons is quite limited.
The electron beam could also be extracted from the circular
orbit at any desired energy by pulsing a deflection coil at the
appropriate time within the one-fourth cycle sine wave rise of
the main magnetic field. Betatrons of 25 to 45 MeV are quite
large and heavy, so they were never developed for gantry type
isocentric mounting around a stationary patient. Instead, the
patient table horizontal axis was moved in a circle as the beta-
tron was rotated, lifting the patient quite high to permit treating
from below. Smaller low energy betatrons, which could have
been isocentrically mounted, had an x-ray intensity that was too
low at the desired distances. The electron beam current in
betatrons was just too low for modem clinical x ray use.
MICROWAVE ELECTRON LINEAR
ACCELERATORS (LINACS)
The term "linac" is a contraction of the term linear accelerator.
It means that the charged particles travel in a straight line as they
gain energy from the accelerating electric field. The term "lin-
ear" is used to distinguish from other types of particle accelera-
tors, such as the cyclotron, in which the particles travel in a
spiral, or the betatron, in which the particles travel in a circle.
Because the linac has superseded direct accelerators and
betatrons and is displacing 60C0, the history of inventions and
developments leading to the modem linac are presented in the
following subsections in some detail. In the decade from 1935
to 1945, the basic theoretical understanding and practical ap-
plication of microwave devices and systems was developed,
including invention of the microwave cavity and of the klystron
and magnetron tubes as sources of microwave power. From
1945 to 1958, linacs were invented and built by physics re-
search laboratories, and the multimegawatt klystron was devel-
oped. British industry built magnetron driven 4-MeV isocentric
medical linacs of limited rotation and also a few nonisocentric
medical linacs of higher energy. In this same period, in the
United States, Stanford University built a 6-MeV orientable
medical linac and a few stationary medical linacs of higher
energy for electron therapy,48,68,73,* which were all driven by
klystrons. In 1962 in the United States, Varian Associates
introduced a fully rotational isocentric 6-MeV bent beam linac.
The side coupled standing wave accelerator structure was
invented at Los Alamos National Laboratory in the late 1960s
and Varian Associates applied it in introducinga fully rotational
isocentric 4-MeV in-line linac in 1970. Several other manufac-
turers initiated manufacture of medical linacs during this pe-
riod. Since 1970, machine performance characteristics have
been extended and precision has been improved. Some exam-
ples are the improved accelerator structures and bend magnet
systems and the introduction of microwave techniques to
achieve widely spaced dual x-ray energies. This accelerator
history is expanded upon in the following subsections.
Microwave cavities
In the mid-1930s Hansen32.33, then at the Stanford University
Physics Department, wanted to accelerate electrons to millions
8 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR
of volts by magnetically reflecting them back and forth through
a hollow copper cavity filled with high-power ultra-high-fre-
quency radio waves called microwaves. He developed the
mathematical techniques for analyzing such cavities in order
to find optimum geometries and found that the efficiency could
be a hundred times greater than with the resonant circuits of
that time, which might use capacitors and coils. The physics
department agreed on the name Rhumbatron for Hansen's
resonant cavity invention, from the Greek words Rhumba
meaning rhythmic oscillations and tron for the place where they
occur. Depending on its application, the rhumbatron might look
like a tomato can or like a soft tennis ball with opposite sides
pushed in. Hansen tried to build an electron accelerator em-
ploying a rhumbatron and powering it with the only device of
the time that could provide power at such high frequencies, a
little "acorn" tube. It had to be little to work at such high
frequencies and hence it could not produce much power. Han-
sen needed a totally new method of providing microwaves to
obtain enough power to accelerate electrons to millions of
volts. Fortunately, within the following 5 years, two new types
of powerful microwave sources were invented: the klystron in
1937 and the high-power pulsed magnetron in 1939.
Klystron invention
While a graduate student at Stanford in 1934, Russell Varian
developed a close association with Hansen. Russell's brother
Sigurd Varian was a pilot for Pan American Airways. In 1936
cities were being bombed by air in Spain and China and
Sigurd recognized the need for a way to detect enemy aircraft
through cloud cover. It occurred to Russell that Hansen's
rhumbatron might be adapted in some way to generate the
microwave power needed to detect aircraft. The two brothers
had started their own private research laboratory but soon
recognized that it was too limited for the task, so in 1937
they negotiated an arrangement to carry on their work at
Stanford University. They were appointed Research Associ-
ates without salary and were given a budget of $100 for
materials and supplies.
Russell conceived a number of ideas for generation of
microwave power using Hansen's rhumbatron. In developing
a classification for all the schemes he thought of an idea that
did not fit any of the classifications-the velocity modulation
principle. A small oscillating signal in one rhumbatron varies
the speed of a steady stream of electrons. As these flow
downstream the speeded up electrons catch up with the slowed
down electrons, forming bunches of electrons that pass
through a second rhumbatron in which the kinetic energy of
the electron stream could produce high power. The idea25.74.75
was conceived on July 22, 1937, and Russell's brother Sigurd
built a tube and got it working within 4 weeks. The beauty
of this invention was that individual separate large components
(cathode, rf input section, rf output section, beam collector)
could be used and still produce high power at very short
wavelengths, 10,000 times shorter than the ordinary radio
waves of local radio stations. This was a major breakthrough,
a complete escape from the previous technical constraints
requiring that microwave sources be physically small, and
hence, be of low power. The highest pulsed output power
achieved with a klystron during World War I1 was 30 kW-
very high indeed for that time but still too low for use in
accelerators.
Magnetron invention
The British were also concentrating heavily on a different form
of microwave power generating device, called a magnetron.
This is a circular beam microwave oscillator, in contrast to the
klystron, which is a linear beam microwave device that can be
operated either as an amplifier or an oscillator. In the magne-
tron, a number of cavity resonators are arranged in a circle and
a magnet bends the electron beam so that it forms a number of
curved spokes that sweep around to excite power in each
resonator. This multicavity concept was suggested by research
workers in the United States in 1936, England and Germany in
1938, and Russia in 1940, but the maximum power achieved
was only about 100 W. The wartime need of radar for a
transmitting tube capable of producing very high pulsed power
at 10 cm or less (a 10 cm wavelength was larger than absorbers
in the atmosphere but small enough to be transmitted in a
narrow beam from an antenna of practical size) led the British
laboratory workers and the British industry to develop a tube
with about 10,000 times the pulse power output that had
previously been available. It provided spatial resolution suit-
able for distinguishing not just whether an airplane was de-
tected but whether it was friend or foe. J. T. Randall and H. A.
H. Boot,6 University of Birmingham; England, invented the
first such tube and in 1939 they achieved over 0.1 MW at 10-cm
wavelength. Further development increased the pulsed output
power to over 1 MW.
Finally, here was a tube suitable for powering a modest
energy microwave linear accelerator, but that application had
to wait until after the war ended.
Microwave linac invention
With the availability of high-power magnetrons and microwave
techniques and components after the radar developments of
World War 11, about 10 groups independently started inventing
and building microwave electron linacs. Two of these groups
became preeminent: W. W. Hansen's group at Stanford Univer-
sity and D. D. Fry's group at the TelecommunicationsResearch
Establishment (TRE), Great Malvern, England, which subse-
quently became part of the Atomic Energy Research Establish-
ment (AERE), Harwell, England. These two groups
leapfrogged each other's accomplishments for the first few
years but had limited knowledge of eachother's work until mid-
1947. Fry's group22,23,53.61.77completed the theoretical design
of a 45-cm long, 0.5-MeV section of accelerator guide in Sep-
tember 1946 and accelerated electrons for the first time in late
 HISTORY OF ELECTRON ACCELERATORS
November 1946. Totally independently, Hansen'sgroup26com-
pleted their work on a 90-cm accelerator guide powered by a
magnetron and obtained 1.7 MeV in early 1947. Fry's gro~p22~sO
proceeded with the development of a 2-m long accelerator guide
driven by a magnetron and achieved 3.5-MeV of electron en-
ergy in ~ o v e m b e 1947.
r Hansen's group4-14extended their ac-
celerator guide to 3 m and obtained 4.5 MeV by November
1947, and subsequently 6 MeV, still using a magnetron. Fry22
states that Cutler18 in 1944 was the first to solve the mathemati-
cal equations, which showed how a corrugated cylinder could
be designed to match the phase velocity of the traveling electro-
magnetic wave to the electron velocity for application to travel-
ing wave tubes. The corrugations are copper disks and
Woodyard79 in Hansen's group suggested using such a wavegu-
ide as a linac forelectrons.
Multimegawatt klystron invention
E. L. Ginzton started working with W. W. Hansen and the
Varian brothers in 1938 and conceived a set of ideas in 1944
that led to a proposal in 1947 to build a klystron 1000 times
more powerful than the most powerful wartime klystron. In
cooperation with Chodorow et a1.,15 a successfi~lhigh-power
klystron was first demonstrated in 1949, and after three more
years of effort, the original goal of 30 MW, 1000 times the
highest wartime klystron power, was achieved. This devel-
opment opened the way to building an electron linear accel-
erator of 1000 MeV for physics research, and eventually,
very compact medical accelerators at energies such as 25
MeV.
First stationary linac for radiotherapy
With the achievement of 3.5 MeV with a 2-m accelerator
section by Fry's group, collaboration of three groups was
arranged under the auspices of the British Ministry of Health
toward the end of 1948 to build an x-ray linac for clinical use.
These groups were the Radiotherapeutic Research Unit of the
Medical Research Council (MRC) under Dr. L. H. Gray, the
linear accelerator team of AERE under D. W. Fry, and the
Metropolitan Vickers Electrical Company (later renamed As-
sociated Electrical Industries), with C. W. Millerso as project
leader. Installation commenced at Hammersmith Hospital,
London, in June 1952 and the first patient was treated on
August 19, 1953. The machine employed a 2-MW magnetron
and a 3 m stationary accelerator guide with a rotatable 90"
magnet on the end. It was typically operated at 100 cGy/min
(100 radlmin) with the 8 MeV x-ray beam flattened over
maximum field sizes of 25 cm in diameter or 15 X 20 cm
rectangular. The treatment room floor could be moved verti-
cally and the treatment table moved laterally as the 90" magnet
radiation head rotated in order to provide patient portals over
a range of angles. These motions were coordinated so as to
rotate the x-ray source on a path of constant distance from a
9
selected point in the patient. This was called pendulum therapy
and was used as well with betatrons.
First orientable linacs for radiotherapy
While the 8-MeV linac for Hammersmith was being built, the
Ministry of Health agreed to have a number of 4-MeV linacs
built for radiotherapy centers in England. Machine designs and
specifications were developed by the Medical Research Coun-
cil (MRC) and AERE, and were supplied to British industry.
The design of an isocentric gantry mount for the accelerator
guide was conceived by P. Howard-Flanders36.37 at MRC,
Hammersmith in 1949. The x-ray beam was emitted along the
axis of the accelerator guide, which was 1 m long and was
designed by AERE. The first double gantry unit19 was installed
at Newcastle General Hospital in August 1953. The first single
gantry units] was installed at Christie Hospital, Manchester,
and operation was started in October 1954. The single gantry
machine could be rotated over an arc of 120°, from 15" beyond
vertical to 15" beyond horizontal, or to 30" beyond horizontal
by lowering part of the treatment room floor (Fig. 1-7). Field
sizes to 20 X 20 cm at 1 m were provided at a typical dose rate
of I00 cGy/min.
Independently, a program of radiotherapy linac develop-
ment proceeded in the United States. Conceptual work was
initiated in 1950 by Kaplan and Ginzton. The first machine27
was built in the Stanford University Microwave Laboratory,
with three faculty members and seven graduate students par-
ticipating. Installation78 of the machine in Kaplan's radiology
department in San Francisco was started in 1954. The acceler-
ator guide (Fig. 1-8) was built as a sealed-off vacuum tube,
without any vacuum pump. This avoided the problems of gun
and accelerator guide contamination from the oil diffusion
pumps of that time and avoided the complexity of a rotating
vacuum seal between the orientable accelerator guide and the
oil diffusion pump, which had to be kept vertical. The 1.65-m
long accelerator guide was electroformed by depositing copper
FIGURE 1-7 . Firs, orientable linearaccelerator-Theorthotron (from
~ , f 51).
.
10 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

Accelerator X- Ray Target

FIGURE 1-8 . First Stanford 6-MeV clinical Accelerator guide (from Ref. 27).

in an acid bath onto an aluminum spacer copper disk mandrel, A team had been assembled with accelerator related experience
then etching out the aluminum. During the construction pm- from high-energy physics laboratories and other sources. This
gram the high-power klystron14 was developed at Stanford, so was later supplemented by engineers having experience with
a 1-MW version was used to power the accelerator. Some British linacs. In response to the advocacy of E. L. Ginzton, a
accelerator guides were built with a gold target sealed into the program was initiated in 1958 to develop and manufacture a
end. Others were built with a thin titanium window, permitting clinical linac. With the British industrial work and the Stanford
radiotherapy directly with electrons or with x-rays from an University work as a starting point, this team, under the direc-
external gold target. Field sizes to 15 X 15 cm were provided tion of C. S. Nunanz8 developed the designs for a 6-MeV
at an unflattened dose rate to 110 cGy/min at 1 m. For tumor isocentric linac so compact that full 360" rotation about a
localization and treatment simulation, a 100-kVp (kilovolt reclining patient could be achieved. This would permit anterior
peak) rod anode x-ray tube could be inserted near the linac and posterior irradiation of a supine patient. A novel isocentric
target position to permit viewing the patient portal with an patient table was developed, which provided clearance for the
image intensifier as well as for taking portal films. The accel- radiation head and permitted fully lowering the patient to the
erator with an in-line radiation head was installed in a trunnion floor. The first production machine (Fig 1-9) was installed in
mount normally used with Van de Graaff accelerators, permit- 1962 at the Stanford University School of Medicine in its new
ting vertical travel of 150 cm and slightly more than 90" facility in Palo Alto. This machine2-3.30,55employed a 1.5-m
accelerator orientation from vertical to approximately
-- horizon-
tal around a reclining, standing, or seated patient. The very
precise, sharp, intense, deeply penetrating x-ray beam from this
linac gave Kaplan et al.41 the confidence to accept an infant
with retinoblastoma as the first patient for treatment, in January
1956. The retina was irradiated without damaging the lens or
cornea of the eye and this patient was still doing well 32 years
later (in 1988), with his vision in the treated eye intact. The
electron beam was also used directly to treat patients with
superficial lesions.
In the period around 1958, Varian Associates was
designing and building linacs for a number of applications,
such as physics and chemistry research, food irradiation, ster-
ilization of medical supplies, and radiography of thick objects.
It also built at this time a rotatable system of magnets69 which
transported and scanned an electron beam from a 50 MeV linac
(accelerator guide built by Stanford), providing electron ther- FIGURE 1-9 . ~ j n 360°
t isocentric linear accelerator-The Clinac 6
apy of a reclining patient from any angle around a 360" circle. (multiple exposures) (from Varian).
 HISTORY OF ELECT'RONACCELERATORS 11

apertures were much larger than the beam diameter, which with
other factors limited the shunt impedance (47 and 56 M Wm
(megaohm per meter) in the machines of Figs. 1-8 and 1-9,
respectively).
In 1968, Knapp et a1.45 invented the side-coupled standing
Water wave structure, in which the microwave power is coupled
Cooled
Fixed between axial cavities via slots to side cavities, and a small
Target aperture is provided on the axis for passage of the beam (see
insert of Fig. 1-15). This separation of functions permitted
Electron designing the slots to the side cavities for desired coupling and
Window
designing the axial cavity geometry in a rather spherical shape
with reentrantnoses and small beam aperture, attaining a shunt
impedance at 10 cm operating wavelength of about 80 M Wm
in initial designs and as much as 110 M Wm in modem
accelerator guides. In the ~ 1 mode
2 (90" phase shift per axial

- I
Flattening Filter And Dual Ionization
Chamber Assembly (Retracts For
cavity and 90" per side cavity) the side cavities are at nulls 180"
apart along the standing wave so they dissipate negligible
microwave power and the axial cavities are at the maxima of
the standing wave. Neighboring resonant modes are spread far
Electron Extraction Operation)
apart, an important frequency stability criterion. (The nearest
FIGURE 1-10 Beam bending system with separate paths for electron neighbor resonant modes are about lMHz (megahertz) away
and x-ray modes (from Ref. 3). in resonance from the fundamental mode and they have a
cosine-like distribution of electric field intensity over the guide
length-high at one end, zero in the middle, and reversed high
long accelerator guide mounted horizontally in a gantry and
at the other end of the length.)
driven by a 2-MW magnetron. A unique 90" magnet system
(Fig. 1-10) provided beam energy discriminationby intercept-
ing a portion of the dispersed beam on the edge of a gold target In-line standing-wave linacs for radiotherapy
for x-ray therapy. The magnet system redirected the accelerated
The invention of the side coupled standing-wave accelerator
beam through an electron window for electron therapy without
structure permitted elimination of the bend magnet and use
moving the x-ray target. The stack of machined copper parts
of an extremely short in-line accelerator guide in a 360"
forming the accelerator guide was silver brazed in a vacuum isocentric gantry for low megavoltage radiotherapy machines.
furnace, thereby also degassing the metal. Small drilled holes Varian Associates applied this technique, along with minia-
in each cavity provided access for tuning and provided high- turization of the electron gun and target, developing the
vacuum pumping speed. The accelerator guide was enclosed in first-in-line 360" isocentric machine43.62 Figure 1-11, a 4-
a stainless steel cylinder and sealed off. Its vacuum was main- MeV unit with an 80-cm source to axis distance, in 1969
tained by a small device called a VacIon pump31, which had
been invented in 1956 at Varian Associates for an entirely
different purpose. This sputter ion pump provided a clean
oil-free high vacuum and it could work in any orientation, so it
was ideal for the clinical accelerator. It provided a major step
forward in the reliability of these machines.

Standing-wave accelerator guide Primary Collimator

For a given beam energy and microwave power loss in the

cavity copper surfaces the required length of the accelerator
guide is inversely proportional to shunt impedance (a term that O~ticsand Source
defines the efficiency of conversion of microwave power to lsocenter
Range Finder
gain in beam energy per unit length) (gain). The early medical Optics and Source
linacs employed a corrugated (disk loaded) accelerator guide
in a traveling-wave mode (Fig. 1-8). The aperture in the disks
served two purposes, to couple microwave power from cavity
to cavity along the accelerator guide and to permit passage of .
FIGURE 1-11 First 360' isocentric in-line linear accelerator-The
the beam along the axis. To provide proper coupling, the Clinic 4 (from Varian).
12 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

VARIAN
KLYSTRON

FIGURE 1-12 . Multimode linac with microwave energy switch and 270" doubly achromatic magnet-the Clinac 1800 (from Varian).

and the first-in-line 6 MeV, 100 cm, 360" isocentric machine
in 1977.
Bent beam standing-wave linacs for radiotherapy
Although distributed doubly achromatic (energy-independent
focal properties) magnet systems were known in the 1950s,
the theory of doubly achromatic magnets compact enough to
use in clinical linacs had not yet been developed. Machines
with a nonachromatic magnet system (such as the 90" system
in the above isocentric 6-MeV machine produced in 1962)
or a singly achromatic magnet system (axial rays of differing
energies from the accelerator converge over a spread in angles
accelerator are reproduced at the output of a doubly achro-
matic bend magnet independent of the energies of these
individual rays.
For machines of energy higher than 6 MeV, this solution
is used; that is a doubly achromatic 270" magnet (Fig. 1-12)
(see Chap. 7 on magnets for further discussion) is installed in
the radiation head. Figure 1-13 shows a compact doubly ach-
romatic 270" magnet proposed by H. A. Engez* in which the
magnetic field gradually increases and then decreases along the
beam path.42 The different energy rays in the electron beam at
the input of the magnet all coalesce at the output. This magnet
270' MAGNET

at the x-ray target) have one basic problem. Small changes

MAGNET POLES
in mean energy of the accelerated beam energy spectrum
result in changes in mean angle and position of the beam
with respect to the axis of the conical flattening filter after
bending in the magnet. This causes variations in treatment
field symmetry, which are difficult to compensate completely
by feedback systems from symmetry monitors. This latter
problem becomes especially severe with the narrow primary
x-ray lobe of higher energy machines. One solution is to use SECTION d l - d 2
a doubly achromatic bend magnet, usually a 270" magnet to
minimize isocenter height. The distribution of positions and FIGURE 1-13 . Beam paths in 270" doubly achromatic magnet (from
angles of all the rays making up the electron beam from the Ref. 42).
 HISTORY OF ELECTRON ACCELERATORS
FIGURE 1-14 . Machine with electron applicator-The Clinac 20
(from Varian).
is difficult to manufacture and align so more practical 270"
magnets were developed such as a type in which the magnetic
field steps from low to high and back to low along the beam
path.10 Figure 1-14 shows a 20-MeV machine in the treatment
room, set up for electron therapy.
Dual x-ray energy standing wave linacs
Compact techniques (e.g., see Figs. 1-12 and 1-15) have now
been developed, which provide both high and low megavoltage
x-ray treatment capability in the same machine. In these units,
the field level is maintained for proper electron bunching and
acceleration in the early part of a standing wave guide but is
raised or lowered in the later part of the guide. One way to
accomplish this is by moving the posts in one side cavity in
order to change the ratio of coupling fields at its two ends while
maintaining its resonance in the 7~12mode, thereby changing
the ratio E21Eo of electric fields in the axial cavities. This
permits switching between two widely displaced x-ray ener-
gies?' such as 6 MeV for head and neck and 18 MeV for pelvic
tumors. Switching to the lower energy is also an advantage
13
-AL2
(mil)
- 80
- 60
+ A L o (mil)
FIGURE 1-15 . Microwave energy switch for control of Axial field
ratio EzIEo (from Ref. 70.).
when taking port films or electronic portal images. In addition
to increasing beam performance capabilities, a number of
treatment aids and accessories have been developed,29 includ-
ing patient immobilization and positioning systems, electron
arc therapy, and treatment recording and verification systems.
The pioneers
From its earliest application by clinicians, which was really a
spin-off from programs in basic physics research, the micro-
wave electron linear accelerator in the ensuing decades has
become the machine of choice for cancer therapy. The designs
of these modern machines did not just appear out of thin air.
Historically,they are rooted in the creative and persistent efforts
of a few research physicists, engineers, and radiotherapists.
RECIRCULATING ELECTRON ACCELERATORS
By using magnets to recirculate the electron beam through the
microwave accelerator cavity (or cavities) one or more times,
a high-beam energy can be achieved with a low energy accel-
erating section. After each orbit in the magnet the electron
bunch must arrive in phase with the accelerator microwave
field. The magnet system acts as an energy spectrometer,
limiting the electron energy acceptance to a narrow energy
width and consequently limiting to some extent the beam
14 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

Electron
Gun
n
d S.W. Linac

I
L - - - - - - - - - - - J
Reflection Magnets

FIGURE 1-18 . Reflexitron (from Ref. 58).

a large circular magnet. Each time the bunch of electrons passes

FIGURE 1-16 . Circular microtron orbits (from Ref. 78a).
current. Three general forms of recirculation have been applied
in machines for radiotherapy; the circular orbit microtron (Fig.
1- 16), the racetrack microtron (Fig. 1-17), and the Reflexitron
(Fig. 1-18). The history of these devices is reviewed in the
following subsections.
Circular orbit microtron
In a classic paper in 1944, V. I. Veksler76 at the Lebedev
Physical Institute in the USSR proposed the circular orbit
microtron. It employs a single accelerating cavity in the gap of
through the accelerating cavity it gains an increment of energy
and follows a correspondingly larger diameter circular orbit.
All the orbits are tangent to each other at the accelerator cavity.
Typically, the length of each orbit is one wavelength longer
than the previous orbits so the electron bunch arrives back at
the accelerating cavity in phase with the accelerating field. The
electron beam can be extracted at each incremental energy by
moving a magnetic shunt into the path of the corresponding
circular orbit.
The Canadians34.-58+59were the first to demonstrate this
principle in 1950. The USSR laboratories worked intensively
on the idea starting in the late 1950s, primarily in the Labora-
tory for Physical Problems of the Nobel Laureate, Pyotr
Kapitza.40 A Swedish company, Scanditronics, was the first to
build practical forms of conventional microtrons for cancer
therapy, starting in the early 1970s. Because of the very narrow
energy spread of the electron beam, it is feasible to transport
the beam from a centrally located microtron to two or more
treatment rooms by relatively small focusing and bending
magnets. The gantry in each treatment room is quite compact,
containing only the beam transport magnets and the radiation
head. A few dual treatment room circular orbit microtron
facilities have been built.

Racetrack nlicrotron
The single accelerating cavity of the circular orbit microtron
can be replaced by a linac structure of several cavities by
arranging a space for it that is free of magnetic field so that the
beam does not curve through the acceleration region. This
concept was first suggested by Schwinger in 1946,67 creating
' - 2cb
1 - L
-
180' "Extract ion" ,/ 180" "Injection" racetrack shaped oval orbits with 180" bends in each of two
~agnet ' "Chicane" Magnet separated magnets. This permits more energy gain per lap,
Injection
hence fewer orbits for a given energy, smaller magnets, and a
0 CM 50 more compact machine.
Research workers at the University of Western Ontario,
Canada developed one form of racetrack microtron.9 Workers60
E l e c t r o n Gun under the direction of 0. Wernholm at the Royal Institute of
Technology, Stockholm, Sweden developed a different form,
FIGURE 1-17 . Racetrack nlicrotron orbits (from Ref. 60). which produced 50 MeV with a 3-MeV energy gain per orbit.
 ELEMENTARY DESCRIPTION OF MEDICAL LINACS
A5O-MeV medical version of this machine has been developed
by the Swedish firm Scanditronics.Because of the high energy,
the electron beam is scanned in both x-ray and electron modes.
The principal virtues of the race track microtron are its com-
pactness for high energy, transportability of the narrow energy
spread beam by magnets, ease of changing energy .over a wide
range for both electron and x-ray beams, and need for only a
relatively low-power microwave source to obtain rather high-
electron energies.
Reflexotron
The research workers at the University of Western Ontario,
Canada, also developed the concept of the Reflexotron.64 In-
stead of guiding the electrons around a circular or oval orbit
around the accelerator structures, they are bent around a much
smaller loop and are sent back along the axis of the accelerator
structure. This takes advantage of the fact that standing-wave
acceleratorscan accelerate in either direction. At a given instant
in time the forward flowing bunch of electrons is in phase with
the forward force in one-half of the axial cavities and the
reflected bunch of electrons is in phase with the backward force
in the intervening other one-half of the axial cavities of the
accelerator structure. A 25-MeV medical version of this ma-
chine has been developed by a Canadian firm, Atomic Energy
Corporation, Limited (AECL).72
ELEMENTARY DESCRIPTION OF
MEDICAL LINACS
In medical linacs, the charged particle is an electron and the
rf accelerating electric field oscillates at about 3 billion cycles
per second (3000 MHz). For comparison, note that radio
waves in the standard AM (amplitude modulation) broadcast
channels oscillate at about 1 million cycles per second
(1 MHz).
The electrons are boiled out (thermionicemission) of a hot
cathode (a concave shaped piece of metal heated to over
1000°C) and speeded up in the gun to about one-fourth the
velocity of light by a pulsed dc electric field. They are formed
(coalesced) into a pencil beam by a convergent electric field
between the gun electrodes (See Fig. 4-4). The rf electric field
in the accelerating structure then forms the electron stream into
bunches, and speeds them up to more than 99 percent the
velocity of light, increasing their mass by many times (e.g., by
a factor of 13 at 6 MeV). Thus, the electrons become ponderous
(massive) and penetrating. It takes about 2.5 cm of water or
0.15 cm of tungsten to stop a 6-MeV electron.
Whenever an electron is shaken (i.e., decelerated, de-
flected, vibrated), it emits radiation. The more violent the
shaking, and the higher the electron energy, the harder (more
penetrating)the radiation that is emitted. For example, in a light
15
bulb hot filament the electrons are vibrating slowly, have very
little energy, and emit quite low energy radiation, some of
which is in the visible range. When a 6-MeV electron enters a
tungsten target, the individual positively charged nuclei of the
tungsten atoms pull on the negatively charged electron, shaking
it violently as it passes by one such tungsten atom after another.
These high-energy electrons thus emit hard penetrating x-rays,
in a forward lobe, giving up a portion of their energy at each
successive target atom that they penetrate.
As x-rays penetrate the patient they shake loose electrons
from the atoms of the patient's tissue, converting them briefly
to ions (hence, the term ionizing radiation). These ions can
produce further ions in the tissue as they are slowed down
(decelerated). The population of ions recombines to form
chemically active species. For example, in the presence of free
oxygen (0.3 diffused to the cells from the vascular system,
water (H20)in the cell nucleus can convert to hydrogen perox-
ide (H202) and free radicals that can attack the cell
deoxyribonuclic acid (DNA) chemically and sterilize the cell
so that it will not reproduce.
These secondary electrons produced in the patient tissue
by x-rays travel primarily forward and produce additional
ionization, depositing energy termed a radiation dose. For
high-energy x-rays the intensity of this secondary electron
flux increases for the first 1 4 cm of tissue, sparing the skin
and producing maximum dose at a tissue depth corresponding
roughly to the range of these secondary electrons (e.g., 1.5
cm for 6-MV x-rays). Beyond this depth, the x-ray intensity
decreases because of absorption and spreading of the beam.
By aiming the x-ray beam at the patient's tumor from more
than one direction, a cross-over of x-ray beams and summation
of irradiation dose can be provided at the tumor while sparing
healthy tissue. One way to do this is to position the patient
table so that the tumor is at a point in space called the isocenter.
(see Figs. 1-19a-c and 1-20). This point is often indicated by
wall-mounted and ceiling-mounted laser beams. The radiation
beam is then rotated to selected portal angles (or in arcs)
around the patient. This technique calls for the source of
radiation to be mounted in an isocentric gantry, which is
rotated on bearings by a motor drive. The machine radiation
head contains heavy metal (e.g., lead and tungsten) radiation
shielding to protect the patient from radiation outside the
intended treatment beam and thick shielding (concrete and
iron) is used in the treatment room walls and ceiling to protect
the persons outside.
For those patients suitable for curative radiotherapy, the
goal is to eradicate the local and regional tumor cells while
preserving the function of involved organs and maintaining
appropriate cosmesis.
All modern microwave electron linacs employ an isocent-
ric gantry. An accelerator waveguide structure is mounted in
the gantry, either relatively horizontal, if a beam bending
magnet is employed, or normal to the gantry axis, if a beam
bending magnet is not required. The term "waveguide" derives
historically from the use of a hollow pipe to transport (guide)
16 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

-
FIGURE 1-19 Isocentrically mounted medical linac. (a) With electron
applicator. (b)X-ray patient set-up. (c) In-line radiation head.

microwave (e.g., radar) power. Corrugations are used in accel-
erator waveguides to slow up the waves (somewhat analogous
to small jetties at a beach to break up the ocean waves). As a
result, the crests of the microwave electric field are made
approximately synchronous with the flowing bunches of elec-
trons.
Figure 1-21 shows a simplified block diagram of the major
parts of a medical linac. The microwave power to accelerate
the electrons is provided from a vacuum tube (magnetron or
klystron), which is pulsed by a high-voltage modulator. Auxil-
iary systems provide a high vacuum inside the accelerator
guide structure, and cooling and temperature control of its
internal conducting surfaces. Insulating gas pressure is
maintained inside the rectangular waveguide components,
which feed the accelerator waveguide from the microwave
power source through ceramic windows. A system of monitors
and automatic feedback systems and interlock circuitry main-
tains stable safe operation at values selected at the control
console.
MICROWAVE ACCELERATION PRINCIPLE
The electromagnetic (EM) field within the open volume of a
microwave cavity induces electrical current flow on the inner
surface (walls) of that cavity. As the field oscillates, the wall
current direction oscillates. During a one-half cycle of EM
field oscillation, the electrical current in the walls will flow
so as to charge the input end of the cavity with electrons. These
electrons on this input end will push the bunch of beam current
electrons forward, accelerating the beam, giving it energy.
During the next one-half cycle of EM field oscillation, the
electrical current in the walls will flow to charge the output
end of the cavity with electrons. If the electron bunch were
 ELEMENTARY DESCRIPTION OF MEDICAL LINACS 17

UNFLATTENED X-RAY LOBE

(18 M'f)

FIGURE 1-20 . Radiation head and x-ray field symmetry (from Ref. 54).

I
I STAND GANTRY

FIGURE 1-21 . Simplified block diagram of major parts of a medical linac

18 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR
still in the cavity, it would be decelerated. However, by this
time the electron bunch is in the next microwave cavity and
is accelerated again because the EM fields oscillation in this
next cavity is delayed in phase (time) relative to the first cavity.
By stringing a number of microwave cavities together and
filling them with EM fields in proper phase relationship to
each other, the electron beam bunch can be accelerated in each
successive cavity.
The subject of microwave acceleration is addressed more
completely in Chap. 3.
BEAM CURRENT REQUIREMENTS
IN X-RAY MODE
The unflattened x-ray intensity on the beam axis from an
optimum thickness x-ray target is proportional to the average
beam current and to about the 2.6 power of the electron
beam energy at the target. This is due to the x-ray lobe cross
section (solid angle) being inversely proportional to the
square of the electron beam energy and due to the efficiency
of conversion of the electron beam power to x-ray power
being proportional to about the 0.6 power of the electron
beam energy (in the 4 to 25-MeV energy range) (see Ap-
pendix A for further details).
The required thickness of flattening filter increases with
an increase in the diameter over which the field is flattened
and increases with x-ray energy. For example, for a field
flattened to a 50-cm diameter at 100-cm source axis distance
(SAD), which is typical for machines with 40 x 40-cm rated
field size (hence, with clipped or unflattened corners), the
transmission of the flattening filter on the axis varies by about
the - 0.8 power of x-ray energy. Thus, the flattened x-ray
intensity is proportional to about the 1.8 power of x-ray energy.
For a given flattened x-ray intensity the required electron
beam current at the x-ray target decreases as about the 1.8
power of beam energy; the required electron beam power
decreases at about the 0.8 power of beam energy. For example,
to produce 500 cGyImin over a 50-cm diameter flattened field
at 100-cm SAD, the average electron beam current and power
at the x-ray target are approximately 125 yA (microamperes)
and 0.75 kW at 6 MV; 17 yA and 0.31 kW at 18 MV-x-ray
energy. That is, it takes 7.2 times as much beam current and
2.4 times as much beam power to produce the same dose rate
at 6 MV as at 18 MV flattened over a 50-cm diameter at
100-cm SAD.
In machines that employ a bend magnet, the actual electron
beam current and power within the accelerator guide are about
1.6 or more times these values, because of beam clipping at the
input collimator to the bend magnet and at the energy slit within
the bend magnet. In machines without a bend magnet, the
accelerated beam current is also larger because of its significant
low-energy electron content.
The gun injects beam into the first cavity of the accelerator
guide continuously during the several microsecond pulse.
However, since the rf electric field in each cavity is oscillating
at 3 GHz from forward to reverse direction, the electrons are
repelled back toward the gun during each 180" of reversed rf
electric field. Even during the time when the rfelectric field is
forward, electrons are captured over only about 120" of the rf
cycle and accelerated. In addition, the input collimator to the
accelerator guide may clip some of the injected electron beam.
The net result is that the gun emits over three times the
accelerated beam current and in bent beam machines, five or
more times the current at the x-ray target. Some machine
designs require much higher gun currents and accelerated beam
currents because of greater clipping of the beam at the collima-
tor and energy slit.
MAJOR SUBSYSTEMS
AND COMPONENTS
Each manufacturer has its own set of fundamental philosophies
and technical approaches to the design of medical electron
linacs. There are fundamentally different types of gantry
mount, modulator, rf power source, microwave power control,
electron gun, accelerator guide structure, energy switching
technique, bend magnet, beam distributing system, ionization
chamber, safety interlock system, control system, computeri-
zation, treatment head, patient table support, treatment beam
modifying and shaping devices, and accessories. Table 1-4
summarizes the range of design choices available.
Modulator and high-voltage pulse
transformer
All linacs employ a modulator, comprising a high-voltage dc
(direct current) power supply and pulse modulator. It converts
ac (alternating current) mains power to high-voltage pulses,
which are applied through a pulse transformer to the cathode
of the rf power tube. It may be mounted in a separate enclosure,
in the stationary stand that supports the gantry, or in the
rotatable gantry itself. The pulse transformer is mounted close
to the rf power tube for optimum pulse shape. It may be in the
modulator enclosure, but more typically it is in the gantry stand
or the gantry. The modulator pulses can be fed through a coaxial
cable of many meters length to the pulse transformer. The
modulator employs a pulse forming network (PFN) and typi-
cally a gas-filled switch tube (thyratron). The PFN comprises
a number of capacitors separated by inductors (coils). When
the switch tube is triggered it connects the PFN across the pulse
transformer primary. The capacitors proceed to discharge their
stored energy, but sequentially, because of the time delay
produced by each successive inductor. After the pulse is over,
the switch tube extinguishes (typically due to a small reverse
voltage reflection from the pulse transformer). The capacitors
of the PFN then recharge from the high-voltage power supply
through a hold-off diode and resonant charging choke to almost
twice the power supply voltage, until a De-Q circuit senses that
 ELEMENTARY DESCRIPTION OF MEDICAL LINACS 19

TABLE 1 4 . Subsystem and component design alternatives TABLE 1 4 (Continued)

-

Item Alternatives Item Alternatives

Gantry Stand supported (internal bearing) Control system electronics Microprocessors

Drum type (external bearing) Computer (s)
Radio frequency source Magnetron Secondary collimator Symmetrical
"Boot" magnetron Independent X. X and Y
Klystron Multileaf
Radio frequency power Wedge filter Manual. Automatic. Dynamic
control Microwave variator Patient table support Pedestal (scissors)
Modulator voltage Extended range (double scissors)
Klystron drive power Ram (deep floor pit)
Elech-on gun Diode Patient table top Carbon fiber. Other
Directly heated wire cathode X Y translation
Impregnated indirectly heated Eccentric axis rotation
cathode Tilt. Pitch
Triode
Wire mesh grid
Focus electrode
Modulating anode the correct charge voltage is reached and dumps the remaining
Accelerator guide Standing wave stored magnetic energy of the charging choke via a second
Side coupled thyratron into a resistive load. The charging choke and the
Axially coupled, biperiodic, or capacitors of the PFN form a resonant circuit with Q of order
triperiodic 100 and when the De-Q switch fires it spoils this resonant Q,
Traveling wave, with or without rf hence " D e - Q (see Appendix C-2 for definition of Q).
feedback The gas-filled thyratron may occasionally fire through
X-ray energy selection without being triggered, especially toward the end of its life.
Standing wave Energy switch in side cavity For improved machine reliability, it would be desirable to
Nonshorting. Shorting eliminate thyratrons. In the future, other types of modulators
Very short buncher may be developed for medical linacs. One type is the magnetic
Beam loading. Detuning modulator, which achieves pulse compression from a long-
Traveling wave Beam loading. Detuning low-current pulse to a short-high-current pulse through a series
Solenoid Buncher only. Full length of successively shorter time constant saturable reactors. This
Bend magnet pulse can be initiated by solid state switches, thus avoiding use
Nonachromatic (older machines) of the thyratron. Solid state modulators have also been built for
Achromatic Radially only. Plus transverse research linacs, using a number of small PFNs and solid state
270" Separated poles switches, switching them simultaneously in parallel to the pulse
Stepped poles transformer.
Tiltable mid-orbit poles
45": -45": + 112" "Slalom"
X-ray target Within vacuum. External Radio frequency power source and radio frequency
Primary collimator Fixed. Round. Square, rotatable
power control
Interchangeable for X and E Low-energy linacs (4-8 MV) employ a magnetron rated about
Beam distribution 2.5-MW pulse rf power output. The magnetron is an oscillator.
X-rays Full flattening filter Its frequency is determined by the resonant frequency of the
Scanning, thin flattening filter cavities machined into its water-cooled cylindrical copper
Electrons Scattering foils anode, by the phase and amplitude of the rf power reflected to
Scanning it from the feed to the accelerator guide, and by a motorized
Ionization chambers Hermetically sealed tuning plunger in one of the magnetron cavities. During the
Open, autocorrection for tempature, many seconds of each radiation treatment, the copper inner
pressure, humidity surfaces of the magnetron anode and of the accelerator guide
Interchangeable for X and E warm up relative to the cooling water, changing their resonant
Control system electronics Discrete components frequencies but not in synchronism. An automatic frequency
PROMS,e.g., control (AFC) circuit senses the resonant frequency of the
accelerator guide and drives the motorized tuning plunger in
20 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR
the magnetron to maintain approximate synchronism of the
magnetron oscillation. A femte device is used to reduce the
amplitude of reflected rf power at the magnetron. Ferrite is a
magnetic ceramic that has the property of rotating the electro-
magnetic wave or advancing its phase, such that with appropri-
ate microwave circuitry, reverse flowing rf power can be
dissipated.
Magnetron rf power output can be controlled by changing
the modulator voltage. However, this creates an impedance
mismatch, since the magnetron current changes rapidly with
small changes in applied voltage. One way to avoid this is to
use an electromagnet to establish the magnetron magnetic field
and vary the current in the electromagnet as the magnetron
voltage is varied. Another way is to run the magnetron at
constant values of voltage and current and use a microwave
power divider (e.g., ferrite and variable position short) to vary
the portion of magnetron power that is fed to the accelerator
guide, the remainder being dumped into an rf load.
Some medium (10-15 MV) and high-energy (to 25 MV)
linacs also employ a magnetron, but of the "Boot" type with an
output of about 4.5 MW. The higher output pulse power is
achieved by making the cathode-anode structure about four
times as long as in the 2.5-MW magnetron, in order to obtain
adequate cathode current. The structure length is a much
greater fraction of a half-wavelength of the fundamental mi-
crowave oscillation frequency,so it is more difficult to suppress
oscillation at other frequencies, to maintain uniform current
loading over the cathode length, and to suppress arcing. The
use of rf feedback with a traveling wave accelerator guide helps
to reduce frequency instabilities and hence is used with this
type of magnetron in some accelerators.
A klystron is used as an rf power source in high-energy
linacs that employ a standing waveguide. Since the klystron is
an amplifier, an rf driver is required. The rf driver output pulse
power needs to be only 100 W. A microwave planar triode can
be used as an rfdriver, stabilized in frequency by a temperature
controlled low loss rf cavity, resonant in a high-order mode.
Alternatively, a solid state driver can be used.
It is preferable to run the klystron in the saturated mode.
This means there is enough rfdrive power to produce optimum
bunching at the klystron output cavity. The output power is then
relatively independent of any variations in drive power.
At 100-kV klystron voltage, the electrons are at 55 percent
of the velocity of light and take about 2 X 10-9 second to
travel from the input cavity to the output cavity. This corre-
sponds to about 2000" of rf phase. A 1 percent change in
klystron voltage corresponds to an 8" change in phase of the
rf output power relative to the phase of the rf input drive
power. The amplitude of the rf output power also varies with
modulator pulse voltage amplitude. The filling time of the
accelerator (to build up the electromagnetic fields) acts as a
filter in reducing the effect of these variations on the phase
and amplitude of the accelerating electric field. Still, it is
important that the modulator provide a voltage pulse that is
flat within relatively tight tolerances.
SUMMARY OF ENERGY CONVERSION STEPS
In summary, a microwave electron linac comprises equipment
to transform electrical energy in a series of steps, from contin-
uous mains power at a few hundred volts ac to successively
higher energetic voltages in successively shorter packets. The
following approximate values apply to a high-energy medical
linac.
1. Alternating current mains power to a high-voltage dc
power supply in the modulator: 208 or 380 V, 15 kVA, 50
or 60-Hz input, transformed and rectified to 10-kV dc.
2. Resonant charge of PFN: 10 kV is doubled to 20 kV
through a charging choke that resonates with capacitors of
the PFN in one-half cycle of 2 X second.
3. Discharge of PFN to klystron: The PFN is switched via a
thyratron tube (or solid state devices) and pulse trans-
former, transferring 100 J (watt seconds) energy stored in
the PFN to the klystron cathode at 120 kV in a 7 X
s pulse.
4. Radio frequency power from the klystron fills the acceler-
ator guide structure with stored electromagnetic energy of
3 J in the first s and continues to replenish this energy
during a 6 X s rf pulse.
5. Radio frequency fields in the accelerator guide transfer
energy to the electron beam: At any instant there are about
15 electron bunches each 1 cm long and 10 cm apart in the
accelerator guide. Assuming 11 X A at 18 MeV, 0.2
MW is transferred to the beam during 5 X s, 1 J per
klystron pulse, 0.7 X J in each of 1.5 X lo4 electron
bunches.
6. Conversion of an electron beam to an x-ray beam by the
braking action of the electric field of atomic nuclei in the
x-ray target: At 18 MeV in a relatively large field of 25 X
25 cm, the x-ray power delivered to a 25-cm thick patient
at 500 cGy1min is only 1 W, or less than loL4of the mains
power to the modulator.
DESIGN CRITERIA FOR RADIOTHERAPY
ACCELERATORS
There is a fundamental set of clinical requirements that must
be satisfied by any type of radiotherapy accelerator. Each
clinical requirement translates into one or more major design
criteria and machine performance criteria. Table 1-5 presents a
summary of clinical requirements and corresponding machine
criteria. The justification for some of these requirements is
discussed in the following first few subsections. Some of the
challenges that they present to the machine designer are dis-
cussed in the subsequent few subsections. Finally, some of the
changes in medical linac technology over the past several
decades are discussed briefly.
TABLE 1-5 . Some clinical requirements of megavoltage radiotherapy accelerators

Item Major criteria

Precise delivered dose throughout target Flatness of fields-all field sizes.

volume Stability of field flatness versus angles of
gantry and beam limiting device
Stability of penetrative quality
Precise dimensions of target volume Spatial precision of machine and radiation beam
Spatial precision of position indicators
Minimal dose to normal tissue Depth to maximum dose
Penetrative quality
Slope of fall-off of electron depth dose
Sharpness of dose profile shoulder
Width of penumbra at depth
Scatter from beam modifiers.
Wide variety of radiation modalities Low and high x-ray energies
Low to high electron energies
Small to large field sizes
Rotational therapy
Reliability Minimal unscheduled down time
Convenience of patient set up Set-up time per field
Range and ease of equipment motions
Height of isocenter above floor
Moderate time to irradiate, for patient comfort, Dose rate (with beam modifiers)
minimal motion
Patient safety Mechanical injury avoidance
Radiation injury avoidance

TABLE 1-6 . Uncertainty in dose at off-axis point in target volume (95% confidence limit, 2
standard deviations)
Uncertainty (%)

Calibration Devices (ICRU - 24)

Physical constants ?1.1
Standardization of beam at Nat'l Stds. Lab. 20.5
Calibration of secondary instrument of Reg. Cal. Lab. f0.4
Calibration of field instrument (optimal model) 21.0
Calibration of treatment beam (optimal model) 21.7
Delivery of dose to tissue phantom (optimal model) 20.7
Calibration root mean square 2.5
Linac (IEC suggested tolerances)
Dose monitoring system:
Reproducibility
Proportionality (linearity)
Dependence on equipment position
Stability throughout the day
Stability throughout the week
Dose monitoring system root mean square
Stability of dose due to 2 5 mm tolerance in SSD indicator
Stability of dose at depth due to ? 1 percent instability in penetrative quality
Stability of flatness with angular position
Beam stability root mean square
Total linac root mean square
Total of calibration and linac root mean square
Other (AAPM)
Imprecision in treatment planning computation
Contributions from organ motion and changes in patient anatomy
Total of all contributions (root mean square)
22 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

CLINICAL REQUIREMENTS confidence limit. Stated differently, in about 9 percent of pa-

Precise delivered dose at depth
The goal of curative radiotherapy is to sterilize the cells of the
primary tumor without excessive damage to intermingled and
surrounding normal tissue. The margin for error in dose can be
quite small for some tumors. An analysis of clinical data by
Herring et al.35 concludes that since + 10 percent changes in
radiation dose can give marked changes in the probability of
normal tissue necrosis or of primary tumor recurrence, the
therapist needs to be able to deliver a dose distribution to the
patient such that the dose at the tumor or at other critical
volumes is known to within t 5 Dercent.
One authoritative assessmenthas been provided by a com-
mittee of the International Commission on Radiation Units and
Measurements(ICRU). Section 7.2 of ICRU-2439 states that for
certain types of tumors an accuracy of + 5 percent in absorbed
dose to the target volume should be the criterion if eradication of
the primary tumor is sought. The implication is that this applies
throughout the target volume. It further states that at the best
level of current practice the uncertainty in calibration of dose in
a phantom is + 2.5 percent at a 95 percent confidence limit (2
standard deviations), exclusive of uncertainties related to the
treatment machine. Table 1-6 lists additional relevant tolerance
values recommended by the International Electrotechnical
Commission (IEC)38 for medical electron accelerators. Com-
bining the ICRU and IEC figures randomly for simplicity, the
uncertainty in delivered dose to the selected point displaced
from the beam axis at depth in the phantom is + 4.2 percent at a
95 percent confidence limit. Uncertainties of 4.2 percent in the
treatment planning computation process, as estimated by
AAPM,' increase the tolerance to + 6 percent at a 95 percent
tients the delivered dose will differ from the isodose treatment
plan by more than + 5 percent somewhere in the target volume.
In summary, even under optimal conditions the many contribu-
tions to dose uncertainty make it difficult to meet the clinical
goal of t 5 percent accuracy of dose throughout the target vol-
ume in the patient, so high precision of linac performance, ease
of precise patient setup and thorough quality assurance proce-
dures arejustified.
precise position, orientation, and size of treatment
fields
Some organs have a low tolerance for radiation, such as
kidneys, spinal cord, lung, liver, and rectum. It is often not
possible to avoid irradiating portions of critical organs and
still ensure an adequate irradiation target volume to treat the
tumor. Low-tolerance organs (and any normal tissue) can
tolerate a higher dose without serious injury if the volume
exposed to radiation is reduced, as determined by Berg et al.5
and Schultheiss.65 Risk of complication in normal tissue
versus dose and portion of organ exposed is summarized56 in
Table 1-7. The patient's organs and tumor in the abdominal
and pelvic regions may move as much as 1-3 cm relative to
bony landmarks according to Chen et al.,l3 due to respiration
and changes in patient anatomy during the course of treat-
ment. There are also practical limits to the precision with
which patients can be routinely positioned each treatment day.
These spatial variations require prescription of treatment
fields sufficiently larger than the assumed tumor volume to
ensure it is always included in the target volume, which
further increases the need for sharp precisely located field

TABLE 1-7 . Cumulative doses of radiation delivered with standard fractionation that have 5 and 50 percent probability of
producing fatallsevere morbidity within 5 years

Whole or partial
organ
Organ Injury TDsls TDso15 (field size or length)

Bone marrow Aplasia, pancytopenia 250 450 Whole

3000 4000 Segmental
Liver Acute and chronic hepatitis 2500 4000 Whole
1500 2000 Whole (strip)
Stomach Perforation, ulcer, hermorrhage 4500 5500 100 cm
Intestine Ulcer, perforation, hemorrhage 4500 5500 400 cm
5000 6500 100 cm
Brain Infarction, necrosis 5000 6000 Whole
Spinal cord Infarction, necrosis 4500 5500 10 cm
Heart Pericarditis, pancarditis 4500 5500 60%
7000 8000 25%
Lung Acute and chronic pneumonitis 3000 3500 100 cm
1500 2500 Whole
Kidney Acute and chronic pneumonitis 1500 2000 Whole (strip)
2000 2500 Whole
Fetus Death 200 400 Whole
 DESIGN CRITERIA FOR RADIOTHERAPY ACCELERATORS 23

I I I I I I I I I
REFERENCE TOLERANCE'
ORGAN VOLUME DOSE.cGy -
SPINAL CORD 10 CM 4500
- RECTUM
100 CM2
100 CM2
5500
5500
-
LOBE 4000
THYROID WHOLE 4500
- INTESTINE 100 CM3 4500 -
WHOLE 2500
BONE MARROW LOCALIZED 2000
- WHOLE 2300 -
'5% PROBABILITY OF INJURY BY 5 YEARS

- -
-

- -

0 I I I 1 I I I I I
0 10 20 30 40 50 60 70 80 90 100
PERCENT OF ORGAN REFERENCE VOLUME

FIGURE 1-22 . Dose-volume dependence for injury to organ (based on Ref. 54).

edges to avoid injury to neighboring critical organs. The
typical dimensional tolerance recommended by the IEC39 is
+ 2 mm for each individual motion and indicator, which
results in a cumulative maximum error of 2 4 mm in the
position of the x-ray field axis and x-ray field edges relative
to the true position in space of the x-ray isocenter.
Errors in abutment of adjacent fields also create the poten-
tial for localized overdose or underdose, leading to injury to
normal tissues or recurrence of the primary tumor. This indi-
cates the need for precise positioning of the edges of the
radiation field, not only at the patient's skin but at the depths
of critical organs. Since the probability for injury increases
rapidly with dose but slowly with the volume exposed (see Fig.
1-22), this problem can be ameliorated by tapering or succes-
sively shifting the abutting edges of the radiation fields.
Wide variety of radiation modalities
What is needed is the capability to vary field sizes over a
wide range and still maintain a flat dose distribution with sharp
shoulders and small penumbra at the depth of the target volume.
For example, x-ray field sizes to 40 X 40 cm at the isocenter
with diagonals to about 50 cm are needed for some applica-
tions.
Above all, the accelerator must be reliable. Unscheduled
down-time can play havoc with patient schedules and patient
faith in the process and can cause uncertainty in biological dose
equivalent. Convenience of patient and beam positioning are
essential, since the time to set up patients exceeds the beam
on-time by a large factor. The safety for patients and staff are
paramount.
140
I I I 3OCMI THICK I I I
~ ~ I O THICK-]
C M

Figure 1-23 compares depth dose distribution for parallel op-

posed 6 and 18-MVx-ray beams through 10- and 30-cm patient
thicknesses, corresponding roughly to head and neck tumors
versus abdominal and pelvic tumors. For example, for delivery
of a given dose to an 8-cm thick treatment volume at mid-depth
in a 30-cm thick patient section, the dose to overlying normal
tissue is significantly less (12 percent) with an 18-MV x-ray
beam. However, for a lOcm thick patient section, the same
treatment volume receives a significantly more uniform dose
(15 percent) with a 6-MV x-ray beam because of the more rapid
I
build up of dose with depth. Mixed beams of different ratios of 0 I I I I I I I I
high- and low-energy x-ray beams or of x-ray and electron -20 -15 -10 -5 0 +S +10 +15 +20
CENTIMETERS
beams provide wide flexibility of treatment plans. Providing
this multiplicity of modes in the same machine can result in RGURE 1-23 . Depth-dose distributionsfor parallel opposed fields
greater precision and convenience of patient setup. (from Ref. 54).
24 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR
SOME DESIGN CHALLENGES
A fundamental aspect that distinguishes the design of acceler-
ators for radiotherapy from accelerators for other applications
is that radiotherapy machines must be people-sized. The patient
and the radiation technologist are all-important. Some design
challenges related to their needs are discussed in the following
subsections.
Compactness
Cancer patients are sometimes quite sick and usually need to lie
on their backs for radiation treatment. Also, the patient's anat-
omy shifts markedly from supine to prone positions. In order to
irradiate the target volume from different directions without
turning the patient over, 360" rotation of the gantry is needed.
For convenience in settingup the patient,the isocenter,the point
in space around which the equipment rotates, should not be too
high above the floor. Adequate space must be provided between
the isocenter and the radiation head for radiation technologist
access to the patient and for beam modifying accessories. Fig-
ure 1-20 shows that this leaves a very limited amount of space
for the various components and the radiation shielding in the ra-
diation head, and particularly for the bend magnet or for an in-
line accelerator. To a significant extent, the design challenge
over the years has been to stay within this space while making
major advances in the clinical utility of machines and in the
treatment beam characteristics, including beam precision and
stability and a wide range of x-ray and electron energies.
High-Dose rate with large fields
One demanding requirement is to achieve a high-dose rate
flattened to the comers of a quite large x-ray field, especially
in the low x-ray energy mode, such as for treatment of lympho-
mas. High-dose rate should be available to limit exposure time,
for patient comfort, and to reduce the probability of patient
motion during beam on time. A high dose rate beam can be
gated on in synchronism with low velocity points in organ
motion while maintaining acceptable treatment times. High-
dose rate is also needed to allow for absorption in wedge filters
and compensatorsand for treatment at extended distances, such
as for hemibody irradiation.
Dose precision
Another demanding requirement is for precision of delivered
dose. Defining gamma as the slope of the curve of tumor
control probability (TCP) versus dose at 50 percent TCP,
Brahmeg lists clinically observed gammas for a variety of
tumor sites and stages. The values of gamma range from 0.4 to
8.0, with a mean value of about 3. This means for a patient with
a TCP of 50 percent and gamma of 3, an underdose of 5 percent
over the full treatment course will reduce the TCP by about 15
percentage points to 35 percent.
Similarly, an overdose of 5 percent may increase the
probability of severe damage to normal tissue from 5 percent
to perhaps 9 percent. Also, if the excess dose to a region of 3
percent asymmetric field is in the most critical organ side for
the course of therapy, the excess dose can increase the proba-
bility of severe injury to that organ.
Beatment beam stability
Treatment plans are typically prepared from a set of isodose
contours measured or calculated for a single gantry angle and
single beam limiting device angle. Although difficult, stable un-
flatness of fields could be accounted for in the treatment plan-
ning process to achieve the desired uniformity of dose over the
target volume. A really insidious contribution to error in deliv-
ered dose distribution is then the potential instability of x-ray
field flatness with rotation of the gantry and beam limiting de-
vice, due to instabilityof position and orientation of the electron
beam at the x-ray target relative to the axis of the flatteningfilter.
The problem is illustratedin Fig. 1-20for an 18-MVx-raybeam.
A point P in the field 10 cm from the isocenter intercepts a ray B
from the point source centered at the x-ray target, but point Pin-
tercepts ray A from a point displaced by 10 mm at the x-ray tar-
get. The attenuation by the flattening filter is 3:l (attenuating
from 300 to 100percent intensity) for ray B but 6:l (attenuating
from 300 to 50 percent intensity) for ray A. Thus, a 10-mmdis-
placement of the electron beam on the x-ray target causes 100
percent field asymmetry, down to a 50 percent dose on one side
of the field, up to a 150 percent on the other side. However, a si-
multaneous tilt of the electron beam by 100 milliradians re-
aligns the x-ray lobe with the peak of the flattening filter
(attenuatingfrom 600 to loopercent intensity) alongray A, can-
celing the asymmetry at the point P. Scaling the above exagger-
ated illustration linearly, in order to maintain field symmetry
within 1%, the mean position and the mean angle of the electron
beam at the x-ray target must be individually maintainedwithin
+
about -t 0.1 rnm and 1milliradiansfor an 18-MV x-ray beam.
It is important that the bend magnet system be doubly
achromatic so that the angle and displacement from axis of
each ray in the electron beam out of the accelerator guide be
reproduced in the electron beam leaving the magnet indepen-
dent of the energy of each ray. This permits unambiguous
feedback from radiation beam monitors to maintain precisely
the mean position and angle of the beam at the x-ray target
independent of any changes in mean energy of the spectrum of
energies transmitted by the energy slits in the magnet. The
magnet system should be achromatic both for rays displaced
from the central ray in the plane of bend (radial plane) and for
rays displaced transversely to this plane (transverse direction).
Instabilities in main beam energy can produce symmetri-
cal instabilities in field flatness, especially at high x-ray ener-
gies resulting from variation of the x-ray lobe width. A + 1
percent error in beam energy at 18 MeV will produce about a +
1.7 percent error in dose near the periphery of a 40 X 40-cm
field relative to the dose on the axis. Such a shift in mean energy
could occur due to changes in the shape of the energy spectrum
transmitted by the energy slits in the bend magnet, which typi-
 DESIGN CRITERIA FOR RADIOTHERAPY ACCELERATORS
cally transmits a 6 percent energy bin. (Some manufacturer's
machines transmit a 10 percent or even larger energy bin). A
full-field ionization chamber is often used for safety and for
high signal-to-noise (S/N) ratio. However, it will respond pri-
marily to dose away from the axis as pointed out by Suther-
land.70 Since calibration with a field instrument is routinely
done on the beam axis, this alone may not be enough and addi-
tional means of energy regulation may be needed. For example,
by operating in a region where the x-ray dose rate is a suffi-
ciently fast function of beam energy, feedback from the dose
rate monitoring system to the microwave power source can be
used to regulate mean energy of the beam at the x-ray target.
Uniform x-ray treatment beams, with minimal
contamination
The x-ray beam is emitted from the target in a forward lobe that
is clipped by a primary collimator, flattened by a conical
flattening filter, monitored by a multiple section ionization
chamber, clipped further by movable jaws and multileaf colli-
mator, and shaped by accessories mounted on optically trans-
parent trays (see Fig 1-20). Each of these items and the
intervening air contribute lower energy scattered photons and
electrons that increase the dose to the sensitive vascular layer
of the patient's skin and modify the shoulder and penumbral
regions of the dose profile. The lateral transport of secondary
electrons from photon interactions in the phantom increases as
the x-ray energy is increased, thereby softening the shoulder
and increasing the penumbral width of the dose profile. For
x-ray energies of 15 MV and above, Monte Carlo calculations
by Mohan et a1.52 show that the contribution to shoulder soft-
ening and penumbra resulting from secondary electrons pro-
duced in the phantom exceeds the total contribution from
machine sources. Nevertheless, for those aspects within the
control of the manufacturer the total of effects can be mini-
mized by the proper choice of materials in the beam and by
proper orientation of the primary collimator and jaw faces of
the beam limiting device.
Uniform electron treatment beams with minimal
contamination
The electron beam can be spread by multiple scattering foils
into a uniform treatment beam that passes through an ionization
chamber and is shaped by an applicator insert. These items and
the intervening air contribute x-rays that produce dose outside
(beyond) the intended treatment volume and contribute lower
energy scattered electrons that modify the depth dose distribu-
tion. These scattered electrons increase the skin dose and
reduce the clinically useful depth of the 90 or 80 percent depth
dose for a given mode energy. The obliquely scattered electrons
also degrade the transverse distribution of dose, resulting in
poor penumbra when a portion of the applicator cannot be close
to the patient's skin, such as in the neck region when the chin
interferes. These effects can be minimized by proper choice of
25
materials and their location and shape to limit production of
lower energy and obliquely scattered electrons and production
of x-rays. For example, thin light weight low atomic number
material can be used for the several layers of the dose monitor
ionization chambers. Fig. 1-25 shows that the depth dose
distribution for electrons from a linac is essentially the same as
for the very narrow energy spread electrons from a microtron.
Energy stability
The IEC39 suggested tolerance on stability of depth dose in the
electron mode corresponds to -+ 1 percent energy stability at
energies above approximately 10 MeV. That is, the deviation
of the mean of the energy spectrum transmitted by the energy
+
slit should be limited to 1 percent. This can be facilitated by
accelerating a broad fairly uniform energy spectrum such as 20
percent width and selecting out only a portion of this spectrum
by using a narrow energy slit such as 6 percent. Electron beam
current can be wasted in the electron mode because for a given
dose rate the required beam current to be delivered to the
electron window is less than 1 percent of the required beam
current at the x-ray target in the x-ray mode.
A narrow energy slit for the electron mode can limit the
dose rate in the x-ray mode if the same slit is used and if the
accelerated beam energy spread is not sufficiently narrow. If a
high dose rate is to be achieved at low x-ray energy fully
flattened to the comers of a large x-ray field, the percentage
beam current transmission through the bend magnet system to
the x-ray target must be relatively high (see Fig. 1-24). To pass
through a narrow energy slit this requires that the gun inject a
beam with low transverse emittance (displacement and angular
dispersion of electron rays within the beam) into the accelerator
guide and that electrons ride the accelerating wave in such a
way as to avoid instabilities and increases in energy spread.
Also, high electron beam transmission through the electron
beam collimator and energy slit permits thinner, lighter weight
shielding in the radiation head.
I I I I I I I I I I
- -
6X MODE 18X MODE
-
6% SLIT 4!-- 6% SLIT 4 k
-
I i i
4 I
I
I
II II
0
0 2 4 6 8 10 12 14 16 18 20 22
ENERGY (MEV)
FIGURE 1-24 . Energy spectra of electron beam in microwave switched
6 and 18-MV x-ray modes (from Ref. 54).
26 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR

frequency power feedback was employed over the accelerator

guide to reduce variations of beam energy due to magnetron
frequency instabilities. The vacuum system employed an oil
diffusion pump, which remained vertical as the gantry rotated.
Because the in-line accelerator guide was so long, the gantry
could be rotated through only 120°, from 15"beyond the vertical
to 15' below the horizontal, or 30" below the horizontal by
retracting a panel in the floor of the treatment room. Because of
limited microwave power, the typical dose rate was only 100
cGyImin with beam flattening over most of only a 20 X 20 cm
maximum field size at a 100-cm SAD. The average treatment
load was 30 patients per day. The mean time between failure of
some of the components was magnetrons, 1Omonths;high-volt-
age rectifiers, 4 months; ignitrons, 1 month; other vacuum
tubes, 1 week; electron gun filaments, 3 months. Table 1-8
summarizes some of the changes in medical linac technology
from early-to-modem machines and the resulting im-
provements in clinical performance. In general, these relate to
improved accelerator guide and magnet systems and beam
modifying systems to provide wide ranges of beamenergy, dose
rate, field size, and operating modes with improved radiation
beam characteristics in compact machines of high reliability.

10 - SUMMARY ACCELERATOR MAJOR

SUBSYSTEMS
, I
I I
0
'2 14
Essentially all modem radiotherapy machines employ an elec-
0 2 4 6 8 10
CENTIMETERS DEPTH tron linac mounted in an isocentric gantry. Accelerators are
loosely classified by their x-ray and electron energies as shown
FIGURE 1-25 . Comparison of electron depth dose curves for linac and in the following table:
microtron (from Ref. 54).

Initial seconds Machine class X-ray mode Electron mode

0 (MeV)
The beam energy, dose distribution, and dose calibration
should be within tight tolerances even during the initial sec- Low energy 4 or 6 None
onds of each portal treatment. In the future, conformal therapy 416 to 9/12'
may call for say 10-port treatments of 5 s each. A 10 percent Medium energy 8 o r 10 416 to 12/15
asymmetry through just the first second could add 2 percentage High energy 15118/20/22/25 416 to 18/25
points to the steady state value of asymmetry. Assuming a Dual energy 4 or 6 and 416 to 18/25
tumor dose of 200 cGy, a 0.1 cGy round-off error or depth 10115/18/20/22/25
dose error in the 20 cGy to each of 10 portals could add another
' I means or
0.5 percent dose error. These errors could become significant
if they add systematically. A similar rationale applies with
hyperfractionation where there are more beam initiations in a All low-energy machines employ a magnetron, which
course of treatment. produces a peak rf power of about 2.5 MW, with 2.5-kW
average rf power. Medium, high, and dual energy machines
employ a larger magnetron or a klystron. The rfpower is pulsed
CHANGES IN TECHNOLOGY FROM on by a modulator for a few microseconds at intervals of a few
EARLY-TO-MODERN MACHINES
milliseconds. With each pulse, the accelerator delivers a dose
The first single gantry isocentric medical electron accelerator at the isocenter of typically 0.01 to 0.03 cGy. The modulator
design was developed in England in the early 1950s and was contains a high-voltage power supply, charging voltage regu-
described by Miller.51 The 4-MV x-ray beam was emitted in line lator (De-Q circuit), PFN, and thyratron switch tube. It pulses
with a 100-cm long traveling-wave accelerator guide. Radio the magnetron or klystron through a pulse transformer, which
 DESIGN CRITERIA FOR RADIOTHERAPY ACCELERATORS 27

TABLE 1-8 . Some changes in medical linac technology from 1950s-1990s

Item Early Modem Result
Accelerator guide type naveling wave Standing wave Doubled guide efficiency

Mev per meter of guide 4 12-18 Shorter guide, simpler, more

(shunt impedance, megohmslmeter) (37-47) (86-1 12) compact machine.
360" gantry rotation
Bend magnet Nonachromatic Achromatic Stable treatment
fields
X-ray field size Modest Large Full mantle at
isocenter
X-ray dose rate 100-200 Short exposure, even
centrigray per minute (radslminute) with wedge filters
X-ray energies, MeV 4-6 Optimal for thin and
(number of modes) (1) thick sections of
patient
Electron energies None or low Low to high Full useful
penetration
Isodose distributions and Fair Excellent Protection of normal
their stability tissue, dose precision
Microwave tube life Months Years Machine uptime
lower cost
Cleanliness Oil pumps Ion pumps Freedom from arcing
brazed guide High energy
gradients
Electronics Tubes and relays Solid state Reliability
modular ease of service

steps the voltage up from about 10 kV to about 50 kV for
magnetrons, to about 120 kV for klystrons.
An automatic frequency control system (AFC) senses the
resonant frequency of the accelerator guide and adjusts the
frequency of the rf source via a tuning plunger in the magnetron
or via the rf driver to the klystron. The dosimetry system servos
beam pulse rate via the gun or rf source modulator to control
dose rate. In low-energy machines without a bend magnet,
x-ray energy is measured indirectly as the ratio of dose rate to
the electron beam current impinging on the x-ray target. In
machines with a bend magnet, the energy is defined by the
energy slit and bend magnet current. The accelerated beam
energy can be maintained by feedback from the dose rate
monitor to control the amplitude of rf power.
ONE FUTURE DIRECTION OF
EQUIPMENT DEVELOPMENT IN
RADIATION THERAPY
The first revolution in the treatment of cancerwas the invention
in the 1950's of machines to produce penetrating Megavoltage
radiation beams (cobalt, various types of electron accelerators).
Because of its superior beam characteristics (penetration, pre-
cision, versatility, dose rate), the electron linear accelerator
(linac) has become the machine of choice among radiation
oncologists. In the industrialized world, over 75% of radiation
machines are linacs.
The second revolution (in the 70s and 80s) was based on
advances in computer power and the invention of the Com-
puterized Tomography scanner (CT) and the Magnetic Res-
onance Imager (MRI). These developments have made
radiation oncology a precise and predictive modality. Tumors
and surrounding normal tissues could now be localized and
characterized with accuracy. However, because of various
limitations, treatment planning was still limited to 2-dimen-
sional visualization and 2, 3 or 4 co-planar treatment fields.
Even so, relative 5-year survival rates7 in the United States
averaged over all tumor sites in which patients (white) were
treated with curative intent have increased from 39% in the
early 1960's to 53% in the mid-1980's and would be close
to 60% if lung cancer were excluded. All cancer sites amenable
to radiation therapy treatment have shared in this improve-
ment.
The third revolution, 3-dimensional conformal radiation
therapy (3-D Conformal RT) is now in progress. Advances
in the ratio of computational power to computer cost are now
making it economically practicable. The data from up to 60
28 CHAPTER 1. THE MEDICAL ELECTRON ACCELERATOR
CT scans (slices) and from MRI data are reformatted by high
speed graphic computer workstation to provide 3-D displays
of the patient's anatomical structure. Accelerator beam dose
distributions are then computed and superimposed on this
anatomical display for beams from many directions in a
search for the optimal treatment plan for that individual
patient. By shaping the outlines of the treatment beam and
aiming it at the tumor from many directions, the high dose
region in the 3-D conformal treatment plan can be concen-
trated in the target volume (tumor plus appropriate safety
margin) while avoiding excess dose to radiation sensitive
surrounding normal tissue. An example is treatment of the
prostate and associated seminal vesicles while minimizing
dose to the nearby rectum and bladder. 3-D visualization
from many directions is crucial to ensuring for example that
a frond of the tumor is not missed or under-dosed (which
would lead to cancer recurrence) but that the high dose region
is not made unnecessarily large, with consequent damage to
normal tissue. Radiation oncologists look for at least 10
percentage points improvement in cure rates for several sites
and 20% improvement has been predicted from computer
modelling for the nasopharynx.
Conformal radiation therapy was originally proposed by
S. Takahashi (see Chapter 2) in Japan in 1975. Japanese indus-
try built several multileaf collimators (MLC) and Japanese
radiation oncologists did treat patients with the technique but
the development of computational power and of MLC's was
less than desired for precision 3-D Conformal RT.
In conventional radiation therapy, typically two or three or
four treatment fields at different angles (portals) are used.
Because the operator must go into the treatment room to change
field shaping devices for each portal, it becomes excessively
time consuming to use more than about four portals. In 3-D
conformal RT optimal treatment may require 10 or 12 or more
FTGURE 1-26 . Multileaf collimator (MLC) mounted on radiation head below collimator jaws. a) Axial view, h ) With patient (from Varian).
portals. This becomes practical through use of a precision MLC
and computerized remote control of movements of the accel-
erator, the patient table and the MLC. Thus, the operator needs
to enter the treatment room only at the beginning and end of
the many-portal treatment session.
Even without 3-D Conformal RT, the advent of the pre-
cision MLC will change the face of radiation therapy. For
many tumor sites, the extra effort to do the treatment planning
for 3-D Conformal RT may not be justified. For these sites,
conventional radiation therapy can be used with two to four
portals. Because of the remote controlled MLC, as well as
computerized linac motions, the operator's activities are mark-
edly reduced, with consequent major saving in time and cost
of patient treatment. Fig. 1-26 shows one type of precision
MLC. It is designed as an accessory so that it can be mounted
on an existing accelerator radiation head below the collimator
jaws. It employs a multiplicity of heavy metal bar leaves
driven relative to two sub-frames which are driven relative to
two jaws of the rectangular field collimator by small electric
motors under computer control. The bars project to 1 cm steps
at 100 cm SAD and can travel 16 cm beyond field axis. This
extended travel capability with limited length leaves is a result
of the use of the two travelling sub-frames. This extended
travel can be used not only for offset fields but also for
dynamic wedge and dynamic compensator shaping of treat-
ment field dose distributions.
The superiority of 3-D Conformal RT over the best con-
ventional RT must be proven by clinical trials. It must be
demonstrated that higher dose to the tumor results in signifi-
cantly greater cure rates without increased damage to normal
tissue. For each tumor site, 1000 patients are required to
demonstrate with 90% confidence that a 10% improvement in
cure rate has been achieved. This takes many years. The most
likely sites for such initial clinical trials are cancers of the
 REFERENCES
prostate, head and neck, and brain. Future trial candidates may
include gynecological and other sites.
There is mounting clinical evidence that increased tumor
dose results in increased cure rate. For example, Sandlefi3
reports that the Patterns of Care Study shows 5-year local
failure free rates for Stage C prostate cancer of 64% with 6000
to 6499 cGy dose, 81% above 7000 cGy dose. This represents
17% of 25000 Stage C prostate cancer patients per year, curing
over 4000 more patients per year. The challenge is to deliver
over 7000 cGy to the entire cancerous region without increased
harm to normal tissue. With conventional RT, the above Pat-
terns of Care Study showed a doubling of serious complications
from 3% to 6%.
The cost of failure to cure far exceeds the extra cost of
planning and delivering 3-D Conformal RT. Extremely expen-
sive patient care is required for patients that fail treatment.
To facilitate delivery of precision radiotherapy such as 3-D
Conformal RT, in addition to MLC's, manufacturers are pro-
viding electronic portal imaging systems to confirm proper
aiming of the beam relative to the patient, RecordNerify sys-
tems to confirm correct machine set-up parameters, C T option
on radiation therapy simulators to aid in precise positioning of
the patient, and networks to integrate all this information. In
the future, all major manufacturers of radiation therapy equip-
ment will need to be able to supply systems for 3-D Conformal
Treatment Planning, including advanced computer graphics
workstations and associated software.
It will take a few more years to make 3-D Conformal RT
a reality. The time to do the 3-D Conformal treatment planning
must be reduced to economical levels. Advances in software
are contributing to this. Training dosimetrists to outline organs
in the many CT scan images is relieving the demand for the
scarcest resource, namely radiation oncologist's time.
The safety of 3-D Conformal RT must be proven. Closing
the high dose volume down around the tumor 3-D shape (plus
margin) and then increasing the dose has its risks. The tumor
position must be set-up daily by the operators and immobilized
(or tracked dynamically), which is quite difficult for some
tumor sites and patients. There is potentially a higher possibil-
ity of error in patient set-up, consequently missing a portion of
the tumor some of the time. Hence, much greater operator care
will be required. This implies the need for extensive operator
training and the need for set-up, immobilization, and tumor
position tracking devices to assist the operator. Stereotactic
devices for different body regions, feedback from on-line elec-
tronic portal imager to robotic controls of patient support,
physiologic gating of high dose rate treatment beam synchro-
nously with organ motion, etc., may be appropriate operator
aids.
What is being learned in the development of 3-D Confor-
mal RT procedures is so valuable and logical that there will be
a strong tendency for both research and nonresearch hospitals
to equip themselves and start applying the technique in at least
a limited way as well as in so-called conventional radiation
therapy.
29
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 C H A P T E R 2

Radiotherapy Modalities

A number of different types of machine produced radiation Comparisons between x-ray beams of different energies are
beams are used for radiotherapy. These include x rays, elec- often made for 10 X 10 cm beams at 10-cm depth.
trons and other particles such as neutrons, protons, and pi
minus mesons, as well as heavier nuclei such as carbon,
helium, neon, and silicon ions. Therapeutic x-rays vary in
energy from about 10 keV to 50 MeV. Such beams are not ORTHOVOLTAGE X-RAY THERAPY
monoenergetic; they contain a spectrum of photon energies
extending from zero to a maximum that corresponds to the Orthovoltage x rays extend in energy from approximately 100
energy of the electron producing it. The mean value of the to 400 kV. The efficiency of x-ray production is low at or-
electron beam energy is used to define the x-ray energy. To thovoltage energies, the x-ray dose rate is low, and shorter
distinguish x ray from electron energy, the term megavolt source to skin distances (SSD) are employed to compensate for
(MV) is frequently used for x rays, whereas, million electron the low output. Such beams deposit maximum dose on or
volts (MeV) is always used for electrons. Megavoltage x rays, within a few millimeters of the skin surface and attenuate
extending from about 1 to 50 MeV (typically in the range of rapidly with increasing depth, in part, because the inverse
4 to 25 MeV), are the most widely used radiotherapy modality square reduction with distance varies rapidly for short SSDs.
and are the focus of this book. These characteristics often limit the therapeutic dose that can
Therapeutic radiation beams are described by their central be delivered to deeply lying tumors because of dose limitations
axis percent depth absorbed dose curves, by isodose dis- of overlying normal tissue.
tributions, and by dose profiles. The absorbed dose of any Arepresentative orthovoltage depth dose curve is shown in
ionizing radiation is defined as the energy imparted to matter Figure 2-1 together with two megavoltage curves. Figure 2-2
by ionizing radiation per unit mass of the irradiated material illustrates isodose curves for the orthovoltage and 6-MV x-ray
at the point of interest. The unit of absorbed dose is the gray
(Gy), or in non - SI units the rad, where 1 Gy = 1 Jlkg and
1 rad = 0.01 Gy = 1 cGy. (When "dose" and "depth dose"
are used, "absorbed dose" and "depth absorbed dose" are
intended.) Depth dose curves portray the relative energy
deposition as a function of depth on the axis of a normally
incident beam in some standard medium such as water, (see
Figure 2-1). Isodose distributions are most often two-
dimensional (2-D) curves of constant dose in water that are
normalized to 100 percent at the dose maximum point on the
central axis. They are plotted in planes containing the central
axis of the beam or in planes parallel to the surface. Such
isodose curves are usually plotted in multiples of 10% dose
and are provided for the field sizes in use (see Fig. 2-2). In
one alternate representation, dose profiles are obtained from Depth In Water (cm)
transverse plots passing through the central axis at specified
depths. Both depth dose and isodose curves are normalized FIGURE 2-1 . Central axis depth dose curves for 10 x IO-cm x-ray
beams in water. The megavoltage curves have admx depth of overlying
to 100 percent at the dose maximum point (d,,,) on the field water. (a) ZOOkV, 50cm SSD, HVL 2.5 mm Cu. (b)6MV, 100 cm SAD. (c)
axis in water, and the dose rate is defined at this point. 24 MV. 100 cm SAD.
34 CHAPTER 2. RADIOTHERAPY MODALITIES
FIGURE 2-2 . Isodose curves for (a) the 200-kV and (b)6-MV x-ray beams described in Figure 2-1. The 6-MV curves have been shaped by a beam-
flattening filter optimized for a 15 X 15-cm beam.
beams defined in Figure 2-1. The 200-kV depth dose (Fig 2-la)
starts at 100% at the phantom surface and attenuates rapidly
with depth. The associated isodose curves (Fig. 2 . 2 ~are) more
curved than the megavoltage curves of Figure 2-2b, due to scat-
ter at large angles being much more probable at low than at high
primary photon energies. The 10 and 20 percent orthovoltage
isodose curves, lying outside the geometrical edges of the beam,
arise primarily from photon scatter radiation. Orthovoltage
beams are identified by a half-value layer (HVL) defined as the
depth in aluminum or copper- that reduces the transmitted inten-
sity to one-half of that incident under standard conditions. A
depth dose of about 35 percent at 10 cm depth in water, with the
dose maximum lying close to the surface, is representative for a
200-kV (HVL = 2.5 mm Cu) orthovoltage beam at 50-cm SSD.
Sequential HVLs after the first are often larger since the lower
energy, less penetrating portion of the orthovoltage x-ray spec-
trum, is preferentially filtered out. High-energy photons (e.g.,
18 MV) scatter at smaller angles, but their Compton electrons
have a large range, so their dose spread is greater than at 6 MV.
The dc voltage applied to the x-ray tube of orthovoltage
equipment is generated by a high-voltage transformer and
rectifier circuit. Use of three-phase power, full-wave bridge
rectification, and capacitor filtration are often employed to
smooth and maximize the voltage applied to the x-ray tube. The
center tap of the high-voltage transformer is often grounded,
which reduces electrical insulation requirements by allowing
the x-ray tube anode to operate at +V/2 with respect to the
ground and similarly, the cathode at - V/2 for an overall
generating voltage V. Orthovoltage equipment is not in wide-
spread use and will not be treated further. Additional charac-
teristics of orthovoltage beams and equipment are described by
Johns and C ~ n n i n g h a m . ~ ~
MEGAVOLTAGE X-RAY THERAPY
Megavoltage x rays, as shown in Figure 2-1, typically deliver a
10-50 percent dose at the surface, reach a maximum at a few
millimeters to several centimeters depth below the surface, and
then attenuate less rapidly with depth than orthovoltage x
ra~s.26~33The skin-sparing effect of this low-surface dose cou-
pled with slow attenuation versus depth facilitate delivery of
high doses to deeply lying tumors. This is an important advan-
tage of megavoltage x rays, since dose to overlying normal
tissues (and especially the vascular layer of the skin at typically
1-5 mm depth) frequently limits the dose that may be delivered
to a tumor. In addition, the greater depth dose permits directing
several beams at the tumor from different directions, with dam-
 TOTAGBODY AND HEMIBODY X-RAY THERAPY (MAGNA-FIELD THERAPY)
age to overlying tissues being further reduced. A depth dose of
67 percent for a 10 X 10 cm field at 10 cm depth with the dose
maximum at 1.5 cm depth is representative of a 6-MV x-ray
beam at 100-cm SSD. Similarly, 72 percent and 2.4 cm depth,
respectively, are for 10-MV x rays. For 24-MV x rays at 100-cm
SSD, an 83 percent depth dose at 10 cm depth, and a 4 cm depth
of dose maximum is characteristic. The isodose distribution for
a 6-MV x-ray field is shown in Figure 2-2.
Figure 2-3 illustrates the four major component units of a
representative megavoltage treatment unit, the Clinac 18. They
consist of (a) gantry mounted accelerator and stand, a treatment
couch, a modulator that powers the accelerator, and the control
console with card rack housing associated printed circuit cards
for electronic control functions. Table 2-1 is an abbreviated list
of x-ray and electron beam performance specifications for the
Clinac 18. The Clinac 18 is often referenced as much data and
experience are available. Several references pertain specific-
ally to the Clinac 18 treatment unit.5,7,18,43
Typically, x-ray energies of linac treatment units range
from 4 to 25 MV with occasional higher energies to 50 MV. The
lower x-ray energy (e.g., 4-8 MV) units, treating shallow lying
tumors in the head, neck, extremities and other organs, are the
workhorse units of radiotherapy departments. The higher x-ray
energy (e.g., 10-25 MV) units are employed for deeper lying tu-
mors in the body trunk such as the pelvis. Although more costly,
multi-x-ray energy units provide both options, in one treatment
unit (see Chap. 11). The optimal x-ray energy will also depend
on the depth dose buildup and exit beam characteristics that in-
fluence the deposition pattern of dose in tumor and surrounding
tissues. The flatness and symmetry of treatment beams is a mea-
sure of their departure from idealized rectangular contours, a
view that simplifies our thinking and treatment planning pro-
cesses. Wedges are beam modification accessories that tilt dose
contours to compensate for a nonperpendicular entrant body
surface. Similarly, tissue compensators are employed for more
complex surface contours. Heavy, thick shielding (sometimes
called shadow) blocks are often employed to shape a treatment
field to the contour of an individual patient's tumor. Electron
beam therapy is commonly employed for shallower tumors ex-
tending to the body surface and for boost doses. Compare the
central axis depth dose curves for x-rays (Fig. 2-1) with Figure
2-4 for electrons, and also the isodose distributions for x-rays
(Fig. 2-2) with Figure 2-5 for electrons. Often the square elec-
tron applicator fields are supplemented by a 1.2-cm thick shield-
ing insert shaped for the individual patient. The production of
treatment beams is described in more detail in Chap. 8 and treat-
ment beam application accessories in Chap. 12.
An extension of multiple field therapy, as noted above, is
photon arc therapy. It provides a continuous change in beam di-
rection by rotating the isocentric gantry over a preset angular
range while directing the beam at the target volume. Most
isocentric treatment units incorporate a 100-cm source axis dis-
tance (SAD). Dose rates at the isocenter may be varied and are
typically 200-400 cGy/min at 1 m SAD, where the depth of
overlying material isjust sufficient to placed,,,,, at the isocenter.
35
Megavoltage radiographs, called port films, taken with the
patient in a treatment position, are used to establish correct
patient positioning in relation to the field shape.l.7.64 The diag-
nostic quality of accelerator port films is a function of photon
energy and anatomic detail visualization for megavoltage
beams is poor, particularly at 10 MV and above. The visualiza-
tion problem with high-energy beams is their high penetration,
hence, small attenuation difference between bone and soft
tissues, and consequently, very poor contrast ratio. The photon
absorption process in megavoltage therapy is primarily due to
Compton interactions. Their frequency of occurrence is closely
proportional to the physical density of the absorber, and
megavoltage port films primarily reveal density differences of
the anatomy. Some high-energy units also provide a lower
energy (4-6 MV) capability, for therapy and for obtaining
better quality port films. A diagnostic voltage x-ray generator
has been incorporated in a high-energy treatment unit.7364 The
absorption process for the low-energy photons used in diagnos-
tic radiology is primarily photoelectric. Photoelectric absorp-
tion is inconsequential even in calcium (bone) above about
0.2-MeV photon energy. This interaction is strongly dependent
on atomic number and photon energy, and diagnostic voltage
films have a richness of detail not found in megavoltage port
films. The absorption of 80-kVp x rays per unit depth may be
100 times greater than for 6 MV in tissue.
TOTAL-BODY AND HEMIBODY X-RAY
THERAPY (MAGNA-FIELD THERAPY)
Very large megavoltage x-ray fields (magna-fields) are used to
treat large portions of or the entire body volume. Various
aspects of this technique have been reported by a number of
Such therapy is often identi-
investigators.'.l8-19.~2.30.31,~7.57.63
fied as total-body irradiation (TBI), hemibody irradiation
(HBI), partial-body irradiation (PBI), total-lymphoid irradia-
tion (TLI), or total-nodal irradiation (TNI). The dose is severely
limited for such large fields by normal lung tissue tolerance,
with pneumonitis a potential clinical complication. High dose
TBI is frequently used for immunosuppression in bone marrow
transplantation as well as for treating lymphomas. It has also
been employed for the treatment of rheumatoid arthritis and
lupus. These magna-field techniques may constitute the pri-
mary treatment or be adjunctive for the latter diseases. Fre-
quently, they are adjunctive for chemotherapy.
The various methods used to irradiate TBI fields, which
may be 2 m in length, have been described by Van Dyk63 and
by Shank.57 A large treatment room permitting SSD values
from 3 to 6 m may be employed. The patient is positioned in
two or more orientations with respect to the treatment beam
that may, itself, have several orientations. Dosimetric consid-
erations for such therapy include dose uniformity, dose rate,
and point of dose specification together with the fractionation
36 CHAPTER 2. RADIOTHERAPY MODALITIES

FIGURE 2-3 . Major coniponent units of a represfntative treatnlent unit, the Clinac 18, providing one x-ray energy of 10 MV and five electron energies
ranging fronl 6 to 18 MeV (courtesy of Varian kqsnciates). (a) Gantry with stand and couch (b)modulator cabinet. (c) Control console with card rack.
 MEGAVOLTAGE ELECTRON THERAPY
Depth In Water (cm)
FIGURE 2 4 . Central axis depth dose curves for 10 x 10-cm electron
beams in water, 6-22 MeV in energy at 100-cm SAD.
regime. Dose rates range from about 5 to 50 cGy/min at the
extended treatment distance. Total dose ranges from about 750
to more than 1000 cGy and lung shielding is frequently em-
ployed. The lower total dose values are delivered in one frac-
tion prior to bone marrow transplantation, and treatment times
as long as several hours may be required. Dose uniformity
within + 10 percent is generally achieved, usually with the use
of bolus and compensators. Linac beam energies used for this
technique have primarily been 6 and 10 MV. A unique total
body irradiation facility employing parallel opposed fields has
been constructed using two 4-MV x-ray units.39
MEGAVOLTAGE ELECTRON THERAPY
Megavoltage electron therapy is used to treat tumors located
near or extending to the skin surface and for boost therapy.
Many articles have been written describing this technique. A
number of these articles are cited herein.5926329-32333938,43761.65
Figure 2-4 illustrates central axis depth dose curves for electron
beams for energies of 6 to 22 MeV. Compared to megavoltage
x-ray beams the penetration is shallower and the surface dose
is higher, typically 80-95 percent. The depth dose tends to
fall-off rapidly beyond the dose maximum, but more slowly as
the energy is increased. Treatment energies range from about 4
to 25 MeV, although some accelerators provide 35-50 MeV
37
capability. Variable dose rates up,to 400 to 500 cGy1min are
easily obtained, since the accelerator beam current required is
typically at least several hundred times less than for similar
megavoltage photon dose rates. This occurs because of the
conversion inefficiency of producing x rays in the target, losses
in the flattening filter, as well as the greater ionization of
electrons occurring in tissue per unit depth when compared to
x rays. At energies of about 25 MeV and above, the shape of
the electron depth dose curve tends increasingly to resemble
that of megavoltage photon beams. The therapeutic depth for
electron beams is often defined as the depth of the 80 percent
dose on the falling portion of the depth dose curve. In centime-
ters of water, this depth is very approximately equal to one-third
of the electron energy in megaelectron volts. Figure 2-3
illustrates a radiotherapy unit, the Clinac 18, providing electron
beams of 6,9, 12, 15, and 18 MeV. The electron beam perfor-
mance specifications are given in Table 2-1.
Figure 2-5 shows a typical isodose distribution in water for
a 20-MeV electron beam. Compared to megavoltage photon
beams, megavoltage electrons interact more rapidly and are
scattered more widely by the intervening air, by treatment head
components, and by the body tissues. Hence, to reduce dose
outside the treatment volume, electron beam collimation is
preferably carried out at or near the skin surface where the
divergent effect of scatter is reduced. Although some continu-
ously variable collimators are employed, fixed field applicators
are customary. Electron applicators attach to the accessory
mount and provide a range of discrete field sizes from about 5
X 5 cm to 25 X 25 cm. Irregular field-shaping inserts of a
FIGURE 2-5 . Isodose curves for a 20-MeV electron beam in water, 10
X 10 cm at 100 cm SSD. The applicator defining the field size is located 5
cm from the water surface. Note the effect of electron scatter in widening
the beam with increasing depth.
38 CHAPTER 2. RADIOTHERAPY MODALITIES
TABLE 2-1 . Clinac 18 performance specificationsfor x-ray and electron beams
X-ray beam
Energy
10 MV
Dose Rate
100-500 cGyImin at 100 cm
Field Size
OXOcmto35 X35cmatlOOcm
continuously adjustable
Flatness
5 3 % at 10 cm depth over 80% of both axes at
100 cm
Symmetry
+2% at 10 cm depth of integrated doses to
longitudinal and transverse halves of the field
at 100 cm
Spot size
<3-mm diameter at target
Collimator transmissiorz
Transmission of movable jaws will not exceed
0.5%
Leakage
< 0.1%
low-melting alloy of lead are often provided for such applica-
tors to provide intermediate field sizes and to tailor the field
shape to the target volume, a volume somewhat larger than the
patient's tumor.5.29 Optical visualization of the irradiation field
area and SSD are provided by the field and range lights,
respectively. An electron arc therapy feature may be provided
and has been found useful in chest wall treatment.33.48 Pal-
iwa148 edited the proceedings of a symposium on electron arc
therapy and associated dosimetry.48
TOTAL SKIN ELECTRON THERAPY
Total skin electron therapy (TSET) provides treatment of vir-
tually the entire body surface to depths of 0.5 to 1.5 cm using
electrons of 3 to 7 MeV at the skin surface. The electron beam
leaving the evacuated linac accelerating structure for this tech-
nique will have an energy of 4 to 10 MeV. The technique is
described in a number of publications.3.lo.28.47 A skin cancer,
mycosis fungoides, is most often treated with this modality.
Usually the patient is standing, and a planar area of approxi-
mately 200 X 6 0 cm must be covered uniformly within +
10
percent. As with magna-field techniques, this is accomplished,
Electron beam
Energy
6,9,12,15, and 18 MeV
Dose Rate
100-500 cGy/rnin at 100 cm
Field Size
4 X 4cmto25 X 25cmat100cm
Flatness
25% at depth of Dmax.
over 80% of both axes at 100 cm
Symmetry
+2% at depth of dm,, to longitudinal and
transverse halves of the field at 100 cm
X-ray contamination
<5% of Dm,, at depth 10 cm beyond
10% isodose line on axis for 15 X 15 cm field
Leakage
< 0.1%
in part, by employing SSDs of several meters with various
combinations of patient and beam orientation chosen to im-
prove uniformity. The technique is easier to implement in a
large treatment room with a suitably placed accelerator. Figure
2-6 illustrates the electron beam geometry, fractionation, and
patient orientation and stances for the six dual-field technique.
The x-ray collimator jaws are opened wide and may be
rotated so as to place the diagonal of the field vertical, which
can improve dose uniformity over the height of the patient for
single-field techniques. Most TSET is carried out with
isocentrically mounted linacs using four-to-eight combinations
of two large angled fields; one field axis directed just over the
head, the otherjust below the feet of a standing patient.10928,47,48
The megavoltage x-ray contamination in the electron beam is
penetrating. For the technique just described, however, it is
largely directed along the beam axes and hence external to the
patient, above the head and below the feet. The relative x-ray
dose averaged over the body volume may be as low as 1 percent
or less of the electron dose. Thus, a prescribed TSET treatment
regime electron dose of 3600 cGy in 9 weeks can be accompa-
nied by a whole body dose of x rays of 36 cGy, a tolerable value.
Electron scatterers of low atomic number, which minimize
x-ray production, are located in or on the front surface of the
treatment head. These, together with several meters of air and
other discrete components in the beam, result in an energy loss
 INTRAOPERATIVEELECTRON THERAPY 39

-
A
3 Meters

Treatment Plane
-
..
...
....
...
Beam center line ...

FIGURE 2-6 . Total skin electron therapy. (a) Geometrical arrangement of the symmetrical dual-field treatment technique. Equal exposures are
given with each beam. The calibration point dose is at x = 0, y = 0 in the treatment plane.

of 1 to 3 MeV between the accelerator vacuum and the patient

treatment plane. Some electrons are initially scattered outside
6 Field Cycle the patient treatment area and then scattered back by air on the
periphery. Such scattered electrons help to achieve a flatter
d field over the patient. However, many electrons are lost from
the treatment beam by this multiple scattering process by the
air as well as other components along the beam axis. As a result,
accelerator beam currents comparable to those for x-ray ther-
apy are needed to provide dose rates of 25 cGyImin or more at
the patient treatment plane. A rigorous quality assurance pro-
gram should be an integral part of the TSET program since
electron dose rates at isocenter are usually several hundred
times higher than that for conventional small field electron
therapy and constitute a safety harzard.

INTRAOPERATIVE RADIATION THERAPY

1st Day
Intraoperativeradiation therapy (IORT) involves directingradi-
-+ 2nd Day
ation through a surgical opening into tumors or the tumor bed,
which constitutesthe remaining adjacent tissue after excision of
-
FIGURE 2-6 (b) Sequential two-day treatment cycle illustrating the the tumor. Typically, an electron beam from a linac or 250 kV x-
angular orientation of the six dual-fields. rays are employed. The tumor region is exposed or excised sur-
40 CHAPTER 2. RADIOTHERAPY MODALITIES

Linac manufacturers are developing specially designed

IORT machines to be installed in normal operating rooms. The
reduced accelerator beam current to achieve the electron dose
prescription and beam direction restrictions for IORT can
significantly reduce room shielding requirements already re-
duced for electrons as compared to megavoltage x rays. The
machine can be fully self-shielded, so bremsstrahlung pro-
duced by the electron beam in the patient is the primary
determinant of the shielding required. The placing of such
shielding close to the patient, without interfering with surgical
procedures, permits minimum room shielding. Thus, the facil-
ity could be incorporated into operating rooms located well
above ground level where the weight of customary shielding
would ordinarily be prohibitive. Orthovoltage x rays, typically
250 kVp, are also used for introperative therapy, since their
penetration is adequate for an exposed tumor or tumor bed,
but their dose uniformity in the treatment volume is inferior
to megavoltage electron beams.51.54
Requirements for IORT include a surgically sterile envi-
ronment, displacement of radiation sensitive organs outside
the field (e.g., a ureter), and a method of easily viewing the
treatment area before and after the treatment. McCullough et
al.43 describe a retractable mirror telescope and illumination
system that permits viewing down the axis of the applicator,
and a commercial version is available. Fraass et al.19 describe
a more elaborate system employing a small TV camera, which
allows simultaneous monitor viewing by several people, to-
gether with hard copy documentation of the treatment area.
A treatment room may be totally or partially dedicated to
IORT.

FIGURE 2-6 . (c) Patient position stances for the anterior, posterior
and two of the angled dual-field exposures.

gically prior to the irradiation. Radiation sensitive critical or-

gans (e.g., ovaries) are repositioned out of the radiation field. A
single dose of radiation, typically 1000-2000cGy, is employed.
Electron
Scattering
Foil
-- } ~ixed

-
The rationale for this technique is that some treatment regimes Ionization
I Collimators
Chamber
fail to eradicate the primary tumor because of the limited toler-
ance of normal tissue overlying the tumor. The IORTprocedure
is usually combined with conventional therapy, surgery, or both Treatment A
ctb Primary Collimators

-Lower
upper

for abdominal and colorectal malignancies, and is used as a Head

Secondaly Collimators
"boost" dose.4~6,9~19-20,43,44,51,54
Figure 2-7 illustrates the colli-
mation layout of a linear accelerator for IORT.
Aluminum "Docking"
In this technique, a special applicator or cone is placed Jocket
inside the incision in the patient at the desired angle.44 Then, Treatment Tube
the coordinate motions of the couch, gantry, and collimator are
carefully adjusted so as to "dock" the cone into an adapter
located on the treatment head. Cones are usually circular and
their ends may be beveled 15"-45". The fields may be further
shaped by adding appropriate sheet lead absorbers. Some treat-
ment centers use a fixed x-ray collimator setting for all circular
r Phantom

Not To Scale
cones. A treatment dose is delivered in several minutes once
the patient is positioned. Electron energies range from about 6 FIGURE 2-7 . Collimation layout of the linear accelerator for intraop
to 30 MeV. erative electron radiotherapy (from Ref. 9).
 DYNAMIC THERAPY AND MULTILEAFCOLLIMATORS
ARC THERAPY
Arc therapy is an extension of multifield isocentric therapy,
wherein the prescribed dose is delivered over a prescribed
arc of the gantry. It is illustrated in Figure 2-8. The technique
is called "rotational therapy," if the arc extends to 360". Both
x-ray and electron arc therapy are available, sometimes as
options. For arc therapy, the dose rate per degree, typically
0.5-5.0 cGy/deg, is preset to deliver the prescribed dose over
a preset arc. A servo-feedback system (not shown in Fig.
2-8) ensures that the dose rate per degree remains constant
over the prescribed arc of gantry travel by control of the
beam pulse rate. Once the patient is correctly positioned, the
gantry is rotated under manual control to verify clearance
of the equipment about the patient prior to treatment.
Electron arc therapy has been effective in postmastectomy,
chest-wall irradiation of cancer patients.35.45 In this technique,
the gantry is arced over the supine patient.34 Collimation is pro-
vided by a three-tiered system (see Fig. 2-8). It commences with
an elongated x-ray collimator opening. Next, an individually
tailored variable-width secondary collimator,attached to theac-
cessory tray, compensates for changes in the radius of the thorax
from superior-to-inferior border. Finally, a foam-lined
Cerrobend cast, which rests on the patient during treatment, de-
fines the beginning and ending border of the arc. Electron ener-
gies from 7 to 18 MeV have been studied. The dose to variable
depths within the volume is controlled by varying the electron
energy and dose rate through the arc and by adding tissue equiv-
alent surface bolus to compensate for lack of tissue depth in por-
tions of the arc. This technique is particularly useful for specific
clinical situations with large areas of chest wall having marked
variation. Such areas can be o ~ t i m a l homage-
l~,
neously irradiated while sparing normal uninvolved tissues.
Treatment planning and providing tailored
for the
technique tend to be labor intensive. The proceedings of a sym-
posium on electron dosimetry and arc therapy edited by Pal-
iwal48 covers both phy sical and clinical considerations.
DYNAMIC AND CONFORMAL THERAPY
AND MULTILEAF COLLIMATORS
Dynamic therapy involves moving the beam and/or moving
the patient via couch, gantry, and collimator motions together
with varying the dose rate. It includes conventional arc therapy
with conformal therapy implied. Dynamic therapy appears to
have started in the 1970s with the methods of Takahashi60
which he called "conformational" radiotherapy. His tech-
niques are centered around rotational arc therapy about the
tumor center with an isocentric treatment unit. A coordinated
motion of the patient couch, gantry, and collimator opening
size and shape (of a multileaf collimator), is employed to best
41
FIGURE 2-8 . Schematic representation of electron arc therapy setup
(from Ref. 34). (a)Location of x-ray target (100 cm from mechanical
isocenter). (The x-ray target is not in the beam during electron arc; its
position is shown for reference only.) (b)Location of electron scattering
foil. (c) Effective source for 6-MeV electrons using secondary
Cerrobend collimator. (d) Primary photon collimator. (e) Secondary
Cerrobend collimator. V) Radius of curvature of patient's contour from
isocenter in "mid-field"central plane. (g) Radius of curvature of
patient's contour from isocenter in "top of field" plane. Location of ter-
tiary collimation breastplate is noted in inset. The arrowed lines super-
imposed on the inset demostrate the location of the mid-field and top
field contours.
encompass the tumor and minimize exposure to surrounding
tissue. A three-dimensional (3-D) assessment of the tumor
volume made use of conventional mot
computerized tomog-
raphy (CV] transverse axial tomography. Mantel et al.41 de-
scribed an early dynamic system in which the field size and
dose rate could be changed as a function of gantry angle
independently or simultaneously during rotation therapy. Tate
et al.62 describes the application of conformation therapy to
improve the irradiation of the spinal axis. The early Japanese
experience with conformational and dynamic treatments has
been updated at a 1980 conference.17 The development of
multileaf collimators (MLC) has facilitated dynamic treatment
using shaped fields encompassing the tumor, particularly
under computer control and has benefited static single and
multipart therapy as well.
Recent definitions distinguish between dynamic confor-
mal therapy, which involves gantry and MLC motion with the
beam on, and segmented conformal therapy, which involves
gantry and MLC motion with the beam off and with the beam
on at each sequential portal. It is believed that the dose distri-
butions with segmented conformal therapy (about 10 portals)
are just as good as with dynamic conformal therapy (infinite
portals) with actual treatment planning done at 15" intervals for
the dynamic case. Advances in conformal therapy benefit from
42 CHAPTER 2. RADIOTHERAPY MODALITIES
improved delineation of tumor using CT and MRI procedures,
improved 3-D treatment planning programs and workstations,
on-line treatment portal imaging and improved color displays.
These components have been integrated so as to more closely
encompass the tumor while sparing nearby healthy tissue.sa
In Britain, a computer-controlled tracking cobalt unit with
a moving couch is being used to reduce the high-dose volume
for tumors of the esophagus, thyroid, bronchus, chains of
lymph nodes, and medulloblastoma.~A somewhat similar
system employing a linac has been developed in the United
States for treating pelvic and para-aortic nodal areas (see Fig.
2-9).13.15,37 Recent Swedish experience in developing the MLC
for medical microtons is described in later paragraphs.
Not all tumor shapes are appropriate for exploiting dy-
namic therapy. Accurate 3-D localization and geometric regis-
tration are required. Digital radiography, CT, and magnetic
resonance imaging (MRI) techniques can better identify le-
sions, which may be advantageously treated by these methods.
Treatment planning for dynamic treatment is 3-D; it tends to
be more complex and requires significantly larger computa-
tional effort. Since the goal is to confine the shape of the
high-dose volume more closely to the shape of the tumor, there
is usually less margin for error in positioning the tumor. Hence,
it is desirable to immobilize the patient and monitor the tumor
position, or immobilize the tumor, itself, where feasible. Dy-
namic therapy requires high spatial accuracy, repeatability, and
reliable performance of the motion control system. The asso-
ciated hardware, as well as software development costs, can be
large. Dynamic treatment necessitates a systems approach to
therapy that includes tumor localization, simulation, treatment
planning, verification, and treatment fulfillment. Numerical
accuracy and spatial registration checks must be provided for
FIGURE 2-9
u Gantry
. Dynamic therapy technique for retroperitioneal nodes. (Courtesy of L. M. chin'')
the increased volume of data, which is transferred from one
phase to the next. Dynamic therapy, with its potential for
reduction in treatment target volume, may allow increased
tumor dose with the consequent possibility of an improved cure
rate or an improved patient tolerance or both.
The diagnostic imaging techniques, CT, MRI, and positron
emission tomography (PET) have served to better delineate
many tumors as 3-D entities. This has led to increased use of
field blocks, wedges, and compensators, as well as 3-D treat-
ment planning, to better encompass the usual, irregularly
shaped tumor. The MLC can efficiently provide irregularly
shaped, static fields, and under computer control, dynamic
fields as well. It has been employed many years for x-ray
therapy and has been recently used in electron therapy, with
scattered as well as scanned pencil electron beams. Under
computer control, the individual leaves and beam intensity can
be modulated to provide wedged and compensated fields as
well as shaped fields. Although MLCs are complex, expensive
devices, their flexibility and labor saving features have encour-
aged their development. There is a growing body of archival
literature pertaining to them,8,12,13,16,17,22a,27,35and commercial
designs vary widely in objectives and implementa-
tion.37,42,46+49.56Some designs incorporate manual control of
individual leaf motion while others are motorized and may be
computer controlled.
The radiation head illustrated in Figure 2-10incorporates a
MLC providing shaped or rectangular fields of x-rays as well as
electrons. The pencil beam of electrons is raster scanned over
the field directly or onto an x-ray target as described in Chap. 8.
There are 64 wedge-shaped leaves comprising one pair of jaws
that move on a circular arc with their end and lateral edges
always aligned with the beam edge and the effective radiation
 STEREOTACTIC RADIOSURGERY 43

source. The projected individual leaf width is 1.25 cm at a

100-cm isocenter, allowing 40-cm maximum field widths. The 11 Electron , \
double focus leaf construction tends to minimize penumbra
Bending magnet
from jaw edge transmission. Electron contamination in x-ray
Vacuum window
therapy and electron scattering in the patient, but also in air for
electron therapy, dominate penumbra. The latter is reduced by Targetldecelerator
Photon beam
filling the radiation head with a helium atmosphere. A magnet Purging magnet
placed just above the primary collimator purges electrons Primary collimator
emerging from the x-ray target for x-ray therapy.12 Figure 2-1 1 Transmission
shows the 1.25-cm "staircase" outline at a 100-cm dose maxi- Monitor
mum for a 20-MV irregular field and the smoothing of isodose Mirror
contours. Biggs et a1.8 compared the penumbra between fo- Helium gas
cused and nondivergent blocks and its implications for multi-
leaf collimators. He concluded that focused blocks are not I \.i fl
Block collimator

justified for most clinical treatments. Hence, the mechanical
complexity of an MLC could be significantly reduced for a
small sacrifice in penumbra by employing nondivergentleaves.
This is consistent with the common convention of planning the
90 percent isodose contour 1 cm outside the tumor margin and
the smoothing effect of tissue scatter around corners in the
outline. However, the 1-cm margin may not be acceptable for
some tumors near the spinal cord, optic nerve, and so on.
Kallman et al.27 studied the shaping of arbitrary dose distribu-
tions by MLCs. They developed computational techniques
using pencil x-ray beams for generating complex dose distribu-
tions; for example, a low-dose irregular region within a larger
irregular field. A TV camera is located in the radiation head of
Figure 2-10 and monitors a "beam's eye" view (BEV) of the
treatment field as illuminated by the field light beam. ACaWO,
crystal photodiode array samples the x-ray beam exiting the
patient and can be employed to monitor and control the treat-
ment beam.
A somewhat similar multileaf collimator has been investi-
gated for neutron beam therapy and its dose distributions
compared with a 6-MV photon beam.14 Differences in dose
distributions appeared generally insignificant for radiation
therapy so that a stringent comparison of the two modalities
will be possible.
An extensive evaluation of MLC design considerations
relative to clinical requirements for x-ray therapy emphasizing
dynamic therapy and shaped static fields has been carried out
by Galvin et a1.22a Investigated parameters included: penumbra
width, leaf shape and speed, field size requirements,orientation
relative to secondary collimation system and ability to shape
complex treatment fields. The findings have been incorporated
in a prototype MLC system.
STEREOTACTIC RADIOSURGERY
Stereotactic (or stereotaxic) radiosurgery involves the ablation
of small tissue structures, usually in the head, by a large
radiation dose delivered with high-spatial precision, typically
Double-focused
multi-leaf collimator
for electrons and
\
photons
I
Helium window
Elementary
photon beams
lsocenter
I
CWO-photodiode
, array
FIGURE 2-10 . Cross section through the scanningsystem and treat-
ment head of a medical microtron equipped with a multileaf collimator.
The conceptually most important design features are that the same com-
ponents are used for electron and photon beam formation The flatten-
ing system, the dose distribution monitor, the collimation system, and
the patient monitor and verification system are all used for both radia-
tion modalities. The detector array below the patient may be used both
to make CT images of the patient with the therapy beam and for verifi-
cation and interlock purposes. (Courtesy of ~rahme.")
within 1 mrn. Stereotaxis is the associated precise localization
of 3-D body structures by means of coordinate landmarks, a
radiographic procedure preceding radiosurgery. Precise target
localization and patient immobilization during treatment is
achieved using a stereotactic head frame. Radiosurgery, which
was introduced by LekselP6, achieved precise localization of
the lesion and alignment of multiple 100-kV treatment beams
with a stereotactic head frame. Later, protons, as well as mul-
tiple 60C0 beams, were employed. More recently, the radiother-
apy linac, with its sharply defined, penetrating, and accurate
treatment beam, has provided safe and efficacious radiosurgery
using the stereotactic immobilization procedures developed
The lesion is positioned at the isocenter for
earlier.23-25,40952,55,59
treatment and the dose is concentrated in a small volume of
tissue using a pencil x-ray beam with multiple arcs of the gantry
for a number of treatment table or treatment chair angles during
a single treatment session (see Figs. 2-12 and 2-13).
Radiation treatment of small umesectable brain tumors
had earlier acquainted the radiotherapy community with the
44 CHAPTER 2. RADIOTHERAPY MODALITIES

FIGURE 2-11 . The isodose distribution of a 20-MV photon beam at the depth of dose maximum in water. The field engages only 26 of the 64 leaves
of the multileaf collimator and the direction of motion of the leaves is vertical. It is seen that control of the shape of the radiation field is achieved. The
thin stairca~eshaped lines correspond to the projected collimator opening on the plane of measurement. It is seen that the staircase structure is consid-
erably smoothed out on 10 and 90% isodoses. (Courtesy of ~rahme.'?

need for precise localization and immobilization. Extension of
such procedures to the 1-mm precision requirements of radio-
surgery followed and have been rep0rted.21.23.40.52.53.55~58The
principal lesions now being treated are inoperable arteriove-
nous malformations (AVMs). In these lesions, blood has been
prematurely shunted from the arterial system to the venous
system with the attendant danger of hemorraging if untreated.
A single high dose of radiation (usually 15-20 Gy), typi-
cally 6 or 10-MV x rays, is delivered in one treatment session
with the objective of cauterizing and sclerosing the vessels and
preventing hemorrhages. Higher energy (e.g. 25-50 MV) x-ray
pencil beams have wider penumbra associated with the longer
lateral range of secondary electrons. The single fraction dose
to brain cells should be less than about 20 Gy to avoid late
effects. Field sizes are small, typically 10-30-mm diameter
circles and concentrated on a small, approximately spherical,
volume of tissue using multiple arcs, as shown in Figure 2-12.
The dose 1.0 cm outside the target volume is typically less than
20 percent of the prescribed dose. A supplemental collimator
extension is customarily used having a range of interchange-
able conical Cerrobend inserts to provide a sharp beam edge.
Since the collimation occurs close to the patient, the contribu-
tion of source diameter to geometric penumbra is reduced,
typically by a factor of about 3. Gager et a1.2' showed how such
narrow beams can be further improved with an added brass
flattening filter. The measurement of such dose distributions
and their incorporation into treatment planning have been
reported by Pike et al.50 and Rice et al.53 and the stereotaxic
localization of intracranial targets by Siddon and Barth.58 The
stereotactic head frame remains rigidly attached to the patient's
skull during the entire sequence of C T or angiographic local-
ization followed by treatment.55 Heilbrun et al.24 gave descrip-
tions of the Brown-Roberts-Wells (BRW) system, a commonly
employed system of computerized hardware and software for
CT stereotactic localization of lesions. Both C T and angiogra-
phy, wherein vessels are injected with contrast media, are
employed diagnostically for localization.
"Localization" is used in portal imaging to meanfinding
the location of the tumor relative to bony landmarks so the
patient can later be positioned accurately. In stereotactic radio-
surgery, localization is used to describe positioning using a
mechanical device. The Cartesian coordinates for localizing
the target volume are derived in treatment planning with the
aid of CT or angiographic information and related to the
stereotactic head frame used in the treatment. The patient lies
supine on the treatment table with their head supported inde-
 REFERENCES
f Vert
100" Arc
.
FIGURE 2-12 Head schematic showing the three coordinate axes and
the four arcs of the typical cranial treatment. (Courtesy of Lutz et al?)
pendently by the stereotactic frame, which is mounted on a
stand attached to the turntable, as shown in Figure 2-13. The
patient is aligned for treatment with the aid of X, Y,and Z
adjustments incorporated into the stand. An important safety
hazard is associated with potential collision of the treatment
FIGURE 2-13 Overview of patient treatment. Shown are the supple-
mental collimator and the head support system, which consists of the
BRW head ring and the BRW floor stand. The floor stand is mounted to
the couch floor plate. lkatments use both gantry and turntable rota-
tions. (Courtesy of Lutz et a]?@)
45
unit with the patient head support frame which is mounted on
the turntable and independent of the treatment table itself (see
Fig. 2-13). Similarly, accidental vertical, lateral, or longitudinal
movement of the patient's body could be very dangerous after
the head is secured to the turntable via the floor stand. A post
bolt, safety switches and appropriate interlocks can minimize
these hazards. The single fraction treatment is then given
immediately after localization with the combined alignment-
treatment sequence typically requiring about 45 rnin. The treat-
ment procedure does not make use of a radiotherapy simulator
nor does it make use of the field light or room lasers.
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 C H A P T E R - 3

Microwave Principles for Linacs

This chapter presents the general theory of microwaves, as it shaped to high accuracy to keep the radar-like wave in synchro-
applies to linear accelerators. It includes relevant microwave nism with the accelerating electrons, and which are coupled
electronics concepts that are used to explain the two types of together to feed microwave power along the accelerator guide.
microwave linear accelerators (linacs): traveling and standing The accelerator guide is typically somewhat less than 10 cm in
wave. This is followed by a description of the most advanced diameter and other accelerator components can be packed in
accelerator structures presently used in various medical linacs. closely around it. This makes for a very compact machine, an
Several books relevant to electromagnetic theory and particle essential requirement for medical applications.
acceleration are listed at the end of this chapter. The intense electric fields, which accelerate electrons
Although all types of medical electron accelerators are along the cavity axes, are set up by electric currents flowing on
described in varying degrees of detail in succeeding chapters, the inner cavity surfaces. There is a simple expression that
a simplified description of the acceleration principle in micro- determines the microwave power P dissipated in the copper
wave electron linear accelerators (linacs) is presented here inner surfaces of the accelerator guide, which is needed to
because over 90 percent of radiotherapy accelerators are of this produce an electron energy gain V. For either a traveling wave
type. or a standing wave constant gradient accelerator guide, it is
The basic element of the linac is a waveguide (accelerator
structure), which looks like a length of hollow copper pipe. It
is divided into a sequence of microwave cavities by a series of
washer like disks. It guides radar-like electromagnetic waves where Z is the so-called shunt impedance per unit length and L
along its length, producing an alternating electric force on is the length of the accelerator. The shunt impedance measures
electrons on its axis. These waves are pulsed into the acceler-
ator structure from a microwave power source, such as a Surfer
magnetron or klystron.
Electrons are emitted from a hot cathode, pulsed to several
tens of kilovolts, passed through a hole in an anode, and formed
/
into bunches a few centimeters apart wh' h ride the electro-
\
magnetic wave down the pipe much as a per on on a surfboard
rides an ocean wave.
In the analogy shown in Figure 3-1 the fish under water
stays pretty much where it is, the water oscillates vertically up
and down, and the surfer is accelerated forward. Similarly, the
electromagnetic energy oscillates radially outward and inward
in each individual cavity of the accelerator structure and the
electron bunch is accelerated forward. The electrons gain more
and more energy from the wave and exit the far end of the pipe
at high energy. In some modern medical machines an electron
energy of 6 MeV can be produced in a length of about 20 cm
and 20 MeV in about 120 cm of accelerator guide. That is, the
electrons can penetrate as much material as if they had transited
a gap with 20 million volts across it. The inside of the acceler- FIGURE 3-1 . Person on a surfbnard riding an ocean wave and a fish
ator guide consists of a series of microwave cavities, which are below the waves.
50 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS

the efficiency of the accelerator. Higher shunt impedance Evacuated

means higher electron energy gain for a given microwave Glass Tube
power. For example, for V = 10 MeV, P = 1 MW, if L = 1 m \
and Z = 100 M Wm, a typical value for some modem struc- Cathode \ Anode
tures. If the electron beam and other parts of the microwave
system consume another megawatt, a pulsed microwavepower
source of 2 MW would be required. For typical dose rates for
radiotherapy its average power rating might be 2-3 kW.
The axial electric field in each cavity of the accelerator
structure swings back and forth in direction 3 billion times per
second. This oscillation in each successive cavity is delayed
(phased) with respect to the previous cavity such that when the
electron bunch arrives at each cavity it is further accelerated.
An analogy would be the synchronous but opposed swinging
of two successive trapezes so that the acrobats (like the electron
bunch) can progress from one trapeze to the next.
The magnetron or klystron, which supplies microwave
power to the accelerator structure, also employs resonant cav-
ities. In these tubes energy is given to a stream of electrons from
a pulsed high-voltage source (modulator). The electron stream
forms into bunches that give up much of their kinetic energy
of motion as they sweep through the resonant cavities.

ELEMENTARY LINAC .
FIGURE 3-2 Electron flow in a diode from cathode to anode. Electric
filed vector E from anode to cathode.

A simple structure example of an electron linac is a vacuum
diode tube as shown in Figure 3-2. Electrons are boiled out of
the cathode surface and accelerated toward the anode, which is
kept at a positive potential V with respect to the cathode. If Va
= 1 V, then each electron gains the energy of 1 eV, which
corresponds to 1.6 X 10-19 Joule, since 1 Joule = 1 Volt X
Coulomb. The electron volt is the energy unit conventionally
used in accelerator science. If Va = 1 kV, then the kinetic energy
gained by the electrons is 1 keV. The classical equation for
kinetic energy of motion is
where me is the electron mass and v is velocity.
One can calculate the velocity of the 1 eV electron at the
anode as being 1.87 X 107 rn/s (6.25 percent of the speed of
light!). In order to accelerate electrons to 1 MeV (= 106 eV),
we need a 1-MV battery, which is physically impractical.
Now consider an accelerator in which an alternating volt-
age is applied between the cathode and the anode. No electrons
will be accelerated from the cathode to the anode during the
negative anode voltage excursion of the cycle as shown shaded
in Figure 3-3a. In order to accelerate electrons effectively
through multiple pafallel plates excited with multiple alternat-
ing voltage sources (frequencyfi as shown in Figure 3-3b, the
electron should travel from one gap between the plates to the
next gap in one-half cycle, with the phase angle difference
between the sources being 180". Consequently, the spacing L,
+,
between the plates and phase should satisfy:
-
v
where 6,= $ ,c is the velocity of light and T,, is the average
electron velocity at gap n. Therefore, if the electron is acceler-
ated from left to right in Figure 3-3b, the gap length must be
progressively increased for maximum energy gain, since the
electron velocity pncis continually increasing. As the electron
gains energy its velocity vn quickly approaches c, its limiting
value, and the gap lengths become uniform.
MICROWAVES
The term ~nicrowaveis loosely used and often not well defined.
Microwaves comprise a part of the electromagnetic spectrum
with a wavelength on the order of 1 to 100 cm. Table 3-1
approximates the frequency bands, wavelengths, and their
designation in the electromagnetic wave spectrum around the
microwave frequency range and extends into x-ray frequen-
cies. The propagation velocity of an electromagnetic wave in
 TRANSMISSION LINES AND WAVEGUIDES 51

fi5
S
9
.-
"
-m
Time
2
w
?
f:
0 k4
> .t-L , -+- L,-+4 L3
w
7J
0
2
(4

-
FIGURE 3-3 (a)Sinusoidaly oscillating voltage between the anode and the cathode. (b)Multiple plates with gaps independently driven from oscil-
lating sources.

free space is that of the velocity of light c, which is 3 X 108 of voltage, current, and impedance in normalized form can be
m/s. The wavelength in centimeters is given by A = elf= 3 0 ~ utilized in order to simplify analysis of microwave circuits.
where f is in gigahertz (GHz). Capitalized letter designations Microwave technology was significantly advanced during
commonly used for microwave frequency bands (particularly and after World War I1 along with military applications, espe-
in references to radar equipment), and frequency range of each cially radar. In recent years, microwaves have been widely used
band, are shown in Table 3-2. in many additional areas such as: communications, radio astron-
If the size of components is the order of the operational omy, basic research (as in microwave spectroscopy), commer-
wavelength, conventional circuit analysis techniques (such as cial use (as in microwave ovens), material processing, and other
Kirchoff's law) are no longer adequate to describe the phenom- industrial and medical applications. Although microwave tech-
ena. By the time an effect caused by a first part of the system nology is considered to be mature, many opportunities remain in
reaches a second part of the system, the fields in the first part basic research and in new medical and industrial applications.
of the system have changed. It is, therefore, necessary to have
an adequate knowledge and understanding of electromagnetic
theory at high frequencies. Despite this, the ordinary concepts
TABLE 3-1 . Frequency bands, wavelength, and their designation TRANSMISSION LINES AND WAVEGUIDES
in the electromagnetic wave spectrum around the microwave
frequency extending to the x-ray range.
A transmission line is a system of material boundaries forming
\
Wavelength, Frequency" Adjectival a continuous path from one spatial location to another and
(cm) (A) (Hz) designation capable of directing the transmission of electromagnetic energy
along the path. Consider a transmission line with differential
LF radio waves
MF radio waves TABLE 3-2 . Microwave frequency bands and frequency range of
HF short waves each band.
VHF short waves
UHF microwaves Frequency Frequency Wavelength Center
SHF microwaves band (GHz) (cm) frequency (GHz)
EHF microwaves
Far-infrared L band
Near-infrared S band
Infrared C band
Visible X band
Ultraviolet K band
X-ray Q band
V band
K = kilo (lo3).M = mega (lo6).G = giga (lo9).T = tera (10"). W band
A = angstrom = 10-8cm.
52 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS
length Az in which the current I is flowing in the z direction as
shown in Figure 3-4a. The equivalent circuit of this transmis-
sion line can be simply represented by using an effective
inductance L per unit length and an effective capacitance Cper
unit length as shown in Figure 3-4b. From this equivalent
circuit, one can derive the 1-D wave equation.
1 impedance of the transmission line.
Here v = and y is the velocity of the wave propaga-
LC
tion. If Vvaries sinusoidally with time, then V = Voe-jot, where
w is the angular frequency. Therefore eq. (3-4) can be rewritten
as
where y = jo and is called the propagation constant of
the electromagnetic wave. If the transmission line has some
loss, y has the form of y= CY + jp, where CY is called the
attenuation constant and p is called the phase constant. For
a lossless transmission line CY = 0 and p = o m .Since
,,=--m
I - fh, the phase constant p can be expressed as
The general solution of eq. (3-53s
Similarly, we can obtain the solution for I as follows:
V V + AV
0 0
+I f-
I + A1
(a) Transmission Line
1 LAz 1 the TE and TM modes for rectangular waveguides. For a circu-
-
L
CAz
(b) Equivalent Circuit
FIGURE 3-4 . Schematic of transn~issionline (a) transmission line and
(b)equivalent circuit.
We can consider an effective impedance, Z,for this trans-
mission line as the ratio of V and I
The effective impedance & is called the characteristic
Finally, Vand I with the time dependent factor dot for the
low loss transmission lines are given by
where V+ ei(mt-Pz) represents the wave propagating in the
forward direction (+z direction) and V ei(~t+Pz) for the back-
ward direction (-z direction).
There are two basic types of transmission lines used at mi-
crowave frequencies. They are illustrated in Figure 3-5. Paral-
lel transmission lines, coaxial transmission lines, and shielded
striplines shown in Figure 3-5a are two conductor transmission
lines, and are commonly used at the lower microwave frequen-
cies. These transmission lines are called TEM lines since they
support the transverse electromagnetic mode, which means Ez
= H, = 0, and where z is measured along their length.
At higher microwave frequencies, hollow pipes such as
rectangular, circular, and ridged waveguides shown in Figure
3-5b are used since they have lower loss and practical dimen-
sions at such frequencies. These waveguides support either the
transverse electric (TE) mode (E, = 0,Hz # 0) or the transverse
magnetic (TM) mode (Hz =0, E, # 0) and do not support the
TEM mode.
The electromagnetic field distribution along the transmis-
sion line is determined by solving Maxwell's equations within
the given boundaries (called boundary-value problems). These
boundaries are the spatial geometry and electrical properties of
the conductors and the associated medium. In a rectangular
waveguide, a TE wave with m half-sine variations in the x
direction and n half-sine variations in they direction is denoted
as a TE, mode wave. Similarly, TM waves are denoted as
TM,,. For a rectangular waveguide, TElo is the most com-
monly used and referred to as the dominant mode of wave
propagation. Figure 3-6 shows field distributions in several of
lar waveguide, cylindrical coordinates (@,r, z) will be used so
that the solutions of Maxwell's equations may be written in
terms of Bessel functions. In a circular waveguide, a TM wave
with m half-Bessel variations in the @ direction and n half-
Bessel variation in the r direction is denoted as a TM, wave.
For a circulator waveguide, the TEI, wave has the lowest cutoff
frequency of all permitted TE and TM waves. Figure 3-7 shows
field distributions in several modes for circular waveguides.
 TRANSMISSION LINES AND WAVEGUIDES 53

- -
(a)Parallel line (6)Coaxial line ( c ) Shielded strip line

-- - - - -
(a)Rectangular (6)Circular ( c ) Ridged

FIGURE 3-5 . Various transmission lines (1) two conductor types and (2) waveguide types. The electric fields E are represented by lines with arrows.

FIGURE 3-6 . Summary of electromagnetic field distribution for rectangular waveguides (from Ref. 5).
54 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS

IMPEDANCE MATCHING AND VOLTAGE

STANDING WAVE RATIO

Figure 3-8 shows a simple circuit of source with internal

impedance R, connected to a load with impedance RL. The
power consumed by RL is given by

-
p = [R, kLJ.
One can show that P will reach maximum when R, = RL.
This condition, called "impedance matched," means that the
load impedance is chosen such that the maximum power can
be delivered from the source to the load.
Similarly, the transmission line impedance Z,should be
matched to the load impedance in order to optimize the power
transmission to the load.
Consider a low-loss transmission line with a characteristic
impedance of q,which is terminated in a load impedance ZL
at z = 0 as shown in Figure 3-9. From eqs. (3-10) and (3-1 1 )
8.
FIGURE 3-8 . Schematic of a source with an internal impedance Rs
connected to a msistive load RL

I(z = 0 ) = -1 (V+ - V-)ejm

we obtain zo (3-14)
We define the reflection coefficient p as the ratio of voltage
V(z = 0) = (V+ + V-)ejWt (3-13) in the reflected wave to that in the incident wave.

-----
-.,, '
----------- .- - - - - -
---_ '. ; , ' ' ' ' .-- ''
,'
------- . ,,>, ;
;
I
;----
--., , ;,
I,
1

I a \ \ , ' I

I I
i iiii - - -
_--i i, t; !\ ! i.---', ; ;
3
I,,
' I , ,
8,
4
\

- , , .- ----- -" : : '-----

_ _ - .' 8

- _ _ _ -,-'
I
'.- - - _ _ _ _ _ _I-I- \\
---___

-b--
-. , I-
----+---- --+--

,---*---.',
\ ,
-b-.
,
', ; ; -*--
1
I
b
,
I
I
,
e

I
c
, \
,
$
$

0
, I
,
8

I
I
,

FIGURE 3-7 . Summary of electromagneticfield distributionsfor circular waveguides (from Ref. 5).
 RESONANCE AND RESONANT CAVITIES 55

FIGURE 3-9 Schematic of a low-loss transmission line.

z= 0
(3-15)
FIGURE 3-10 - Voltage waveform with ZL # ZOterminated with ZL.
since V(z = 0) = ZL X I(z = 0).
One can also derive an equation for the input impedance RESONANCE AND RESONANT CAVITIES
at z = - 1 looking toward the load as follows:
Resonance or resonant phenomena can be observed in every-
ZL + jZo tan pl
zi = zox Zo + jZL tan pl day life. For example, in most musical instruments, such as the
piano or violin, strings of discrete length vibrate at certain
frequencies, and this phenomenon is called resonance. Sirni-
If ZL = Zo, no power will be reflected since V- = 0 and larly, atoms or molecules can resonate at much higher frequen-
for this condition it is said that the transmission line is matched cies. Figure 3-11 shows three mechanical resonant phenomena
to the load. we may encounter, which can be visually observed in everyday
If ZL # ZO,then the voltage envelope along the transmis- life. In mechanical resonance, kinetic and potential energy are
sion line will look as shown in Figure 3-10. We define the transferred back and forth. In electrical resonance, which we
voltage standing-wave r a t i 4 ~ as~the~ ratio ~ )of the maxi- cannot visually observe without the help of sophisticated in-
mum voltage amplitude to the minimum voltage amplitude. struments,the electric and magnetic energy are interchanged at
the resonant frequency f. Figure 3-12 shows simple lumped
VSWR
Vm,
= --
-
Iv+l+ Iv-l 1 + lp\ element resonant circuits for two different cases, that is, (a)
Vmin I
IV+ - IV-I - 1 - IPI (3-17) series resonant and (b) parallel resonant circuits. One can

FIGURE 3-11 - Examples of mechanical resonance.

56 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS

( a ) Series resonance (b) Parallel resonance

FIGURE 3-12 . Lumped element circuits. (a) Series resonant and (b) Parallel resonant circuits.

derive second-order differential equations for these circuits in The term "Q," which stands for "quality" or "quality
terms of the voltage and current. factor," concerns relative energy damping and is often used in
resonant circuit analysis. For a resonator with resonant angular
frequency o , Q is defined as follows:
(3-18)
. .
energy stored in the circuit
Q=oX
d2v dV V energy dissipated in the circuit per second (3-26)
Cp,+G -+-=O
dt 'dl \Lp (3-19)
The stored energy in the series resonant circuit is %LSP
The general solutions of these equations have the follow- and the average power is m s P . Therefore,
ing form:

I = Ioe-aSt (Al cos w,t + A2 sin w,t) (3-20)

V = Voe-apt(B, cos opt + B2 sin opt) (3-21) The stored energy in the parallel resonant circuit is lhCpVZ
and the average power dissipated is l/(ZGpV2.Therefore,
where

For the case of L,= Lp = L; C, = Cp = C;

1 1
R, = - = R and a << -(low loss case),
(3-23) GP LC

and
(3-25)

where AIA2,B1, and B2 are constants.

 RESONANCE AND RESONANT CAVITIES
FIGURE 3-13 . Resonant structures, parallel plate ends connected by
(a)coil, (h) straps, and (c) cylinder.
Figure 3- 130 shows an example of an electrical resonant
circuit where two parallel plates (capacitor) are connected
with a helical coil (inductor). At the higher frequencies, this
type of inductor is not preferred since the impedance becomes
too high and the electrical energy cannot be quickly transferred
between the inductor and the capacitor. Figure 3-13b shows
multiple inductive straps suitable for higher frequencies and
Figure 3-13c shows when the straps completely surround the
capacitor. This latter type of completely enclosed resonator
is called a microwave cavity and is often used in the micro-
wave frequency range, where its dimensions can be practical.
The electromagnetic field distributions in a circular cylin-
drical cavity (often called a pill-box cavity), as shown at one
57
Current
I
Electric field
FIGURE 3-14 . Electric and magnetic field distributions in a TMolo
mode cylindrical cavity (from Ref. 5).
instant of time in Figure 3-14, can be analytically determined
by solving Maxwell's equations with the given boundary con-
ditions. Adaptations of this type of cavity are often used in
practice for accelerators, rf generators and other rf components
such as wavemeters. The resonant frequency of a pill-box
cavity varies with the geometry and the resonant mode. The
field distribution in a pill-box cavity can be determined from
the corresponding wave of the waveguide mode (TE,,,,, or
TM,,,,,) traveling forward in the +z direction and backward in
the -z direction. For TM,,,,, waves resonance with I variation
of the field within the z boundaries, is denoted as TM,,,,I.
Similarly, TE,,,,,,is the notation for TE,,,,,wave resonance where
1 again relates to the z coordinate and boundaries. Figure 3-15
shows the mode chart for a pill-box cavity of radius a and length
d. For the reader's reference, other TM mode field distributions
in a cylindrical cavity are shown in Figure 3-16. For 2a > d,
the lowest resonant mode is TMo,,,. This mode can be consid-
ered as a TMol mode in a circular waveguide operating at
cutoff. The electromagnetic fields are given as follows:
~ E o
H - -J , (kr)
+ - 11
where k = 2.40510, q = intrinsic impedance of the medium and
equals 120 x ohms for vacuum. The terms J, and J , are zero-
58 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS

order and first-orderBessel functions of the first kind. As shown

20 x in Figure 3- 17, the unique features of a TMonomode are that the
electric field is parallel to the axis and has maximumintensity at
the axis of the cavity. Therefore, the TMo,Omode is suitable for
accelerating paraxial particles. Figure 3-17 indicates the dis-
placement current flow (in dashed line) and the real current flow
15 x (in solid line). For n > 1, the cavity is divided into n resonant LC
circuits as shown in the equivalent circuits. The energy stored,
N
- U,in the cavity at aresonance TMol, mode is given by
E
0

-r".-
N

C
N lox
5-
-
N
where E, is the dielectric constant of the enclosed medium and
Q is the permittivity in free space in faradlmeter

5x

The power loss P, is calculated as follows:

7 ~ R, E;
P, =
a

q2
:
J (ka)[d + a]

FIGURE 3-15 . Mode chart for a cylindrical cavity: Resonant fre-
quency versus square of ratio of diameter to length for TM ri?_dTE fun-
~-
damental and higher order modes (from Ref. 6).
where R, is the surface resistivity and equals 2.61 X 10-7 e
in ohms for copper at a frequency f. Therefore the Q of the
TMolomode for copper is given by

(a) TMolomode (b) TM,, ,mode (c) TM, ,,mode (4 TM,,,mode

(e) TMo,,mode (0 TM,,,mode (g) TM1,,mode (h) TM,,,mode

FIGURE 3-16 - Direction of electric and magnetic fields for TM fundamental and higher order modes for cylindrical cavity (from Ref. 9).
 PERIODIC STRUCTURES AND COUPLING 59

dz o
Therefore the velocity of the wave propagation - = -.
dt S
Since this is the velocity of the constant phase, it is called the
phase velocity and is often denoted as up.

o
Axis up = P (3-39)

In order to conceptually understand the group velocity,

consider that two waves with the same amplitude but slightly
TM010
different frequency are added as follows:

where

-5
Therefore;

This means a wave with phase velocity up is modulated

Axis with a low-angular frequency A o as shown in Figure 3-18. The
velocity of this modulation wave is called the group velocity
us and is given as follows:

FIGURE 3-17 . Radial variation of axial electric field E, (r) and equiva- Group velocity is usually the same as the velocity of
lent circuits for (a) the TMolo mode and (b)the TMozo mode (from Ref.
energy travel.
4 of Chap. 4).

PHASE VELOCITY
AND GROUP VELOCITY PERIODIC STRUCTURES
AND COUPLING
Consider a wave propagating in the forward direction described
- - -

by a voltage function of A periodic structure is a system consisting of multiple discrete

v+ei(ot - Pd elements spaced in a periodic manner. For example, the crystal
(3-36) structure of a monoatomic lattice, such as silicon, is a periodic
If the phase (wt - Pz) is constant @, as
Modulation =-+%
o t - PZ = bc

then 'Carrier Wave

+w
(3-38)
FIGURE 3-18 . Illustration of group velocity (from Ref. 14).
60 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS

K M K M K M K M K
(a)

FIGURE 3-19 . Periodic Structures (a) Mechanical analogy with periodic springs and masses. (b)Microwave transmission line loaded with lumped
impedences.

vp* = fA, 5 c

(4

.
FIGURE 3-20 Instantaneous electric field in (a) a cylindrical waveguide and (b)a disk loaded cy-
lindrical waveguide.
 PERIODIC STRUCTURES AND COUPLING
structure. These mechanical periodic structures can be repre-
sented by a series of mass M and spring K combinations, as
shown in Figure 3-19a. A microwave transmission line loaded
with lumped impedance, Z, spaced at periodic intervals, d, as
shown in Figure 3-19b, is often used in microwave active and
passive devices. There are two basic important properties for
all periodic structures: (a) the phase velocity is less than the
velocity of light and (b) they transmit only in the frequencies
of the pass bands and not in the stopbands.
Figure 3-20a shows a simple circular waveguide of radius
a and the instantaneous electromagnetic field distributions of
the TM,, mode. This structure cannot be employed for particle
acceleration since the phase velocity up,given by
is greater than the velocilty of light c.
By introducing a series of annular disks, as shown in
Figure 3-20b, the phase velocity will be reduced. Thus, this
Cavity 1 Cavity 2
(a)
FIGURE 3-21 . Electric coupling of two cylindrical cavities (a) via axial
iris and (h) via capacitance Cc in an equivalent circuit.
61
kind of structure is often called a slow wave structure. If a
transmission line with the phase velocity up,given by
is loaded with lumped shunt capacitances Co at periodic inter-
vals d, the new phase velocity will be given by
This means that the energy of propagating electromagnetic
wave is locally stored in the shunt capacitances, hence slowing
down the wave propagation. Slow wave structures are very
often utilized in microwave passive and active devices. They
hav very important roles in slowing the phase velocity to
!
mat h the velocity of the electrons, especially in traveling wave
amplifiers or in accelerators, where the electron beam must
strongly interact with electromagnetic waves.
The characteristics of passband and stopband can be un-
derstood by plotting propagation constant P versus wave num-
Cavity 1 Cavity 2
(a)
FIGURE 3 2 2 . Magnetic coupling of two cylindrical cavities (a) via slots
in the disk between cavities and (b) via mutual inductance M in an equiva-
lent circuit.
62 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS

ber k, where k is given by k = 6.

o.The plot is called the
k p diagram or the Brillouin diagram.
As shown in Figure 3-20b, a disk loaded waveguide can
be considered a series of cylindrical cavities coupled through
their apertures. Figure 3-21a shows two resonant cavities with
TMolomodes coupled through an aperture. Since the aperture
is located near the axis of the cavity where the electric field
strength is maximum, these cavities are electrically coupled.
Figure 3-21b shows an equivalent circuit of this type of cou-
pling in which the electrical coupling aperture will be repre-
sented in a coupling capacitance C,. Similarly, a magnetic
coupling can be achieved through a magnetic coupling iris as
shown in Figure 3-22a. The equivalent circuit of this type of
coupling is shown in Figure 3-226, where M is a mutual
inductance. The relation between M and self-inductances L,
and 4 is usually written as follows:
where k is called the coupling constant between L, and &.
When two identical cavities (C, = C2, L1 = &, and R1 =
R2) of resonant frequency fo are coupled, the total resonant
frequencies are not fo anymore, as shown in Figure 3-23. For
tight coupling (large k), two clearly separated resonancesfi and
f2 appear. The relation between the coupling constant k and
frequencies is given by
resonant mode or the waveguide mode. Figure 3-24 illustrates
the differencebetween a single cavity and two coupled cavities.
Figure 3-25 shows three identical pendulums coupled by
springs. One can imagine three different pendulum motions.
They are
1. All pendulums move in the same direction synchronously.
2. Each pendulum moves in an opposite direction.
3. Two end pendulums move in opposite directions while the
center pendulum does not move at all.
The mathematical analysis of these pendulum motions is
rather complicated, but one can estimate the force acting on
each pendulum. For case I, there is no force on the springs and
for case 11, the force on the springs will be maximum, while for
case 111, the force will be somewhere in between case I and case
11.
Therefore, the velocity of motion of the pendulums for
case I will be lowest since three masses move together, while
case I1 will be highest. Thus, the frequency of pendulum
motion will be highest for case 11, lowest for case I, and the
frequency of motion for case I11 will be somewhere in be-
Single Resonator Coupled Resonator

MODE AND DISPERSION

When N resonators are coupled, N different resonator opera-

tional modes appear. These modes are different from the cavity
Amplitude Amplitude
Amplitude 4 4

fo

-
FIGURE 3-23 Frequency spectrum (relative field amplitude vs. fre-
quency) for various degrees of coupling: (a) fork = 0, (no coupling), the
system resonance stays at fo. (b)For relatively light coupling, (k small), .
FIGURE 3-24 Mechanical analogy, equivalent circuit, frequency spec-
two resonance peaks appear. (c) For tight coupling, (large k), two reso- trum, and cylindrical cavity electric field direction for single resonator
nances are further apart. and for two coupled resonators.
 MODE AND DISPERSION 63

Case I

Case II
Compressed

Stretched ----

Case Ill

u f u
No Motion

FIGURE 3-25 . Three coupled pendulums, showing different modes of oscillation.

tween. The operational mode for case I is called zero mode,
that is, zero phase shift between adjacent pendulum motions.
Similarly, case 11mode is called the 7t mode (180" phase shift
between adjacent pendulum) and case I11 mode is called the
1~12mode. When N resonators are coupled (see Figure 3-26
for an example of N = 7), N different operational modes exist
and each mode is defined as follows:
where n = 0,1,2,3 ,..., N - 1.
Figure 3-27 shows the amplitudes of axial electric fields
for the allowed modes of seven coupled resonators. The seven
operational modes and resonant frequencies can be plotted on
a mode diagram as shown by the circles in Figure 3-28. This
diagram is often called the dispersion relation of resonators,
and the phenomenon is called dispersion; that is, the phases of
motion of pendulums vary with frequency. In the disk loaded
waveguide, as shown in Figure 3-26, the phase velocity of the
wave varies with frequency.
64 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS

Multicavitv O~erationalMode

Amplitude j
A

-pass band
7 resonances

- : Freq.

FIGURE ,-26 . An example of seven coupled cavities and their corresponding seven resonance fre-
quencies in the lowest pass band of frequencies.

SHUNT IMPEDANCE AND TRANSIT TIME

A simple circuit theory states that the power loss PL in a

where Eo is the accelerating field and is given by

resistance R is given by
where V is the voltage drop across the resistor. Similarly, we
define the shunt impedance r of an accelerating cavity assum-
ing the accelerating field is time independent, as follows:
where Vm is the maximum energy gain by a particle going
through the cavity and PL is the power lost in the cavity. If the
cavity length is L, then the shunt impedance per unit length is
given by
Figure 3-29a shows an ideal pill-box cavity for a particle
accelerated from left to right by passing through the cavity. The
accelerating electric field E varies with time t as E = Eocos ot.
In the real case, the finite radius beam aperture creates radial
components of the E field as shown in Figure 3-29b, thus the
axial electric field E depends on z. Assuming E is independent
of z, the velocity u of the particle is constant, and it passes
through the center of the cavity at t = 0, the energy gain V of
the particle is given by

Since z = ut
 SHUNT IMPEDANCE AND TRANSIT TIME 65

Frequency

II Shift
I I I I I I :Per
Cavity

FIGURE 3-28 Dispersion diagram for seven coupled cavities.

Thus the effective shunt impedance, Z,, in which the

transit time effect is considered, can be defined as follows:

Zeff =zT'=- v
P, xL

Section A-A

+
Current I
Charge +,-
-EField
+---'A'
HField
LI

a b c

FIGURE 3-27 . Amplitudes of axial electric fields for the allowed modes
of seven coupled cavities (from Ref. 4 of Chap. 4).

Section A-A

(3-54)
where

T=
sin(oL/2u)
0L/2v (3-55)
-
Current I
Charge +,-
t--
EField
+---'A'
HField
b

and is called the transit time factor. This factor is always less a b c
than unity. From eqs. (3-51), (3-52), and (3-54), Z will be (4
given by
FIGURE 3-29 . Wall current flow I, end plate charges, E field and H
field in cylindrical (pill-box) cavity: (a) without coupling apertures and
(3-56) (b) with axial coupling aperatures.
66 CHAPTER 3. MICROWAVE PRINCIPLES FOR LINACS
If w e assume a n accelerator consists of a series of pill-box
cavities each of length L = M2 and the particle velocity v = c,
K K
the transit time factor will be only 0.637 ( = sin -/-), and the
2 2
Z,, will b e only 0.406 Z.
For a pill-box cavity of radius a and length L, the shunt
impedance per unit length Z is given b y
rl; L
z=
na R, ( L + a) J : (ka)
where q, = 1207r and R, = 2.61 X 10-7 X $(for copper).
Since ka = 2.405 for a TMOlomode resonance, cavity radius a
should b e 3.825 c m in order to resonate at the f r e ~ e n c of
y 2998
MHz. If L = 5 c m (A = 10 cm), the shunt impedance per unit
length Z will b e 146 M W m . Therefore the effective shunt
impedance is 146 X 0.406 = 59 M W m . T h e transit time factor
will increase if L is decreased, but Z will decrease. Figure 3-30
shows the relationship of Z,, and L.
I n general, the accelerating cavities have beam holes, as
shown in Figure 3-29b, and the accelerating electric field, E
along the beam axis, is not uniform like the pill-box in Figure
3-29a.
If E = Eo(z) cos wt, then the transit time factor should b e
given by
FIGURE 3-30 . Effective shunt impedance Z? versus length L of cylin-
drical (pill-box)cavity.
0 2n
where y = - = -and p = -.
v
v Qh c
T h e most useful references for Chap. 3 are textbooks,
which are listed in the reference section (1-21).
REFERENCES
1. Panofsky W, M. Phillips: Classical electricity and magnetism,
New York, Addison-Weslley Publishing Co., 1962.
2. Purcell, EM: Electricity and magnetism. Berkeley Physics
Course; New York, McGraw-Hill Book Co., 1965, vol2.
3. Slater JC, NH Frank: Electromagnetism. New York, McGraw-
Hill Book Co., 1947.
4. Cheng, D.: Field and wave electromagnetics, New York, Addi-
son-Wesley Publishing Co., 1983.
5. Ramo S, John R. Whinnery, T. Van Duzer: Fields and waves in
communication electronics. New York, 1965.
6. Collin RE: Foundations for microwave engineering, New York,
McGraw-Hill Book Co., 1966.
7. Feynman R: Lectures on physics: New York, Addison-Wesley
Publishing Co., 1964.
8. Slater JC: Microwaved electronics. Van Nostrand Co., 1950.
9. Ishii TK: Microwave engineering, The Ronald Press Co., 1966.
10. Ginzton EL: Microwave measurement. New York, McGraw-Hill
Book Co., 1957.
11. Laverghetta TS: Microwave measurements and techniques.
Artech House Inc., 1975.
12. Slater JC: Microwave transmission. New York, McGraw-Hill
Book Co., 1942.
13. Plonsey R, R Collin: Principles and applications of electromag-
netic fields. New York. McGraw-Hill Book Co., 1961.
14. Brillouin L: Wave propagation and group velocity. New York,
Academic Press, 1960.
15. Crawford, Jr. Frank S: Waves. Berkeley Physics Course, New
York, McGraw-Hill Book Co., 1968, vol3.
16. Atwater, HA: Introduction to Microwave Theory. New York,
McGraw-Hill Book Co., 1962.
17. Cardiol, FE: Intorduction to Microwaves. Artech House, Inc.,
1984.
18. Stratton, JA: Electromagnetic Theory. New York, McGraw-Hill
Book Co., 1941.
19. Moreno, T: Microwave Transmission Design Data. New York,
McGraw-Hill Book Co., 1948.
20. Purcell,EM: Electricity and magnetism. Berkeley physics course;
New York, McGraw-Hill Book Co., 1965, vol. 2.
21. Marcuvitz, N: Waveguide Handbook. New York, McGraw-Hill
Book Co., 1951.

Microwave Accelerator Structures
In this chapter, the structures of typical microwave electron
accelerators are described. Electrons are generated in an elec-
tron gun and injected into the accelerator. There are basically
two distinctly different types of accelerators, namely, the "trav-
eling-wave accelerator" and the "standing-wave accelerator".
These two accelerators have advantages and disadvantagesand
this chapter gives a detailed comparison of both types.
ELECTRON GUNS AND INJECTION
Electrons are injected into an accelerator structure from an
electron gun. A cross-sectional view of a two-electrode diode
electron gun is shown in Figure 4-1. It consists of a spherically
shaped cathode button 1,focus electrode 2, anode 3, and heater
4. The cathode is at a negative potential with respect to the
anode. Electrons emitted from the cathode are accelerated and
focused through the beam hole in the anode, which is usually
Focus (
Electrode
FIGURE 4-1 . Cross-sectional view of a diode electron gun.
C H A P T E R 4
at ground potential. The current in the beam for a given anode-
to-cathode voltage is largely determined by the ratio of the
cathode-anode spacing and the cathode diameter. In order to
vary the beam current over a wide range without varying the
anode-to-cathode voltage, a control grid is incorporated be-
tween the cathode and the anode as shown in Figure 4-2
forming a triode, a three-electrode electron gun. The required
grid voltage to control the beam current is typically 2-5% of
the anode-to-cathode voltage.
CATHODE
There are many types of cathodes in use for various gun
applications. They are basically divided into two different
types-namely, oxide cathodes and dispenser cathodes. The
oxide cathode can be operated at relatively low temperaturebut
the maximum current density is about 1 Alcmz. The advantages
of dispenser cathodes are generally, higher current density at
the cathode (100 AIcm2) and less susceptibility to gas poison-
ing. But the operating temperature for dispenser cathodes is
much higher (1 100°C) than for oxide cathodes (800°C). Tung-
Heater @-
Anode
FIGURE 4-2 - Cross-sectional view of a triode electron gun with con-
trol grid.
68 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES
sten dispenser cathodes are used almost exclusively in micro-
wave devices, since they are capable of high current densities
with long lifetimes. Oxide cathodes are used in low current
applications, such as in cathode ray tubes.
A tungsten dispenser cathode consists of a porous tungsten
matrix impregnated with barium oxide (BaO), calcium oxide
(CaO), and alumina (A1203)compounds with a proper molar
ratio. Because of the high temperatures required, the surface
coverage of barium decreases with time, which means, the
cathode life is limited. A significant improvement in cathode
life can be made by overcoating the tungsten surface with
osmium, iridium, or ruthenium, thus reducing the work func-
tion by about 20 percent. Consequently,the cathode can operate
at 100°C lower temperature, which increases the life of the
cathode by a factor of about 10.
DESIGN OF AN ELECTRON GUN
Pierce type convergent electron guns are commonly used in
linear accelerators and klystrons. The conceptual model of a
Pierce gun uses an annular segment of the electron flow be-
tween two concentric spheres. The outer sphere comprises the
cathode, and the inner sphere the anode. The formation of the
electron beam using this concept is shown in Figure 4-3.
The current from such a gun will be given by solving
Poisson's equation.
1 - cos 8
I = 29.3 X
a2
v"
where
V = voltage between cathode and anode
0 = cathode radius angle
. Electron
Beam
-z
Cathode
49 - Catl
,
Electrode \
.- - - - _ - -.,
FIGURE 4-3 . Pierce gun electron beam trajectories.
Equation 4-1 can be rewritten as I = P X V, where P
is a geometrical function called "perveance," I is in amperes
(A) and V is in volts, (V). Typical values of perveance for
electron guns used in medical linear accelerators range from
0.1 x 10-6 to 0.5 X 10-6. Modern electron guns are designed
using a combination of digital computer techniques and ex-
periments using a beam analyzer. Figure 4 4 shows typical
electron trajectories in a diode gun of perveance 1.4 X 10-6
(1.4 rnicroperveance unit) at 40-kV anode voltage.
ELECTRON INTERACTION WITH
MICROWAVE FIELD
MOTION OF ELECTRONS
Electrons are accelerated in the direction of motion only by an
electric field E, while magnetic fields exert forces at right angle
to the direction of electron motion and to the direction of the
magnetic field B. This relation which is called the Lorentz force
equation, is given by
where F is the force acting on an electron of charge e and
velocity v. This equation says that an electric charge is acted
on by two types of force: an electric force, independent of its
velocity, and a magnetic force, proportional to its velocity u.
Also, it says that the electric force is along the electric field line
and the magnetic force is at right angles to its velocity and the
magnetic field. In the MKS system of units the force is given
in newtons, the charge in coulombs, electric field E in volts per
meter, u in meters per second, and magnetic field B in webers
per square meter (1 weberIm2 = 104 gauss). Since
dP d
F = - = - (mu), eq. (4-2) can be written as
dt dt
d
- (mu) = e (E
dt
+ v X B)
Equipotential Lines
40 kV Anode Electron
FIGURE 4-4 . Conlputer simulated electron trajectories in a diode
gun. (Microperveance = 1.4. Voltage = 40 kV.)
 ELECTRON INTERACTION WITH MICROWAVE FIELD 69

For relativistic motion,

where mo is the rest mass of an electron and c is the velocity of

light. It can be shown that the kinetic energy T of an electron
is given by T = (m - mo) c2. Thus
Energy. Mev

FIGURE 4-5 . Relative velocity for an electron and a protron as a func-

tion of kinetic energy.

where:

1
P = -vc and y = (1 - P2)-2
For p <<I, equation (4-5) can be written as:
(4-6) Assume electrons are accelerated and decelerated by the
TMoI like mode microwave field near the axis, B, = B, = E,
= 0. Thus eqs.(4-9 and 4-1 1) reduce to

d
which is the classical expression of kenetic energy. Equation - (mi) = eE,
df
+ e;Be (4- 13)
(4-5) suggests that we should define a total energy W by:
Equations (4-12 and 4-13) represent the radial and longi-
w = r n c 2 = ~ +w o = y w o (4-8) tudinal forces governing the motion of electrons within the
microwave field of a TMol like cavity as shown in Figure 4-6.
The electric and magnetic fields of a TMoIlike mode cavity are
where Wo = moc2 and is called rest energy of the electron of
rest mass Ill0 and y = WIW,. The rest energy is 0.5 11 MeV for given by
an electron and 938 MeV for a proton, since the proton is 1836
times heavier than the electron. E, = Eo Jo(k,r) exp b(wt - Pz)] (4- 14)
Figure 4-5 shows the relation of kinetic energy T and
relative velocity for two particles, an electron and a proton. At
the same velocity, the energy of electron is 111836 the energy
of a proton.
The motion of electrons within an accelerator can be
divided into two parts: the longitudinal motion of electrons
traveling near the axis of the accelerator and the transverse
motion.
Assume an accelerator structure of periodically coupled
-[T[- 4=+~~
3

- . - . - . - . - . - - . - . - . - . - - - . - . - . - .- . - . - . -
cavities operating in a 'I'M,, like mode, which has an accel-
erating electric field component E, in the direction of accel-
eration z.
In cylindrical coordinates eq. (4-3) is

d
- (111;) - 111r6~= eE,
dt
+ e&B, - &Be
(4-9)

1 d FIGURE 4-6 . Radial and longitudinal components of r f electric force

- - (m?8) = eEe
r dt
+ eiB, - e;B, (4-10) in a cavity of a disk loaded accelerator structure.
70 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

4 = h4
Be
[ 1- -(.IT J 1 (kcr)exp

= ~ P E J,(k,r)
O ~ X b(wt
P - Pz)]
- Pz)l (blS)

(4-16)
ities of the structure are identical and the power attenuation
along z is held constant; hence the accelerating field decreases
with z. For the constant gradient case, the accelerator cavities
of the structure are not identical and the attenuation is increased
as z increases; thus the accelerating field can be held constant
where Jo and J1are Bessel functions, w, is the cut-offfrequency, along the axis z. This is accomplished by gradually decreasing
the diameter of the axial coupling apertures as the TW proceeds
down the structure. Figure 4-7 ( a ) shows the cross section of
k = -UC
c the constant impedance TW accelerator structure where all
cavities are the same while Figure 4-7 (b) shows a cross section
o of constant gradient TW accelerator structure where beam
p=- apertures are gradually decreasing for a wave traveling from
left to right. In the examples that follow, assume all the rfpower
p 2 = k2 - k2 propagatesthrough the acceleratorcavities to the load (no beam
loading case).
o For the constant impedance case, the rf power P at z is
k=-
c given by
and q is the intrinsic impedance of the medium. For an electron
traveling on the axis (r = O), the radial components of electric
field and azimuthal magnetic field are vanishingly small and where a is the attenuation factor constant and given by
radial momentum becomes zero for eq. (4-12).Consequently,
as long as the electrons are accelerated close to the accelerating a=-o
cavity axis, the transverse momentum is negligibly small com- 2vgQ (4-18)
pared to the longitudinal momentum.
where v, is the group velocity at which the rf energy flows
through ihe accelerator. The time required to fill the accelerator
1
SPACE HARMONICS with rf energy is called the "filling time" t, and is given by -,
"g
In the cylindrical coordinate system, the electric field configu- where 1 is the accelerator length. Thus the filling time for
ration can be Fourier analyzed in terms of space harmonics of constant impedance TW accelerator is given by
relative amplitude a,, as E, = Z a, Jo (k,,r)ei(W - P,z) where PI,
2nn
= Po + 7 Po is the propagation constant of the fundamental tF =
0 (4-19)
z.
space harmonic and k: = k2 - p This relation states that the Since the accelerating electric field E(z) is given by
phase shift per period for the fundamental space harmonic is
Pod and the phase shift per period of any other space harmonic E(z) = Eoe-az (4-20)
differs from Pod by an integral number of 2n. Also, all space
the energy gained by a synchronous electron can be obtained
do
harmonics propagate with the same group velocity - with by integrating over the accelerator length 1.
dP
amplitudea,,and become synchronous with the electrons. If the
fundamental harmonic (n = 0 ) is traveling at up = c, then Po
= k, and ko = 0 . Thus Jo(kl,r)is independent of r and E, has no
radial variation. Hence, for a beam of finite radial dimensions,
all electrons are subject to the same accelerating field.

TRAVELING-WAVE ACCELERATORS

THEORY OF OPERATION
Constant Impedance Constant Gradient
Traveling-wave ( T W ) accelerators make use of TW fields to
accelerate electrons. There are two different types of TW (a) (4
accelerators: namely, "constant impedance" and "constant gra- HGURE 4-7 . ~ i loaded
~ k TW accelerator strueturrs. (a) constant
im-
dient." For the constant impedance case, the accelerating cav- pedance type and (b)constant gradient type.
 TRAVELING-WAVE ACCELERATORS 71

The shunt impedance per unit length ro can be redefined
as follows:
From eqs (4-20) and (4-21), the energy gain V over the
accelerator length 1 can be written in terms of measurable
quantities as follows:
where attenuation T = GI.
For the constant gradient case, the attenuation factor
should be a function of z to maintain the constant electric field
E along the beam axis. Thus,
dP
- = constant
dz
By redefining the attenuation factor 7 as follows:
the linear decaying power profile P(z) will be given as follows:
and the filling time for constant gradient structure tFis given by
By substituting (4-26) into (4-22), the energy gain is
obtained by integrating the electric field over the accelerator
length and is given by
passes through a prebuncher cavity. The electric field in the
prebuncher cavity alternately accelerates and decelerates suc-
ceeding portions of the electron stream during a microwave
cycle. Consequently, the velocity of these electrons is mod-
ulated and they are increasingly bunched as they traverse the
structure as shown in Figure 4-8a. Figure 4-8b shows a cross
sectional view of the Varian Clinac 35 traveling wave accel-
erator structure, where guide section 1 (buncher) and guide
section 2 (main accelerator) are series connected through an
attenuator and phaseshifter in order to continously vary the
final energy.
The phase shift per cavity of the electric field is one of the
more important parameters in design of a TW accelerator. In
'IC
early accelerators, the - mode (four cavities per wavelength)
2
(see Figure 4-9a) was used. However, the optimum choice of
2'IC
mode of operation is the - mode (three cavities per wave-
3
length) (see Figure 4-9b) and this was used in later TW accel-
erators of the disk-loaded type. Figure 4-10 shows a cutaway
view of a TW accelerator structure. The nonuniform buncher
portion is on the bottom and the constant impedance uniform
accelerator portion is on the top. The coupling aperture diam-
eters of the buncher are gradually reduced in order to gradually
increase accelerating gradient. Table 4-1 is a summary of
SLAC TW accelerator design parameters.
The cross-sectional shape of the disk-loaded accelerator to
achieve the SLAC design parameters is shown in Figure 4-1 1.
There are many other variations of TW accelerator structure
designs, such as rounding off the corners of the cavities orusing
cavities connected by drift tubes, as shown in Figure 4-12a and
b, respectively. Both designs have a somewhat higher shunt
impedance, but the complication of the structure, and therefore
higher cost limit practical use. Figure 4-13 shows a TW accel-
erator using recirculation of rf power, to reduce frequency
sensitivity of the guide.

TABLE4-1 Summary of SLAC traveling-waveacceleratordesign

parameters
Although the constant gradient accelerator structure is
physically somewhat more complicated than a constant imped- Type of accelerator Constant gradient
ance structure, there are a number of advantages over the
constant impedance structure. They are (a) uniform power Operating frequency 2856 MHz
dissipation per unit length, (b) higher beam power conversion Length of sections 3.05 m
efficiency, (c) less sensitivity to frequency deviations, and (d) Phase shift per cavity 2~13
Attenuation T = a1 0.57 nepers
less susceptibility to beam breakup.
Shunt impedance per unit length 52-60 MOlm
Group velocity (vg/c) 0.0204-0.0065
Qo 13,000
STRUCTURES Filling time 0.83~s
Waveguide ID (2b)' 8.3461-8.1793 cm
Figure 4-8(a) shows a schematic view of a TW linac, in which Aperture diameter (2a)* 2.622-1.924 cm
the electrons are accelerated from left to right, the same Disk thickness (t) 0.5842 cm
direction as the rf power flow. The 80-kV electrons injected Average accelerating gradient 6.5 MeVIm
from the electron gun have a velocity nearly equal to one-half
the velocity of light. This continuous stream of electrons first 'See Fig. 4- 11.
72 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

Prebuncher Main Accelerator

F'IGURE 4-8 . (a) A schematic of two section TW linear accelerator.

A% Klystron

ELECTRON INJECTION AND BUNCHING
The functions of the injector and buncher (see Fig. 4-8) are
1. To generate, preaccelerate, and shape the electron beam
leaving the electron gun.
2. To prebunch electrons with the prebuncher cavity.
3. To accelerate and further bunch the electrons in the bun-
cher so that they match the phase velocity of the rf wave
in the main accelerator as they exit the buncher.
Velocity modulation by the rf fields causes some electrons
to be accelerated, others to be decelerated, according to the
phase of the rfrelative to the injected electrons. As the electrons
pass through a drift space the fast electrons overtake the slow
electrons and bunching takes place.
This effect of electron bunching can be demonstrated by
means of an electron travel plot as shown in Figure 4-14. The
injected electrons enter the prebuncher gap at z = 0 with the
velocity vo.If the rf field at the gap is E, sin ot, the velocity v
of the electron leaving the prebuncher cavity is given by

/-
4. To tightly bunch the electrons to obtain a narrow electron
beam energy spectrum.
v = vo vo
The gun injection voltage for TW accelerators is typically
80-150 kV. A prebuncher cavity consists of a simple reentrant
cavity followed by a drift space as shown in Figure 4-8a. The VI sin 8
drift space is involved in the bunching action as described
below. The prebuncher cavity is generally excited by the rf
= vo /L=L&-T)"0 (3 (4-29)

power branched off from the main waveguide using a direc- where Vo = gun voltage, vl = E,g, wg
= - and tl is the time
tional coupler, an attenuator and a phase shifter (see Figure 2%
4-8b). when the electron exits the gap of length g.
 TRAVELING-WAVE ACCELERATORS
FIGURE 4-8 . (b)A variable energy TW linear accelerator.
If we assume the gap to be much shorter than the rf
wavelength, the fastest and the slowest electrons meet at
(4-30)
If 4, is the rf phase at the time t , , when the electron departs
from the prebuncher cavity gap, and +2 is the rf phase at the
time t2 when the electron arrives at the end of the drift space D,
then:
where
u = velocity of the electrons after the prebuncher cavity
The relationship given by eq. (4-31) is shown in Figure
4- 15 for a gun voltage Vo of 150 kV and two different values
of R, the bunching parameter, which is given by
73
Figure 4-15 shows that 5 0 percent of electrons from the
gun (departure phase @,, from -90" to +90°) will be bunched
in 30" (arrival phase from - 15" to + 15") for R = 2.0.
The buncher (see Fig. 4-10) consists of a special section
of TW accelerator, which has tapered apertures so that the
phase velocity and field strength of the rf wave increase from
low value at the input end to the characteristic accelerator
values at the output end. As the electrons pass through the
buncher, they simultaneously gain energy and are bunched
longitudinally. In medical accelerators, tight bunching of elec-
trons is required to obtain a sharp energy spectrum for many
reasons. Tightly bunched electrons contribute to optimal treat-
ment beam characteristics and offer efficient, stable operation
of the accelerator. In addition, the buncher should: (a) permit
electrons to be injected at a relatively low voltage and captured
with high efficiency, which makes the electron gun design
simpler and more compact, and (b) increase the velocity of
exiting electrons to match the phase velocity of rfwaves within
the main accelerator.
Electron bunching requires that a slow electron traveling
74 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

FIGURE 4-9 . Radio frequency electric fields in disk loaded accelera-

tor structure. (a)
2
' X
mode, four disks per wavelength. (b)a 2- mode,
3
three d i s h per wavelength.
FIGURE 4-10 . Cutaway view of a TW accelerator structure with ta-
pered buncher initial portion and constant gradient final portion.
ahead of the peak accelerating field gradually drops back
towards the peak field, thus passing through the accelerator at
a phase where the accelerating field is greater. This allows the
slow electron to gain enough energy to catch up to and even
overtake the bunch. Fig. 4-16 shows this bunching process
along several wave crests within the buncher section where the
accelerating wave phase velocity and field strength increase as
electrons travel along.
Assume electrons in a 30" long group of prebunched
electrons are injected and located at the first crest of the
buncher field as shown at positions 1, 2 and 3.
The electron at position 1 will receive a greater accelera-
tion, and move forward in phase to overtake electron 2 as
shown on the second crest. An electron at position 3 will receive
a smaller acceleration and will be overtaken by the electrons 2
and 1. Finally, and by this process, electrons will asymptoti-
cally approach the crest of the wave as their velocity ap-
proaches the velocity of light. Note that the bunch width has
narrowed from 30" to 10' by this process.
The fundamental equations of longitudinal electron mo- FIGURE 4-11 . Shape of disk loaded accelerator structure to achieve
tion define the energy and phase as a function of 2. SLAC design parameters.
 TRAVELING-WAVEACCELERATORS 75

where AVis directly proportional to the accelerator total shunt

impedance Z and accelerated beam current i. This can be
understood by assuming a bunch of electrons is accelerated by
a simple gap capacitor, which is shunted with the impedance,
Z as shown in Figure 4-17.
Assuming the accelerating electrons are synchronous in
phase and ride on the crest of the wave, the power loss equation
with beam loading will be given by

Since the shunt impedance r is given by

Equation (4-36) can be converted to an equation for elec-

tric field E as follows:

for the constant impedance case and

for the case of constant gradient at i = 0.

The total energy gains for each case are given by integrat-
FIGURE 4-12 Examples of TW accelerator structure shapes to ing the eqs. (4-38) and (4-39)
achieve improved shunt impedance.

dz
= e~~ (z) sin +
for the constant impedance case and
and

+
where V(z) is the energy at position z, is the phase angle
for the case of constant gradient structure.
between the electron and the zero field position, and P,, and Po
are the normalized phase velocity of the wave and velocity of Both eqs. (4-40) and (4-41) have the form of
the electron.

where F and G are constants dependent on the design of the

BEAM LOADING AND LOAD LINE
The beam loading effect causes the rf-energy in the accelerator
electromagnetic fields to be reduced as the bunched electrons
are accelerated and gain energy from the accelerating fields.
Thus the resultant total energy gain is reduced to VT from the
unloaded energy gain Vo by AV
accelerator. A linear dependence of Von i is often called a load
line.
For example, assuming a 3-m length SLAC type constant
gradient TW accelerator (see Table 4-1) and Po = 5 MW, the
load line becomes
76 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

Input Return

' U
Phase Shifter

Termination

FIGURE 4-13 . A TW acceleratorwith recirculation of rf power, to reduce frequency

sensitivity and power loss.

This means the accelerator can provide 23.7 MeV of
energy without beam loading, but with an energy reduction of
0.0383 MeVImA of peak beam current.
STANDING-WAVE ACCELERATORS
THEORY OF OPERATION
In the TW accelerator, the rf power travels in one direction
through the structure and any residual power is absorbed in the
matched resistive load at the end of the structure. In the stand-
ing-wave (SW) accelerator, both ends of the structure are
effectively shorted so that the rf power is reflected back and
forth to create a SW within the accelerator. Figure 4-18
illustrates how the SW accelerator works. Unlike the surf boy
moving with the wave traveling, as shown in Figure 3-1, a ball
can travel continuously if the head motions of seals are syn-
chronized, as shown in Figure 4-18.
Figure 4-19a illustrates how the SW is generated by two
waves traveling in opposite directions within a lossless struc-
7C
ture operating in the - mode. A forward wave propagates from
2
left to right and is reflected losslessly at the structure end
boundaries. The backward wave propagates from right to left.

- Time

Time

-10 v

FIGURE 4-14 . Velocity modulation in time and resulting bean1 bunching in distance.
 STANDING-WAVE ACCELERATORS
Normalized Arrival Phase ( 1 ) ~ - 4 ~ )
FIGURE 4-15 . Departure-arrival phase relationships for velocity
modulated electron beam.
The forward and reflected electric fields are additive at time t ,
and t3 but zero everywhere at time t,. The resultant standing
waves are spatially stationary in phase but their magnitude
oscillates in time (see Fig. 4-19b).
In order to accelerate electrons efficiently with this SW
structure, the length of each cavity could be chosen to be equal
to a one-quarter wavelength. In this case, the energy gain V of
this type of SW accelerator of length 1 assuming attenuation is
zero, is given by
(4-44)
where ro is the shunt impedance Per unit length and PO the
power per unit length.
Since one-half of the cavities have zero field at all times
(see Fig. 4-1% and b) and have no role in acceleration, these
cavities can be very short or moved off the beam axis as shown
FIGURE 4-16 . Process of electron bunching by an oscillating electric field.
77
FIGURE 4-17 Schematic effect of beam loading on electron energy.
in Figure 4-20a and b, respectively. The resonant frequency of
such axial cavities depends only on their diameter, not their
length, allowing the structure design pattern of Figure 4-20a.
This type of SW accelerator is called a biperiodic SW acceler-
ator. It is also referred to as an on-axis coupled SW structure.
The arrangement in Figure 4-20b with coupling cavities moved
off beam axis is called a side-coupled SW structure. For
readers' reference, the triperiodic SW accelerator structures are
shown in Figure 4-21a and b.
In the case of a side-coupled SW accelerator, eq (4-44) for
energy gain will reduce to
v = m (4-45)
when the cavity length is equal to a half-wave length. In SW
accelerators, magnetic coupling is used instead of the electric
coupling of TW accelerators in order to efficiently couple each
cavity in the desired mode of operation and may shorten the
overall structure length.
Figure 4-22a shows a biperiodic chain of cavities with
nearest neighbor coupling k l , and second nearest neighbor
couplings 4 and k3. The accelerating cavities resonant fie-
78 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

FIGURE 4 1 8 . Ball moves continuosly down the line of seals, moving their head synchronously.

quency is o,and the connecting coupling cavities resonant where + is the mode number and given by
frequency is w2. Figure 4-22b shows the equivalent circuit of
the biperiodic cavity chain. Assuming - a number of accelerating- +=~q/2N q = O , l , ..., 2N (4-47)
cavities it = 0,2,. .., 2N and coupling cavities n = 1,3,. .., 2N The typical values of k,, kZ, and k3 for side-coupled SW
- 1, one can develop a series of equivalent circuit equations. accelerators are 0.03, -0.002, and 0, respectively,
By solving these equations, the dispersion relation of the equiv-
alent circuit is given by
STRUCTURES
+ cos 2 + + k3 cos 2+ Figures 4-23a and b show the optimized biperiodic and
triperiodic SW accelerator structures, respectively. These
(4-46)

TlME
fl

-1-
TIME \ \

Forward ??: :it: I

I
f, \

:
\
I 1 I I I
Backward *\\:
I I\ I I I
\ I \ /

1 \ / \
1
Forward l 4 - I
I
t," I I

I I I I I
Backward I I 1 I I

Pos.
EField Maxima
Neg.

Neg.
t-
+ EField Maxima

(4
n
FIGURE 4 1 9 . (a) Generation of a SW in a lossless TW accelerator operating in - mode. (b)Spatially stationary SW oscillating in amplitude versus
time. 2
 STANDING-WAVE ACCELERATORS 79

Coupling lris relatively simple structures offer a rather high shunt imped-
ance (about 80 Mfllm at the S-band frequency) and coupling
Beam Aperture factor (- 10 percent). These structures are suitable for
/ 1 application when the transverse space is limited but the
interaction between coupling cavities and the beam may be
serious. Since the cavity walls are mechanically weakly
supported, they are unstable for higher power operation.
Figure 4-24 shows a cross section and perspective of an

,--
optimized side coupled SW accelerator structure. Figure 4-25
illustrates how the axial electric field pattern changes in time
over a complete microwave cycle for the side coupled
Coupling lris structure. In Figure 4-26a, a complete SW accelerator, elec-
,-Beam Aperture tron gun, and buncher are integral with the structure (Varian
Clinac 20). Figure 4-26b shows a Siemens accelerator struc-
ture where the electron gun and vacuum chamber are an
integral part of the accelerator. Figure 4-27 shows a cut-away
of a Varian Clinac 4 side-coupled SW accelerator structure.
Electrons attain an energy of 4 MeV in this 27.5cm long
structure having five and one-half accelerating cavities and
five side-coupling cavities. The input waveguide is on the
bottom, while the electron gun attaches on the left and the
x-ray target is permanently sealed into the structure on the
right end.

FIGURE 4-20 . Biperiodic SW structures with magnetic coupling ap-

ertures. (a) On-axis coupling and (b) side-cavity coupling. ELECTRON INJECTION AND BUNCHING
In order to minimize length in most standing wave accelerators
used in medical and industrial applications, electrons are in-
,-
Coupling lris

f Beam Aperture
jected directly into the high gradient accelerator structure (bun-
cher). Consequently, about two-thirds of the electrons are not

r Coupling lris

Beam Aperture

.
FIGURE 4-21 Triperiodic SW structures with magnetic coupling. (a) FIGURE 4-22 . (a) A hiperiodic cavity chain and (b) it's equivalent cir-
On-axis coupling and (b)sidecavity coupling. cuit.
80 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

(a) (b)

FIGURE 4 2 3 . (a) An optimized hiperiodic SW accelerator structure and (b) an optimized triperiodic SW accelerator structure.
captured and some are even accelerated back to the electron BEAM LOADING AND LOAD LINE
gun. As shown inFigure 4-26a, the very first cavity that the elec-
tron sees is a one-half-cavity instead of the subsequent full sized An SW accelerator coupled through a coupling network to a
cavities in order to be launched adequately forward on the rf power source can be represented by a parallel resonant circuit
wave. Normally, the accelerating gradient is constant along the as shown in Figure 4-30a. The interaction of a stream of
length of the SW accelerator and runs 10-25 MeV/m depending bunched electron beam with the accelerating cavity can be
on the design. This means the electrons gain a maximum energy understood by adding a constant source parallel to the circuit
of 250 to 600 kV in the first one-half- cavity, thereby reaching a as shown in Figure 4-30b.
velocity approaching the speed of light (0.8~).Assuming the in- Assume Po is the unloaded beam coupling factor given by
jected electron has an initial energy of 15 kV (electron gun volt-
age), the average velocity of the electron leaving the gun will be
Q
p0 -02
-
0.2 c. Therefore the optimum length of the first cavity should be Qext R (4-48)

h,
around- in orderto match the phase velocity with the averaged
4
electron velocity. Figure 4-28 shows the computed phase orbit
diagram of an accelerator (Varian Clinac-1800 accelerator for
18X mode). As shown, the most accepted electrons (between
- 110" and 20") at the first half-cavity are accelerated and
bunched into the output phase angles between - 10" and -60°,
during the electron travel within the buncher.
Figure 4-29 shows the relation of the accelerating gradient
and the length of a buncher cavity (normalized) for various
injection energies. In this case, the initial three and one-half
cavities, having uniform lengths, constitute the buncher fol-
lowed by centerline cavities of f3 = 1 structure.

-
Beam
Channel

Cavity
Coupling
Cavity

FIGURE 4 2 4 Perspective of interior of side coupled SW accelerator FIGURE 4-25 Sequential look at the axial electric field pattern for
s~Nc~u~T. one full cycle of side-coupled structure.
 STANDING-WAVE ACCELERATORS 81

Side Centerline
Cavities Cavities

Electron
Window

RF Window

FIGURE 4-26 . Crosssection of typical side-coupled SW linear accelerator structures. (a) A Varian Clinac 20 accelerator and (b)a Siemens Meva-
tron accelerator.

where Z = rl, Qois the Q factor of the accelerating cavity itself, 4Po
Q,,, is the external Q factor, and R is the impedance coupled to PT = Po - P, =
(1 + I%,)2 (4-50)
the external circuit. For the unloaded beam case, the potential
Vo (unloaded energy gain) will be given by where Po is the source power and P, is the reflected power. By
substituting eq. (4-48) into eq. (4-47) the unloaded energy gain
(4-49) will be given by
where PTis the power transmitted to the accelerating cavity and
given by
82 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

magnetic wave bounces back and forth from one end to the
other many times (-20) per microsecond. From a TW point of
view, only the forward electromagnetic wave in the SW accel-
erator usefully couples to the traveling electron bunch and one
might conclude that one-half of the electromagnetic power is
wasted in the backward electromagnetic wave. However, this
can be a misleading view.
Both TW and SW accelerators employ a string of coupled
cavities. The electromagnetic energy in each individual cavity
oscillates sinusoidally at the accelerator resonant frequency.
The electric field amplitude in each cavity reaches approxi-
mately maximum value as an electron bunch passes its midgap.
The efficiency of conversion of rf power to electron energy gain
FIGURE 4-27 Cut-away of the Clinac-4 SW accelerator. in crossing the cavity gap is about twice as high in a SW acceler-
ator as in aTW accelerator. There are two major reasons for this.
For the beam loaded case, there is a potential drop V,, and
1. The SW accelerator has only two cavities per wavelength,
the total energy V will be given by
hence only four radial walls per wavelength on which rf
v = v, - v,, power is dissipated in the copper to establish the electro-
z magnetic field. The TW accelerator will not feed rf power
Since R = -, the total impedance encountered by the along its length with only two cavities per wavelength,
Po since this would be at pass-band cut-off. Typically, three
beam is -, the potential drop of a beam of current i is cavities are used per wavelength, hence 50 percent more
(1 + Po) radial walls on which rf excitation power is wasted.
given by 2. The SW accelerator couples rf power inductively, through
peripheral slots from one cavity to its two neighbors. This
leaves the axial region free to be shaped optimally. By
Thus the final energy V is using reentrant noses and small diameter apertures, the rf
electric field can be concentrated both in time and space
at the electron bunch in the gap. The forward TW type
accelerator couples rf power primarily electrically through
apertures on axis. These apertures must be quite large and
This equation shows the linear relationships of energy gain thin, in order to couple enough rf power from one cavity
V and accelerated beam current i , and is called the "load line." to its successor cavity. Thus, the spatial concentration of
Figure 4-31 shows load lines for two SW accelerators (Clinac the electric field at the electron bunch is much poorer than
1800 and Clinac 61100). in the SW accelerator. The time concentration of the elec-
The filling time for SW accelerator is given by tric field at the electron bunch is also typically somewhat
less in a TW accelerator than in a SW accelerator. It is
possible to use off-axis inductive coupling in a backward
TW accelerator and thereby be able to shape the axial
Thus the time dependent load line will be given by region for optimum efficiency, but this approach is still not
as efficient as a SW accelerator.
t - tb
v = % orl~(1 - e-t/tF) - -
rli [1 - exp(- -)I
1 + Po 1 + Po t~ Because the SW cavities are more efficient (higher Q), it
takes longer to fill them with electromagnetic energy than in a
where t6 is the time when the beam is turned on. TW accelerator. The filling time tf may be typically about 1.0
p s in a SW accelerator and 0.8ps in a TW accelerator. Thus,
with say a 4 p s rf input pulse, the usefiil (constant energy) beam
pulse is about 5 percent shorter with the SW accelerator than
TRAVELING-WAVE VERSUS with the TW accelerator, reducing useful average beam power
STANDING-WAVE ACCELERATORS accordingly.
In the SW accelerator the cavities are coupled tightly to
In the TW accelerator the electromagnetic wave travels only in each other, the coupling constant being many times larger than
one direction, from input to output end, and the electron bunch in a TW accelerator. Hence, the SW accelerator is many times
travels continuously with it. In the SW accelerator, the electro- more stable in phase versus temperature variations. Since the
 TRAVELING-WAVE VERSUS STANDING-WAVE ACCELERATORS 83

-k Input half cavity-+ First full buncher cavity 4-

z-Axial Direction

FIGURE 4-28 . Computed phase orbits (injected electron phase vs. distance) in a SW accelerator.

filling rf power flows only from input to output in a TW
accelerator, the output end does not "know" that a phase change
has occurred in the input end for about 0 . 8 ~ shence
, the higher
instability in phase. This effect has been reduced somewhat in
feedback type TW accelerators in order to make them less
sensitive to the natural frequency instability of magnetron
sources in some medical accelerators. However, the SW accel-
erator is many times more phase stable than even the feedback
type TW accelerator.
In summary, for physics research type machines and high
beam power industrial irradiators there can be advantages in
using either forward or backward wave type TW accelerators.
However, for the special needs of medical accelerators, where
physical space and rf power are at a premium and beam stability
is essential, the SW accelerator offers a number of advantages.
Table 4-2 shows a comparison between two Varian ma-
chine models, the Clinac-6 built in the 1960's employing TW
accelerator guide and the modem Clinac-61100 employing SW
accelerator guide. The shunt impedance per unit length is
almost twice as high for SW guide as for TW guide. Thus, for
the same input RF power and beam energy, the SW guide can
be much shorter than the TW guide. Because of the tight
coupling between cavities in SW guide, the group velocity is
2.5 times as high in SW guide as in TW guide. Thus, for the 4
to 1 ratio of guide lengths listed in Table 4-2, the RF power
travels from one end to the other in SW guide in one-tenth the
time it takes for TW guide. This is important in keeping all the
cavities in phase with the electron beam. The filling time to
reach prescribed accelerating gradient is essentially the same
for the TW and SW guides in Table 4-2, in spite of the higher
unloaded Qo of the SW guide (compare equations 4-19 and
4-53). The ratio of peak surface electric field to accelerating
gradient is much higher for SW guide than for TW guide and
the accelerating gradient is also higher for a given energy
84 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

"G
(Gun Voltage)
-

.
FIGURE 4-30 Equivalent circuit of SW accleerator coupled through
a coupling network to a power source. (a)When coupled with ideal
Normalized Buncher Cavity transformer. (b) When all quantities referred to secondary of ideal
Length (2IBlh) transformer. (From Ref. 1)

-
FIGURE 4-29 Optimum accelerator gradient versus buncher cavity
length for various injection energies

h
r
A
25 -

Rc
-

P 15 -
a,

-
Z /
/
/
/
I

I
I I k

0 100 200

Beam Current (mA) I :z

0 Lw L " LC
FIGURE 4-31 Load lines for various SW accelerator structures
(guides) and modes. FIGURE 4-32 Standing-wave cavity scaled cross-section.
 TRAVELING-WAVEVERSUS STANDING-WAVE ACCELERATORS 85

Nose Height L, in cm

Beam Hole Radius (mm)

ZT'
FIGURE 4-35 .Effective shunt impedance -versus nose height Ln
L
ZT' for a SW accelerator structure.
FIGURE 4-33 . Effective shunt impedance -versus beam hole rad-
L
ious for a SW accelerator structure. gain in a shorter length. Thus, SW cavity surfaces must be
machined and processed with great care. Another advantage of
the TW accelerator is the smaller diameter of the overall
structure compared to the side coupled SW structure, where
side cavities take considerable radial space (but not compared
to on-axis coupled SW structures).
Table 4-3 shows the factors to consider when selecting an
accelerator.
In general, a TW structure is less complex, hence less cost
for production per unit length. It does not require an isolator or

TABLE 4-2 - Cornparision o f T W vs S W acclerators

TW SW
accelerator accelerator

Machine CL-6 CL-61100

Energy (MeV) 6 6
Operating mode 2 ~ 1 3TW rl2 SW
Accelerator length (m) 1.4 0.3
Zefi-(MR/m> 55 100
Transit time factor 0.82 0.91
Accelerating gradient (MVIm) 4.3 20
Normalized peak
surface field 2.7 6.5
Web Thickness (2 x )
,
.I in mm Group velocity (%) .012 0.03
Beam Hole Diameter (mm) 22 5
Fill time (ps) .37 .35
ZT'
FIGURE 4-34 - Effective shunt impedance -versus thickness of
L
Magnetron power (MW)
web between cavities of a SW acceleratorstructure.
at accelerator input 1.8 2.3
86 CHAPTER 4. MICROWAVE ACCELERATOR STRUCTURES

TABLE 4-3 . General comparison of TW and SW accelerators TABLE 4-5 - LALA computational examples
~p --

TW accelerator SW accelerator Axial average accelerating field 1 MVlm

Frequency f = 3002.16 MHz
Shunt impedance Low High Transit time factor 0.788
Isolator or circulator Not needed Needed Q Factor 18,529
Maximum accelerating ZPlL 102.80 MWm
beam current High -2 A Low -0.5 A Maximum surface field 3.03 MVlm
Tuning sensitivity High Low Stored energy 0.77 X 10- J
Input coupler design Complex Simple Power loss 485.8 W
Buncher design Rather complex Simple
Spectrum sensitivity on
accelerating field Low High
Coupler Dual Single equations with given boundary conditions. Since most of the
Coupler position First and last Any accelerator cavities do not support pure TM or TE modes, it is
almost impossible to use analytical techniques to solve them.
Within the last two decades, computer programs have been
circulator, since it is a matched device. The maximum acceler- developed and used to optimize cavity structures. Table 4-4
ating current can be as high as 2 A for a 2 m length TW summarizes these programs in the order of the year developed.
accelerator. Also, the bunching characteristics of the TW struc- Recently, the 3-D computer codes such as MAFIA, have been
ture are inherently less sensitive to the variation of the acceler- extensively used in computation of nonaxisymmetric cavity
ating field. This means the T W accelerator can offer a relatively structures. Figure 4-32 shows a typical S W accelerator cavity
wide range of energy variation without sacrificing the quality cross section, and Table 4-5 summarizes a computational ex-
of the beam spectrum. ample of a cavity used in the Varian Clinac 6X accelerator
guide.
As shown in Table 4-5, power loss, stored energy, and
surface electromagnetic field measurements are given in terms
DESIGN OF ACCELERATOR CAVITIES of the normalized axial accelerating gradient of 1 MeVIm. One
of the most important parameters for cavity geometry optimi-
There are many important parameters of an accelerator cavity zation is the effective shunt impedance per unit length, that is,
to consider in designing a highly efficient linear accelerator.
They are frequency, shunt impedance, (Q), transit time factor,
=.
L
This quantity varies with beam hole radius R,, nose outer

power loss, stored energy, and peak surface electric and mag- radius R,, nose cone radii R R l and RR2, web thickness L,,
netic fields. These values can be obtained by solving Maxwell's nose height L,, and cavity radius R, (see Figure 4-32). Since

TABLE 4 4 . List of programs for computing accelerator cavities

Name of Year Developed
program developed by Features

LALA 1965 H. Holt Axisymmetric lowest mode (TMol)

(Los Alamos) Finite difference method
Rectangular mesh (constant mesh size)
SUPERFISH 1976 K. Halbach (LBL) Axisymmetric higher mode (TMon)Triangular mesh
(variable mesh density)
LACC 1978 A. Konrad Axisymmetric higher mode (TMon)
Finite element method
Triangular mesh with variable mesh size
ULTRAFISH 1981 R.Gluckstern Nonaxisymmetric higher mode (TMmn)
Triangular variable mesh
URMEL 1982 T. Wciland (DESY) Nonaxisymmetric higher mode (TM,)
Rectangular mesh
MAFIA 1984 T. Wciland Three dimensional finite difference code with PIC
(particle in cell) modules allowing self con-
sistent particle-field interactions
 DESIGN OF ACCELERATOR CAVITIES 87

the resonant frequency f should be kept constant during opti- REFERENCES

mization of the cavity geometry, these dimensional quantities
cannot be varied independently from each other. For instance,
1. Lapostalle PM: Linear accelerators. North Holland Publishing
if R, is increased (increase inductance), then L,, must be de-
Co., 1970.
creased (decrease capacitance). 2. Septier A: Focusing of charged particles. New York, Academic
Figure 4-33 shows the effective shunt impedance as a Press, 1967, vol 1 and 2.
function of beam hole radius. A 1-mm reduction of beam hole 3. Livingston M, Blewett J: Particle accelerators. New York,
radius results in 272 improvement of greater than 3 percent. McGraw-Hill Book Co., 1962.
ZT2 4. Humphries Jr, S: Principles of charged particle accelerators. New
Figures 4-34 and 4-35 shows -as a function of web thick-
L York, Wiley, 1986.
ness L, and nose height L,. In all computations, the cavity 5. Livingston MS: Particle accelerators: A brief history. Harvard
radius R, was adjusted to keep the resonant frequency at 3 GHz. University Press, 1969.
In practice, the actual observed shunt impedance is about 6. Chodorow M and Susskind C: Fundamentals of microwave elec-
tronics. New York, McGraw-Hill Book Co., 1964.
15percent lower than the computed result.. This occurs because
we do not include the effects of surface roughness, coupling
slots and iris, coupling cavity power loss, finite beam energy
spectrum, and wake field excitation by the beam.

Microwave Power Sources and Systems
The various microwave components that are used to generate
the multimegawatt pulses of rf power and to transport them to
the accelerator guide are discussed in this chapter. Medical
electron accelerators are usually operated in the S-band at 2998
MHz (10cm wavelength) or 2856 MHz (10.5-cm wavelength).
The dimensions of the microwave components are of this order,
that is, in the general region of 10 cm. The capability of a
microwave source to produce peak power varies approximately
as the square of the wavelength. Thus, operation at an X-band
(-3-cm wavelength) to permit shorter accelerator structures has
been limited by the availability of reliable multimegawatt rf
sources. However, this is in the process of change, since such
sources are becoming available for physics accelerators. Oper-
ation at the L-band (-23-cm wavelength) has not been practical
or desirable for medical accelerators because the accelerator
structure and the microwave components become too large and
there is no need for the high rf power capability of L-band.
The rf sources for medical accelerators are usually mag-
netrons for low and medium energy machines and klystrons for
high energy machines. The high peak rf pulse power needed
for high energy machines is more readily and reliably obtained
with a klystron than a magnetron. This occurs because the
functions of electron emission, cavity-beam interaction and
spent electron beam power dissipation are separated and dis-
tributed in the klystron but are all wound up in one small
volume in a magnetron.
The magnetron is a self-oscillator. It is kept tuned to the
natural frequency of the accelerator structure by feedback
(automatic frequency control, AFC) of an rf signal from the
accelerator structure electromagnetic field to a motorized
plunger in the magnetron cavity array. The klystron is used as
an amplifier. Its frequency is determined by that of the rfdriver,
which is usually an essentially all solid state oscillator ampli-
fier, perhaps with a cavity stabilized microwave grid-tube
output stage. The rf source needs to be isolated from rf power
reflections from the accelerator structure. This need is greater
with SW than with TW structures. Fenite microwave devices
(circulators) are used to divert such reflected power away from
the rf source into a water cooled rf load. A rectangular wavegu-
ide, pressurized to hold off the high rf electric fields, is used to
C H A P T E R - 5
transport the rf power. Radio frequency ceramic windows in a
short cylindrical waveguide section are used to separate the
pressurized section (power source side) from the vacuum (ac-
celerator and rf source). A rotary joint in a short cylindrical
waveguide section is used in the connection between the sta-
tionary stand and the rotary gantry. Various other waveguide
components are used to change direction or divide the flow of
rf power. The cross section width of rectangular waveguides
and related components is somewhat larger than one-half
wavelength, in order to transmit the fundamental frequency rf
power efficiently. These various types of microwave sources
and components are described with greater clarity in the fol-
lowing subsections.
MAGNETRONS
Magnetrons are frequently used as a source of microwave
power for linacs, particularly for lower energy x-ray treatment
units. The diode type magnetron was invented in 1913 by
Arthur Hull. It is confined to short wave frequencies and
requires an external LC resonant circuit. The cavity type mag-
netron was invented by Boot and Randall in 1940. Both the
output power and frequency were markedly increased com-
pared to previous split anode type magnetrons, making high
definition radar possible during World War 11. Such a device is
placed in a static magnetic field B, which is perpendicular to
the plane of Figure 5-1. The electrons emitted from the inner
cylindrical cathode are drawn toward the concentric anode by
the positive anode potential. Surrounding the cathode is an
array of small cavities linked together so as to form a slow wave
structure. Figure 5-1 shows the cross section of electron trajec-
tories, the dc pulsed electric field Edc,the magnetic field H, and
the wall current I in the individual cavities of a magnetron. As
soon as the electrons acquire a velocity, they are subjected to
the Lorentz force e(u X B), and are turned in a tangential
direction, as shown in Figure 5-la. The individual electrons
perform a complex cycloidal motion around the cathode. Ro-
90 CHAPTER 5. MICROWAVE POWER SOURCES AND SYSTEMS

tial build up of oscillation is obscure, experimental results sug-

gests that the dense space-charge cloud becomes unstable and
causes preoscillation before full oscillation. In order to have a
smooth transition between these states, the rise time of the
anode dc bias should be at a limited rate (100 kV/ps).
The performance of a magnetron in practical operation can
be characterizedby two different diagrams. They are known as
the performance chart (see Fig. 5-2) and Rieke diagram (see
Fig. 5-3). Several parameters determine the operational perfor-
mance of the magnetron. They are (a) the magnetic field B; (b)
the anode current I,; (c) the anode voltage V,; (d) the load
impedance Z,; (e) the output power Po; and (f) the operation
frequency f.
Figure 5-2 shows the performance chart of the English
Electric Valve (EEV) magnetron 5125. This chart shows curves
of constant magnetic field, peak output power, and efficiency
versus peak cathode voltage and current. The dependence of
overall efficiency on current for a constant magnetic field is re-
lated to the extent to which the rotating space charge spokes de-
part from synchronism with the phase velocity of the rf field on
the anode structure. This chart does not show that the operation
frequency varies with the anode current. This phenomenon is
known as frequency-pushing and the value of AJAI, atf = fo,
the resonant frequency, is called the "pushing figure".
The Rieke diagram of Figure 5-3 shows the dependence of

Magnetic Field (Grauss)

- - - Peak Power Out (MW)
- . - . - . - Efficiency (%)

FIGURE 5-1 . Cross section of cavity type magnetron, showing (a) elec-
tron trajectories, wall current I, rf magnetic field H, and dc pulse electric
field: Ede. (b)Radio frequency electric field Er/and rotating electron
space charge cloud. (From Ref. 10)

tating spokes of electrons, as shown in Figure 5-lb, are formed

due to the influence of space charge forces, and interaction with
the rf cavities.
This action induces the oscillatingrfelectric fields Edin the
resonant cavities. the^ mode, in which the phase differencebe-
tween adjacent cavities is .rr radians, is most commonly used.
When the rotating spokes of electrons are traveling at the same
velocity as the phase velocity of the mode, a strong interaction
between the rf electric field at the entrance of cavities and elec-
trons takes place. As the rf fields act so as to remove energy from
the moving electrons,the reduction in kinetic energy of the elec-
trons will be converted into the high-frequency electromagnetic
energy. The electron will take up a new orbit of smaller radius Peak Cathode Current (A)
and will spin back into the cathode, heating it, a phenomenon
called back bombardment. Though the exact mechanism of ini- FIGURE 5-2 . Performance chart for EEV 5125 magnetron.
 KLYSTRONS 91

minimum ratings of operating conditions for the 2.6 MW EEV

5193 magnetron. These magnetrons are mounted in a gantry
such that the tuner axis is parallel to the axis of gantry rotation to
minimize frequency variation from this source.
The heater power is sewoed to a lower value as the rf power
is increased in order to protect the cathode from over heating by
back bombardment from electrons as described earlier.

KLYSTRONS

The klystron was invented in 1937 by the Varian brothers. The

klystron became a precursor for the development of the multi-
cavity magnetron in England. It was ironic that the early
klystron did not exhibit high power and efficiency comparable
to the magnetron, which was employed in the World War I1
radar transmitter. Therefore, the klystron was destined only for
local oscillator use in wartime radarreceivers. Since World War
11, the klystron amplifier has undergone a spectacular evolu-
tion, and it has become one of the most widely used devices for
FIGURE 5-3 . Rieke diagram for EEV 5167 magnetron. (Pulse width; the amplification of microwave signals and can provide multi-
4ps PRF; 250, Magnetic Field; 1550 G, Anode curret; 110 A.) megawatt power output.
Figure 5-4 shows a cross-sectional representation of a
output power and frequency on the load impedance. The polar typical klystron amplifier. It consists of three major sections-
coordinate system consists of concentric circles, which give the the electron gun, four rf cavities, and the collector section. An
reflection coefficient in terms of the VSWR [see eqs. (3-15) and electron beam, formed at a high potential, leaves the electron
(3-17)] and the straight lines give the phase position of the first gun and passes into the first cavity (buncher cavity), which is
minimum of the electric field from a reference plane. Table 5-1 excited at approximately its resonant frequency by the input rf
lists the performance specifications of three EEV magnetrons signal. In each rf period, late arriving electrons are accelerated
used for Varian Clinacs. Table 5-2 shows the maximum and and early arriving electrons are decelerated by the axial electric
field of this cavity. This causes the late electrons to catch up
TABLE 5-1 . English electric valve magnetron specifications with the early electrons in each rf period as they drift towards
the output rf cavity.
The effect of this velocity modulation on electrons of the
beam is to produce a bunching of the electrons into clusters
Machine model CL-4 CL-61100 CL-41100 along the beam axis. These bunches of electrons will induce rf
CL-6X L- 1000 current within the output cavity (catcher cavity), producing the
L-200 L-3000
Typical peak 43 47 47
input voltage (44 max) (48 max) (48 max) TABLE 5-2 EEV 5193 magnetron operating conditions
vp OtV)
Peak input 90 105 105 Minimum Maximum Unit
current (100 max) (110 max) (110 max)
1, (A) Magnetic field 1000 1575 G
Average 5.o 4.4 7.O Heater voltage 8.0 10.0 V
input power (4.7 max) Heater current
Pi (kW) (surge) 20 A
Peak output 2.0 2.6 2.6 VSWR (load) 1.5
power Pulse width 4.5 PS
Po(MW) Rate of rise 120 kV/ps
End of life 1.7 2.4 2.4 Outlet water
power Temperature 50 "C
Po end (MW) Water flow 1.06 GPM
Maximum duty 0.00116 0.00085 0.00135 Anode voltage 42 48 kV
Maximum PPS 323 230 323 Anode current 60 110 A
92 CHAPTER 5. MICROWAVE POWER SOURCES AND SYSTEMS

rf rf
Output
Buncher

Buncher
Tube
1 1 Catcher

Heater
Collector
Cathode First Last
Cavity 1st 2nd Cavity
(Buncher) (Catcher)
I Intermediate I
I Cavities I
I I
+- Electron Gun rf Section Collector+
I I

FIGURE 5-4 . Cross section of a typical klystron amplifier.

rfpoweroutput from the tube. Figure5-5 illustrateshow abunch

of electrons,passing through the output cavity, generates an os-
cillating rf current on the cavity wall. As the bunch of electrons
approaches grid 1, the free electrons in grid 1 will be repelled,
since negative charges repel each other, as shown in Figure 5-5.
These repelled electrons flow from grid 1 toward grid 2, gener-
ating an rf displacement current across the gap from grid 2 to
grid 1. Similarly,as the bunch of electrons approaches grid 2, a
reverse rf current is generated. When the sequential bunches of
electrons traverse the output cavity gap, with a time interval be-
tween them equal to the time interval of one cycle of the rfreso-
nant frequency of the cavity, a strong interaction will take place
and lead to the generation ofrfpower. Since theelectron beamis
delivering energy to the cavity (conversion of kinetic energy to
electromagnetic energy), it is slowed in velocity. The beam
thereforeamves at the collector with less total energy than it had
when it passed through the input cavity. This difference in elec-
tron beam energy is approximately equal to the rf energy deliv-
ered from the output of the cavity. The residual kinetic energy of
-
FIGURE 5-5 Excitation of rf wall curmnts in klystron intermediate
or output cavity by passage of electron bunch.
the beam is dissipated as heat in the collector.
Figure 5-6 is a schematic cross section of a high power, Table 5-4 summarizes the comparison of S-band magne-
four-cavity klystron. The effect of the two intermediatecavities tron and klystron tubes. The peak output power of the klystron
is to improve the bunching process. The partially bunched can be extremely high (recently, a 60-MW klystron develop
beam excites the intermediate cavity and is further bunched by ment was completed at SLAC), but it is bulky and requires very
the rf field. The result of the additional cavities is to increase high voltage to drive. Thus, it cannot be placed in the rotational
amplifiergain, efficiency, and power output. The electron beam gantry.
can be focused by the axial magnetic field of the magnetic focus
coils, as shown in Figure 5-6. Figure 5-7 shows a cutaway view
of a high power four-cavity pulsed klystron amplifier similar
to the one used in the Varian Clinac 1800. Table 5-3 shows the
RADIO FREQUENCY DRIVERS
typical operating condition of this klystron. The operating
frequency can be varied by adjusting the diaphragms in the The rf driver is a stable, tunable rf source used to drive a high
buncher and intermediate cavities, which are shown in the power klystron amplifier. For medical linacs, a pulsed rf driver
enlarged view in Figure 5-7. Radio frequency drive is intro- is used with peak power around 300 Wand nominal pulse width
duced from a coaxial line by the coupling loop in the input of 12 ps. The rf frequency can be locally set and remotely
cavity. varied about the set point. The peak power can be remotely
 RADIO FREQUENCY DRIVERS 93

TABLE 5 4 . Comparison of S Band magnetron and klystron

Magnetron Klystron

Output Function Oscillator Amplifier

Window Output power Low (3 MW) High (7 MW)
Life Short (2000 h) Long(10,OOO h)
Cost Low High
Electron Magnet Permanent Electromagnet
Bunch Operation Moving Stationary
Voltage Low (45 kV) High (140 kV)
Output Insulation Potting Oil tank
Iris
Output
Cavity programmable. The pulse repetition rate (prr) can be controlled
(catcher)
by an externally supplied trigger pulse, and the pulse width can
Third be adjustable. Table 5-5 lists the specifications of the 2856-
Cavity MHz rf driver used for the CL-1800. Frequency stability is one
of the most important criteria for stable operation of the linac.
Second
Cavity Compared to the magnetron system, improved frequency
stability arises in the klystron system where the frequency
lnput
determining and amplification functions are separated.
Cavity
(buncher)
TABLE 5-5 . Radio frequency driver specifications
lnput Min. Nom. Max. Unit
Loop

4
! Electron
Beam

Cathode
L::!::\*
.. ....... .. .
. . . :.',
;.:.:.:.:
A"ode

Heater
1. Frequency
Center frequency
Local tuning range
Local tuning sensitivity
2. Output power
MHz
MHz
MHzItum

Peak power W
Isolation dB
Adjustment range %
FIGURE 5-6 - Schematic cross section of a high power four-cavity kly-
stron. 3. Amplitude stability
Short term (droop
and jitter) %
Long term (flat top) %
TABLE 5-3 - Clinac 1800, (VA8252) klystron operating 4. Frequency stability
parameters Deviation and pulling
--
kHz
Transient deviation rate kHds
Mode Low mode High mode Unit
Warm-up drift kHz
Frequencyltemperature
Frequency +
2856 2.5 +
2856 2.5 MHz coefficient kHzf'C
Peak output power 3.0 5.5 MW
Peak beam power 7.5 11.5 MW 5. Pulse rate
Gain at saturation 47 50 dB P'= PPS
Load VSWR 1.2 1.2 Width (start to stop) FS
Beam pulse width 5.8 5.8 PS Turn on time PS
Repetition rate (max) 360 180 Hz 6. Others
Peak beam voltage 110 127 kV VSWR of load
Peak beam current 72 92 A Input voltage vrms
Heater voltage 7.5 7.5 Vr.m.s. Trigger in pulse
Heater current 30 3+ 30 + 3 Ar.m.s. amplitude v
Warm-up time 10 10 min Trigger in pulse
Efficiency 43 53 % duration PS
FIGURE 5-7 , (a) Cut-away four-cavity klystron, similar to that employed in the Clinac 18. Views (b)and (c)are
cut away individual cavity sections. (b)Enlarged view of the bottom cavity, the input power coupling loop is on the
right and a fine tuning device is on the left. (c) Enlarged view of cavity number three; the fine tuning device has
been cut away in this view.
 CIRCULATORS
FIGURE 5-8 . Block diagram of klystron rf driver employing triode output stage.
Figure 5-8 shows the block diagram of an rf driver. It
consists of a voltage controlled oscillator (VCO) and frequency
multiplier, S-band phase locked oscillator (PLO), positive-in-
trinsic-negative (PIN) diode modulator, S-band amplifier and
final triode amplifier. The VCO must have a high-frequency
temperature stability of 10-5 MHzPC. The S-band PLO has a
phase lock range of 2 6 MHz and provides a low noise, stable
rf signal. The PIN modulator modulates the rf signal by the
modulation pulse (360 pps, 1 2 ~ ssupplied
) from the modulator
drive circuit. This is amplified by a three-stage transistor S-
band amplifier to 30 dBm (1 W). This pulse modulated signal
is amplified by a triode amplifier to between 55 (300 W) and
57 dBm (500 W). An isolator is provided at the final output end
to prevent damage due to external load variations.
CIRCULATORS
A circulator protects the rf source from rf power reflected back
to the source. Circulators are either three or four port devices
using ferrites, a magnetic material which rotates electromag-
netic fields. A three port circulator has the property that a wave
incident in port 1 is coupled into port 2 only; a wave in port 2
is coupled into port 3 only; and so on. The ideal circulator is an
impedance matched device; that is, with all ports except one
95
terminated in matched loads. The input impedance of the
remaining port is equal to the matched load.
Figure 5-9 shows the schematic diagram and cross section
of a Y junction waveguide type three-port circulator. The ferrite
disks are magnetized by a static magnetic field B, which is
applied perpendicular to the figure shown and gives the junc-
tion the required nonreciprocal property. This can be under-
stood as follows. A Y junction circulator behaves like alow loss
transmission cavity. The resonance of the circular disk is in the
dipolar mode in which the electric field vectors are perpendicu-
lar to the plane of the disk (parallel to B) and the rf magnetic
field vector lies parallel to the plane of the disk. Figure 5-9a
illustrates this dipolar mode of a ferrite disk in the un-
magnetized case. The rf input power at port 1 will then divide
equally between port 2 and port 3. When the disk is magnetized
as shown in Figure 5-913, the mode defined by the E and H field
pattern rotates 30" and port 1 will couple to port 2, but port 3
will be isolated from port 1. Figure 5-10 shows the TM,,, like
mode pattern for the magnetized case where a wave incident in
port 1 is coupled to port 2 only. Alternatively, any power enter-
ing at port 2 will set up a new mode that will result in this power
leaving at port 3, and port 1 will be isolated, and so on. Typical
values of insertion loss and isolation for waveguide type S band
three-port circulators are 0.15 and 20 dB, respectively.
A four-port circulator may be constructed from two magic
Ts or hybrid junctions and a gyrator as shown in Figure 5-lla.
% CHAPTER 5. MICROWAVE POWER SOURCES AND SYSTEMS

Port 3

Isolated Port

1 Port 3

-
FIGURE 5-10 Mode pattern of an H plane three-port circulator
using TMiio mode.

The gyrator produces a phase shift of 180" for propagation in

one direction but not for the other direction. Consider a wave
incident in port 1. This wave is split into two waves, which are

Y Output
FIGURE 5-9 . Dipolar modes of a ferrite disk and Yjunction three-
port circulator in (a) an unmagnetized state and (b) a magnetized state.
(From Ref. 4) The static magnetic field B perpendicular to the page is
not shown.
in-phase and equal in amplitude in the side waveguides b and
d, with no power delivered to port 3. These waves are combined
and delivered to port 2, since the gyrator does not affect the
phase of the wave leaving waveguide b. Awave incident in port
2 will be similarly split into two waves, but this time with one
arriving at d with a phase c$ and other arriving at b with a phase
c$ + IT, because of the presence of the gyrator. The two waves
cancel at port 1 but combine and emerge from port 3 in the
hybrid junction (magic T). Figure 5-llb shows two different
types of four-port circulator, where one of the circulators uses

--t
Gyrator

-
FIGURE 5-11 Afour-port circulator. (a) Conceptual view of a four-port circulator. (b) Two four-point circulators; one uses a 180' gyrator and the
other uses two 90' gyrators. (From Ref. 6 and Ref. 17 of Chap. 3)
 OTHER MICROWAVE COMPONENTS 97

To Accelerator

u
Shunt Tee I pO?Pofi
I Circulator
H-Plane Bend lan

RF
Source

.
FIGURE 5-12 Schematic of a four-port circulator between the source
and accelerator structure.

a 180" gyrator and the other one uses two 90' gyrators. The
latter offers a more compact structure, but requires multiples of
magnets forboth gyrators. Figure 5-12 shows schematically the
use of a four-port circulator between the rf source and the
accelerator structure, in order to continuously vary the rf power
into the accelerator. Since the ferrite volume, which interacts
with the rf power, is much larger than in the three-port circula-
tor, the four-port circulator can be operated at a much higher
power level. Yet, its insertion loss is much higher than a
three-port one. The typical insertion loss and isolation values
for four-port circulators are 0.3 and up to 30 dB, respectively.

FIGURE 5-13 . Rectangular waveguide components. (a) E plane and

OTHER MICROWAVE COMPONENTS H plane bends, (b)a waveguide 90" twist, and (c) a flexible waveguide.

WAVEGUIDE BENDS AND TWISTS, AND
FLEXIBLE WAVEGUIDES
The waveguide used to transport power from the microwave
power source to the accelerator changes direction at several
points. This is accomplished by bends and twists in the wavegu-
ide. Figure 5-13a shows two types of waveguide bends. They
are designated as an E plane bend if the electric field changes
direction and an H plane bend if the magnetic field changes
direction. To avoid excessive reflections the cross section of
the bend waveguide should be uniform and the radius of
curvature should be large. With precision machining or casting
techniques, it is possible to make low VSWR bends, with radius
of curvature R r 1.5b for E plane bends and R r 1.5 a for H
plane bends, where a and b are the width and height of the
waveguide, respectively.
Rectangular waveguides may be twisted to change the
direction of polarization as shown in Figure 5-13b. Twists
should be uniform and long in comparison to a wavelength to
minimize reflections. For a 90" twist, the length should be
longer than four times the guide wavelength.
Figure 5-13c shows a flexible waveguide. Flexible
waveguides, which can provide small bends and twists, are
98 CHAPTER 5. MICROWAVE POWER SOURCES AND SYSTEMS

often used to compensate for slight misalignment between rigid Coupled

microwave components. A flexible waveguide also reduces
mechanical stress on delicate rf windows of rf sources and
accelerators.
+ Ins Loss

DIRECTIONAL COUPLERS
A directional coupler is a four-port device for transferring
power from one transmission line to another in one direction,
while isolating them from each other in the opposite direction.
Figure 5-14 illustrates a schematic of a directional coupler and
its symbols. A signal entering port 1 will travel to port 2 and
a predetermined portion of this signal will appear at port 4,
when all ports are matched. There will be no output at port 3.
Similarly, if a signal travels from port 2 to port 1, output
appears at port 3, but none at port 4. The coupling coefficient
I
of a directional coupler is the ratio of the input power to the Coupled
coupled output power, expressed in decibels. For instance, in
a 20-dB coupler, 1 percent of power would appear at port 3 FIGURE 5-14 . Schematic diagram and symbols for directional cou-
and 99 percent at port 2, if the input signal at port 1 is 100 plers.
percent.
There are many types of directional couplers and no signals are separated in time by 90" of rf period from one
unique classification is possible. The type of directional cou- another.
pler often used in linear accelerators is the 60 dB (which is
0.0001 percent of input power coupled) waveguide type as
SHUNT, SERIES, AND HYBRID TEES
shown in Figure 5-15a and the low power 3-dB coaxial type
quadrature hybrid coupler as shown in Figure 5-15b. A quad- Figure 5-16a illustrates an H-plane tee, in which a waveguide is
rature hybrid is a 3-dB directional coupler, capable of dividing attached perpendicular to the narrow wall of a straight length of
an input signal into two mutually isolated quadrature phased waveguide. This type of H-plane tee is often called a shunt tee,
outputs while maintaining isolation of the port 3 from the input, and the schematic view of the magnetic field distribution in an
port 1. The term quadrature phased means that the two output H-plane tee is illustrated in Figure 5-16b. If port 2 is shorted and

FIGURE 5-15 . Examples of directional couplers. (a) A 60-dB waveguide type coupler and (b)a quadrature hybrid power dividers (often called a 3-
dB hybrid).
 OTHER MICROWAVE COMPONENTS
(a)
Note that wavelength is shorter here
FIGURE 9 1 6 . (a) H plane (shunt) tee and (b)magnetic field lines.
port 3 is terminated, the VSWR looking from port 1 to the load
varies with the length I of the shorted waveguide associated with
port 2. The equation of this relationship is given by
where s is the VSWR at port 1. In this way, the reflected
power level can be varied continuously by varying the length
of short position I. Varian high energy machines use this
concept to vary the rf power level. Similarly, an E-plane tee,
in which a waveguide is attached to the broad wall, is
illustrated in Figure 5-17a with electric field distributions.
This type of junction is called a series tee. These tees are
used either to split the power or to match the impedance.
FIGURE 5-17 . (a) E plane (series) tee and electric field lines and (b)hybrid tees.
99
Figure 5-17b shows two types of hybrid tees that are often
used in microwave circuitry. In the hybrid tee, the incident TElo
mode waves in port 1 split equally and appear at ports 2 and 4
in phase. Since this electric field has even symmetry about the
midplane, it cannot excite the TElo mode in port 3. Thus there
is no coupling between ports 1 and 3. Similarly, the incident
TE,, mode wave in port 3 will appear in ports 2 and 4 in equal
magnitude but 180° out of phase.
ROTARY JOINTS
The gantry, on which the accelerator is mounted in high
energy medical linacs, rotates around the patient. The rf
source (klystron) and other rf components (circulator, shunt
tee, etc.) remain fixed in stand type machines. Thus, it is
necessary to have an rf joint that allows rotational motion
but provides rf continuity. This can be accomplished by using
a "choke joint," which allows relative rotation of two coaxial
sections with electrical continuity (see Fig. 5-18a). The choke
joint utilizes two quartenvave transmission lines of different
impedances. The ratio of these impedances Zol and ZO2is
given by
where r l = d2 - d l and r2 = d4 - d3. If one made r2 = lor,,
an improvement in rf continuity by a factor of 100 over the
method without these structure will be seen. This scheme is
often used in microwave circuitry where a good rf connection
is required without providing physical contact.
Figure 5-18b shows a rotary joint using a coaxial line
operating in the TEM mode as the transmission line mode,
which is circularly symmetric and coupled to a rectangular
waveguide. Suitable bearings are supplied outside of the junc-
tion so that the rotational motion is smooth.
Figure 5-18c shows a cylindrical waveguide rotary joint
where TM,, mode is used for propagation of microwaves
within the circulator section.
100 CHAPTER 5. MICROWAVE POWER SOURCES AND SYSTEMS

Short Circuit Open =o

3: I Circuit

L "Across the Line

and Guide Transition" Dynamic Seal
Bearing Housing
4

FIGURE 5-18 - Choke joint and rf rotary joint. (a)Achoke joint, (b) a coaxial type rotary joint, and (c) a cylindrical waveguide type rotary joint.

WAVEGUIDE WINDOWS
A waveguide window is used to separate the accelerator
vacuum side from the gas pressurized (Freon or SF6) rf
system side. Figure 5-19 illustrates a pill-box type window
used in Varian accelerators. A high purity alumina disk
(Al-300, which is 97% pure A1203) provides the ceramic
window. It is brazed into a thin cylindrical copper sleeve.
The sleeve in turn is brazed to a stainless steel cylinder that
is brazed to copper flanges, forming a pill-box cavity. The
thin sleeve is provided to relieve stress caused by the thermal
expansion differences between the ceramic window and the
metal. The alumina disk is coated by sputtering with a thin
 OTHER MICROWAVE COMPONENTS
7h/4
+E field
FIGURE 5-18 . (Continued)
layer of titanium nitride on the vacuum side after it is brazed
to the sleeve assembly in order to reduce secondary electron
emission and thus prevent multipactoring (a regenerative
secondary electron emission process occumng at the ceramic
window surface). Radio frequency window failure is very
rare but could seriously damage the accelerator. The most
FIGURE 5-19 - Cut away view of pill-box type rf window.
101
choke
(4
common failure is thermal failure with loss of vacuum
integrity due to excessive localized heat produced in the
window material. The sources of window heating are elec-
trical breakdown, multipactoring and dielectric loss in the
alumina, and resistive loss in the titanium coating. Therefore,
the choice of window materials and techniques of coating
and assembling of the window become very important factors
in accelerator development and fabrication.
WATER LOADS
Loads are designed to absorb incident microwave power
without reflection. Water loads are used for extremely high
power termination. Two different types of waveguide water
load are used in accelerators, namely, (a) water filled load
and (b) water cooled dry load. Figure 5-20 shows the
schematic cross section of these water loads. The water filled
load is designed such that incident microwave power entering
via the ceramic window is absorbed directly by the cooling
water. The ceramic window behaves as a quarter wave
matching section between the gas pressurized waveguide and
the water filled section. Since the relative dielectric constant
of water is about 80 at 3 GHz and E,, = 1, the dielectric
constant of the window EW, is computed as E, = (E,,, X
~,,,,)1/2 = 9. A low loss dielectric material of dielectric
102 CHAPTER 5. MICROWAVE POWER SOURCES AND SYSTEMS

Nondirectional varying impedance mismatch with rotation, hence power

Coupler reflection.

Cooling
Water
AUTOMATIC FREQUENCY CONTROL
lnlet &
Outlet
The resonant frequency of an accelerator structure varies with
temperature, input power level, beam loading, and other me-
chanical and electrical perturbations of the accelerating cavi-
Ceramic
Window
ties. In order to keep the frequency of a microwave source, such
as a klystron or magnetron, tuned to the accelerator resonance
frequency, a frequency locking circuit called an automatic
frequency control (AFC) is required. The methods are some-
what different for magnetron and klystron driven accelerators.
Cooling Water
lnlet

LOW ENERGY (MAGNETRON) AUTOMATIC

FREQUENCY CONTROL
Aluminum
/ Housing Figure 5-21 shows a schematic AFC circuit diagram for a low
energy accelerator machine such as the Clinac 61100, which uti-
lizes a magnetron as the microwave power source. The vernier
mechanical tuner of the magnetron is sewoed to the resonant

60-dB
Motor Magnetron Directional 3 Port Circulator
Coupler

t Lossy Dielectric
Cooling Water Material Phase
Outlet (Sic) Accelerator

Nondirectional

.
FIGURE 5-20 Cross section of types of water loads. (a) Filled with
Servo Water Load
water, and (b) externally water cooled dry load.
Drive
Amplifer

constant 9 is alumina (A1203), which is also used in the rf

window to provide an impedance match. The optimum 3-dB
thickness t of the water load window can be computed by
Coupler

Attenuators
Detectors
where Ag is the guide wavelength and represents a quarter wave Differential
length within the ceramic window. Amplifier
The water cooled dry load is constructed by mounting
power absorbing lossy dielectric material (SIC) along the
waveguide. Tapers are used to avoid reflection. For minimiz-
ing reflection, the taper length must be longer than one guide
Panel
wavelength. The maximum average power handling capability Meter
for these loads is about 3 kW versus water loads that can
handle over 10 kW. However, water loads cannot be used in .
FIGURE 5-21 Block diagram of AFC circuit for low energy magne-
he gantry since the air pocket within the cooling water creates tron machines
 AUTOMATIC FREQUENCY CONTROL
frequency of the accelerator using the reflected signal. The
pulsed forward microwave power is supplied to the accelerator
through port 1 of a three-port circulator. The reflected power
from the accelerator travels back to the circulator via port 2 and
out of the third port (lower) and, hence, via phase shifter to the
water load. This variable phase shifter, often called a "phase
wand," is provided forreflecting a small fraction of the reflected
power from the accelerator back through the three-port circula-
tor to the magnetron. This intentionally introduced reflected
signal at a certain phase exerts a "frequency pulling effect" on
the magnetron frequency towards the accelerator resonant fre-
quency. This technique works well only when the frequency of
the magnetron is within the one-half powerbandwidth of the ac-
celeratorresonance. However, due to the relativelyhigh Qof the
accelerator, the magnetron may have an initial frequency setting
outside the bandwidth of the accelerator,since the mechanically
tunable magnetron frequency range is about 10 MHz, while the
accelerator resonant bandwidth is only about 0.5 MHz. Hence,
another mechanism is needed to bring the magnetron frequency
close to the acceleratorresonant frequency.
In addition to the "frequency pulling effect" noted above,
the microwave phase comparator circuit of Figure 5-21 is
utilized to provide an AFC circuit that will track a relatively
wide variation in the accelerator resonant frequency using the
magnetron mechanical tuner. Departure of the source fre-
quency from the accelerator resonant frequency can be sensed
by comparing the phase of the incident power +i to the accel-
erator with the phase of reflected power 4, from the accelerator.
A 3-dB hybrid coupler is provided for comparing this phase
difference. Radio frequency signals from the two output ports
are rectified by crystal detectors, and the resultant differential
amplifier provides the input signals for the servopower ampli-
fier that drives the servomotor until the correct magnetron
frequency is reached.
The frequency discriminating action of the phase compa-
rator circuit, embodied in the 3-dB hybrid coupler, is shown in
Figure 5-21. In the hybrid coupler, the incident power signal
Vi, which is applied to the input port no. 1, is split and supplied
to output terminals with equal amplitude but with 90°phase lag
at the output port no. 2 with respect to the output port no. 4.
Similarly, the reflected power signal V, applied to the second
input terminal no. 3 is split equally and supplied to output
terminals nos. 2 and 4 with a 90" phase lag at the output port
no. 4 with respect to the output port no. 2. The resultant signals
at output ports are rectified by crystal detector diodes to pro-
duce dc output voltages that are subtracted from each other and
amplified with a differential amplifier.
HIGH ENERGY (KLYSTRON) AUTOMATIC
FREQUENCY CONTROL
In high energy accelerators, in which klystron amplifiers are
used as therf power sources,the AFC circuit is somewhat differ-
ent from that in low energy magnetron powered accelerators.
103
Figure 5-22 shows the block diagram of the AFC system
used for the Clinac 1800. Here the function of the oscillator (rf
driver) and the amplifier are separated. The frequency of the rf
driver can be set precisely at a desired accelerator resonance,
independent of the load condition and the frequency tuning
range can be set in a relatively narrow range, such as 1 MHz.
The center frequency of the rf driver is set nominally at 2856
MHz. The forward and the reflected signals are monitored at
the accelerator guide through a 60-dB bidirectional coupler.
Frequency discrimination can be obtained in a manner similar
to that described for the low energy machine. In this case, the
delay line used for the low energy machine is not necessary
since the next nearest resonance will not appear within the rf
driver tuning range.
Figure 5-23 shows how the phase and amplitude of re-
flected signals vary with frequency for the case of the acceler-
ator overcoupled to the input waveguide, where the accelerator
resonant frequency is fo. The frequency discriminating action
of the AFC circuit can be described by the vector diagram of
Figure 5-24, which shows the relationship of the klystron
frequency f versus rf signals at the hybrid coupler output port
and, hence, the differential amplifier output signal. However,
this relationship applies only for the condition where the trans-
mission path length for the incident wave Vi and the reflected
wave V, are equal. Normally, the path length for the reflected
wave V, is greater than the path length for the incident wave Vi,
whereby the frequency discriminating output characteristic for
the phase comparator would be skewed. Accordingly, a long
,
line section of transmission line (often called delay line) is
Pads Are Typically 5 dB
(but may vary)
-
60 dB
Direction
Cou~ler
Shifter
30 Hybrid
AFC
Tuning
to RF
Driver
AFC
2.2KQ
I317 on
Program Board
FIGURE 5-22 . Block diagram of AFC circuit for high energy klystron
machine.
104 CHAPTER 5. MICROWAVE POWER SOURCES AND SYSTEMS

provided in the path between the forward output port of the

60-dB directional coupler and the input port of the 3-dB hybrid
coupler, as shown in Figure 5-21.

Freq.
REFERENCES

1. Granastein VL and Alexeff I: High power microwave sources.

Artech House, Inc., 1987.
2. Veley VF: Modem microwave technology. Prentice-Hall, Inc.,
1987.
3. Gilmour AS: Microwave tubes. Artech House, Inc., 1986.
4. Linkhart DK: Microwave circulator design. Artech House, Inc.,
1989.
0. * Freq. 5. Hinkel K: Magnetrons. New York, John F. Rider Publisher, Inc.,
A
1961.
2
6. Harvey AF: Microwave Engineering. Academic Press, 1963.
7. Rizzi PA: Microwave Engineering, passive circuits. Prentice-
Hall, 1988.
-
FIGURE 5-23 Voltage and phase versus frequency for frequency dis-
8. Cheung WS and Frederic HL: Microwaves made simple: princi-
criminating action of AFC circuit. ples and applications. Artech House, Inc., 1985.
10. Collins, GB: Microwave Magnetrons. McGraw-Hill Book Co.,
Inc., 1948.

Frequency Output Port Output Port Differential

No. 1 No. 2 Amplitude

FIGURE 5-24 . Vector relationships at hybrid output port and result-

ing differential amplitude at various frequencies.
 Pulse Modulators and Auxiliary Systems

PULSE MODULATORS
The pulse modulator provides a pulsed voltage or current
waveform to power microwave sources (magnetrons or kly-
strons). Figure 6-1 shows a basic modulator configuration. The
electrical energy, supplied by a power supply circuit, is stored
in an energy storage circuit. An isolating circuit prevents flow
of the stored energy back to the power supply. A switch circuit
provides for the discharge of energy in pulses into the load.
Figure 6-2 shows a simplified circuit of a line type modulator.
The name, line type, came from the similarity of the behavior
of the energy storage circuit to that of a transmission line having
a characteristic impedance &.Such a line is charged to voltage
V and then discharged to a load with an impedance typically
equal to that of the transmission line and with a wave propaga-
tion velocity v.
As shown in Figure 3-4, transmission lines can be repre-
sented as a network of lumped capacitive and inductive ele-
ments. Such a network (see Figure 6-3) is called a pulse forming
network (PFN). The PFN serves a dual purpose of storing the
energy required for a single pulse and of discharging this energy
into a load in the form of a pulse of specified shape. The PFN
of Figure 6-3 consists of N equal-valued capacitors, Cl..C6,and
a continuously wound, tapped coil representing Nequal-valued
inductances L1..L6,and whose physical dimensions are chosen
such that it provides the proper mutual coupling at each mesh.
The PFN capacitors are charged through a resonant charging
choke to 2V, where V is the power supply voltage. When the
switch S , is closed, the charge stored in C1 starts to discharge
through L, into the load R,. The characteristic impedance ofthe
PFN is designed to be equal to the load impedance. When the
voltage across the load reaches V, C1 will stop discharging, and
C2willbegin to discharge through and L,, and so on, through
C&. This sequence of events results in a rectangular current
pulse of energy being supplied to the load with a duration that
is twice the transmission time of the PFN. In essence, a negative
wave of amplitude Vl2 flows from the load end to the charge
end of the PFN, reflects and flows back to the load end,
discharging the stored energy in the capacitors fully. The im-
portant relationships of the PFN are
where
Zo = characteristic impedance of PFN
T = pulse width
L, = total network inductance = NL
C, = total network capacitance = NC
L = inductance per section
C = capacitance per section
N = number of sections

i
Isolating Switch
Circuit Circuit
The PFN used in the CL-1800 modulator has six sections

1 Circuit
FIGURE 6-1 . Block diagram of basic modulator.
Load
a.
and a characteristic impedance of 11.4 In order to obtain a
5.8-ps pulse width, one can solve eqs. (6-1) and (6-2) in terms
of L and C, and obtain L = 36.5 pH and C = 0.28 pF.
The modulator must supply the klystron or magnetron with
a pulse of precise amplitude. One method of PFN charge
regulation involves diverting the discharge of stored energy in
the charging choke, by abruptly reducing the "Q" of the charg-
ing circuit. This is called deQing. Figure 6-4 shows the resonant
charging system with De-Q. By sensing the PFN charging
106 CHAPTER 6. PULSE MODULATORS AND AUXILIARY SYSTEMS

30 Clipper Current
High Voltage Fault Monitor
PWR Supply Circuit = 1000:l Ratio System

- - 1 0 kV
Current Toroid
Ll
O
n

DeQing Switch
- Trig. Gen.
System
End

r
\ HVPS Current
Monit0;Circuit
---
I
I -1
I
I
Pulse XFMR
Turns Ratio = 1:4
Clipper
Circuit

L-----J
I R2 I
o 'VVL ! o Magnetron
L ---- _I
Equivalent Circuit
r---1r.-- --------
Despiking --A

HVPS O/C Network

I Fault Monitor
System I
I I
- I----- J I I I vs= I
I I I

FIGURE 6-2 . Simplified circuit of line type modulator.

Charging
Choke
U
PFN -
-
---- --
-- ---- ---- ---- ----
Cl c2 c3 c4 c5 C6
--
-
-
--
Switch I
4
:- - - - - - - - - - - - - - - - - - Voltage
Sensor

A FIGURE 6-4 Schematic of PFN resonant charging with regulation of

-4

FIGURE 6-3 . Pulse forming network. charge by De-Q network.

 VACUUM SYSTEMS 107

voltage and closing switch S2,the charging process will be
terminated by dumping the residual energy stored in the charg-
ing choke into the resistor R,.
VACUUM SYSTEMS
-
An accelerator must be kept at high vacuum (pressure of 10-7
torr level) (1 torr = 1 mmHg, 1 atm = 760 ton) to prevent elec-
trical breakdown in the residual gas forthe high electromagnetic
fields used to accelerateelectrons. Figure 6-5 shows a schematic
view of the Clinac 1800vacuum system. There are three Vacion
pump subsystems; two 2-Lls diode Vacion pump systems for
klystron and electron gun, and one 20-Lls triode Vacion pump
for the accelerator and the bend magnet vacuum chamber.
Figure 6-6 shows a schematic of two Vacion pumps: (a) a
diode pump and (b) a triode pump. The external permanent
magnets are 0.1-0.3-tesla strength and cathode voltages of
approximately 5 kV are applied. The electric field traps the
electrons in a potential well between that of the two cathodes
and the axial magnetic field forces the electrons into circular
orbits, which prevent their reaching the anode quickly. The
combination of electric and magnetic fields causes the elec-
trons to travel long distances in oscillating spiral paths before
colliding with the anode and results in a high probability of
ionizing collisions with residual gas molecules. The ions pro-
duced in these collisions are accelerated toward the cathodes,
where they collide, sputter away the titanium cathode, and
release secondary electrons that in turn are accelerated by the
electric field. The mechanism of pumping is dependent on the
nature of the gas being pumped and is based on one or more of
the following mechanisms.
1. Trapping of electrons in orbits by a magnetic field.
2. Ionization of gas by collision with electrons.
3. Sputtering of titanium by ion bombardment.
4. Gettering of active gases by titanium.
5. Diffusion of hydrogen and helium into titanium.
6. Dissociation of complex molecules into simple ones for
easy pumping.
Organic gases, active gases, hydrogen, and inert gases are
pumped in different ways. Organic gases are easily pumped by
adsorption and precipitation after being dissociated by electron
bombardment. Active gases such as oxygen, carbon monoxide,
and nitrogen are pumped by reaction with titanium, which is
sputtered on the anode surfaces, and by ion burial in the
cathode. Hydrogen is initially pumped by ion burial and neutral
adsorption and diffuses into the bulk of the titanium forming a
hydride. Inert gases are not pumped efficiently as active gases
in a diode pump. Argon, in particular, suffers from a pumping
instability. In the triode pump, as shown in Figure 6-6b, argon
ions are neutralized by glancing collisions with the sputter
cathode, impact the pump wall, and are covered with sputtered

I
Stand Gantly
I
I
I
I
Bend
Klystron 1 Gun Accelerator
Magnet
I
I
I
I
Diode I Diode Triode
Vacion
Pump
I Vacion
Pump
Vacion
Pump
I A13 A1 9
I A h
+3.2 kV
+3.2 kV -5 kV
I
I
I Vacion PIS
I

FIGURE 6-5 . Block diagram of vacuum system for Clinac 1800.

108 CHAPTER 6. PULSE MODULATORS AND AUXEIARY SYSTEMS

Ti?
Control Unit
I 7-7

--

control Unit

Magnet -
Multi-Cell Anode

Pump Wall Forms

Third Electrode

I Sputter Cathodes,
Multi-Cell Anodes
Titanium Vanes

(3)

FIGURE 6-6 . VacIon pumps. (a) A diode type and (b)a triode type.

Target
Mechanism
Gun
Magnet
Vacuum
Accelerator
A13 Guide
2-Liter
Vacion
Diode Type Bellows
Ceramic Connection Over Research Port

IQ I
Vacuum Window
Beryllium
Window
Nitrogen
Let-Up Valve

I Valve
i
20-Liter
Vacion
.
Useful Down
to 10 torr

torr

JlC Gauge
Useful Down
To torr

Coaxial ....................... Sargent-Welch

Trap Mod. 8805
Pump-Down 1.75 CFM
Butterfly Valve (Stops Pumping
at 1o - torr)
~
FIGURE 6-7 . Vacuum components in the gantry of a Clinac 1800.
 VACUUM SYSTEMS 109

titanium. The pump wall surface in the triode pump operates at pressure for various Vacion pumps. Since the conductance of
the anode potential and collects low energy ions that could not the accelerator for molecular flow is so low, the pressure level
sputter. The lifetime of a diode pump is a function of the time in the accelerator is higher than that shown by the pump curve.
necessary to sputter through the cathodes. A typical value is The basic vacuum system relationships are
5000 h at 10-5 torr or 50,000 h at 10-6 torr.
Vacuum requirements are more stringent in the klystron Q=CXAP=SXP=DXA (6-3)
than in the accelerator since the klystron oxide cathode is where
highly susceptible to poisoning by atmospheric gases and va- Q = throughput (gas flow) in torr times liters per second
pors. The klystron pressure (5 X 10-8 torr) is an order of C = conductance in liters per second
magnitude lower than the accelerator pressure and is separated AP = pressure difference in torr
from it by rf windows. Figure 6-7 shows the vacuum compo- D = surface outgassing rate in tom x liters per
nents in the gantry. The accelerator is initially evacuated by a second x square centimeters
vane type roughing pump through a coaxial oil trap. The trap A = total internal surface area in square centimeters
is filled with copper wool to provide a large surface area to S = pumping speed in liters per second
prevent oil leaving the pump from contaminating the acceler- For example, consider the SLAC constant impedance TW
ator. While the roughing pump is evacuating the system, the structure (see Figure 6-9)
degree of vacuum is monitored by a thermocouple gauge.
When the roughing pump has evacuated 99.9999 percent of the Operating mode 21~13
air, the vacuum pressure in the accelerator is down to 10-3 torr. Number of cavities 50
Then the main valve is closed and the 20-Lls Vacion pump is Accelerator length 1.75 m
turned on, pulling the accelerator down to a pressure of 10-7 Inside diameter 3.247 in.
torr. Figure 6-8 shows the relationship of Vacion current versus Disk hole diameter 0.890 in.

10 pA 100 pA 1 mA 10 mA 100

Pump Current

FIGURE 6-8 . Relationship of VacIon current versus pressure for various pumps.
110 CHAPTER 6. PULSE MODULATORS AND AUXILIARY SYSTEMS

The cavity conductance Cc is calculated as follows:

cc= 453.9 U s
Then the accelerator total conductance Camwill be

where N is the number of cavities. Since N = 50, C ~ C=C

0.67 Us.
2. The conductance of coupling aperture assuming infinitely
Accelerator thin wall can be computed from
Waveguide Guide

I 1 ft L
F

where a and bare aperture height and width in centimeters.

Thus,

Vacion Pump 3. The conductance of the 12-in. rectangular waveguide is

RF Window
calculated from

I I Pumpout Tubing

FIGURE 6-9 . Vacuum system of a SLAC TW accelerator structure,
for computation of conductances and pumping speed.
Disk thickness 0.230 in.
Period length 1.378 in.
Matching iris aperture 1.014 X 1.34 in.
Waveguide dimension 2.84 X 1.34 in.
Pump tubing diameter 1.115 in.
Pump speed 20 U s
where a and b are dimensions of the waveguide (cm), L is
the length (cm), and K is a factor depending on the ratio of
bla. For a = 7.214 and b = 3.404, Kis about 1.16. Hence
c w = 57.5 L/s.
4. The conductance of the 12-in. length pump tubing Cp is
calculated from eqs. (6-4) and (6-5), hence or = 0.85, Cp
= 7.6 Us.
5. The total conductance CT is computed by

Neglecting the input and output beam holes and coupling

iris to the load, the pressure ratio between the end cavity and
the pump can be computed as follows:
hence CT = 0.61 Us. Since
1. The conductance of accelerator vacuum components, C,
can be calculated as follows: Ppump 'pump = CT (Pacc - ppUmp)

where D is the diameter of the tube (cm), L is the length

of the tube (cm), and or is the Causing factor depending on The pressure at the far end of the accelerator is 34
the ratio of LID and given by times higher than the pressure at the pump for this example.

WATER COOLING SYSTEM

The water cooling system cools critical components such as

accelerator guide structures, rf power source, and electromag-
Therefore, the aperture conductance Ca is calculated as
nets in the drive stand and gantry, keeping them at a relatively
follows:
constant temperature. The cooling system contains a submers-
ible water pump enclosed in an 18-gal tank, a heat exchanger
 MISCELLANEOUS SYSTEMS 111

Heat Exchanger

Y
City Water Supply
-
-
II l t

--I(t
Water Return Path
I :r:
I
Stand
Components
Gantry
Components

Rotary Joint
1 -
cM.2hb
Submersible pump in 18 gallon
cu water tank pumps demineralized
a water through heat exchanger,
a
5 Then through components in
stand and gantry that require
E stable operating temperatures
18 5
Gal (I,

Cap $
-IN
7

FIGURE 6-10 . Block diagram of basic water cooling system.

connected to the hospital city water supply, return manifolds,
water hoses, temperature and pressure gauges, and temperature
control circuitry (see Fig. 6-10). For the Clinac 2100, assem-
blies and components in the gantry and stand are cooled by
circulating water; in the gantry: accelerator guide, bend mag-
net, accelerator solenoid, primary collimator, energy slit, and
target; and in the stand: klystron, klystron solenoid, circulator,
rf driver, rf load, and pulse transformer.
+
The water, at a temperature of 40 5°C and at a pressure
of 50psi, enters the gantry from the stand through a rotary joint,
cools the components in the stand, and returns to the stand
through another rotary joint shown in Figure 6-11. If the
volume of water flowing through any of the flow interlock
switches falls below the values indicated the switch will open,
transmitting a flow fault signal to the console and where
appropriate, shut down the associated systems.
The heat exchanger assembly isolates the city water from
the accelerator water closed-loop circulatory system as shown
in Figure 6-10 while allowing heat to be exchanged between
the two water circuits. The city water is connected by hoses and
filtered before reaching the heat exchanger. A pressure gauge
monitors the incoming city water, and controls the flow by an
electromechanical control unit, valve, and temperature sensor
in the closed-loop water circuit. A submersible pump in the
18-gal tank circulates distilled water at a nominal pressure of
50 psig throughout the closed-loop water circuit. Interlocks
monitor and protect the water level and tank temperature. The
interlocks also activate the pump fault lamp on the console. The
water is kept pure by a filter between the pump and heat
exchanger and also by a demineralizer cartridge in the rf driver
branch of the closed-loop system. The temperature of the
cooled water is monitored at the output of the heat exchanger.
When the temperature deviates, the electromechanical temper-
ature controller sends a signal to the control valve, changing
the flow rate of the city water; thereby correcting the amount
of heat transferred.
MISCELLANEOUS SYSTEMS
GAS DIELECTRIC SYSTEM
Pressurized gases such as SF6 or Freon 12 are used as a
dielectric for the waveguide system between the rf source and
the accelerator. A gas dielectric assembly supplies sulfur hexa-
112 CHAPTER 6. PULSE MODULATORS AND AUXILIARY SYSTEMS

A
7

FIGURE 6-11 . View of cooling water supply to various gantry components.

fluoride (SF6) in gaseous form under pressure to the wavegu- Relative Power Characteristics
ide, between the klystron window and the accelerator guide 100 1
window. Freon 12 gas is normally used in a magnetron system.
The gas acts as a high dielectric that minimizes arcing in the
waveguide. Figure 6-12 compares two pressurized gases with
air for peak power handling capability. This figure shows that
SF6gas at a pressure of 25 psi operates at 10times higher power
than air at atmospheric pressure.
The gas dielectric assembly is located on the side of the
drive stand. It consists of an SF6 tank, a single-stage regulator
and shut-off valves, copper tubing, drier filter, solenoid valve,
relief valve, diaphragm valve, pressure switch, and terminal
board. The SF6gas is stored in a metal tank at a pressure of 310
psig. The gas is supplied through copper tubing to the gas
dielectric assembly, where it is dried through a filter and
regulated to a normal pressure of 32 psig by a solenoid acti-
vated valve. The pressure is controlled by two pressure Absolute Pressure (lbf/in2a)
switches. If the gas pressure drops to less than 30 psig, the no.
1 switch opens to let in more gas until the pressure is 32 psig, .
FIGURE 6-12 Relative peak power breakdown threshold versus pres-
then closes. This continues until the gas bottle is depleted. sure for nitrogen, air, and SF6.
 MISCELLANEOUS SYSTEMS
When this occurs, the no. 2 switch opens and activates the gas
pressure interlock circuitry, causing beam termination and the
gas lamp on the console to light.
PNEUMATIC SYSTEM
This system provides pressurized air for air driven mechanisms.
Pressurized air is used for various purposes; (a) to move the
target, (b) to operate the locking pin plungers on the carrousel,
(c) to operate the plungers on the shunt tee, and (d) to move the
energy switch. The air pressure is controlled by an air regulator
assembly, and set between 45 and 50 psig. The application of air
pressure to all the drive mechanisms is turned on and off by
electrically operated air control solenoids. Abnormal air pres-
113
sure will cause the air lamp on the console to light and cause an
automatic shut-down of the system.
REFERENCES
1. O'Hanlon JF: A user's guide to vacuum technology. John Wiley
& Sons, 1980.
2. Guthrie A: Vacuum equipment and techniques. McGraw-Hill
Book Co., 1949.
3. Hablanian MH: High-vacuum technology, a practical guide. Mar-
cel Dekker, Inc., 1990.
4. Guthrie A: Vacuum Technology. John Wiley & Sons, Inc., 1963.
5. Glasoe GN and Lebacquz JV: Pulse generators. McGraw-Hill
Book Co., Inc., 1948.

Beam Optics of Magnet Systems
OVERVIEW
This chapter is an introduction to the subject of how magnets
are used to confine, deflect, and focus the electron beam in
medical accelerators. The emphasis is on the motion of
electron rays and bundles of such rays through individual
types of magnets and through systems of magnets. This first
section discusses the need for a bend magnet in high energy
medical accelerators and the need for its beam orbit height
above the x-ray target to be limited, thereby restricting the
choice of magnet geometries. The second section (Electron
Motion in Magnetic Fields) presents the basic physics of
electron motion in free space and in the magnetic forces of
dipole, quadrupole, solenoidal, and steering magnets. The
third section (Beam Emittance) discusses a very useful con-
cept for treating bundles of electron rays, namely, beam
emittance. The next two sections (Nonachromatic Bend Mag-
net Systems and Achromatic Bend Magnet Systems) describe
a number of different bend magnet types that have been used
in medical accelerators from the point of view of their ability
to faithfully transport a beam of significant energy spread
from the output of the accelerator structure to the x-ray target,
that is, their degree of achromaticity.
STRAIGHT AHEAD LINACS
Isocentric linacs of straight-ahead beam design are produced
with x-ray energies of 4 or 6 MV without the use of magnets.
The SW accelerator structures in these machines are typically
25-35 cm long, so short that a beam diameter of about 3 mm
is achieved at the x-ray target without the use of a solenoid
or magnetic lens to confine and focus the beam. Such ma-
chines employ an accelerator structure of high shunt imped-
ance to keep it short, a short gun, and a minimal length x-ray
target structure in order to limit the isocenter height with 360"
gantry rotation. The accelerator structure must be able to
sustain a high electric field, having an energy gradient of
approximately 20 MeVIm.
C H A P T E R 7
BENT BEAM LINACS
Isocentric linacs of bent beam design achieve acceptable
isocenter height without severe constraints on the length of the
gun, accelerator structure, and x-ray target region. Bent beam
design is used by choice in some 4 and 6-MV x-ray energy
machines and it becomes essential for machines of higher x-ray
energy. The accelerator structure in such machines is approxi-
mately horizontal, typically 1-2.5 m long, with solenoid andlor
magnetic lenses to maintain small beam diameter over this
length. A magnet system bends the beam through a net angle
of approximately 90"-270" onto the x-ray target, electron out-
put window, electron scattering foils, or electron scanning
magnet axis. Such an array of magnets and drift spaces is
termed the beam transport system. In medical linacs it is
comprised primarily of the bend magnet. The characteristics of
linac electron beams and their motion in various types of
magnets are discussed in the following sections.
LINAC BEAM CHARACTERISTICS
The accelerated electron beam is comprised of an array of
electrons each of which differs in energy (hence momentum)
and in radial displacement and radial divergence (angle) from
the electron ray representing central momentum and central
trajectory. Energy slits and collimators are used to limit the
energy spectrum width and the beam cross section and angular
divergence, which are accepted by the transport system for
delivery to its output. Typical beam transport acceptance values
for medical linacs are in the ranges of 3 to 10 percent energy
spread full width, 2 to 4-mm beam diameter, and 2 1 to 5-mrad
(milliradian) angular divergence from axis.
EFFECT OF MAGNET SYSTEM CHOICE ON
ISOCENTER HEIGHT
For convenience in setting up the patient, the isocenter should
not be too high above the floor. Figure 1-20 shows a radiation
116 CHAPTER 7. BEAM OPTICS OFMAGNET SYSTEMS

technologist of typical height. Assuming a 30-cm thick patient radius of curvature of p = 5 cm, the value of h would be
with upper surface at the radiation technologist's eye level of between 9 and 18 cm, a range of 9 cm (3 112 in). In the magnet
150 cm, the center of the patient would be 135 cm above the systems of Figures 7-19, 7-22, and 7-23, this value of h could
floor. It is desirable to have an isocenter height of less than this have been reduced by about 5 cm by locating the x-ray target
135 cm, so this requires use of a bend magnet type with limited near the intersection of the exit and entrance beam trajectories,
beam orbit dimensions. With 360" isocentric gantry aimed as is done in the magnet system of Figure 7-21.
upward and 100-cm source axis distance, there is a space of
less than 35 cm between the x-ray target and the floor for the
following: ELECTRON MOTION IN MAGNETIC
FIELDS
Rotation clearance
Radiation head enclosure thickness
Supplementary radiation shielding ELECTRON MOMENTUM
Magnet return yoke The product mv is termed momentump, where m is the relativ-
Yoke to pole edge spacing istic mass. The ratio P of electron velocity v to the velocity of
Pole edge to beam trajectory margin light c is a function of kinetic energy T. Defining the electron
Beam trajectory height h above the x-ray target. rest energy as Wo = rnoc2, the total energy W = Wo T and+
their ratio WIW, as y:
One example of the space required by these items is
illustrated in Figure 7-1.
In order to limit beam aberrations due to magnet saturation
effects, practical bend magnets are usually not operated above
about 1.7 T (Tesla) (17 kG), which corresponds to a radius of
curvature of 5 cm at 25 MeV. To permit comparison of orbit The ratio of moving electron rest mass m to electron rest
designs on a common basis for the various types of bend mass mo is
magnet systems used in medical electron accelerators, the ratio
of the trajectory height h above the x-ray target, to the radius
of curvature p can be used. If all systems employed the same

The momentum is

It is convenient to state electron momentump* in units of

moc.

The electron rest energy, Wo = moc2is 0.510985 MeV. For

example, at T = 10 MeV,

P = 0.998818, y = 20.5700, p = 20.5457 m,c

m0 = 9.1085 X g, c = 2.997929 X 101Ocm/s,
e = 1.60207 X Coulomb

ELECTRON MOTION IN THE DIPOLE

MAGNETIC FIELD
Figure 7-2 shows the force F, experienced by an electron
FIGURE 7-1 . Example of bend magnet cross section in radiation moving in a magnetic field. The direction of the force is at a
head, showing limited total space and typical space for individual items. right angle to the direction of the magnetic field and at a right
 ELECTRON MOTION IN MAGNET FIELDS
-
FIGURE 7-2 Direction of force, F = mv2/r, on an electron moving in
the median plane of a magnetic field.
angle to the direction of the electron motion, deflecting the
electron on a circular trajectory of radius p. The resulting
centrepital force F = ntv21p is balanced by the centrifugal force
Bev. The term Bev is called magnetic rigidity. Equating these
two forces give
Bp = rnvle = ple (7-5)
Substituting from eq. (7-4),
For example, at T = 10 Mev, Bp = 35,019 G cm, and B =
7004 G for p = 5-cm radius of curvature.
For beam energies typical of medical accelerators eq. (7-6)
can be approximated by the following, with B in kilogauss, p
in centimeters, T i n million electron volts.
Figure 7-3 shows that the radial bending of electron rays
that are parallel to each other on entry normal to a uniform field
magnet sector tends to converge these rays in the median plane
toward a focal point for the geometry illustrated. It also shows
the dispersion of these rays and their foci due to their different
momenta.
ELECTRON MOTION IN THE FRINGE FIELD AT
THE EDGE OF THE DIPOLE MAGNET
The magnetic lines of force in the gap between the poles tend to
repel each other, bulging out of the entrance and exit faces of a
117
FIGURE 7-3 . Dispersion of foci due to momentum spread in a dipole
sector magnet.
bend magnet. In these fringe field regions, the magnetic field
has vector components normal to the entrance and exit faces,
which act on electron rays that are displaced in they direction
above and below the magnet median plane and that are at an
angle to these faces other than 90" (see Fig. 7-4). If the plane of
the input face is rotated away from the center of curvature of the
bending beam, there is a component of the force that pulls the y
displaced rays toward the median plane during passage through
the fringe field. Conversely, a ray in the median plane and
displaced in its x direction toward (or away from) the center of
curvature from the central ray passes through an extra (orlesser)
region of magnetic field due to this entrance face rotation and is
deflected away from the central ray. Thus, rotating the entrance
or exit face of a bend magnet produces the same effect as a
quadn~pole(see the next section) magnet at that point, causing
beam convergence in one plane and beam divergence in the
other plane. The process of bending results in initially parallel
rays converging toward each other in the median plane as shown
in Figure 7-3. By rotating the input and output pole faces a
parallel beam can thus be focused in both radial and transverse
planes to a point beyond the bend magnet, as illustrated in
Figure 7-4b and 7-5b and discussed by Engels and Livingood.?-5
In the midplane of the magnet the fringe field starts rising
from zero at some point outside the magnet and reaches full
value (or nearly so) a short distance inside the pole gap (see
Figure 7-4c). For simplicity in transport calculations, a "hard
edge" approximation is made in which the field is assumed to
step from zero to full value at a point a distance d from the pole
edge. The ratio of d to the total pole gap g is defined as the
constant k, which typically has a value between 0.4 and 0.7.
The value of k can be reduced significantly by use of a field
clamp, as illustrated in Figure 7-4d. The field clamp shunts
much of the fringe field around the beam. This is especially
useful in magnets having a total gap that is a significant
percentage of the beam path length within the poles. Since bend
magnets for medical linacs are necessarily compact, gaplpath
length ratios are often fairly large and focusing properties are
 Median Plane Elevation Cross-section

k = dlg
Hard Edge Hard Edge

FIGURE 7-4 Fringe field. (a) In the radial plane offset by y from the median plane: Direction of force on an electron moving in the fringe field of a
rotated input pole face of a dipole sector magnet. (b) In the transverse plane: Effect of input pole face rotation on position of focus (from Ref. 4). (c)
Fringe field distribution and hard-edge approximation without field clamp. (d) With field clamp.
 ELECTRON MOTION IN MAGNET FIELDS
FIGURE 7-5 . Effect of input pole face rotation on position of focus in
median plane. (a) Input face normal to beam and (b) input face rotated
away from beam.
improved by use of field clamps. The positioning of such field
clamps also provides an additional parameter for tuning of the
magnet focusing properties.
ELECTRON MOTION IN THE QUADRUPOLE
MAGNETIC FIELD
Figure 7-6a shows the shape of the magnetic field and magnetic
equipotentials produced by a quadrupole magnet. The mag-
119
netic flux lines, and the lines of force orthogonal to them, are
rectangular hyperbolas. For the pole polarities shown and for
electrons coming out of the paper in Figure 7-6a:along the x
axis, the magnetic field is in the y direction, the force on an
electron is in the x direction, and both field and force increase
linearly with x from zero at the axis; along the y axis, the
magnetic field is in the x direction, the force is in they direction,
both field and force increase linearly with y from zero at the
axis. By = gx, B, = gy, where g is the magnetic field gradient
in units of change in gauss per centimeter. For the polarity
shown and for electrons coming out of the paper the magnet is
focusing in the y plane (Fig 7-6b), defocusing in the x plane
(Fig 7-&). To first order, the motion in the focusing plane is
described by sinusoidal functions; the motion in the defocusing
plane by hyperbolic sinusoidal functions:
Y(Z) = y1 cos wz + y; w-' sin o z
Y'(z) = -yl sin o z + y; cos a z
+
x(z) = X, C O S ~o z x,' a - I sinh oz
~ ' ( 2 )= x , o sinh o z +x cosh Wz (7-8)
where x l , y l ~ ' land y f l are the initial positions and angles
relative to the axis and z is the distance along the axis. the
B0
parameter w is the ratio of magnetic field gradient - and the
a
product Bp of the magnetic field and radius of curvature for the
particle. Hence,
where Bo is magnetic field magnitude at the surface of the pole
at minimum distance a from the axis.
For example, Bp = 35,019 G cm for a 10 MeV kinetic
energy electron. Let Bo = 5 kg at the pole at a = 0.5 cm from
7r
the axis. Then wz would equal- at 2.75 cm. Thus, a quadrupole
4
doublet suitable for focusing 10-MeV electrons could be in-
stalled in an axial length of less than 10 cm.
A single quadrupole magnet (quadrupole singlet) converts
an initially circular cross-section beam into an elliptical cross
section. Usually, quadrupole magnets are used in pairs
(quadrupole doublet) or in threes (quadrupole triplet), with
pole orientations such that in a given plane defocusing in
one magnet is followed by focusing in the next magnet,
permitting stigmatic focusing (circular output beam cross
section for circular input beam cross section). Ray paths in
yz and xz planes are shown in Figure 7-6b and c for parallel
to point focusing in a quadrupole doublet. The ratio of
imagelobject size is termed the magnification M. The spread
in divergence angles in the image plane is proportional to
11M (see Fig.7-7). That is, increased image size corresponds
to reduced spread of divergence angles of rays from a point
at the object.
A quadrupole singlet is sometimes used before a bend
120 CHAPTER 7. BEAM OPTICS OFMAGNET SYSTEMS
FIGURE 7-6 . Quadrupole magnet. (a) Magnet equipotentials (solid
curves,xy = constant); lines of force (dashed curves, y2 - x2 = con-
stant). Forces on an electron coming out of the paper. Single arrows in-
dicate magnetic field direction; double arrows indicate force direction.
(b)Motion of an electron in transverse yz plane and (c) in transverse xz
plane of quadrupole doublet and triplet.
FIGURE 7-7 . Formation of paraxial image with magnificationM.
magnet to correct for astigmatism in the bend magnet.
Quadrupole doublets and triplets may be used to transport a
beam over a considerable drift distance between the output of
an accelerator structure and the region of application of the
beam. An example might be one accelerator feeding beams to
two gantries in separate treatment rooms. Where space permits,
the triplet is superior to the doublet since it provides more
symmetric focusing of the beam and permits independent
control of focusing in the two transverse planes.
ELECTRON MOTION IN THE MAGNETIC FIELD
OF A SOLENOID
The word solenoid is derived from Greek words meaning like
a pipe or channel. Its magnetic field confines the diameter of
flow of the beam electrons.
A solenoid magnet is often used over at least a portion of
the length of the accelerator structure in bent beam medical
electron accelerators. It produces a field that is parallel to the
accelerator axis. One purpose is to limit expansion of the beam
diameter due to its spread in divergence angles at injection so
that it will pass through the accelerating cavity apertures. A
second purpose is to compensate for radial defocusing forces
of the accelerating microwave field in a portion of its cycle in
the early part of the accelerator structure where the electron
beam is less relativistic.
Electrons that pass through the midplane of an accelerator
cavity gap, while the accelerating electric component of the
electromagnetic field is rising (i.e., ahead of the crest of
accelerating field), experience a longitudinal bunching force
(early electrons accelerated less than late electrons) but ex-
perience a net radial defocusing force. The electrons experi-
ence less convergent electric force on entering the gap than
divergent electric'force on leaving the gap. This electric radial
outward force is partially compensated by a magnetic radial
inward force due to the product of the azimuthal magnetic
component of the electromagnetic field and the longitudinal
velocity p,c of the electron. The crest of the magnetic com-
ponent is 90" ahead of the electric component of the electro-
magnetic field. This net difference of electric and magnetic
radial forces is thus dependent on the phase of the electron
and it also varies as 1 - bePo,where Po is the phase velocity
of the electromagnetic field. In medical accelerators the elec-
 ELECTRON MOTION IN MAGNET FIELDS
tron velocity and the electromagnetic field phase velocity
rapidly approach the velocity of light. Thus, the radial defocus-
ing force drops rapidly as the electron gains energy, so external
means of focusing to compensate is needed primarily in low
beam energy regions of the accelerator guide. For &,Po the
required solenoidal magnetic field B, to just compensate for
the net electromagnetic radial force, is shown by Chodorow
et al.14 [their eq. (5.23)] to be
For example, let EeAlm0c2 = 4, corresponding to 20
MeVIm at 10 cm wavelength, sin 0 = 0.5 (electron 30" ahead
of the electric field crest, 60" behind the magnetic field crest),
and p = 0.70, corresponding to 0.2-MeV beam energy. Then
B = 824 Oe. For these same conditions, the required value of
solenoidal field drops to 414 Oe at 1 MeV, 314 Oe at 2 MeV,
192 Oersted (Oe) at 6 MeV. Of course, a larger value than this
just compensating value of B can be used. In high energy and,
especially, dual x-ray energy medical accelerators, the solenoid
may extend over most of the accelerator structure length and
produce a uniform field of about 1000 Oe. In low energy
accelerators, especially those that do not employ a bend mag-
net, a solenoid may not be used because the accelerator struc-
ture length is so short that radial momentumof the electron does
not have time to produce excessive radial displacement at the
x-ray target. Also, radial outward momentum produced in the
first accelerator structure cavity can be partially compensated
by injecting the electrons from the gun into this cavity with
radial inward momentum.
The lines of magnetic flux are parallel to its axis z inside
the solenoid and flare out at its ends (usually ending on the
FIGURE 7-8 . Motion of electron in field of solenoid magnet.
121
aperture of an enclosing iron cylinder), as shown in Figure 7-8.
In this end field, the integral of the radial component of magnet
field over a path parallel to z and displaced from the axis by r
is equal to one-half the integral of the z component of the field
inside the solenoid over this displacement distance r. Thus, the
azimuthal acceleration given an electron by this fringe field is
proportional to the displacement of the electron from the axis.
The resulting azimuthal motion in the axial field produces a
radial restoring force. All electrons entering parallel to the axis
form helices tangent to the axis, the helix diameter equaling the
displacement from the axis of the entering electron. Electrons
entering with a divergence angle follow correspondingly larger
diameter helical paths, the radial component of momentum due
to divergence adding vectorially to the azimuthal component
of momentum produced by the fringe field. The reverse process
occurs in the exit fringe field, converting from helical motion
to simple displacement and divergence. All electrons rotate
around their helices at a frequency of 2.800 X 10" revolutions
per second, where B is in gauss.
For example, an electron entering a 1-kG solenoid field on
a parallel path displaced 0.1 cm from the axis is deflected
azimuthally through the same angle as if it had traveled 0.05
cm through a 1-kG bend magnet field, about 10.5 mrad at 1
MeV. It has an axial momentum of 2.78 moc and a radial
momentum of 0.0292 mOc.It follows a 0. l-cm diameter helical
path tangent to the axis, completing a helix period in 0.1 n
2.7810.0292 = 30 cm at 1 MeV. It crosses the axis at 15 cm at
an angle of 10.5 mrad. This example is illustrated in Figure 7-8.
As the electron accelerates to higher energy, the transverse
momentum is retained and the helix stretches out. For example,
at 6 MeV the axial momentum is 12.7 mot, corresponding to a
137-cm helix period and axis crossing angle of 2.3 mrad at a
68-cm axial distance from where its trajectory was parallel to
the axis at 6 MeV.
:--=@-e-
Axis of Helix
122 CHAPTER 7. BEAM OPTICS OF MAGNET SYSTEMS
A short solenoid can function as a thick lens. For example,
a 7.5-cm long I-kg solenoid (with sharply defined pole ends)
would cause a ray entering offset by 0.1 cm and parallel to the
axis to follow 90" of helix rotation to the solenoid exit. At that
point, its radius from the axis would be 0.0707 cm; it would
have 0.0206 moc azimuthal momentum and 0.00856 mocradial
momentum. In passing through the exit magnetic fringe field,
the azimuthal momentum would be canceled. The radial mo-
mentum would be retained. The 1-MeV electron would con-
verge toward the axis with an angle of 3.08 mrad, crossing the
axis in another 23 cm, a total distance from the 1-kg solenoid
entrance of 30.5 cm.
At 6 MeV, a 34-cm long solenoid would rotate the
parallel entering electron at 0.1 cm from the axis through
90" of the helical path, producing 0.67 mrad radial conver-
gence and axis cross-over at 182 cm from the solenoid
entrance. Thus, even a thick solenoidal lens is not very useful
in a medical accelerator beyond about the first few million
electron volts.
Solenoids require much more coil excitation power than
quadrupoles for equivalent focusing force, but the transverse
excursion of the electron rays of a typical beam is less with a
solenoid. Hence, for small aperture accelerator structures, such
as high shunt impedance SW medical accelerators, solenoidal
focusing is used.
BEAM STEERING COILS
A set of four coils is typically located near the entrance of the
accelerator structure and another set is near its exit. Each set
forms a pair of orthogonal dipole magnets to permit deflecting
the beam by a small angle in the x and y transverse directions.
The entrance set can correct for error in angle of injection of
the beam from the gun, aiming the beam along the axis of the
solenoid, which is concentric with the axis of the accelerator
guide structure. The exit set can correct for an error in angle
between the axis of the solenoid and the proper entrance axis
of the collimator into the bend magnet. If the deflection angles
produced at the entrance and exit are equal and opposite, the
result is a transverse displacement of the beam. The angle and
position of the electron beam at the output of the accelerator
structure, into the bend magnet system, and at the x-ray target
or electron window can be controlled by this steering process,
thereby correcting for deviations in the electron beam align-
ment, such as may be caused by mechanical changes or un-
wanted magnetic fields.
When steering coils are used within a solenoid, they pro-
duce a change in the radial component of momentum of the
electron, which causes it to follow a larger or smaller diameter
helical path in the solenoidal field. This converts to simple
displacement and divergence as the beam transits the solenoid
exit field. The net steering effect is a function of the number of
degrees of helical motion, hence of beam energy. In addition
to a set of coils near the entrance and another near the exit of
the solenoid, a single set distributed over the full length of the
solenoid may be used, which can have the effect of tilting the
magnetic axis of the solenoid. This can be used to correct for
misalignment of the accelerator structure axis with respect to
the solenoid axis (e.g., due to the winding pattern of the
solenoid coils), while maintaining minimum helical excursion,
hence maximum clearance from the apertures of the accelerator
structure.
BEAM TRANSPORT
In order to compute the passage of a bundle of electrons
comprising the beam through an array of magnets and drift
spaces, a set of simultaneous equations needs to be solved.
A program titled TRANSPORT has been developed by
Brown- and Careyl2.13 to accomplish these calculations on
a computer.
In the following sections some conventional terms and
formalisms used in beam transport computations are defined.
Beam emittance, drift lengths, dipole, quadrupole and sex-
tupole magnets, solenoids and magnetic lenses, and their trans-
port of beams are described. Nonachromatic, single
achromatic, double achromatic, and isochronous magnet sys-
tems and scanning magnets are then discussed in relation to
their use in medical accelerators.
Table 7-1 lists definitions of terms commonly used in
discussing beam transport magnet systems. The transport of a
beam from the object plane to the image plane through a
magnet system is analogous to the transmission of light through
an optical system. Historically, terms from optics have been
adopted for use in the development of beam transport theory.
For example, chromaticity refers to color wavelength in optics
and to particle momentum (electron energylc) in electron beam
transport.
BEAM EMITTANCE
Beam ernittance is a convenient way of describing the
parameters of a bundle of individual electron rays. The
acceptance of a beam transport component or system is
simply the maximum beam emittance that it will transmit.
These concepts are convenient in understanding the perfor-
mance of an accelerator or beam transport system and in
optimizing their design.
The motion of electrons within an rf beam bunch is usually
defined relative to the bunch centroid, as discussed, for exam-
ple, by Banford.4 A set of Cartesian coordinate axes is defined
with origin at the bunch centroid, z axis in the direction of
motion, x and y axes in the transverse plane, normal to the
direction of motion. In bend magnets, the origin follows a
central trajectory in the median plane between the two poles of
 BEAM EMITTANCE 123

Table 7-1. Beam transport system terminology

--
-

Trajectory The path (orbit) followed by an individual electron ray

Displacement The distance of an individual trajectory from the central trajectory, measured
normal to the central trajectory at any point along it
Divergence The angle between the slope of an individual trajectory and the slope of the
central trajectory at any point along it
Dispersion The spreading of displacement and divergence of individual trajectories
solely from their spread in momenta, due to their spread in radii of curvature
when bending in a given magnetic field.
chromatic^ "Doubly achromatic." Spatial dispersion and its derivative, angular dispersion,
of a beam are both zero at a selected distance along the central trajectory
from the object plane, independent of beam momentum
Magnification The ratio of a spatial dimensions of the beam section at the image plane to
the corresponding dimension at the object plane
Stigmatic "Doubly focused." The image of both the radial and transverse components
of the object occur at the same point along the central trajectory. They
occur at two different points in an astigmatic image
Radial In a plane parallel to the median plane of a bend magnet
Transverse A surface normal to the median plane and containing the electron trajectory
Focus Reconvergence of the object plane beam cross section at the image plane,
with magnification

aHistorically, some magnet systems have confusingly been termed achromatic or zero dispersion for cases where the
spatial dispersion is zero but its derivative, angular dispersion, is not zero. To eliminate confusion, systems having zero
dispersion in both displacement and divergence are sometimes termed "doubly achromatic", permitting the use of the
term "singly achromatic" for systems having zero dispersion only in displacement.

the magnet, the x axis is in the median plane and the y axis is cept xi, and maximum projection onto the p,-axis p,,,,, or
normal to the median plane. The state of motion of a particular maximum projection onto the x-axis x,,, and p,-axis intercept
electron in the beam is then represented by a six-dimensional px, divided by mot.
hypervolume phase space vector For beam transport systems through which the momentum
of the beam remains constant, it is conventional to divide
px and p, by p, of the centroid electron, giving divergence
angles 0 = dxldz and = dyldz. (It is also common to use
x' and y' instead of 0 and 0 to designate divergence in
where x, y, z are position vectors and p,, p,,, Ap, are momentum
phase space.) Thus, in the x,0 dimension in phase space the
vectors relative to the position and momentum of the centroid emittance would be the product of the x-axis intercept and
electron. the 0-axis projection of the ellipse containing all electrons
Ignoring such effects as space charge forces and gas scat- in the beam. The term x is usually stated in millimeters and
tering, Liouville's theorem (see, e.g., Ref. 4) implies that the
phase space volume representing the particle states of the beam
remains constant. Assuming the components of motion are
independent in the x, y, and z directions, the areas of xe,, yp,,
zp, planes remain constant.
In the transverse dimensions this area is known as the
emittance of the beam. It is convenient to assume that this area
in phase space is bounded by an ellipse. Each point within the
ellipse represents a possible electron ray. Portions of the ellipse
area may be void of electron rays but it is assumed that no
electron rays have phase space values outside the ellipse. The
magnitude of the emittance ellipse is usually defined as the
ellipse area divided by T and is usually normalized to nzoc.The
area of an ellipse is given by the product of T , the maximum
projection onto one axis, and the intercept with the other axis.
Thus in Figure 7-9, in the x, p, dimension in phase space, the
normalized emittance would be the product of the x-axis inter- FIGURE 7-9 . Beam emittance ellipse inx,p, phase space.
124 CHAPTER 7. BEAM OPTICS OF MAGNET SYSTEMS
FIGURE 7-10 . Current density across the beam in real space for a uni-
form density in six-dimensional phase space.
0 in milliradians. A statement of normalized emittance would
be x0 (pzl~~zoc).
Figure 7-10 shows the current density across a beam in real
space corresponding to a uniform density in x0 and y@ space,
similar to that observed in practice. Figure 7-11 shows two
electrons a and b, changing their displacement and divergence
in real space and correspondingly moving on a constant area
ellipse in phase space. For example, electron a moves from x
= 1,0=Oatzl,tox=0.707,0 =0.707atz2tox=0,0 = 1
at z3. Similarly, electron b moves from 0 = 1, x = 0 to 0 = 0,
x = 1. In a solenoidal field, an initially upright ellipse would
remain upright. In other types of beam transport systems, the
shape of the ellipse can change from an oblong tilted one way
I I
I I
I I
FIGURE 7-11 . Positions in real space and phase space for electrons a and b in a solenoidal field.
to circular to oblong tilted the other way, but in the absence of
nonlinear forces its area does not change. This is illustrated in
Figure 7-12 with limiting ray trajectories and corresponding
phase space plots for the x dimension at positions along a field
free drift length. The region at minimum beam envelope diam-
eter is termed a waist. It has an upright ellipse in phase space.
Figure 7-13 shows phase space plots immediately before and
after a thin lens; Om, changes but X,, is constant.
Nonlinear forces do not change the area in phase space,
but the shape can change to nonelliptical so that a larger
effective ellipse is required to contain it. This is illustrated
in Figure 7-14. Increasing the energy of an electron by linear
acceleration (without transverse forces) does not affect its
transverse momentum; hence, its divergence angle decreases
but its normalized emittance x0 (p,lm,c) does not change.
For example, an electron beam from a 30-kV gun, injected
with a maximum beam radius of 0.1 cm at its waist (zero
divergence at periphery), and maximum divergence on the
axis of 2 100 rnrad would have an axial momentum of 0.348
nzoc, and maximum transverse momentum of 0.349 moc.
After linear acceleration to 10 MeV in 100 cm, the axial
momentum would be 20.546 moc, and the maximum transverse
momentum would still be 0.349 moc, corresponding to a
maximum divergence of 0.349120.946 = +1.7 mrad. The
phase space ellipse of the output beam would have tilted
due to the transverse displacement of the initially axial
divergent rays by 0.175 cm over the relativistically fore-
shortened acceleration length L,:
I m a s e space
-x
a
Ia
I
I
 NONACHROMATIC BEND MAGNET SYSTEMS 125

NONACHROMATIC BEND
MAGNET SYSTEMS

Isocentric treatment units of early design employed a nominal

90" or 270" nonachromatic beam-bending magnet with the
accelerator guide structure mounted approximately horizon-
tally in the gantry. Figure 7-15 illustrates the effect of a simple
90" dipole magnet on the exit beam for entrant beams having
an energy spread + AE about E,, or a radial displacement k ,
or a divergence be. These aberrations, which are easiest to
understand individually in the radial plane of simple 90" mag-
nets, can appear in combination and are also present in the
transverse plane of magnets. Typically, the beam energy spread
is restricted to + 10 percent or less about its central value. The
trajectories of the low, central, and high energy components in
Figure 7-15a are denoted by I , c, and h, respectively.
A single 90" bend magnet, such as shown in Figure 7-15a,
is not achromatic. It can bend a monoenergetic beam on axis to
a point at the x-ray target but the spread of energies of the actual
beam results in a spread of such focal points at the x-ray target
as shown. This spreading effect can be minimized by reducing
the bending radius of the magnet, restricting the emittance and
FIGURE 7-12 . Tilting of phase ellipse in transiting drift space. the energy spread of the beam, stabilizing the operation of
components that affect beam energy, or by incorporating a
second magnet to provide focusing. However, even with these
precautions, changes of energy, as well as variations of the
angle and position of the entrant electron beam, will produce
detrimental asymmetries in the exit beam and treatment field.
As illustrated in Figure 7-16, the principal effect of an energy
change of the entrant beam in a nonachromatic 90" magnet
where system is a lateral change in displacement and angle of the
beam at the target with consequent production of asymmetry
L = accelerationlength of the treatment field, especially at high x-ray energies because
E, = input beam energy of the steep slope of the x-ray flattening filter. Energy control-
E, = output beam energy ling slits can be located near the output of a 90" magnet, but

I Phase Space

FIGURE 7-13 . Tilting of phase ellipse by thin lens.

126 CHAPTER 7. BEAM OPTICS OF MAGNET SYSTEMS

FIGURE 7-14 . Area of phase space ellipse remains constant from a to b under action of linear forces (Liouville's theorem). The area in phase space
remains constant from a to c under action of nonlinear forces but the contour is distorted, requiring an enlarged ellipse to encompass it, hence en-
larged effective emittance (from Ref. 4).

Magnet
Pole
/ AX

r
Electron Beam
C C L
*
t
.- C
r

AX

lf
7 7
l c h c C
EO- A E Eo Eo+A E

FIGURE 7-15 . Effect of 90" dipole magnet on exit beam having (a) energy spread, (b) radial displacement, and (c) radial divergence.
 NONACHROMATIC BEND MAGNET SYSTEMS 127

Electron Beam

max

FIGURE 7-16 . Flattened x-ray field distributions. (a) Symmetrical, electron beam axial at x-ray target, (b) asymmetrical, electron beam tilted at x-
ray target; and (c) asymmetrical, electron beam displaced at x-ray target.

here they tend to become pseudo-targets enlarging the effective

focal spot size.
The design and performance of the 90" bent-beam Clinac
6 treatment unit have been reported by Austin,] Haimson et al.18
and Horsley et a1.20 and its magnet described by Avery.2 It
avoided some of the beam lateral displacement and angle
problems at the x-ray target by allowing the lower energy
portion of the beam spectrum to sweep by the edge of the target
into a shielded cup and by using feedback to keep the high
energy portion of the beam spectrum directed at the correct
angle onto the x-ray target near its edge.
Figure 7-17 illustrates a 270" uniform field magnet
wherein a + 10 percent energy spread beam comprised of
parallel rays is brought to a single focal point in both the radial
and transverse planes at the x-ray target, in part by choice of
the of the-entrant and exit pole faces' higher energy RGURE 7-17 . Spmd in an& of exit bean by 1700
component h is deflected through a circle of larger radius9 the achromatic Ytriple-focus"bend magnet due to energy spread I to h, of en-
lower energy component through a circle of smaller radius, but trant beam.
128 CHAPTER 7. BEAM OPTICS OF MAGNET SYSTEMS

270" Magnet

Magnet Poles

Section dl - d2

FIGURE 7-18 . A 270"magnetic mirror-approxin~ately hyperbolic pole contours.

Magnet sectors

~ a ~ n poles
e t

FIGURE 7-19 . A 270' single sector magnet with locally tilted pole gap (gradient shim pole pieces) and adjustable angle input
and output pole faces.
 ACHROMATIC BEND MAGNET SYSTEMS
both converge on the target at the same point on the central
energy trajectory c.
However, a change in mean energy of the beam from the
accelerator structure will result in a change in mean angle of
the beam at the target and, hence, to asymmetry in the x-ray
field. This magnet has been termed "triple-focus zero disper-
sion" because initially parallel cosine-like rays in both radial
and transverse planes are brought to a point focus, independent
of momentum. It has also been termed "singly achromatic," but
it does not comply with the definition of "achromatic" (doubly
achromatic) because of the dependence of angular divergence
at the image plane on momentum.
ACHROMATIC BEND MAGNET SYSTEMS
In order to minimize distortions in flatness of radiation fields
due to changes in mean energy of the energy spectrum from lin-
ear accelerators, machines that require bending the electron
beam employ an achromatic bend magnet system. Taking into
account the magnification factor from object to image, the char-
acteristics of the individual rays making up the electron beam
are the same after the bend as before it, independent of their mo-
mentum spread. With unity magnification this has an effect
equivalent to placing the accelerator structure output directly at
the x-ray target and in line with the x-ray beam axis. Achromatic
magnet systems have been used for decades for translation or
deflection of beams from stationary linacs (see e.g., Panofsky et
al.,26 Penner,27 and Brown et al.9). In general, more compact
systems are required for 360" isocentric accelerators. This need
has led to the several different designs of achromatic magnet
systems in use in medical electron accelerators. Each of these
designs is discussed in the following sections.
SYMMETRICAL 270" SINGLE SECTOR
HYPERBOLIC POLE GAP
Figure 7-18 shows the earliest concept of an achromatic bend
magnet that was sufficiently compact to be applicable to high
energy medical electron accelerators. It was proposed by
Engels-17and is called a magnetic mirror because particles that
traverse it appear to be reflected from the plane at its entry. It
is employed in the Brown-Boveri Dynaray treatment units,
which are described by Sutherland.30 Its magnetic field in-
creases approximately in proportion to distance in from the
entrance plane, the field exponent, n having a value of about
- 1 for the first 1 cm in from the entrance plane and -0.8 for the
remaining several centimeters. That is, By = Gr-n, where G is
the field gradient and r is the distance in from the magnet
effective entrance face (with field clamp). Higher momentum
electrons travel through a higher magnetic field, lower momen-
tum electrons travel through a lower magnetic field.
All electrons entering on the 0" axis coalesce on the 270"
axis regardless of their momentum difference. There is no
129
dispersion and the deflection is achromatic. This magnet is
capable of faithfully focusing a wide range of momenta as
limited by slits S1 and S2 placed at the symmetry plane dl-d2.
However, highly precise manufacturing tolerances are required
to shape the contoured pole faces. To obtain greater freedom of
design and control, locally wedged and stepped pole gap mag-
nets have been developed.
SYMMETRICAL 270" SINGLE SECTOR LOCALLY
TILTED POLE GAP
Figure 7-19 shows one way to achieve the achromatic beam
transport of the "mirror" magnet, by combining uniform and
nonuniform field regions in the same magnet sector, as proposed
by Enge.16 It focuses a range of entrant momenta, and an input
configuration of lateral displacements and angular divergences
of the electron beam, to an optically similar configuration at the
output focal plane. Its entrant and exit pole face angles a l and
a2can be adjusted for optimal radial and transverse focusing of
each monoenergetic bundle of rays at the dl-d2 plane. In addi-
tion, two adjustable pole sections of the magnet, shown in
section view dl-d2, provide an adjustable radial field gradient
with 12 < 0. Higher momenta rays travel through a higher
magnet field, lower energy rays through a lower magnetic field
in this localized 1.1 < 0 region. This radial gradient is controlled
by adjusting angle a3to reconverge the different energy bundles
or rays into a single spot at the x-ray target. The distribution of
rays in this spot are the same as in the beam cross section that
enters the magnet. Petersilka et a1.28 describes the employment
of this type of bending magnet in the Siemens Mevatron.
SYMMETRICAL 270" SINGLE SECTOR STEPPED
POLE GAP
Figures 7-20 and 7-21 show another way to achieve the achro-
matic beam transport of the Enge "mirror" magnet. Brown et
al.1 and Tronc31 describe the beam trajectory in this type
magnet. In the specific example depicted here, the tnjectory
bends approximately 49" on a large radius, pol in a uniform low
magnetic field wide pole gap region; approximately 172" on a
short radius po2 in a uniform high magnetic field narrow pole
gap region; and again 49" on a large radius pol in a uniform low
magnetic field wide pole gap region. High energy rays follow
a longerpath length than low energy rays, in order to experience
the same total bend angle. Rays of different momenta are
spread apart at the symmetry plane, where energy selection slits
are located. Both cosine-like and sine-like rays have cross-
overs in the median plane at this symmetry plane, the sine-like
loop appearing to tilt with the entrance divergence angle. In the
transverse plane, the cosine-like rays have a cross-over at the
symmetry plane so the transverse dimension of the beam at the
symmetry plane is defined by the sine-like rays. The magnet
entrancelexit pole face is at 4.5" to the beam, as in the Enge
mirror magnet. The position of the step and the ratio of high/low
magnetic fields (as aided by trim coils) are chosen so that the
130 CHAPTER 7. BEAM OPTICS OF MAGNET SYSTEMS
' Entrance
Collimator
FIGURE 7-20 . A270° single sector stepped pole gap magnet: Cosine-like Cr,sine-like Sx, and dispersion Dx trajectories in median plane and sine-
like Sg trajectory in transverse plane (from Ref. 11).
object and image planes are located at a distance from the
entrancelexit pole face, providing room for a magnetic field
clamp to shape the fringe field and for the entrance beam
collimator, exit beam window, and x-ray target.
2700THREE
POLE GAP, TWO Cx CROSS-OVERS
The illustrations comprising Figure 7-22 a-d, describe the
nominal 270" magnet system proposed by Brownlo and used in
the Varian Clinac 18 family of treatment units. Figure 7-22a is
Target
Plane
' /
Median
Plane
a cross-sectional view of this magnet in the median bending
plane of the central orbit. It incorporates three uniform field
dipole sectors, M,, M,,and M3 with short drift tubes connecting
them. A magnetic shunt between poles (not shown) provides a
region relatively free of magnetic field for passage of the
varticles between sectors. The emittance of the beam entering
the magnet system is typical of the output beam of an electron
linac in terms of cross-sectional area, divergence, and energy
spread. The performance of the system is analyzed with respect
to the particle that enters along the central axis with reference
momentum po and whose central orbit reference trajectory is
shown as a heavy dashed line in Figure 7-22a and b.
 ACHROMATIC BEND MAGNET SYSTEMS
Entrance
FIGURE 7-21 . Cross section of a 270' single sector stepped pole gap
magnet structure and of edge field clamp (from Ref. 11).
Brown6 showed that the properties of such a system are
completely determined to second order by specifying five
representative trajectories or paths relative to the reference
trajectory. Spatial departures from the reference trajectory
by particles of reference momentum are separated into or-
thogonal radial and transverse components for rays initially
at the axis but with divergent trajectories S, and Sy and for
rays initially parallel to the axis but displaced from it on
trajectories C, and Cy The momentum trajectories D, dis-
persed by the magnetic field from the reference trajectory
in the median plane are for particles that are initially axial
and with momenta differing by + A p from the reference
momentum yo.
Two of these trajectories (see Fig. 7-22a) depict diver-
gence from the central orbit (ST)and lateral displacement from
the central orbit (C,) in the median plane. Figure 7-226 is a
simplified view similar to Figure 7-22a depicting trajectory D,
of momentum dispersed particles initially on the central axis.
The trajectories of all particles through the system are symmet-
rical about a plane of symmetry located at 135" midway along
and normal to the reference trajectory. The energy selection slit
is placed at approximately the first C,ycross-over to intercept
131
all particles outside a selected momentum band tAp centered
aboutpo. An end view of this magnet system in the transverse
plane is shown in Figure 7-22c. The entering angular diver-
gence S, and lateral displacement Cx in the beam cross section
from the accelerator are reproduced at the target plane (see Fig.
7-22a) with no significant increase in their magnitude. Figure
7-22d illustrates focusing properties in the transverse plane due
to the fringing fields of the shaped pole faces along and near
the reference trajectory and depict angular divergence Sy and
lateral displacement C,. Again, the entering transverse diver-
gences and displacements are reproduced at the target with no
significant increase in their magnitude. The dimensions of the
entering radial and transverse divergence and displacement are
the same in the radial (bending) plane, so a circular symmetric
beam from the accelerator structure is reproduced in all its
aspects to first order by the magnet system, at its exit, indepen-
dent of energy. The system is achromatic since both the spatial
dispersion and its derivative are zero at the output plane. The
energy slits are sources of leakage radiation from stopped
electrons. However, this bremsstrahlung is directed away from
the isocenter and not directly contributory to patient exposure.
A magnetic analysis of the electron treatment beams from a
Clinac 18 by Wessels et al.32 gave energy dispersion values of
50.4 to 0.7 MeV full width at half-maximum (fwhm) over the
range 6-18 MeV, respectively. These dispersion values include
the effect of scatter from the linac thin window and 1 meter of
air. A description of magnetic and threshold techniques for
energy calibration of high energy radiations has been given by
LanzI.23
SYMMETRICAL 270" THREE SECTOR UNIFORM
POLE GAP, ONE Cx CROSS-OVER
Achromatic systems with three sectors have been used in
the past for beam transport in applications not directly related
to radiotherapy. Steffen29 shows such a system with three
identical sectors (see his Fig. 3.3a), with two Cx crossovers
and with one S, cross-over in the midplane. Livingood25
shows such a system (see his Figs. 11-9 to 11-11) with first
and third sectors identical and the central sector angle chosen
between 90" and 216", depending on the desired locations
of the object and image planes. Leboutet24 describes a 270"
three sector system applicable to medical electron accelera-
tors. As with Livingood,25 the first and third sectors are
identical and the angle of the central sector is selected to
provide a suitable drift space between sectors. Two types of
design parameters are described, one having two cosine-like
cross-overs in the median plane and the other having one
cosine-like cross-over. The entrance and exit pole faces of
the central sector can be curved cylindrically to compensate
for second-order aberrations. The single cross-over design is
used in the Therac 20 accelerator, with three identical 90"
sectors (see Fig. 7-23).
132 CHAPTER 7. BEAM OPTICS OFMAGNET SYSTEMS

Magnet Coil Magnet Sector

Reference
Trajectory '.___..'

Plane of
Symmetry

Slit

Entrant I ,
n c.. ! Energy
Trajectory ' ./ Dx A Pi/ Selection
I /
Slit
',
I Central Orbit
I Reference I I I *P
Trajectory

Magnet Coil
\

Plane of Symmetry

Central Orbit
Reference
Beam Trajectory
Apertures

(4

FIGURE 7-22 . A 270" three sector uniform pole gap magnet (baqed on Ref. 10). (a) Cosine-like Cx and sine-like Sx trajectories in median plane (b).
Momentum trajectories Dx dispersed to maximum at 135'. Energy slit is at Cx focus at 90'. (c) A transverse cross section. (d) Cosine-like Cy and sine-
like S, trajectories in transvefse plane.
 ACHROMATIC BEND MAGNET SYSTEMS 133

and the second bend is 77". The exit pole of the first sector and

i - -
Material Code
Tungsten B
Lead BZBi 1 the entrance pole of the second sector are parallel to each other
but rotated by angles ---ql and + y 2 of 32" from normal to the
central trajectory. A quadrupole doublet is placed between the
accelerator structure and the bend magnet system to transform
the beam phase space ellipse to match the acceptance phase
space of the magnet system. The measured dependence on the
energy of the output beam parameters is less than 0.05-mm
displacement and less than 1.2-mrad divergence per percent
energy change.

ASYMMETRIC 112 Y2" THREE SECTOR

UNIFORM POLE GAP
Fixed Collimator
Figure 7-25 shows a system described by Bates? which is used
in the SL25 accelerator. This machine employs a drum type
Im gantry, a design that provides more space horizontally than in
Scale
10 cm:
stand-mounted gantries. The accelerator guide can extend back
through the gantry support bearings nearly to the treatment
room wall instead of stopping near a gantry stand. There is
Treatment Field 4 Adjustable Collimator, room to distribute the magnet sectors along the gantry axis
Axis Set For 10 cm Field direction and still use a relatively long (2.5 m) accelerator
-Y
. lsocenter structure. This permits using a total bend nearer to 90" instead
Patient of the conventional 270°, still achieving approximate achroma-
I Plane ticity. The goal is to minimize the height of the trajectory above
the x-ray target in order to minimize isocenter height.
FIGURE 7-23 . Cross section of 270" three sector uniform pole gap The system employs identical +45" first and -45" second
magnet showing electron beam sweeping magnet and radiation head.
Magnet employs single cosine-like Cx cross-over (from Ref. 3).
sectors and a 112 IhOthird sector. The accelerator guide and
input beam aim 22 lhO away from the gantry axis. There is a C,
cross-over at the plane 4between the second and third sectors.
ASYMMETRIC 270" TWO SECTOR UNIFORM As shown, a second C, cross-over occurs at the image plane F
POLE GAP independent of momentum, producing a reduction in beam
Figure 7-24 shows a system described by Hutcheon et al.",22 cross section at the target for initially parallel rays but an
which is designed to minimize the height of the 270" trajectory increase in angular spread at the target for initially divergent
loop in order to limit the required isocenter height of an rays. Maximum dispersion of momenta occurs at plane L2, but
isocentric medical electron accelerator. The first bend is 193" the energy slit S is located at the entrance to the second sector
to minimize x-ray shielding above the third sector, again to
minimize isocenter height. The entrance and exit pole faces of
the three sectors are rotated by a few degrees to provide a C,
cross-over at the object plane. Under these conditions the beam
cross-section at the object plane is determined by the input
beam divergence S.r,S,., which can be small, especially at high
energy. The sector faces are curved to correct for second-
order aberrations.

1I

nn, SYMMETRICAL 180" FOUR SECTOR UNIFORM

Target, ;
FIGURE 7-24 . A symmetric 270' two-sector uniform pole gap mag-
net en~ploying193' first bend and 77" second bend. Solid line is nomi-
nal energy central ray. Dashed line is higher energy ray (from Ref. 22).
POLE GAP-ISOCHRONOUS
Figure 7-26 shows a system described by Heighway,lg which
is used to reflect the beam 180" for a second pass through the
accelerator structure of the Therac 25 accelerator. An isochro-
nous design is employed to avoid spreading of the rf electron
bunch length from input to output of the magnet. This is
134 CHAPTER 7. BEAM OPTICS OF MAGNET SYSTEMS
FIGURE 7-25 . A symmetrical 112 YzOthree-sector uniform pole gap "slalom" magnet (from Ref. 5) .(a)Cosine-like Cx ray in median plane at nomi-
nal, higher, and lower energies. (6)Cosine-like Cx rays in transverse plane.
important to achieve adequate beam current through the energy
slits to achieve an adequate dose rate in the x-ray mode,
especially at low x-ray energy. The central trajectory bends
approximately -6O0, +115", +35" to a symmetry plane and
+35", + 115", -60" to return to the accelerator structure axis.
To first order, all electrons take the same time to traverse the
magnet system, independent of their input displacement, diver-
gence or momentum relative to the centroid electron ray and
each electron ray has the same displacement and divergence on
exit from the magnet system as on entrance to it. The magnet
location can be adjusted to position the returning electron
bunch at the desired phase on the accelerating wave. This
method of shifting the phase of the return electron bunch can
be used to control output beam energy, provided that the bunch
length after this bend is short to avoid excessive energy spread.
Electrons of different momenta pass through symmetri-
cally located cross-over points before and after the symmetry
plane and cross the symmetry plane normal to it. A higher
energy ray follows a longer path than the central trajectory
before the first and after the second momentum cross-over
and a shorter path between them, such that rays of different
momenta have the same total transit time, and, hence are
isochronous. Figure 7-26b shows the beam envelope in the
median plane and Figure 7-26c in the transverse plane, with
a waist at the symmetry plane. The relatively large ratio of
magnet gap / orbit length within each sector implies the need
for field clamps, with precise adjustment of their positions to
tune the focusing properties of the system.
REFERENCES
1. Austin NA: Electron weapon against cancer. Electronics April
6:88-92, 1964.
2. Avery RT: Electron accelerator with specific deflecting mag-
net structure and x-ray target. U.S. Patent 3,360,647, issued
1967.
3. Bading JR, L Zeitz, JS Laughlin: Phosphorus activation neutron
dosimetry. Med Phys. 837-843, 1982.
4. Banford AP: The transport of charged particle beams. London,
E. & F. N. Spon, Ltd., 1966.
5. Bates T: Deflection system for charged particle beam. U.S. Patent
4,409,486, issued 1983.
6. Brown KL: A first- and second-order matrix theory for the design
of beam transport systems and charged particle spectrometers.
Stanford Linear Accelerator Center Report. SLAC 75 (Rev. 3)
UC-28, 1972.
7. Brown KL.: Beam envelope matching for beam guidance sys-
tems. Stanford Linear Accelerator Center Report. SLAC; PUB
2370: 1-32,1980.
 REFERENCES
.
FIGURE 7-26 Isochronous 180° four-sector uniform pole gap magnet (from Ref. 19). (a) Cosine-like Crray in median plane and central ray at nom-
inal, higher and lower energy. (b) Relative beam sue in median plane versus path length. (c) Relative beam sue in transverse plane versus path length.
8. Brown KL, DC Carey, Ch. Iselin, F Rothacker: Transport-A
computer program for designing charged particle beam transport
systems. CERN 80-04 CERN - Service d'information scientifique 18.
-RD/437 -2500, Mars 1-251,1980.
9. Brown KL, WKH Panofsky, JF Streib: Method of focusing 19.
charged particles to provide zero momentum dispersion. U.S.
Patent 3,138,706, issued 1964. 20.
10. Brown KL, WG Turnbull: Achromatic magnetic beam deflection
system. U.S. Patent 3,867,635, issued 1975.
11. Brown KL, WG Turnbull, F T Jones: Stepped gap achromatic 21.
bending magnet. U.S. Patent 4,425,506, issued 1984.
12. Carey DC: TURTLE (Trace unlimited rays through lumped ele-
ments). Fermilab Report No. NAL-64. 1971. 22.
13. Carey DC: New features in TRANSPORT. Fermilab TM-
1046, 2041.000. Batavia, Illinois, Fermilab, September 7,
1981.
14. Chodorow M, EL Ginzton, WW Hansen, RL Kyhl, RB Neal, 23.
WKH Panofsky: Stanford high-energy linear electron accelerator
(Mark 111). Rev Sci Instr 26: 134-204, 1955.
15. Enge HA: Effect of extended fringing fields on ion-focusing 24.
properties of deflecting magnets. Rev Sci Instr 35:278-287,
1964. 25.
16. Enge HA: Deflecting magnets, in A Septier (Ed): Focusing of
Charged Particles. New York, Academic Press, 1967; vol 2, 26.
203-265.
17. Enge HA: Particle accelerator provided with an adjustable 270'
135
non-dispersive magnetic charged-particle beam bender. U.S. Pa-
tent 3,379,91l , issued 1968.
Haimson J, CJ Karzmark: A new design 6 MeV linear accelerator
system for supervoltage therapy. Br J Radiol 36:650-659, 1963.
Heighway EA: Magnetic beam deflection system. Canadian Pa-
tent 993124, issued 1976.
Horsley RJ, RH Price, JE Saunders, PW Dingwall: Performance
of a 6 MeV Varian linear accelerator. Br J Radiol 41:312-3 16,
1968.
HutcheonRM, EA Heighway: Anew compact doubly achromatic
asymmetrictwo-magnet beam deflection system. Nucl Instr Meth
187:81-87, 1981.
Hutcheon RM, SB Hodge: Design and construction of a novel
compact doubly achromatic asymmetric 270" magnet system for
a 25 MeV therapy electron accelerator. AECL. Chalk River,
Ontario, 7057: 1-100, 1980.
Lanzl LH: Magnetic and threshold techniques for energy cali-
bration of high-energy radiations. Ann NY Acad Sci 161:lOl-
118,1969.
Leboutet H: Magnetic deflecting and focusing device for a
charged particle beam. U.S. Patent 4,046,728, issued 1977.
Livingood JJ: The optics of dipole magnets. New York, Academic
Press, 1969.
Panofsky WKH, JA McIntyre: Achromatic beam translation sys-
tems for use with the linear accelerator. Rev Sci Instr 25287-290,
1954.
136 CHAPTER 7. BEAM OPTICS OF MAGNET SYSTEMS

27. Penner S: Calculations of properties of magnetic deflection sys-
tem. Rev Sci Insrru 32: 150-160, 1961.
28. Petersilka E, WE Schiegl: Mevatron linear accelerator and its
position between the cobalt unit and betatron. Electromedica
2-3/75: 99-103, 1975.
29. Steffen KG: High energy beam optics. New York, Wiley Inter-
science, 1965, 1-21 1.
30. Sutherland WH: Stability of a linear accelerator with "ach-
romatic" electron beam bending. Br J Radio1 49:262-266,
1975.
3 1. Tronc D: Device for the achromatic magnetic deflection of a beam
of charged particles and an irradiation apparatus using such a
device. U.S. Patent 4,322,622, issued 1982.
32. Wessels BW, BR Paliwal, MJ Parrot, MC Choi: Characterization
of Clinac-18 electron beam energy using a magnetic analysis
method. Med Phys 6:45-48, 1979.
 Treatment Beam Production

Production of both x-ray and electron treatment beams for ra- movements. In addition, it controls the field-defining and
diotherapy originates in the radiation head. The radiation head rangefinder lights together with room and laser patient posi-
(often called treatment head) is the structure from which the use- tioning lights. One type of portable hand pendant may be dis-
ful treatment beam emerges. The characteristics of x-ray and connected from the cable and used to exercise control via an
electron treatment beams are strongly influenced by the design infrared (IR) communications link. Remote control of collima-
of the radiation head. The characteristics that significantly in- tors from the console facilitates obtaining full-field exposures
fluence radiation treatment are often assessed from the central superposed on a port film taken periodically to verify patient
axis depth dose and isodose curves of representative x-ray and positioning during a course of therapy. The full-field exposures
electron treatment fields (Chap. 2, p 33-37). Standard methods portray additional anatomic detail near the tumor to aid in the
of measuring and stating the characteristics of radiation beams verification of treatment beam positioning.
have been established and are described herein as well as in sev- The radiation head may incorporate a collision-avoidance
eral publications31~8~,83-~5and in Chap. 2 and Appendix B. Char- safety system to stop gantry and couch motion in order to
acteristics of specific commercial treatment units are cited for prevent contact with the couch or the patient. Such a system
illustration and many others are extensively reviewed in identi- may be activated by a suitably placed guard ring, touch plate,
fied references in this chapter. The treatment beam production
features of multi-x-ray energy linacs are described in Chap. 11.
X-Ray Target
Much of the information of Chap. 8 applies to the modern ma- Retractable
chines, such as the Clinac 2100C, listed in Appendix B, an ex-
tensive survey of commercial linacs and their features.
A representative radiation head design is illustrated in
Figure 8-1. The head provides a number of beam-shaping,
\ Bending Magnet Assembly
\ Electron Orbit
Primaly Collimator
localizing, and monitoring devices. They include a bending
magnet if used, fixed shielding, the x-ray target, flattening
filter, and a series of single or dual electron scattering foils,
often mounted on a large carousel, and finally large movable
collimator jaws. Included also is a field light with a sizable
mirror for illumination up to full field size and an optical
distance indicator (rangefinder) together with a large diameter, Dual Ionization
parallel plate, transmission type ionization chamber assembly
for monitoring of the full field for control, and interlocking.
The ionization chamber and its role in dose monitoring and
beam stabilization are described in Chap. 9. An alternate head
design is illustrated in Figure 8-2.120
The lower portion of the radiation head containing the col-
limator jaws and mirror can be rotated over a 180" (or larger)
range around the beam axis to accommodate fields angled with
respect to the gantry axis. The radiation head rotation and colli-
mator jaw movements are usually motor driven and controlled
from a cable-connected hand pendant. This hand pendant also
controls the speed and direction of gantry rotation and couch FIGURE 8-1 . Clinac 18 'keatnient head. (Courtesy of Varian)
138 CHAPTER 8. TREATMENT BEAM PRODUCTION
Electron Beam
--
X-Ray Target or Electron Window
Primary Electron
Scattering Foils Rotatable Dual-Aperture
- - Collimator 15 MV Flattening
Carousel With Filter
Secondary Electron
Scattering Foils
and 6 MV Flattening
Filter
Mylar Mirror -yz IMonitor Ion Chamber
Shutter
Wedge
Independently Moveable
Beam Limiting Diaphrams
FIGURE 8-2 . Philips S U 5 treatment head. (Courtesy of Philips Medi-
cal Systems.)
or a capacitive sensor. Such a system may, however, lead the
operator to place undue reliance on it.
The radiation head of contemporary high energy linacs is
crowded with components and subassemblies. A cross section
of a radiation head with a bend magnet illustrating limited total
space and typical space for individual components is shown in
Figure 7-1. Accessibility for service often becomes difficult,
but a Clinac 2500 "swing away" collimator design, described
by Barnes,l3 may significantly improve access. An earlier
Therac 20 head design allows one of the magnet half-yokes and
associated shielding to be hinged for improved access.168 The
Clinac 1800 and 2100C radiation head can be split into upper
and lower halves for servicing.
The detailed penetration characteristicsof radiation beams
for use in radiotherapy are often described by tables of numer-
ical central axis dose depth data. A standard reference covering
a wide range of x-ray and particle beam energies has been
published by the British Institute of Radiology31 and a related
commentary by La Rivierell2 (see also pp 147-148).
GEOMETRIC RESTRICTIONS OF
RADIATION HEAD
The provision of large field size capabilities (e.g., for mantle
fields or total body irradiation) and for asymmetric fields,
particularly when employing dual independent jaws, has re-
sulted in an increased diameter of the lower portion of the
radiation head to permit full opening of the enlarged collimator
jaws. Care must be taken in design of the radiation head
dimensional outline to ensure that the treatment beam can still
be oriented optimally without interference with the patient,
such as for tangential irradiation for breast treatments.
The provision of a high x-ray energy capability has re-
quired the incorporation of a large bend magnet system which,
with associated radiation shielding, has resulted in increased
diameter and height of the upper input portion of the radiation
head. Loss and impingement of the accelerator beam on the
input electron collimator, energy slits, and bend magnet vac-
uum chamber walls causes them to act as intense radiation
sources, which require compact high density, high atomic
number shielding material around and integral with the bend-
ing magnet to reduce leakage radiation to acceptable levels.15
Such spurious sources can be quantitatively investigated by
accurately positioning radiographic film around the radiation
head in conjunction with a defined exposure.33
The provision of multiple treatment modalities with an
associated carousel for the interchange of electron scattering
foils and flattening filter(s) in some machines, x-ray target@),
and has affected the size of the midportion of the radiation head
and, hence, requires a large source-axis-distance (SAD) to
ensure adequate clearance between patient and radiation head.
(Most treatment units are 100-cm SAD.) At least two linac
models employ a slide machanism, rather than a carousel, to
change between x-ray and electron modalities.l73.195 In some
high energy machines, low density hydrogenous shielding
materials, often with boron added, have been incorporated in
the head for neutron shielding, further increasing its size.
Appropriate choice of beam-line materials and precision beam
alignment and focusing, will reduce photo-neutron production,
and therefore the need for such shielding.
The distance from the x-ray target to the top of the radia-
tion head is restricted because of limitations on convenient
isocenter height associated with the need for the radiation head
to clear the floor. The incorporation of 270" achromatic bend
magnets results in improved beam characteristicsbut may raise
the isocenter height 10cm or more compared to earlier 90°bend
magnet systems. A low isocenter height facilitates the
technologist's work in setting up a patient. This requirement
has been a challenge in the design of accelerator structures for
in-line 4 and 6-MeV machines and in the design of magnet
systems for bent-beam machines. These magnet systems are
discussed in more detail in Chapter 7.
The distance from the x-ray target to the distal surface of
the collimatorjaws must be chosen large enough to accomrno-
date the various intervening components and to limit geometric
penumbra. At the same time, this distance must be small
enough to provide room for the external x-ray wedge filter
mount, accessory mount and their insert trays with accessories,
an auxillary multileaf collimator (MLC), and still provide
adequate clearance from the patient and patient table. Provision
for two trays (for shadow blocks, wedge filter, or compensator)
severely restricts the distance the radiation head can extend
from the x-ray target along the beam axis. The use of compen-
sators tailored for individual patients is becoming increasingly
prevalent with the availability of convenient methods for their
construction and improved treatment planning.
The distance from the last tray to the isocenter must be
large enough to provide for convenient access to the patient
and for clearance from the patient table, for example, when
 ANCKLARY COMPONENTS 139

rotating the gantry, as well as to provide enough distance in design. The desire for larger field sizes, improved beam
the air to limit the scatter radiation reaching the patient from characteristics, and convenient, functional accessories has
the radiation head. This is most easily achieved with a long led to a number of studies and improvements in radiation
SAD, typically 100 cm. Although an 80-cm SAD has become head design.165,170,195
a relatively standard distance for 60C0 radiotherapy units,
the high radiation intensity of linacs has permitted common
usage of 100-cm SAD while maintaining convenient isocenter
height. Many 4- and 6-MeV machines in use are of in-line ANCILLARY COMPONENTS
design. Progress in microwave accelerator technology has
per&tted obtaining an adequate dose rate at ~ O O - C ~ - S A D
Some radiation head components are intimately part of the
in such machines in the necessarily short accelerator guides.
beam transport system and are treated in Chapter 7. These
Here most of the power from the microwave source is used
include typical bend magnet systems, magnet core and coils,
to produce the required beam energy with little beam power
electron beam collimators, and energy slits together with the
left for providing a sufficiently high dose rate. However,
associated vacuum system. Other radiation head components
such accelerators provide an improvement in patient clearance
or subsystems are treated in this chapter except the dosemeter
over the 80-cm SAD of earlier in-line designs. There are
ionization monitor chambers, which are covered in Chap. 9.
also many 4- and 6-MeV machines in use that employ a
Several accessories, which modify treatment beam char-
bend magnet and hence, have always permitted 100-cm SAD
acteristics or aid patient positioning, may be attached to the
design. However, at 8 MeV and above, longer accelerating
front of the radiation head. Many of these are described in
structures are required, so they are usually incorporated into
Chap. 12.Most treatment units are provided with a selection of
beam-bent isocentric units. Figure 8-3 is a block diagram of
wedge filters that are mounted externally. Any accessory that
a typical medical linac illustrating the two basic linac con-
can modify the treatment beam must be appropriately inter-
figurations: the bent-beam and the in-line, straight-through,
locked. A single, 60" wedge, mounted inside the head and

////////
/ /
/ II I----
--1
Electron -
Bending
I
I Treatment Head I
Gun
t Accelerating Structure t. Magnet :I (Straight-thru
(Optional) I I Design) I
I
Waveguide I I- -- __--I

Target
Circulator
(Optional) Primary Collimator

Flattening Filter
Waveguide

Variable Collimator
Pulsed Klystron or
Modulator Magnetron
Treatment Head
(Bent-beam Design)

tt
4

System Support

-
FIGURE 8-3 Block diagram of typical medical linac illustrating the two basic radiotherapy linac configurations-the bent-beam and the straight-
through designs. In this bent-beam design, the beam emerging from the accelerating structure is bent approximately 90' by the bending magnet be-
fore entering the treatment head. In the straight-through design, the treatment head is placed just beyond and collinear with the accelerating
structure and the bending magnet is unnecessary.
140 CHAPTER 8. TREATMENT BEAM PRODUCTION
remotely positioned by motor control, may also be used as a
universal wedge. Beams with effective wedge angles less than
60" are obtained by delivering an appropriate portion of the
dose with the 60" wedged field and the remaining portion with
an open (unwedged) field. Measurements of such a universal
wedge by Petti and Siddonl67 agree well with the model pro-
posed by the manufacturer. Miller and van de Geijn 136 describe
a modification of the wedge interlock circuit so as to accom-
modate additional large-field wedges in a Clinac 18/20. The
advent of computer-controlled independent collimator jaws
has led to the development of the dynamic wedge with im-
proved wedged-field characteristics (see Ref. 32a in Chap. 12
and p 206).
Stevens et a1 190 describe a satellite digital display that
provides a remote indication of gantry, couch, and collimator
positions at the console of a Clinac 18 treatment unit. Such a
remote display can help minimize patient treatment errors and
is provided on at least one linac design.
RADIATION SHIELDING
Much of the weight and bulk of the treatment head is
associated with radiation shielding and x-ray beam collima-
tion components. This is largely determined by the need to
limit radiation leakage around the machine outside the useful
treatment beam. In an isocentric machine, this weight must
be counterbalanced, adding to the overall machine weight
and bulk. Alternatively, the machine may be configured with
a primary beamstopper, which may be a fixed or retractable
shield to intercept the primary beam emerging from the
patient. Supporting these heavy structures entails exacting
structural rigidity specifications in order to satisfy the geo-
metric stability requirement of the treatment beams. As
discussed in Reference 85, regulations and safety standards
have been issued regarding radiation leakage measured at a
distance of 1 m from the path of the electron beam as it
travels from the gun to the x-ray target; its purpose is to
protect personnel outside the treatment room wall. A second
criterion relates to leakage in the patient plane outside the
maximum useful field; its purpose is to limit total body dose
in the patient. A third criterion relates to leakage through
the collimator jaws, in the area between the useful beam
and the maximum useful beam; its purpose is to limit the
dose given to the patient's normal tissue immediately sur-
rounding the treatment volume. Dixonso notes that since 90"
and 180" leakage is limited in energy, shielding thicknesses
at large angles with respect to the forward direction may be
reduced. Devanney48 reviewed leakage radiation require-
ments to the patient area and outside the patient area of
several regulatory and standards setting bodies. Conere et
al.42 note that x-ray head leakage may vary with energy in
dual energy accelerators.
All radiation head components that stop a significant por-
tion of the electron beam involves shielding. These include
discrete sources such as the x-ray target, electron beam colli-
mators, and energy slits, as well as more diffuse sources result-
ing from electrons lost and stopped along the entire electron
beam path. When the electrons are stopped, they generate
bremsstrahlung radiation, which is largely forward directed at
these megavoltage energies. The discrete sources are more
intense and more localized but are usually easier to shield.
Locating the shielding as close to the source as feasible will
reduce its volume and mass for a given attenuation. The design
of nominal 270" bending magnets can affect isocenter height
depending on where beam energy defining slits are located.15
An optimal beam focus location from electron optics consider-
ations may place the beamsstrahlung-producing slits at a loca-
tion where the shielding requirement would increase the
radiation head dimension in the direction away from the isocen-
ter and, hence, increase isocenter height in order for the radia-
tion head to clear the floor.
High density, high atomic number materials (e.g., lead
and tungsten) are commonly used for radiation head shielding.
Tungsten and heavy metal alloys are more costly than lead
but their higher densities (- 18vs. 11.3 gIcm3) may dictate
their use since such shielding can be placed closer to the
radiation sources, target, and energy slits, saving space and
mass. However, tungsten, a costly brittle metal, is harder to
machine when compared to lead, which is easily shaped,
typically by casting, but is more easily damaged. An optimal
radiation head design incorporates both metals. Depleted
uranium (depleted in the fissionable isotope U-238) is an
excellent absorber of x rays with a high density of almost 19
g/cm3, and an atomic number of 92 and structural properties
equivalent to mild steel.21 Depleted uranium has been used
at lower energies but its residual radioactivity, the necessity
to electroplate its surface to control scaling, and increased
regulatory requirements have combined to raise its cost and
restrict its use. Uranium is not used above 6 MeV because
of increased photoneutron production. Methods of measure-
ment and characteristics of leakage radiation for a Clinac 18
treatment unit have been described by Lane et al.108 and earlier
by Capone and Karzmark33 for 6-MV x rays. Other aspects
of head leakage radiation are covered by a number of inves-
tigators,42,48,50,78.97,150,178,195,201
Shielding the head for megavoltage x-ray therapy is the
dominant need when contrasted to electron therapy. This fol-
lows for several reasons. First, the beam current requirement
for electron therapy is significantly less, often by a factor of
several hundred to as much as 1000. Electrons are less pene-
trating than x rays and some are absorbed completely in the
shielding material by ionization losses. Others are converted to
energetic x rays by the bremsstrahlung process, but the process
has low efficiency.
At x-ray energies of 15 MV and above, an increasingly
significant yield ~f'~hotoneutrons is produced by components
in the radiation head. Here, low atomic number (Z) materials
loaded with boron are effective radiation shields. Borated
poly(ethy1ene) has been used as neutron shielding in one head
 ANCILLARY COMPONENTS
design. This neutron shielding was incorporated at an earlier
date when neutron protection standards were expressed as
effective dose in roentgen equivalent man (rem). This was a
more stringent requirement for neutrons by a factor of about 10
compared to the present standard expressed as absorbed dose
in Gy and presented extreme containment problems above
about 25 MeV. The topics of neutron leakage and radioactiva-
tion are treated on pages 150-151 and in Chap. 14, page 252.
BEAM COLLIMATORS
The treatment head provides two treatment beam collimators
for x-rays as shown in Fig 8-1; a fixed primary collimator, and
an adjustable secondary collimator, which is also termed the
beam limiting device or "jaws." The primary beam collimator
defines the maximum angular spread of the x-ray beam. The
opening through it is in the shape of a truncated cone or a
four-sided pyramid. A conical primary collimator may be fixed
in the head but a four-sided pyramidal one must rotate in order
to preserve correct orientation of its sides relative to the jaws
of the beam limiting device. For the corners of a 40 X 40-cm
field at 100 cm SAD not to be restricted, a half-angle of about
16" would be required for a cone or the comers of the pyramid.
Typical practice is to provide a 14" half-angle, corresponding
to a 5 0 cm diameter at 100-cm SAD, a 35 X 35-cm fully square
field, and a 40 X 40-cm maximum field with comers clipped
by several centimeters. Tungsten is the material of choice for
both the primary and secondary collimators. Space is at a
premium in this location and tungsten collimators take up less
space than lead. Also, where the x-ray energy is high enough
for significant neutron production, tungsten attenuates the neu-
trons to a much lower energy than does lead. For example, the
average energy of photoneutrons arising from 15-MeV incident
energy electrons is reduced to about 0.6 MeV in 10 cm of
tungsten and only to about 1.5 MeV in 10 cm of lead.131
A dual x-ray energy linac will have at least two different
flattening filters in order to provide flat fields at two ener-
gies.53J20.176 The simplest flattening filters are shaped some-
what like a volcano, the more pointed cones being associated
with higher energies. In some machine designs, they are in-
serted coaxially into the primary collimator to preserve space.
In one dual energy design, two primary collimator filter assem-
blies are mounted on the carousel and selected by rotation of
the carousel.53
The adjustable collimators consist of two pairs ofjaws, one
above the other and at right angles. Their defining edges often
traverse arcs, or approximate arcs, such that their inner faces
are approximately tangential to the radiation beam emanating
from the x-ray target thereby reducing penumbra. They define
the size of the x-ray trtatment field and act in combination with
the electron applicator to produce a properly shaped electron
treatment field dose distribution. They are made of lead, tung-
sten, or depleted uranium so as to limit transmission of the
primary x-ray beam to about 1hto 1 percent. Because of scatter
141
from tissue in the useful beam, the dose to the tissue shadowed
by the jaws is often significantly higher than would result
simply from leakage radiation through the jaws of the beam
limiting device. For small fields, most of the shadowed area is
covered by two jaw thicknesses, one from each pair, and the
primary transmission is very small. For large fields, most of the
shadowed area is covered by only one jaw. These and other
leakage radiation considerations have been reviewed by
Devanney.48 The contamination of electron and x-ray beams
within and outside the useful beam is treated on page 150.
In normal use, each pair ofjaws is coupled to provide sym-
metric rectangular fields centered about the axis. However, for
some therapy techniques, independent motion of the jaws of one
or both pairs is desirable in providing asymmetric rectangular
fields. For example, many breast and other therapy techniques
half-block one of two pairs of abutting-opposed fields along the
beam axis. Positioningone independentjaw along the beamaxis
to provide the half-blocked field eliminates beam divergence
without the need for a larger, heavier inconvenient external
beam half-block. This simplifies the abutment of adjacent fields
with negligible field overlap but necessitates precise patient po-
sitioning. Such a beam is also useful for shallow tangential arc
treatment minimizing the dose to sensitive underlying tissues
(e.g., lung). Independent jaw motion is accomplished by un-
coupling the symmetrical motion of a pair ofjaws and indepen-
dently positioning eachjaw with one jaw edge left on axis forthe
half-blocked field. Both jaws may also be independently posi-
tioned, allowing one jaw of the pair to cross the central axis, to
define fields where both field edges are on one side of the central
axis. Dual independent collimators, allowing independent mo-
tion of all four jaws, provide additional flexibility in blocking
offset field edges. However, this necessitates very large jaws
and a large secondary collimator diameter in order to shield all
areas subtended by the primary collimator. The applications and
physics measurements for the independent jaw system of the
Clinac 2500 have been described by Loshek.ll9The dosimetry,
treatment planning, and specification of these asymmetric
fields are more complex than for the symmetric fields
case.39.l~,lo2.159.160Khan et al.lmnote that the effect of the inde-
pendentjaws is similar to that of secondary blocking. They have
modified their computer program for generating isodose curves
for Clinac 2500 asymmetric fields. Palta et al.160 point out sev-
eral unusual dose distributions available via asymmetric arc ro-
tation. A simplified technique for treating breast cancer uses
both pairs of asymmetric jaws and a single set-up point without
the need for couch angulation.180a
Multileaf x-ray collimators have been developed to closely
encompass irregularly shaped tumors by an alternative method
than by constructing individual Cerrobend shields. In one
example, 64 independent leaves comprise one pair of jaws.
They can be rapidly set under computer control and can be
programmed to follow the changing tumor outline for dynamic
therapy. Such a multileaf collimator permits leaf spacing equiv-
alent of about 1 cm at 100-cm TSD. They are discussed in more
detail in Chap. 2, pages 41-43.
142 CHAPTER 8. TREATMENT BEAM PRODUCTION
FIELD LIGHT AND RANGEFINDER
Patient treatment fields are positioned with the aid of reference
points or lines. These are often marked indelibly on the skin
with the patient in the treatment position. The center of the field
may be marked with a cross, the edges with dashes or lines, all
of which aid the set up procedure. These markings are affixed
during simulation once the field sizes, field positions, and
angulation are agreed upon. They are referenced to the internal
anatomy revealed in the localizing radiographs taken with the
simulator and to the bony landmarks externally identifiable.
The markings remain on the patient's skin through the course
of treatment but may be removed and redrawn as appropriate.
For example, a tumor may shrink in size during a course of
therapy and then be treated with a reduced field size.
The field defining light and rangefinder (see Fig 8-1)
provide convenient visual methods for correctly positioning
the patient for treatment using the reference markings. The field
light illuminates an area that coincides with the radiation
treatment field on the patient's skin. The field size is defined
by the 50 percent x-ray isodose contour extended perpendicular
to the incident normal surface from the depth of dose maxi-
mum. The spatial coincidence of the x-ray and light fields is
typically within 2 mm. The center of the field is marked by the
shadow of a small cross located on the beam axis near the light
source or on the Mylar window covering the collimator open-
ing and illuminated by the field light. A high intensity lamp
with the filament approximating a point source is needed to
provide bright, sharp images of the field with minimal penum-
bra. This lamp is located off the beam axis, and its light is
reflected by a mirror placed on the axis as shown in Figure 8-1.
The geometry is such that the filament appears to be located at
the effective x-ray target focal source. The lamp involves
conflicting requirements: high intensity and a small filament
size, as well as long bulb life and mechanical stability of the
filament. These requirements may be best satisfied by some
slide projector lamps, which have a small filament, a quartz
envelope, and are halogen filled. In general, a larger source
results in a brighter field and a larger penumbra; a smaller
source results in a dimmer field and a smaller penumbra. A thin
metal or front-surfaced glass mirror fixed in position on the
beam axis is often used as the field light reflector if only x-rays
are employed. However, if electrons are available, it would
unduly scatter the electron beam and must be moved out of the
way for electron therapy. The metal or glass type mirror may
be translated out of its normal position or located on a carousel,
which is rotated to remove the mirror from the field. In either
case, such a mirror must be repositioned with spatial precision
in order that the coincidence of the light and radiation field is
preserved.
Alternatively, the mirror can be in the form of a thin sil-
vered or aluminizedplastic film, which only minimally scatters
the electron beam and, hence, can remain fixed in position. The
field defining lamp assembly must incorporate convenient, 3-D
adjustments for positioning the filament at the effective x-ray
source location. Some field light designs incorporate fiber op-
tics with the source size being defined by the output size of the
fiber optic, not the bulb filament. Similarly, the spot location is
that of the output fiber optic, not the lamp filament. The quality
assurance (QA) program will usually include weekly assess-
ment of the congruence of x-ray and light fields.
Often, the exit opening of the radiation head may be
covered with a thin transparent film or other plastic lamina to
provide a fiducial reference surface and to protect the interior
of the radiation head from dust and falling objects during
undercouch treatments. The retrospective installation of such
a cover results in small changes in x-ray beam characteristics.
Compton electrons emitted from the film increase the skin dose
and modify the depth dose distribution. The film can result in
significant changes in electron output, which varies with both
energy and field size.4 The beam central axis reference (cross
hair) can also be built into the field light projector or can be
crossed wires in the light beam.
The rangefinder is used to place the patient at the correct
treatment distance. It may be located on the outer front or back
edge of the treatment head or on the gantry. It projects a
centimeter scale whose image on the patient indicates the target
skin distance (TSD). The image of the scale intersects the beam
axis at the isocenter and indicates the normal treatment distance
(see Fig. 8-1). If the skin is located nearer the target, as in
isocentric techniques, a smaller value of TSD than normal is
imaged and displaced from the axis. Larger than normal values
of TSD will be displaced from the axis in the opposite direction.
The rangefinder is also operable for electron therapy. A slot is
provided in some electron applicators to accommodate the
projected rangefinder image.
ELECTRON THERAPY
Since the requisite beam current for electron therapy is typi-
cally many hundred times less than for x-ray therapy, most
shielding problems, including those for neutron shielding, are
comparatively insignificant even at the higher energies. One is
concerned clinically with providing:
1. Wide, flat electron fields with modest penumbra.
2. Relatively low surface dose.
3. Deep 80 percent depth dose for each selected energy.
4. Rapid fall-off of dose with depth on the distal side of the
depth dose curve.
5. Small amount of contaminating x-ray radiation.
6. Negligible applicator leakage.
Achieving and assessing these electron beam character-
istics have been the subject of a large number of studies.
4,16,20,29,30,46,56,78,81,88,92,94,99,101,114,116,126,127,134,135,137,145149,156,
160a172.177a,180,183,184,185,187,192,195.1201 Specific commercial
 ELECTRON THERAPY
equipments may often be identified from these generic refer-
ences by manufacturer, model, or energy. In addition, specific
more specialized topics are discussed and referenced under
individual chapter sections (e.g., electron energy measure-
ments, spectra, dual x-ray energy linacs, and independent
collimator jaws). Performance specifications for electron and
x-ray beams for a representative treatment unit, the Clinac
18, are given in Table 2-1. Figure 8-4 shows an example of
the basic beam subsystem for electron therapy. The x-ray
target has been retracted and the carousel rotated to the
appropriate scattering foil position for the electron energy to
be used. The ion chamber monitors this scattered electron
beam. The accessory mount is attached to the radiation head
together with the electron applicator for the field size chosen
into which a shaped cut-out is inserted. The dosimetric char-
acteristics of electron applicators have been studied by a
number of investigators.38.94.97.98.116,175,183.192,205They have
been greatly improved from earlier implementations in regards
to the factors listed above.
Electron Beam : study, Huizenga and Storchi79 indicate how measurements of
T penumbra widths of scanned electron beams in air can be used
I X-Ray Target
I-
Primary
Collimator
Scattering Foil \ Flattening Filter
-
Patient
FIGURE 8-4 Beam subsystem for electron beam therapy. Cross sec-
tion view including central axis of the beam.
143
Bell and Waggenerls describe a method for rapid determi-
nation of the energy of electron treatment beams from medical
linacs. Anderson and George839 suggest some modifications of
the early, range-energy equation developed by Markus128 for
scanned electron beam energy calibrations. The latter was de-
rived largely from betatron data for scattered electron beam en-
ergies up to about 15 MeV. Johnsen 90 describes how
wedge-shaped absorbers can be used with ion chambers to
measure electron energy. Almeida and Almond47 describe how
Cerenkov radiation from nuclear reactions can be used to deter-
mine electron beam energy. Film analysis of electron depth
dose has also been employed for energy determinations.57 Do-
simetric measurements for scanned and pulsed linac electron
beams are more difficult than for scattered beams because of
the moving spatial, time sequence of pulses and more difficult
chamber saturation.41 Ertan et a1.52 describe a scan-triggered,
computer-controlled measurement system. Nafstadius et a1.142
describe dosimetry measurements for a computer-controlled,
scanned-beam and an associated data acquisition system. This
equipment has both electron and x-ray beams with energies up
to 50 MeV from a medical microtron. In a later theoretical
to generate electron distributions at the surface of the patient.
These, in turn, serve as input for calculation of patient dose dis-
tributions for radiation therapy treatment planning.
The clinically relevant electron energy is often specified
by the depth of the 80 percent relative ionization on the central
axis on the distal slope of the depth dose curve (see Fig. 2-4).
Central axis depth dose measurements have been carried out
on specific accelerators noted in the preceding references and
by the Radiological Physics Center on over 70 electron-pro-
ducing machines used in radiation therapy.101 These latter data
appear consistent for each machine model and nominal energy.
However, the data show that depth dose distributions can vary
significantly among different machine models for electron
beams having the same nominal energy. The shape of electron
depth dose curves can vary widely at shallower depths for the
same nominal energy, particularly from contaminants in the
build-up regions. Characteristics of electron beams from a
medical microtron have been described by George et a1.61 and
others.14,25-27 Those for a scanned-beam 25-MeV linac are
described by O'Brien et a1.154 and different scanned beams by
OtheTS.34,52,168,181,188
Usually, electron applicators are attached to the treatment
head with the x-ray collimator jaws set and interlocked to
subtend fields a few centimeters larger than the field defined
by the applicator. There is accompanying improvement in
electron field flatness from this procedure, preferentially at
shallower depths. An excessively wide setting may create
radiation leakage problems outside the treatment volume, as
in the case of pregnant patients for one particular linac,zos
as well as more generally in early designs.98.1@.175 Schnie-
derl83 evaluated such leakage radiation for another model of
linac, and Jones94 suggests that the leakage may be a specific
144 CHAPTER 8. TREATMENT BEAM PRODUCTION
machine's characteristic, which should be evaluated by in-
dividual users. Often, a lead or Lipowitz's alloy78 cutout
defines the final electron field size and shape. It is placed
in the end of the applicator at or near (e.g., 5 cm) the patient
skin surface. The dosimetry of such shaped small and irregular
fields has been described for electrons from 4 to 10 MeV.145
The systematic variation of small field, electron beam char-
acteristics, particularly the output factor, with standard cone
sizes and Cerrobend cut-outs, has been studied extensively
at 6, 10, and 20 MeV.177a Electrons scattered off the applicator
walls improve flatness at the periphery of the field at a
shallow depth, but with less penetrating electrons. However,
such fields have poorer flatness at greater depth. A contin-
uously variable segmented electron beam collimator has been
described by Robinson and McDougall,l80 and at least one
manufacturer makes such an option available. An alternate
approach is to provide rectangular electron field definition
by attaching four lightweight, quick-connect trimmers to the
x-ray collimator jaws. One electron beam collimating, flat-
tening, and monitoring system for a 35-MeV betatron has
been described by Svensson,l92 and another by Lindskoug
and Dahler.116 Multileaf collimators for electrons are described
in Chapter 2, pages 41-43.
The provision of electron treatment fields defined in size
by electron applicators or collimators is provided by scanning
a pencil beam of electrons over the field area or by scattering
the static axial electron beam with one or more thin foils as
described in the following sections.
ELECTRON SCATTERING SYSTEM
The electron beam leaving the bend magnet (or accelerator
structure for straight-ahead machines) is about 3 mm in diam-
eter (Fig. 8-3). Scattering foils (or a scanning system) are used
to spread this beam to the much larger area required for therapy.
Most studies find that a single, high atomic number scat-
terer will adequately flatten small fields up to about 10 cm in
diameter for low electron energies up to about 10 MeV. Addi-
tional steps are taken at higher energies and for larger fields.
Providing several different scatter thicknesses, often in a car-
ousel, facilitates optimization of beam characteristics for dif-
ferent energies.127 A dual-foil scattering system, with a few
centimeters or more between the two foils, significantly im-
proves electron beam flatness characteristics with reduced
x-ray contamination, particularly above 15 MeV and for fields
15 cm in diameter and larger.195 Such a dual-foil scattering
system is illustrated in Figure 8-5. The first high atomic number
(Z)foil is selected to minimize energy loss for a given scattering
distribution and the second scatterer made of a low Zcompos-
ite, thicker on axis, functions more as a field flattening filter
preferentially scattering electrons to the periphery.195 The thic-
ker portion of the second scatterer may be in the form of a high
Z "button" on a low Z foil. Hence, the electron applicator in
such systems primarily serves to define the field size and only
Narrow Beam
11
9 8
First Scatterer
Second Scatterer
I I
Both Scatterers
One Scatterer
Only
FIGURE 8-5 . Double scattering foil system (adapted from Brahme
1977).
affects flatness secondarily. Athorough analysis of the dual-foil
scattering system has been provided by Mandour and
Harder.126 The interdependence of electron dose rate, energy,
field size, effective source size, distance, and beam scattering
or scanning, is more complex than for x rays and should be
measured for the individual treatment unit. A large effective
electron source size will produce a much larger amount of
wide-angle, outside of collimator-limited electrons. It and other
parameters for electron scattering have been the subject of a
number of s&dies.35.87,101.1~aa197
The location of the effective electron source is usually
different from the effective x-ray source location. The effective
position of the source for electron therapy is less well defined
than for x rays and has been studied by several investiga-
tors.35+87,97,197Where scatterers are employed, it has been useful
to define a virtual point source location, which differs from that
of the scatterer. Its location is dependent on machine design and
varies with SSD, field size, and electron beam energy.
ELECTRON SCANNING SYSTEM
Most medical electron accelerators employ a pair of metallic
foils to scatter the bend magnet output electron beam for
electron therapy. Brahme27.28 describes a technique in which a
first high Z foil produces a Gaussian distribution of scattered
electrons and a second small diameter foil located a few centi-
meters from the first foil rescatters the central portion of the
Gaussian distribution to flatten the electron dose distribution at
the normal treatment distance. This technique is satisfactory for
electron energies up to about 25 MeV at field sizes up to about
25 X 25 cm at 100-cm SAD, producing x-ray contamination
 ELECTRON SCATTERING SYSTEM
of less than 5 percent and falloff of depth dose from 80 to 20
percent quite similar to the falloff depth dose of scanned beams.
The required thickness of high atomic number scatterer in-
creases as the square of energy and as the square of maximum
field size. Thus, electron scanning is justified for large fields at
energies higher than 25 MeV to avoid deterioration of the shape
of the electron depth dose curve and to avoid excessive x-ray
contamination.
Historically, mechanically translated and rotated magnets
were first used for scanning the electron beam in an isocentric
radiation head, as described by Rozenfeld et a1.181 for a 70-MeV
stationary linac. Rosenfeld et a]., developed a scanned pencil
beam system for arbitrarily shaped fields defined by a full size
template, in lieu of using scattering foils.34.188 This early
isocentrically directed and scanned beam, up to 50 MeV in en-
ergy, employs a large, complex nonachromatic beam transport
system with attendant treatment beam stability problems. It
combines a linear translation of the magnet up to 21 cm along
the direction of the gantry axis with an indexed rotation of the
gantry to provide 5-mm spacing between scan lines at the skin
surface. A treatment is completed in one scan series covering
the field, and different electron energies can be used in different
portions of the field. Electronic scanning of the electron beam
in an isocentric machine was first used in the Sagittaire isocent-
ric radiation head, which was fed from a stationary linac at ener-
gies up to 32 MeV in standard machines and up to 40 MeV as an
option. Briot et a1,29.30 investigated the scanned electron beam
of a Sagittaire 35-MeV treatment unit. They concluded that an
adjustable outboard metallic collimator, which could be at-
tached to the x-ray jaws, improved the depth dose and dose gra-
dient at the edges of the field. In regard to this machine,
Leboutetlls states that to achieve wide fields at these energies,
scanning of the beam had to be used, in addition to the scatter-
ing by the window, radiation monitors, and thin scattering foils.
Because of the pulsed nature of the beam, the scanning pro-
duced a sequence of spots and some foil scattering was found
necessary to provide sufficient spot overlap for adequate uni-
formity of dose distribution. Having developed electron scan-
ning for the 32-40-MeV machine, the manufacturer continued
this technique for the Satume type 20-MeV machine as de-
scribed by Aucouturier et al.10 and Azam et al." and its sequel,
the Therac 20 type 20-MeV machine (see Fig. 7-23). With the
introduction of the 50-MeV racetrack microtron for radiother-
apy, electron scanning is again used to obtain large fields at
such high energies without the excessive deterioration of depth
dose falloff and excessive x-ray contamination that would re-
sult if thick scattering foils were used.27.28
To achieve such scanning in the Therac 20, saw tooth
modulated currents of 0.615 Hz in the x direction and the 4 Hz
in the y direction are applied to a four-pole sweeping magnet
below the 270" bend magnet, as depicted by Badingl2 and
shown in Figure 7-23. The amplitude and polarity are con-
trolled to produce a raster scan in the electron treatment mode.
Both the x-ray target and the sweep magnet are in air, just
outside the electron beam vacuum window, the x-ray target
145
being retracted for electron mode. Incidentally, a four-pole
magnet may look physically like a quadrupole but it functions
like a rotatable dipole, as illustrated in the following pole
polarity sequences (see also Fig. 7-6).
N S S N
Quadrupole or
S N N S
Pfalzner and Clark168 carried out a depth-dose study of the
scanned electron treatment beams of the Therac 20 and con-
cluded that they did not differ appreciably from those of the
foil-scattered electron treatment beams of the MM-22 circular
microtron reported by Svensson et a1.193 O'Brien et al.l54,155
similarly studied the scanned electron beam from a Therac 25.
Others have compared the Siemens betatron and Sagittaire
linac electron beams.46
MICROTRONS VERSUS LINACS FOR ELECTRON
THERAPY
Microtrons, having a wide energy range, have come to be
employed for electron therapy.24,25,27,61A controversial aspect
of linac versus microtron treatment beams concerns depen-
dence of the characteristics of the electron beam depth dose on
the energy spread of the electron beam. Brahme and Svensson24
contend that the microtron beam has a depth dose significantly
improved (sharper build-up and steeper fall-off regions) over
that of the linac, which they attribute in part, to the narrower
energy spread of the microtron beam. Fregene56 suggests that
a small difference in energy spread, which is of the same order
of magnitude in the microtron and linac beams, should not lead
to appreciable differences in depth dose at 10 MeV. Some of
the disagreement between observers might be explained on the
basis that measurements were performed on different acceler-
ators having different treatment heads (different collimators,
scatterers, geometry, etc.) using different phantom materials
and dosimetry techniques. Measurements by Johnsen et al.92 of
electron beams from a single linac operated at nominal peak
energies of 6 and 12 MeV appear to have resolved this contro-
versy. Based on magnetic analysis of the beams, they compare
narrow energy spread beams (0.1-and 0.2-MeV fwhm) with
broad energy spread beams (0.8-and 1.2-MeV fwhm) for 6 and
12 MeV, respectively. They conclude that, when consistent
measurement techniques are used for the beams tested on the
same beam collimator system, the electron depth-dose charac-
teristics are not significantly affected by these relatively large
changes in the width of the accelerator's energy spectrum (see
also Appendix, Fig. A-7). Earlier, Bjamgard et a1.20 found no
significant difference between the Mevatron XI1 electron depth
dose curves and those from a microtron.20
146 CHAPTER 8. TREATMENT BEAM PRODUCTION

X-RAY THERAPY ate accessory mounting slot. The x-ray energy of a treatment
unit is often expressed and compared with other units by
specifying the percent of central axis depth dose for a 10 X 10
Megavoltage x-ray characteristics and the equipment that cm field at 100-cm SSD at 10cm depth in water. Representative
provide them constitute a widely studied area of radiological values are 67 percent at 6 MV, 70 percent at 8 MV, 73 percent
sCienCe~3,5,32,33,36,37,4O,42,49,584O,68,72,73,75,77,8O,8293,104,122,123,13O,
at 10 MV, 77 percent at 15 MV, and 80 percent at 18 MV. The
Specific c o m e r -
138,146,152,158,1M),160b,163,171,174,177.182,185,196,202
penetrability of an x-ray beam may be defined by the ratio of
cia1 equipments may often be identified from these generic ionization measurements made with a fixed sourcedetector
references by manufacture, model, or beam energy. Most of distance at depths of 20 and 10 cm of water.' Performance
the high or dual x-ray energy equipments also provide electron specifications for x-ray beams for a representative treatment
therapy. unit, the Clinac 18, are given in Table 2- 1.
Figure 8-6 shows an example of the basic beam subsystem Acomparison of the x-ray central axis depth dose data with
for x-ray therapy. Typically, the x-ray field size is continuously
published data for a number of commercial linacs has been
variable from zero, or within a few centimeters of zero, usually presented by Gastorf et al.58 and others.31.36.171 Among their
to a maximum of 40 X 40 cm at 100-cm TSD. The bremsstrah- individual conclusions, they recommend that physicists verify
lung beam from the x-ray target is limited in maximum field the applicability of published data to their machine rather than
size by the primary collimator. The comers of the largest field
rely upon a set of data measured independently and assumed
sizes may be cut off by this restriction. The carousel is rotated to be valid. Characteristics of the photon and electron beams
to bring the appropriate x-ray flattening filter into position. The
produced by dual energy linear accelerators have been reported
ion chamber monitors the flattened x-ray field. The secondary
by a number of inve~tigators.6~13~53.82.93~1~~1~a+16~~176 A more
collimator jaws are set to the correct field size, and any neces-
general reference on the parameters of electron and photon
sary wedge, block, or compensator is mounted in the appropri-
treatment beams is Supplement
.. 17 of the British Institute of
Radiology (BIR)31 and a related commentary of La Riviere.112
The latter questions the Supplement 17 method of correlating
Electron Beam
4' the penetrative quality of high energy x-rays with depth dose
at 10-cm depth by the use of nominal accelerator megavoltage
MV. He suggests instead that the dose-weighted average energy
of the filtered beam be used as a true measure of x-ray beam
Primary quality at 10-cm depth. Where applicable the earlier BIR
Collimator
Supplement 11 provides a more consistant set of data.
Megavoltage x-ray beams exhibit an increased surface
Forward Peaked
Flattening Filter dose in the build-up region and a shift of Dm,,towards the
X- Ray Beam
Scattering Foil
surface as the field size is increased. Recent investigations
indicate that these effects are largely due to low energy electron
Carrousel - contaminants originating in components of the treatment head,
- primarily the flattening filter,19.124 Petti et al.166 identified the
Ion Chamber ~-4 1 ; ;; ; ; ; ! I sources of electron contamination for a 25-MV photon beam
from a Clinac 35. Such contamination can significantly alter
the build-up characteristics of x-ray beams. They conclude that,
for normal treatment distances, the flattening filter and monitor
Secondary / chamber contribute 70 percent of these electrons. Treatment
Collimator
I I I
. I. I '
heads can be equipped with electron filters to attenuate this
Flattened
-I I
1 I
I
I
I
I
\--
\
I Slot For Wedges,
Blocks, Compensators
component.23,74."8 Reductions of 10-20 percent in surface
X-Ray Beam - 1r--i---i--,---l
I I I ) dose and an increase in depth of Dm,,from 2.5 to 4.5 cm at 25
MeV have been observed for such filters.74 These reductions
I I I I I I
I I I I I l may be negated however, when using shadow trays, wedges,
I I I I I I
I I I I I l
and so on.
I I I I I l Moyer has identified systematic patient x-ray dose errors
I I I I I \
1 1 1 1 1 1
for 4 and 10-MeVbeams associated with elongated rectangular
1 1 1 1 1 ~ collimator fields.139 This "collimator exchange effect", which
' I
depends on which movable collimator pair forms the larger or
Patient smaller field dimension, approaches 2.5 percent for highly
elongated fields. A smaller dose is delivered when the upper
.
FIGURE 8-6 Beam subsystem for x-ray beam therapy. Cross section collimator pair adjacent to the monitor chamber forms the
view including central axis of the beam. smaller field dimension. Hence, the corresponding correction
 X-RAY THERAPY
factor may be applied to the dosemeter readings. This effect
appears to be associated with secondary scatter from the colli-
mator into the treatment field and not backscatter into the
monitor chamber, which contributes only a vanishingly small
amount as shown by Huang et a1.77 and by Watts and Ibbott.203
Kubo et al.lo~,lo6found that backscatter into the monitor ion-
ization chamber can vary with radiation head design. It ranges
from less than 1 and 2 percent for 6 and-18 MV photon beams,
respectively, for a Clinac 1800 to as large as 7.5 percent for a
Therac 20. The x-ray beam characteristics of the Therac 20
have been reported by Patterson and Shraggel62; those for a
Clinac 18 by Connor et a1.,43 those for the 18-MV Mevatron 77
by Palta et a1.,158 those for the Clinac 1800 by Findley et al.>3
the Therac 25 by Aldrich et a1.> the Phillips SL 25 by Palta et
a1,160b and those for the Clinac 2500 by Krithivas and Rao.104
X-RAY TARGET AND FLATTENING FILTER
The x-ray target and flattening filter combine to determine
important characteristics of the x-ray treatment beam. The
bremsstrahlung beam emerging from the target has fluence,
energy, and angular distributions. These distributions are
modified in important ways by the flattening filter. Figure
8-7 shows the isodose curves for a 20-MV x-ray beam
without and with a beam flattening filter. The detailed effects
of the filter on beam flatness for several alignment situations
are illustrated in Figure 7-16. An angular or a lateral
displacement of the beam on the target produces the un-
flattened distributions shown. Both effects may be present
-
FIGURE 8-7 Isodose curves for 20-MV x-ray beams; (a) without and
(b)with a bean1 flattening filter. (Courtesy of W. J. Meredith and J. B.
Massey.)
147
at the same time, complicating the analysis. Even the chang-
ing earth's magnetic field encountered in gantry rotation may
have an effect. A mechanically stable structure together with
an automatic beam steering system such as described in
Chap. 9 may be used to maintain the beam accurately
centered on the axis of the flattening filter. Rigid linac
mechanical construction is a distinct advantage. A number
of studies have focused on x-ray flattening filters, target
selection, bremsstrahlung, and beam penetration (e.g., per-
cent depth dose at 10 cm o r depth of 50 percent depth
doSe)~22,26,27.34,36,44,45,54,62,65d7775-78,86,9,95,97,lO7,l13,117,121,129,
130,143,144,152,167,170,171,179,191,195
X-ray spectra have been investigated by several
groups3-18-75,13O9138and are an important parameter in the design
of flattening filters and the characteristics of high energy x-ray
beams. An early discussion of beam flatness of seven different
treatment units including betatrons, 60C0, and linacs was in-
cluded in a study by Chan et al.36
Kase and Svensson97 examined scatter from the head on
the central axis for eight different treatment units. They con-
clude that, except for one unique collimator design, head scatter
originates primarily in the flattening filter and is relatively
independent of energy and machine, and is usually less than 5
percent. Significant scatter contributions also originate from
wedges and compensators as shown by Huang et al.76 Nordell
and Brahmel52 developed an integral expression for the calcu-
lation of the absolute yield and angular distribution of photons
from any material and for electron energies between 6 and 50
MeV. Good agreement is found with published experimental
and theoretical data. The dominant contribution to the absorbed
dose outside the useful photon beam is due to phantom or
patient scattered photons as determined by a calculation of
Nilsson and Brahme.151
Podgorsak et al.170 examined the effects of different atomic
number targets and flattening filters on small 10-cm diameter
fields 100 cm from the target for energies of 25 MeV. They
found that x-ray output on the central axis does not depend
significantly on the Z of the target. The dose rate at about 14"
determines, after flattening, the dose rate on the axis. An
aluminum target gives a more penetrating beam, although high
Z targets emit more radiation at large angles. They also found
that an aluminum filter hardens the beam and a high Z filter
softens it at this energy of 25 MeV. The latter is due to loss of
high photon energies by pair production in high Z filters. They
recommend a thick aluminum target and flattening filter above
15 MeV for the most penetrating beam.171 Below 15 MeV, a
high Z target and a low Z filter are recommended. At 25 MeV,
an aluminum flattening filter is 25 cm in length, an impractical
size to incorporate in most linac treatment heads. The relatively
low melting point of aluminum precludes its use as a target
material. Ideally, one wishes flattened fields for all field sizes,
at all depths, an impossible requirement because of energy
changes and scattering in the phantom. One early 4-MV filter
design provided satisfactory flatness at 10-cm depth, but re-
sulted in excessive dose at shallow depths near the edges of
148 CHAPTER 8. TREATMENT BEAM PRODUCTION
large fields.62.86 Invariably, flattening filter choice involves a
compromise in order to achieve uniform small and large fields
over a range of depths and yet fit into the radiation head. Two
flattening filters for a given x-ray energy are provided in some
treatment units to optimize beam flattening with a changeover
at about the 10 X 10-cm field, or an additional filter may be
attached to the accessory ring for assuring large field flat-
ness.22.107 Dual x-ray energy units are equipped with two
flattening filters, one for each energy. Removable filters, which
affect dosemeter calibration, must be appropriately inter-
locked.
McCall et al.130 examined linac depth dose distributions
using a semiempirical analytic depth dose model correlated
with experimental measurements. They find that an aluminum
filter at 25 MeV produces a great deal more beam hardening
on the axis than do nickel and tungsten and consequently, there
is a larger variation of photon energy with production angle for
aluminum, a significant effect for large field sizes. Aluminum
would appear to be a desirable flattener, but the penalty is a
significant energy spread across large flattened fields and
hence, larger variation in field flatness at depths above and
below the design depth. For the Clinac 35, operating at 25-MeV
x-ray energy, they recommend a copper target with an iron filter
containing a tungsten conical insert for an optimum combina-
tion so as to minimize energy variation with angle and restrict
beam hardening on the central axis.
Other desirable properties of a good target-flattener sys-
tem are that the flattener should not become too radioactive in
operation, and that neutron production be minimized.130 Thus,
copper filters are not commonly used above 10 MeV since the
gamma ray dose rate from 9.76 min T% 62Cu activation be-
comes very high. Iron, on the other hand, has essentially the
same absorption properties as copper, and the induced activity
is much weaker.
Flattening filters may absorb 50-90 percent of the central
axis photon intensity. They, as well as wedge filters, increase
scatter, most noticeably outside the geometric confines of the
beam.76 Brahme et a1.,27 recommend scanned photon beams at
very high energies (25-50 MeV) pointing out that the flatness
and intensity problems are greatly alleviated. Hence, some
radiation shielding problems (including those for neutrons)
may be as much as two to five times less for 20 to 50-MeV
scanned x-ray beams than for a heavily filtered unscanned
beam at such energies.
The spectral change problem associated with flattening
filters was cited earlier by Hansen, et al.65 who identified its
importance for a 4-MV linac beam. Later, Larsen et al.113
developed a calculative program for filter design and applied
it to a 4-MV beam. Their program summarizes the primary and
scattered components in an iterative manner to fit the dose
profile. Flock and Shragge54 developed a semianalytical
method for the design of an improved Therac 20 flattening
filter. Jones95 points out that the dominant effect is selective
hardening of the beam by the flattening filter and, that for thin
targets, the effective energy decreases with distance off axis.
Although an x-ray beam can be within flatness specification at
10-cm depth, it may be significantly unflat at the depth of dose
maximum. Constantinou and Sternick44 found a 19 percent
increase in the off-axis "horns" of a 6-MV unit, which was
reduced to 8.5 percent by increasing the beam energy. A 1
percent increase in beam energy resulted in approximately a 1
percent reduction in the horns at the depth of dose maximum
and is associated with the angular distribution of bremsstrah-
lung as a function of beam energy. Hanson et al.66,67 measured
the off-axis quality change for 4- to 10-MV beams and sug-
gested a technique to correct for the effect in treatment planning
calculations. Lutz and Larsenl21 looked at the effect of flatten-
ing filter design on quality variations within an 8-MV primary
x-ray beam. They found that the single material flattening filter
supplied by the manufacturer introduces most of the quality
variation. By adding a hardening filter or employing a compos-
ite brass and lead filter, the quality variation was reduced by
one-half, but output is reduced by 25 percent. Flattening an
x-ray field involves a compromise between penetrability, uni-
formity, and output. Contemporary machines employ energy
interlocks whose limits place constraints on field unflatness.
Naylor and Chiverallsl48 examined the variations in x-ray
beam flatness and calibration as a function of gantry angle over
a period of time for an 8-MV unit equipped with a 90' bending
magnet. They conclude 'that such variations are confined to a
few percent when averaged over 4-week periods, an interim
pertinent to treatment. In one treatment unit, Dale found that
an anomalous asymmetry with gantry angle was caused by the
leads of the electron chamber sagging into the edge of the
useful beam.45 Padikal et a1.,156 describe a method for assessing
the stability of symmetry for gantry angle rotation. The effect
of the earth's magnetic field on the electron beam in the linac
can change with gantry rotation. The heavy iron frame cast in
the floor and used for mounting the linac can produce signifi-
cant distortions in the earth's field and changes in fringing
fields of bend and solenoid magnets as a function of gantry
angle of rotation. Sutherlandlgl notes that dose monitoring
methods employing circular chambers bias their output for
unflat fields so as to affect calibration factors by as much as 2
3 percent. In an early study, Naylor and Williamsl49 call atten-
tion to the need for frequent symmetry,dose monitor, and beam
energy checks of linac treatment units. Martell et al.,129 de-
scribe a flatness monitor that can be used to quickly and
accurately check beam flatness and calibrations. It consists of
a 7 X 7 matrix of ion chambers, a sampling multiplexer, and
computer hardware and software to provide a hard copy print-
out. An earlier matrix dosemeter for the uniformity of high
energy x-ray beams is described by Johns et al.89
X-RAY SCANNING SYSTEM
At x-ray energies above 25 MeV the x-ray lobe becomes so
narrow that use of a conventional flattening filter for large
fields becomes undesirable for a number of reasons. The pri-
 X-RAY THERAPY
mary radiation photon absorption process in the x-ray target at
such energies results in positron~lectronpair production, with
consequent reduction in mean photon energy in the central
portions of the field. There is not enough space available in the
radiation head of 360" isocentric linacs at these high energies
to permit use of low Z materials in the central portion of the
flattening filter to avoid this radius-dependent degradation of
the x-ray spectrum (as studied by Podgorsak et al.).l70 Also, the
mean displacement of the beam at the x-ray target would have
to be controlled still hore precisely at these high energies if a
flattening filter were used, because of its greater centrallperiph-
era1 attenuation ratio and because of greater geometric magni-
fication if the filter length were increased by placing its tip
closer to the x-ray target than in conventional designs.
Figure 8-8 shows a magnet system design proposed by
Brahme et al.27 for producing a scanned x-ray beam. The
narrow energy spread (- 0.1 percent) horizontal beam from a
50-MeV racetrack microtron is bent by a 90" bend magnet onto
an x-ray target in a treatment gantry. A radial scanning magnet
is located ahead of the 90" bend magnet. An electron ray
diverging radially from the center of this radial scanning mag-
net reconverge at the center of a transverse scanning magnet
located after the 90" bend magnet and just before the x-ray
target. Although the angular scanning enlarges the beam spot
on the x-ray target, the x-ray lobe is so narrow at 50 MeV that
at the normal treatment distance it appears to originate from the
electron beam radialltransverse convergence/divergence point
in the middle of the transverse scanning magnet ahead of the
x-ray target. A raster scan or a spiral scan in the angle of the
x-ray beam lobe can be generated by appropriate control of
timing and amplitude of the currents in the two scan magnets.
Scanning of the x-ray lobe angle can produce a relatively
flat dose distribution with only a thin x-ray filter needed to
Bending
Magnet
Electron
Beam n
Scanning
Magnets 11
FIGURE 8-8 . Cross sections of magnet system for scanning the angle of arrival of the beam at the x-ray target (from Ref. 28). (a) The radial
plane, (b) the transverse plane, and (c) the adopted scanning magnet system.
149
correct small nonuniforrnities. Thus, the effective energy of the
x-ray spectrum remains high and uniform over the treatment
field, even for large fields. At 50 MeV, the full-width of the
unflattened x-ray lobe at 50 percent intensity is about 8 cm at
100-cmnormal treatment distance. Overscanning onto the jaws
of the beam limiting system is required to obtain adequate
overlap of the individual beam lobe pulses for uniform dose
distribution out to the edges of the maximum field size. Thus,
some of the x-ray power that would be lost from the central
portion of the x-ray lobe with a conventional flattening filter is
lost instead outside the periphery of the maximum field. X-ray
beam scanning could be usefully applied at energies lower than
50 MeV as well. For example, at 20 MeV the diameter of the
unflattened lobe at 50 percent intensity is about 20 cm so that
a 40 X 40-cm maximum field size would require scanning the
x-ray lobe axis over approximately a 60 X 60cm area. The
maximum treatment field area would be approximately 44
percent of the x-ray scan area. If a flattening filter were used
instead, the flattened field intensity would be approximately 16
percent of the unflattened lobe maximum at 50 MeV. Thus, for
a given dose rate the required beam current and power on the
x-ray target and consequent stray x-ray and neutron emission
would be reduced by a significant factor (a factor of 2V2) -
even at 20 MeV by use of scanning.
A single 90" nonachromatic bend magnet can be used in
the system of Figure 8-8 because of the narrow energy spread
of the microtron. For linacs, either a major reduction of the
energy spread or an achromatic bend magnet would be re-
quired. Radial scanning ahead of the bend magnet over the
approximately 2300 milliradians needed to adequately over-
scan the treatment field would far exceed the acceptance of
achromatic bend magnets. Thus, for linacs, it is more practical
to scan in both radial and transverse planes at a point after the
150 CHAPTER 8. TREATMENT BEAM PRODUCTION
bend. Bensussan et al.17 proposed such a technique for x-ray
scanning of a linac beam, employing a four-pole magnet.
SCANNED BEAM DOSIMETRY
Patient dosimetry and beam monitoring is more difficult with
scanned electron and scanned x-ray beams. Because of the
narrow radiation lobe and its short pulse length, the instanta-
neous ionization intensity is high in the core of the radiation
lobe in the ionization chamber of the machine dose monitoring
system. Collection efficiency can be significantly impaired,
requiring correction for resulting nonlinearity.141 Measure-
ments of the dose distribution in a phantom can be made with
integrating techniques, such as by using film, but use of scan-
ning probe type detectors is more complex and may involve the
linac pulse repetition frequency. More complex interlocking is
required to ensure that dose uniformity over the field is not
affected by missed accelerator pulses (see also Chap. 9).
CONTAMINATION OF RADIATION BEAM
A treatment beam of x-rays or electrons contains contaminants,
both inside and outside the useful beam intended to encompass
the tumor. These contaminants are electrons and photons as
well as neutrons, which are considered separately in the fol-
lowing section. The contaminants modify the intended dose
distribution pattern deposited inside the useful beam as well as
exposing tissues outside to unnecessary and, perhaps, harmful
radiations. Fraass et a155 pointed out the wide variation in
thresholds of deleterious dose-effect phenomena ranging from
less than 5 to 200 cGy or about 0.1 to 3 percent of the prescribed
doses. Contaminant limits have been proposed by the IEC85 in
terms of leakage radiation through beam limiting devices,
surface dose during x-ray irradiation and stray radiation during
electron irradiation.
The major contaminants of megavoltage x-ray beams
(electrons, scattered photons, and leakage radiation), have
received the most study. Here the important effect within
the useful beam is the reduction in skin sparing which results
from increasing skin and build-up dose and a shift of the
dose maximum towards the surface as the field size is
increased. Efforts to ameliorate this effect have been
successful and many investigators have contributed to the
study and reduction of these surface dose phenom-
ena~19,23,74,76,96,103,111,118,124,125,161,166,194,2M
The loss of skin sparing is due primarily to electrons as
shown by Biggs and Ling19 using a sweeping magnet placed
just below the radiation head of a megavoltage linac. This loss
can be partially regained with transparent lead-loaded acrylic
filters.118 Huang et al.74 report a 3 to 13 percent reduction in
surface dose compared with pure acrylic, which is often em-
ployed for supporting field blocks. Build-up data for compari-
son purposes must be obtained with operational plastic shadow
trays in place. The x-ray flattening filter has been suggested by
experiments of Mackie and Scrimgerl24 as the main source of
contaminant electrons. Monte Carlo studies confirm these find-
ings.1517166The main sources of scattered photons are the
primary collimator for 6 MV and the flattening filter for 2 1-MV
bremsstahlung sources.151
The contaminants outside the useful beam of x-rays in-
volve lower doses but larger volumes and may expose radiation
sensitive entities such as the fetus or the lens of the eye. These
peripheral doses have been the subject of a number of stud-
ies.55,63,@,96,186,189Electrons may contribute as much as 20
percent of the dose maximum up to the depth of dose maxi-
mum. However, other components, phantom or patient, and
collimator scatter and leakage transmitted through the radiation
head, are dominant at greater depths. Fraass et a1.55 find in-
phantom scatter and leakage dose to be roughly equal and
varying with the field size, while Greenea and Kase et al.96
identify collimator scatter as a major source. Leakage radiation
becomes dominant at large distances from the electron beam
axis although dose from leakage is small and the cost in money
and weight to reduce this dose component further than the 0.1
percent limit guideline may not be warranted.
Wedges and blocks contribute dose outside a treatment
field. Sherazi and Kase186 found that wedges can increase such
doses by a factor of 2 to 4 from the unwedged value but the
effect of adding blocks is much smaller and generally less than
a factor of 2.
Electron treatment beams are contaminated by brems-
strahlung, which dominate the depth dose beyond the practical
electron ranges. This dose increases with energy but can be
minimized by attention to radiation head design. The surface
dose of electron beams increases with field size. A Monte
Carlo study by Udalel98 relates this effect to the adjustable
x-ray collimators that shield the phantom or patient from
secondary electrons for smaller fields, and to the electron
applicators that increasingly filter the beam as they get
narrower for smaller fields, thereby raising the mean energy
of the electrons. Photon contamination in electron arc therapy
has been studied by Pla et al.169 It is a function of arc angle,
field width and isocenter depth and under certain conditions
can amount to a large fraction (up to 50 percent) of the
prescribed electron dose.
NEUTRON LEAKAGE AND
RADIOACTIVATION
A significant number of neutrons are produced by high energy
x-ray beams. The neutrons and the radioactivation that they
may induce have been the subject of a number of stud-
For most rele-
ieS~2,7,18,51,69,70,71,109,110,I30-133,1,147,153,157,183,200
vant materials, the neutron production threshold occurs at 8 to
 REFERENCES
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are filtered through the radiation head, a few are generated in
the patient (see Chap. 14,p 252 and many are multiply scattered
by barriers comprising the treatment room, which themselves
are a source of neutrons. These neutrons, together with x-ray
leakage, can expose the patient as well as those outside the
treatment room. McCall and Swansonl3l provide a thorough
description of neutron sources and their characteristics origi-
nating in linac radiation heads. They find that high Z shielding
materials do not significantly alter the neutron fluence, but do
substantially reduce the average energy of the transmitted
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Rawlinson and Johns178 note that the energy imparted outside
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leakage. Some simplification in assessment have resulted from
defining two pertinent measurement surfaces for protection
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neutron problem together with recommendations regarding
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risk of carcinogenesis is extremely small, and the implementa-
tion of more restrictive regulation is unnecessary and would be
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 Dose Monitoring and Beam Stabilization
Radiation therapy involves the identification, adoption, and
implementation of an optimal treatment plan for the individual
patient. Such a plan includes a treatment prescription specify-
ing the individual field sizes, their orientation, and their indi-
vidual contribution to the composite dose distribution in the
target volume. It includes the fractionation scheme (sequence
of daily treatments) for delivering the prescribed total dose, as
well as provision for planned changes in fields during the
course of therapy. In addition, the treatment plan may include
the use of beam modifying accessories such as wedge filters,
compensators, shadow blocks, or combinations of these. The
safe, quantitative, and accurate delivery of the individual field
dose portions of the treatment prescription is the central func-
tion of the dose monitoring and beam stabilization system.
Radiation treatment beams must be precisely directed and
accessories accurately positioned in order to achieve maximum
clinical benefit. See Fig. 13-4 for an example treatment pre-
scription.
The dose monitoring system incorporates a transmission
ionization chamber. This chamber is located in the radiation
head of the linac and samples the treatment beam (see Fig. 8-1).
Electrical signals from it are used to monitor and control the
treatment beam. Various aspects of electron dosimetry includ-
ing monitoring have been described in two International Com-
mission on Radiation Units and Measurements (ICRU)
reports.16.20 Ageneral reference on the physics of electron beam
therapy is that of Klevenhagen.28 The dosimetry of x-ray beams
is described in ICRU Report Nos. 23 and 24,17918 and NCRP
Report No. 69.41 The dosimetry of pulsed radiation, especially
relevant to electron linacs, is treated in ICRU Report No. 34.19
IEC document 601-2-1, specifies radiation safety performance
standards and test requirements for dose monitoring systems.21
Patient dosimetry and beam monitoring is more difficult
with scanned electron and scanned x-ray beams. Because of the
narrow radiation lobe and its short pulse length, the instanta-
neous ionization intensity is high in the core of the radiation
lobe in the ionization chamber of the machine dose monitoring
system. Collection efficiency can be significantly impaired,
requiring correction for resulting nonlinearity. Measurements
of the dose distribution in a phantom can be made with inte-
grating techniques, such as by using film, but use of scanning
probe type detectors is more complex and one must account for
the linac pulse repetition frequency. More complex interlock-
ing is required to ensure that dose uniformity over the field is
not affected by missed accelerator pulses.
IONIZATION CHAMBER
The transmission ionization chamber of a contemporary high
energy linac is constructed of several plates or electrodes,
whose areas may be divided into sectors so as to serve two
different monitoring purposes.
1. Dose rate and integral dose of the x-ray and electron
treatment beams.
2. Angular and radial (positional) distribution of the radiation
in the treatment
In many accelerators, the resultant electrical signals are
also used in automatic feedback circuits to steer the electron
beam through the accelerator and bending magnet onto the
target (or scatterer) in order to ensure treatment beam flatness
and symmetry. How these needs are satisfied in one represen-
tative treatment unit, the Varian Clinac 18, is described below
and illustrated in Figure 9-1, which is a simplified diagram of
the ion chamber, dosimetry, and beam steering system. Addi-
tional details of this35 and othefi.48.52 monitor chamber designs
are described in the patent literature. Ionization chamber posi-
tion misalignments can significantly alter their response.
Hence, precise repositioning is critical where two independent
moveable chambers are employed for x-ray and electron beam
monitoring, especially where heavy flattening filters are also
moved. Figure 9-2 illustrates typical electron paths, between
gun cathode and x-ray target and the beam steering system for
the Clinac 18. Figure 9-3 is the logic diagram of the dual
channel dosimetry system of the Clinac 18 as described herein.
The transmission ionization chamber, shown in the radia-
tion head diagram of Figure 8-1, subtends the entire useful
158 CHAPTER 9. DOSE MONITORING AND BEAM STABILIZATION

Position
Steering
Coils

Angle
Steering
Coils

FIGURE 9-1 . Five-electrode ionization chamber with simplified block diagram of dosimetry and beam steering system. The radial and transverse
coordinate planes of the bending magnet orbit are identified in the upper left. The radial angle steering coils are actually located in the bending mag-
net, as shown in more detail in Figure 9-2.

beam and provides two independent outputs for the dual do-
simetry monitor described in the section that follows. Located
just below the x-ray flattening filter or electron scattering foil,
it monitors the emergent flattened x-ray beam or scattered
electron beam. One design of this ionization chamber, shown
in more detail in Figure 9-1, consists of three polarizing plates
and two intervening collecting plates- Each of the latter is
divided into four collecting sectors, with each sector defining
a distinct laminar collecting volume. The parallel-plate con-
struction of the ion chamber allows monitoring the entire useful
beam emerging from the primary collimator and permits close
spacing of the plates, ensuring good ion collection at moderate
voltages. Treatment beam x-rays and electrons eject secondary
electrons from the plates into the gas between the plates,
 IONIZATION CHAMBER 159

Primary
3rd Polepiece Collimator

/
2nd Polepiece
Radial Angle
Steering Coil

: , &
I l:. ,
1
High Energy e-
Nominal Energy e-

dl 6, Low Energy

Gun
Cathode Gun
-7
Anode
w- Buncher Radial
Steerina Coil
Accelerator
Solenoid (2 Coils)
Input Collimator
\
' 1st Polepiece
Transverse Angle
Steering Coil

FIGURE 9-2 . Accelerator, bean1 steering, bend magnet, and typical electron paths for Clinac 18 treatment unit. (Courtesy of Varian)

ionizing it, with some ionizing of the gas also caused directly
- - -IONIZATION -- -- - --
- - - - -CHAMBER by the treatment beam. An energetic electron will typically
I
CALIBRATE -- 4 produce about 60 ion pairs per centimeter of path in air at
I
I
I
COLLECTOR I COLLECTOR
1 2 normal temperature and pressure (NTP). The positive and
negative ions drift in opposite directions towards the two plates
under the influence of the electric field between the plates. The
INTEGRATOR SYMMETRY
MONITOR
SYMMETRY
MONITOR INTEGRATOR electrons produced in the gas are attracted to the electrode +
DOSE RATE (RADIAL)
and + ions to the - electrode, the fraction arriving being
dependent on the collecting voltage, plate spacing, dose per
pulse, and the particular gas employed and its density. Some
ions recombine, either from the initial pair created (initial
recombination) or from close encounters with ions of opposite
polarity during the collection process (volume recombination).
INTERLOCKS The frequency of the latter depends on the density of ions
created and the collecting field strength. Saturation is defined
as collection of all of the ions produced. To avoid significant
COMPARATOR CDMPARATOR
nonlinearities at operational dose rates, an ionization chamber
is usually operated very near saturation. A small gap and high
collecting voltage minimize this recombination loss, which is
nonlinear and a function of dose rate. A 500-V polarizing
voltage is used with a plate spacing of 1 mm. The two inner
D-like sectors provide signals for both dosimetry and angle
steering and the two outer arclike sectors for displacement
steering. The dosimetry system monitors and displays readings
1 4I
ACCUMULATED
DOSE DISPLAY rtl
IIACCUMULATED
DOSE DISPLAY rR
related to the quantity (dose), dose rate and uniformity (sym-
metry) of the useful beam of radiation.
L- - - - - - - - - - - - - - - - - - -J
CONSOLE SETTINGS In one construction technique, the collecting plate sectors
AND DISPLAYS
are formed by vacuum deposition of a thin metallic coating on
FIGURE 9-3 . Dual dosinletry logic for ionization chamber systenl defined areas of an insulating lamina of mica. Additional
illustrated in Figure 9-1. (Courtesy of Varian.) grounded metallic coatings, not shown in Figure 9-1, surround
160 CHAPTER 9. DOSE MONITORING AND BEAM STABILIZATION
the collecting areas and serve as guard rings to minimize leak-
age currents over the insulation. Ionization chambers may be
sealed to the outside air, making them free of the need for tem-
perature and pressure corrections provided that the pressure dia-
phragms are not used as electrodes. Hrejsa et al.,ls describe a
temperature-pressure compensation system for an unsealed
ionization chamber.By its use, observed fluctuations of the dose
calibration per monitor unit were reduced from 3 to 6 percent to
approximately 20.5 percent over extended periods of time.
The thin exit and entrance windows of sealed, parallel
plate transmission ion chambers may flex with ambient pres-
sure changes altering slightly the mass of the central volume of
gas being monitored and, hence, the calibration. Sealed ion
chambers are preferably filled to a positive pressure above
atmospheric pressure. If chambers leak, or are intentionally
vented to the atmosphere, their sensitivity will also shift with
ambient pressure and temperature changes.5.47 Assessment of
such variations in monitoring ion chamber sensitivity is diffi-
cult under routine treatment unit operation. An improved test-
ing procedure for sealed, parallel plate monitor chambers has
been developed by Kehoe and Barnard." By placing the cham-
ber in a testing jig, they are able to simulate and exaggerate
ambient pressure variations and detect leaks quickly. Suther-
land49 recommends collecting ion current for dosimetry only
from the central part of the ion chamber, guarding against the
effect of the more unstable peripheral rays, which may unduly
bias ion chamber response.
A relatively new material for ion chamber plates is
Kapton," a synthetic polyimide, thin film. It is extremely
resistant to radiation damage, compared to the other insulating
materials used in ion chamber construction. It can be readily
plated with copper to which leads can be soft soldered. A
chamber of this construction has significantly fewer grams per
square centimeter in the electron beam than a mica plate
chamber. While not an important consideration for x-ray ther-
apy, it allows the discrete electron scatterers to more com-
pletely control scattering for electron therapy. Kapton film is
very strong, not subject to adverse effects of heat, and may be
stretched taut. However, some sealed, nitrogen filled, Kapton
chambers developed troublesome calibration changes after
several months of routine use. Dry-air-filled Kapton chambers
appear to be free of this anomaly.
INTEGRATED DOSE AND DOSE RATE
Contemporary linacs employ two independent integrated dose
monitors, a dose rate monitor and a backup timer, which should
be preset to preclude excessive dose delivery by restricting
treatment "beam-on" time. As shown in Figure 9-1, the dose
monitors are fed by the inner D-like sectors of the two collector
plates. The dose rate monitor derives its signal from both the
*Kapton, Du Pont de Nemours & Company, Wilmington, DE 19898.
inner D-like and outer arclike sectors of the upper collecting
plate. Sutherland49 early recommended that integrated dose be
based on monitoring only the central portion of the field. Most
treatment fields are small, and he found that monitoring the
large area of the entire beam profile can result in axial calibra-
+
tion errors as large as 3 percent. An ion chamber incorporat-
ing a circular area, centered on the beam axis, has been
described by Boux6 and by Stieber.48
For safety, two independent dose monitors are needed. The
electron beam center line (central orbit) through the linac struc-
ture and 270" bending magnet is shown in Figure 9-1. This cen-
' ter line determines the reference orientation of the semicircular
plates with respect to the radial and transverse coordinate planes
of the beam as established by the bending magnet. As shown, the
upper collecting plate of Figure 9-1 is concerned with signals
pertinent to the radial plane of the bend magnet, the lower col-
lecting plate to the transverse plane signals. Semicircular elec-
trodes, A and B, are oriented to provide signals related to the
radial plane. Their current signals are first converted to voltage
and amplified via A and A2, then summed via A3 to provide a
console indication of dose rate and of integrated dose via inte-
grator no.1 for the DOSE 1 channel as shown. Similarly, semi-
circular electrodes C and D are oriented to provide signals
related to the transverse plane. They feed the DOSE 2 channel
via amplifiers A5 and A6, summing amplifier A, and integrator
no. 2. The two integrateddose channels are completely indepen-
dent; either can terminate the preset exposure or if the second
channel lags the first by more than 25 monitor units. Hence, if
the treatment is not terminated normally by the first dose chan-
nel on completion of the preset monitor units, the second dose
channel will terminate the treatment 25 monitor units (MU)
later or at + 10percent, whichever is lower (as required by some
State Laws). The dual 500-V power supply furnishes indepen-
dent collecting voltages for the two ion chambers. Dose moni-
tors are calibrated on site so that a monitor unit (MU) read out on
the control console is uniquely and unambiguously related to
the absorbed dose in a phantom under prescribed conditions.
For example, 1 MU may equal 1 cGy for a 10 X 10-cm field on
axis at 100-cm SSD and 10 cm depth (or at D,,,) in a water
phantom.
Ionization chambers may exhibit nonlinearities as a func-
tion of dose rate if there is significant ion recombination.54 In
this case the ions that are formed in the gas, usually air, between
the collecting plates recombine before reaching the collecting
electrodes. Ion collection is more difficult in the radiation beam
of linacs where the pulsed nature of the beam results in high
ion density prior to collection. Hence, large collecting voltages
are employed to provide high collecting E-fields for overcom-
ing recombination. In well-designed systems and under normal
operation, ion collection efficiencies over 99 percent are
achievable with x-rays, and somewhat less with electrons,
particularly at lower (4-6 MeV) electron energies. The dosim-
etry of pulsed radiation beams and a simple two-voltage tech-
nique for assessing collection efficiency in pulsed beams has
been described.19 Several radiotherapy linacs now incorporate
 FIELD UNIFORMITY CONTROL
magnetically swept rather than scattered electron beams, which
present different design and additional ion collection efficiency
problems.8.36.ss Conere and Boag9 extended the two-voltage
assessment technique cited above to such beams.
Johnsen and La Riviere23 examined the collection effi-
ciency of commercial thimble ionization chambers in pulsed
x-ray and electron beams. Using a 0.6-cm3 Farmer chamber
they measure collection efficiencies of above 99 percent and as
low as 90 percent for exposures of 0.04 Rlpulse for routine
radiotherapy and 0.5 Rlpulse for scanned electron beams re-
spectively. O'Brien et al.43 calculated the collection efficiency
for this chamber as between 14 percent and 10 percent when
exposed to the abnormal dose per pulse of between 1 and 2 Gy.
Pillar et al.46 describe an independent dose monitor totalizer
unit that is especially useful for patients being treated at ex-
tended distances when it is necessary to reset the control
console dosemeter several times.
Dependence of integrated dose on dose rate can stem from
nonlinearities of ion chamber electronics as well as from ion
recombination. Cheng and Kubo7 found that a defective circuit
board resulted in a 20 percent decrease in integrated dose for a
dose rate increase from 100 to 500 MUlmin. Cox et al.10 found
amplifier saturation a problem in developing a total skin elec-
tron therapy (TSET) technique, which required a very high
beam intensity at the location of the dual ion chamber monitors
in the radiation head. By improving amplifier linearity, increas-
ing the collector voltage, and requiring the primary dosemeter
to be connected to the most distant of the dual chambers from
the scatterer, satisfactory monitoring was assured using exist-
ing monitor chambers in the radiation head. The initialized use
of shall below indicates a mandatory requirement.
Dual dosimetry monitors, which provide independent ex-
posure limit backup, are recommended by safety organi-
zations.21 Malfunctioning of one dose monitoring system
shall not affect the correct functioning of the other system.
Failure of an element which could affect the correct func-
tion of either dose monitoring system shall terminate
irradiation. In the case of separate power supplies, failure
of the power supplies of either system shall terminate
irradiation. If the performance of the detectors is depen-
dent on hermetic sealing, then they shall be independently
sealed.
The two dose monitoring systems shall be arranged
either as a redundant dose monitoring combination or as a
primarylsecondary dose monitoring combination. In the
case of a redundant dose monitoring combination, both
systems shall be capable of a given performance. In the
case of a primarylsecondary dose monitoring combina-
tion, at least the primary dose monitoring system shall be
capable of this performance. This performance shall be
maintained up to absorbed dose rates of twice the specified
maximum. The secondary dose monitoring system shall
be set to terminate irradiation when the preselected num-
ber of dose monitor units has been exceeded by not more
161
than 15 percent if a percentage margin is used or not more
than the equivalent of 40 cGy of absorbed dose if a fixed
margin is used.
The digital logic of many dosemeter and control systems
facilitates the development of rapid automatic self-test regi-
mens of dosemeter and other circuits prior to each treatment
exposure. In such self-test systems, a known current substitutes
for the ion current during a short fixed time, producing a
pseudodose integrand whose value assesses the correct func-
tion of the dose integrating circuit, but not the radiation
response of the ionization chambers. Under computer control,
the dose integrating circuit may be tested in this manner prior
to each treatment exposure. Figure 9-3 illustrates the logic
diagram for a dual channel dosimetry system wherein the
backup channel will terminate treatment at a dose 40 MU
higher than the dose set on the thumbwheel. The self-test
calibrate current is introduced in each ionization chamber
collector plate lead. The interlock also terminates the treatment
if either of the preset radial or transverse symmetry limits are
exceeded.
Digital circuits can be very reliable, are less subject to
failure, are easier to design, and are increasingly incorporated
in monitor and control systems. They exhibit freedom from
drift and need fewer adjustable controls than analog circuits.
They can serve to implement software solutions to problems,
often as test regimes. It seems likely that microprocessor and
firmware will be increasingly incorporated into radiotherapy
linacs as in other computer applications. This allows the flexi-
bility of program development in software and, once agreed,
the "freezing" of the program in inexpensive read only memory
(ROM). However, the cost of software development is often
many times the cost of the hardware development. Additional
aspects of digital logic, monitor and control systems as well as
computer usage are presented in Chap. 10.
FIELD UNIFORMITY CONTROL
The field uniformity control system is designed to ensure that
the treatment field is symmetrical in both the radial and trans-
verse directions and uniform to within the stated specification
of the manufacturer. This entails control of the beam energy
and the accurate placement of the beam on the axis of the
target-flattening filter for x-ray therapy or the scattering foil
system for electron therapy.6 This placement can be accom-
plished by the use of steering coils located along and around
the accelerating structure, as well as at the bend magnet. By
energizing them from appropriate ionization chamber signals,
beam control in both radial and transverse directions is pro-
vided. Figures 9-1 and 9-2 illustrate the beam steering system,
which provides field uniformity in the Clinac 18. The radial
and transverse planes intersect along the beam center line and
162 CHAPTER 9. DOSE MONITORING AND BEAM STABILIZATION
the axis of the x-ray flattening filter (see Fig. 8-1). As shown
in Figure 9-1, two groups of four steering coils are used in a
servofeedback system, using signals from the ion chamber
sectors to control and limit the divergence (angle) and displace-
ment (position) of the electron beam from the axis in the radial
and transverse directions. Both groups of steering coils provide
small angular deflections of the electron beam. Adetailed view
of the Clinac 18 accelerator and beam steering and bending
magnet system is illustrated in Figure 9-2.
The transverse angle steering coils shown on the left in
Figure 9-1 are located at the entrant image aperture of the 270"
bending magnet, as illustrated in Figure 9-2. The exact location
of such coils may vary, depending on the design of the overall
beam transport system, but magnet optics dictate their location
in a particular design. In an achromatic magnet, an entry
trajectory angle at the entrant image plane results in the same
exit angle at the object image plane without producing a change
in displacement at the image plane. The radial angle steering
coils are located at the second polepieces of the three-dipole
bending magnet as shown in Figure 9-2.
The position steering coils, shown on the right in Figure
9-1, are located at a distance from the bending magnet entrant
aperture and at the output end of the accelerating structure as
illustrated in more detail in Figure 9-2. As shown in Figures 9-1
and 9-2, two of the beam position steering coils are connected
to control the radial position, and two, the transverse position of
the electron beam from the beam center line axis. The principal
effect of their small angular deflection is to provide a lateral dis-
placement (position) correction at the bending magnet entrant
aperture, which is at or near the beam collimator. The small an-
gular error introduced is then corrected by the angle servo.
These steering coil groups are energized by error signals gener-
ated if the electron beam strikes the target, or scattering foil, at
an angle or at a position that produces an asymmetrical x-ray or
electron beam, as detected by the two monitor chambers and as
shown in Figure 7-16b and c, respectively. In the Clinac 18, a
third group of four coils, shown in Figure 9-2, is also positioned
around the beam at the buncher (input) end of the linac struc-
ture. These unsewoed buncher coils also control beam position
in the radial and transverse planes, steering electron beams of
all energies leaving the gun onto the center line of the micro-
wave accelerator structure in the first few cavities.
Signals from peripheral plates E and F are amplified by
amplifiers A9 and Ale. Their difference signal (E-F) from A,,
feeds a "sample-and-hold" circuit, which provides a dc signal
to the radial position steering coils. The radial position steering
coils control the radial component of lateral displacement of the
electron beam with respect to the flattening filter axis, as shown
in Figures 9-1 and 7-16 c. Amplified signals from semicircular
plates A and B are subtracted in difference amplifier A,, which
feeds a sample-and-hold circuit which, in turn, provides a dc
signal to the radial angle steering coils. The radial angle steer-
ing coils control the radial component of angular divergence of
the electron beam with respect to the x-ray target and field
flattening filter axis (see Figs. 9-1 and 7-16 b). The angle and
position asymmetry signals from amplifiers A4 and A l , and
their associated sample-and-hold circuits, are compared to pro-
vide a visual display of radial plane beam asymmetry at the
console. They are set to provide an operational radial asymme-
try limit beyond which the beam is turned off. In a similar
manner, as shown in Figure 9-1, but not described here, the
transverse position and transverse steering coils are connected
to amplifiers and ion chamber sectors so as to semocontrol,
display, and limit the beam asymmetry in the transverse plane.
The symmetry meter (see Fig. 9-I), can be switched to indicate
either radial or transverse symmetry. The symmetry ineter and
the associated steering coils are connected to use all signals
from the collecting electrodes. Asymmetry interlock interrupts
the beam if asymmetry exceeds a preset value (e.g., 2 percent).
The beam position and beam angle steering amplifiers are each
provided with six programmable groups of gain and balance
controls corresponding to the one x-ray and five electron modes
of operation of the Clinac 18.The associated steering interlocks
are verified during Quality Assurance (QA) procedures. The
beam position signals are not used in the electron mode because
the electron beam is not widely spread at the ion chamber and
the precise steering associated with high energy, x-ray flatten-
ing filters is unnecessary. Here, the signals from the small outer
plates E, F and G, Hare small and provide little useful informa-
tion. Quality assurance procedures are particularly important if
a broad beam illuminates the primary collimator and steering
interlocks are not employed.
MONITORING AND CONTROL OF
MULTIMODALITY TREATMENT UNITS
Multimodality treatment units involve significant beam moni-
toring and stabilization requirements, and present a hazard that
is not found in single modality units. The radiation safety
hazard of high abnormal electron beam currents in an early dual
modality treatment unit was identified many years ago.25 A
particular combination of electronic and mechanical malfunc-
tions, combined with failure of the software to respond properly
to an operator action, appears to have been responsible for
several overexposures in 1985-1987, where a large electron
bearn current emerged as an unscattered, unscanned (and al-
most unmonitored) beam from the radiation head.
In normal x-ray therapy, the electron beam is intercepted
by the x-ray target or by the x-ray flattening filter if the target is
retracted erroneously. In normal electron therapy, the electron
beam is spread out by a scattering foil(s) or scanned over the
treatment field magnetically. In normal electron therapy mode
operation, the beam current through the electron window is of
the order of 111000 of the beam current at the x-ray target for x-
ray therapy mode. For example, at 4 Gylmin at 100 cm in the 6-
MV x-ray mode, the average beam current at the x-ray target in
one linac treatment unit is of the order of 100 PA. At the same
 MONITORING AND CONTROL OF MULTIMODALITY TREATMENT UNITS 163

dose rate in 6-MeV electron mode, the average beam current at
the electron window is of the order of 0.1 pA. Similarly, an av-
erage beam current of 20 pA is typical for 25-MV x-ray ther-
apy, and approximately 0.02 p A for 25-MeV electron therapy.
Typical beam currents at the accelerator vacuum window are
given in Table 9-1 for specified x-ray and electron dose rates as
a function of energy.
Through hardware and/or software failure, a large electron
beam current intended for x-ray operation can emerge without
being intercepted by the x-ray target andlor x-ray flattening
filter. Even with the scattering foil(s) in place or scanning
operable, an estimated dose comparable to a typical 2-Gy dose
fraction can be delivered to the patient in a time of the order of
0.03 seconds at a dose rate of 4000 Gylmin. This is far too short
a time for operator reaction, so safety protection is totally
dependent on fast monitoring and radiation terminating elec-
tronics.
The hazard is exacerbated if it is possible for the electron
scattering foil@)or scanning system to fail at the same time as
the failure described above. Recently, O'Brien et a1.42.43 mea-
sured a dose of l to 2 Gy per pulse from 25-MeV electrons at
the normal treatment distance for such abnormal operating
conditions. The electron beam lobe will then be more forward
peaked at the patient, and the electron dose rate can be of the
order of 15,000 Gylmin and deliver a normal 2-Gy dose frac-
tion to a small volume of tissue in only one pulse of the
accelerator. Clearly, the safety electronics must include the
provision to monitor the radiation beam on a pulse-by-pulse
basis and to terminate radiation within one interpulse period,
that is a time of the order of 0.002 seconds. The experiments of
O'Brien et al.,43 pertinent to this hazard, also demonstrate the
severe limitations of many of the commonly used calibration
standard dosemeters when they are used outside of the normal
dose and dose rate ranges encountered in a radiotherapy depart-
ment. The quantitative values presented above will vary from
one treatment unit to another, depending on the reference dose
rate, the pulse repetition frequency, the electron energy and its
energy spectrum, the design of the x-ray target-filter system,
and the electron scattering or scanning system. However, they
are believed representative of contemporary designs. Protec-
tion of the patient against hazards from unwanted or excessive
radiation are reviewed in an IEC document.21
One approach to the overexposure hazard where very high
dose rates are possible (more than 10 times normal maximum
rates), is to incorporate an additional independent monitor
whose sole function is to monitor and interlock the radiation
beam on a pulse-by-pulse basis. It has been recommended that
this detector be operated on a different physical principle than
those already employed.21Possible candidates include the elec-
tron secondary emission monitor, as well as electrostatic and
electromagnetic induction monitors.l4,24.50 Significant experi-
ence with such devices may be found in many high energy
particle physics laboratories. Frequently, operator error andlor
procedural deficiencies are involved in radiation accidents.
Suggestions for improvements in these aspects have been pre-
sented.26
Loyd et al.32 assessed the dose delivery error in a dual
photon energy, computer-controlled Philips SL 25 linac. This
unit has a complex collimation and beam delivery system, is
magnetron powered and provides eight electron energies from
4 to 20 MeV as well as 6 and 15-MV x-rays (see Fig. 8-2). It is
equipped with a motor-driven nominal 60" wedge for providing
variable wedge angle fields, and independent upper collimator
jaws for providing asymmetric fields. Beam intensity, flatness,
and symmetry status are monitored by the computer using
analog signals from a thin Mylar window transmission ioniza-
tion chamber.
A given beam selection involves positioning six separate
motorized, beam-modifying elements. They each must be
properly aligned for accurate dose delivery. A number of inter-
locks are designed to detect any misalignment prior to abeam-
on condition. In this study the authors investigated the ability of
the computer-controlled system to detect and respond to treat-
ment beam dosimetry errors arising from misalignment, which

TABLE 9-1 - Linac operating parameters

X-ray? Electron?

Average Average
Energy, beam current Filter Dose Rate Energy beam current Scatter Dose rate,
(Mv) in pA trans. (%) (cGy/m/lm) (MeV) in nA Foil (mil) (cG~/m/lm)

4 200 45 2oob
6 100 35 400b 6 100 3 Ta 500
10 70 30 5OOC 9 97 500
15
18
50
30
25
18
5OOC
5OOC
12
16
67
42 { 1% button
500

25 20 10 5OOC 20 30 500

OlpA = A. = 1 0 - ~ n ~
b ~300
t pps, 3.5-ps pulse.
CAt150 pps, 3.5-ps pulse.
164 CHAPTER 9. DOSE MONITORING AND BEAM STABILIZATION
produced a nonflat beam, an asymmetric beam, an incorrect
dose delivery, or some combination of these three factors.
For conditions that may be encountered during normal
treatment situations, symmetry, flatness, and dose delivery
errors were detected and the radiation beam interrupted rela-
tively quickly. However, for extremely artificial situationswith
both the flattening filter and the backscatter shield (shutter)
removed (see Fig. 8-2), the fault detection system failed. No
fault or error message was displayed and the beam was not
interrupted for conditions of excessive dose delivery. Although
the experimental conditions described were extremely improb-
able, a QA check on the positional integrity of the flattening
filter was instituted. The 3-mm A1 backscatter shield (shutter),
overlying the incident surface of the monitor chamber for x-ray
beams, appeared essential for the thin-walled Mylar ion cham-
ber to respond appropriately to x-ray beam dosimetry errors.
TREATMENT BEAM STABILIZATION
Effective and safe radiation therapy requires the performance
characteristics of radiation treatment beams to remain constant
during each individual treatment, as well as during a series of
treatments extending over long periods of time. These charac-
teristics can change with time for stationary field therapy. They
can also vary with gantry angle and may change with gantry
movement during arc or rotation (moving field) therapy. Their
stability will depend on the design and construction of mechan-
ical, electrical, electronic, and ancillary systems of the treat-
ment unit. The operational requirements for treatment beams
are best specified in the three IEC documents cited below.
The publication IEC 976,21a a standard for medical accel-
erators, provides recommendations for the methods of test, and
disclosure by manufacturers, of functional performance char-
acteristics deemed necessary for radiotherapy. The publication
IEC 977,21b a related technical report, provides guidelines for
the functional performance characteristics for medical acceler-
ators. These guidelines are recommendationsboth to manufac-
turers and users with respect to the performance of medical
electron accelerators. They provide guidance to manufacturers
on the needs of radiotherapists in respect to the performance of
medical electron accelerators. They provide guidance to users
wishing to check a manufacturer's declared performance char-
acteristics, as well as for acceptance tests and periodic tests
during the life of the equipment. The technical report IEC 977
includes a format for manufacturers to disclose their values of
the functional performance characteristics together with a set
of suggested values, which reflect the need for precision in
radiotherapy and the knowledge of what is reliably achievable
technically. An included rationale presents a concise view of
the essential reasoning for many of the suggested values. It also
includes a summary of test methods and conditions for accep-
tance and periodic tests and the recommended frequencies of
the latter. The International Electrotechnical Commission pub-
lication 601-2-1,21 is a general safety standard particularly
relevant for the radiation safety aspects of patients and staff in
the use of contemporary medical linacs.
Of the many functional performance characteristics re-
lated to x-ray and electron radiotherapy, many are readily
stabilized and need be measured only infrequently. Others,
such as dose calibration, beam uniformity including flatness
and symmetry, penetrative quality or beam energy, displace-
ment of isocenter, congruence of radiation and light fields and
dose rate are very important for accurate and safe dose delivery,
are more apt to change, and require more frequent assessment.
Calibration dose stability for x-ray and electron therapy is
assessed by the variation of absorbed dose per monitor unit
under specified conditions for both stationery and moving
beams. It is first tested extensively during acceptance tests for
high doses, as well as throughout a day, a week, and then
periodically, and after relevant maintenance and repair work.
Sirniliarly, beam uniformity, symmetry, flatness, isocenter dis-
placement, congruence of radiation and light fields are assessed
for their adherence within specified tolerance values on a
scheduled basis as part of an ongoing QA program. The details
of an individual QA program will depend on the type of
equipment employed and the user's experience with it.
Treatment beam stability often depends on electronic or
electromechanical servo-feedback systems. Such systems
monitor the treatment beam, or a related variable pertaining to
the factor being servo-controlled.They generate an error signal
which, when amplified, is used to operate a control element
restoring the beam to within the required tolerance value for
the particular factor. Servo-feedback systems are widely used
in medical accelerators to control and stabilize important treat-
ment beam factors.
Several of the factors affecting beam stability, specifically
those concerned with the incident angle and position of the
electron beam on the x-ray target, or scatterer, are described in
earlier sections of this chapter. For example, the electron beam
is kept radially centered on the x-ray target and axis of the
flattening filter by steering coils servocontrolled by signals
from a sectored, ion chamber as described on pages 157-162.
An advantage of such feedback systems is that tolerance limits,
in this example in fractions of a millimeter displacement radi-
ally from the center, can be set by adjusting the gain of the
amplifier incorporated in the feedback loop.
Stabilization of electron beam energy, especially for bent-
beam linacs, has been an important concern. A small change in
beam energy, where such linacs employ 90" magnets, can
produce a significant shift in beam direction, flatness, and
symmetry in the treatment plane. An early approach to achiev-
ing beam energy stability was to servocontrol beam energy by
varying the beam current by changing the electron gun emis-
sion. This alters the loading effect on the microwave fields in
the accelerator structure, which results in an energy change of
the accelerated beam. This approach was satisfactory for the
peak beam currents needed for x-ray production, typically of
 TREATMENT BEAM STABILIZATION
order 100 mA. For electron therapy, however, beam currents
are smaller, typically of order 0.1 mA or less, and beam energy
depends little on beam current and beam loading. Here, small
changes in microwave source frequency differing from the
frequency producing maximum output, can be used to vary
beam energy. However, the beam energylsource frequency
control characteristic is steep and the control method is not
entirely satisfactory.
Contemporary high energy linacs contain many treatment
beam stabilization features and servo-control systems of varied
complexity. These linacs usually employ 270" achromatic
bend-magnets together with servoed beam-steering systems.
Beam energy stabilization is provided by control of the pulse
modulator supplying voltage to the microwave power source.
The dose rate signal from the monitor ionization chamber is
used to stabilize beam current and radiation output. Such linacs
may provide both x-ray and electron treatment modalities with
two or more x-ray energies and five or more electron energies.
This versatility is achieved using the flexibility and stabiliza-
tion provided by servo-feedback control systems.
Beam symmetry may change with position of the gantry
angle because of the influence of the earth's magnetic field over
the electron path in the accelerator structure and the magnetic
effect of the structural iron comprising the accelerator gantry,
stand and base. Steel incorporated into the treatment room, as
reinforcing rebar and thick primary barrier slabs, can exert a
significant effect. Electrical arc welding of such steel can
magnetize it and further perturb accelerator beams. The heavy
steel magnetic shielding and magnetic fields of nearby MRI
units can also be influential (see p 166). These effects will be
most pronounced in the lower energy modes of machines
employing long waveguides. To minimize these effects, the
beam should gain a relativistic energy and the final energy over
short distances of waveguide structure.
Some systems provide adequate stability inherently with-
out feedback. For example, the long-term voltage stability
requirements of a power supply for an ion chamber operating
well saturated need not be great. The performance of many
subsystems and components can affect beam stability and
experience has led to improved designs. Equipment modifica-
tions should be examined scrupulously by designers and engi-
neers for their possible effect on beam stabilization.
The findings noted and equipment employed in the study
of treatment beam stability and anomalies have been exten-
sively reported. Aird et al.2 found electron therapy output
variations ranging from - 17 to +20 percent, depending on
energy and field size, when the beam limiting aperture of the
radiation head is covered with 2 mm of protective plastic. Even
a 100-p Mylar cover, protecting the radiation head interior
from dust, falling objects, and liquids (when upside down)
affects changes of several percent depending on field size and
energy. Dale11 cites an anomalous electron beam asymmetry
problem. This problem was caused by the leads of the electron
dose monitor chamber, which were separate from the x-ray
chamber,sl sagging into the edge of the useful beam when the
165
gantry was rotated. The electron beam energy of linacs incor-
porating bend magnets can be inferred from the bend magnet
current. The x-ray energy of low energy, straight-through linacs
is usually monitored and feedback controlled by the ratio of
peripheral to axial dose rate and checked from the ratio of ion
chamber measurements placed at depths of 10 and 20 cm on
the central axis. Gillen and Quillenl2 found that magnetron
power in one such 4-MV linac, as assessed by magnetron
current over its working range, caused a 10 percent change in
output calibration and a 5-22 percent variation in flatness of
large fields over a range of 1 to-10 cm depths. Padikal et a1.44
have described an apparatus for measuring symmetry during
rotation using two off-axis detectors and an x-y recorder.
Naylor and Williams39 describe an instrument designed for
measuring small differences in dose rate at points in a radiation
beam such as occur for small values of asymmetry. Loyd et al.31
studied the long-term variation in x-ray beam symmetry as a
function of gantry angle for a Philips SL20 dual-energy, com-
puter-controlled linac. They find day-to-day instabilities pro-
duce an overall variation in beam symmetry on the order of &2
percent suggesting that measurement of symmetry be incorpo-
rated in routine quality assurance procedures for this unit.
Linacs employ water cooling to establish a stable operating
temperature. Temperature is particularly critical for the ferrite
materials of microwave circulators, a device that functions to
prevent reflected microwave power from reaching and damag-
ing the klystron or magnetron power source. A microprocessor-
based temperature controller has been designed, which limits
temperature excursions to less than 1°C for changes in operat-
ing conditions.37 Two 1970s studies focused on the x-ray and
electron beam performance and stability of an early model
radiotherapy linac incorporating a bend magnet and 360" gan-
try rotation.38.40 X-ray output constancy measurements exhib-
ited 2 3 percent limits and flatness 25.5 percent limits for
gantry angle effects during rotation.38 However, averaged over
4-week periods, a relevant interval for a course of radiation
therapy, x-ray output constancy, and flatness were each within
+ 1 percent. Similar variations characterized electron therapy
performance from 5 to 10 MeV.40 Here flatness limits were
within ?4 percent, output constancy within 2 2 percent and
energy constancy within 0.2 MeV over an 18-month period. By
contrast, the stability of contemporary linacs is likely to be
significantly improved from these values.4sa
Radiation beam characteristics are measured, recorded,
and incorporated into treatment planning under circumstances
in which transient effects are eliminated. When treatments are
given, the therapy unit is assumed to deliver radiation beams
that match the data acquired during measurement. The ability
of therapy units to reach their steady-state conditions of energy,
output constancy, and field uniformity becomes a matter of
increasing concern as the dose required for an individual pro-
cedure decreases. Often, such parameters as energy, field uni-
formity, and output constancy may vary significantly during
the first second or two of operation and particularly during the
first few MUs. The magnitude and implications of these per-
166 CHAPTER 9. DOSE MONITORING AND BEAM STABILIZATION
turbations on patient treatment, port filming, and film dosime-
try have been studied extensively for seven linacs and one
cobalt teletherapy unit.4 Output and energy were evaluated
using ion chambers placed on axis at dm,, 10 and 20 cm depths.
Field uniformity (flamess and symmetry) measurements made
use of a 30 ion chamber array connected to a microprocessor-
based analyzer system providing both graphic and numerical
display of data. Uniformity data were examined in both the
radial (gun-target) and transverse directions. Most modem
treatment units achieved steady-state x-ray beam energy
(within a few tenths of a percent) in the first 2 MUs. One unit
had a 6 percent initial energy variation but this was improved
by reducing the pulse repetition frequency (PRF). Most units
delivered a constant dose per monitor unit within a few percent
at 10-cm depth after 8 MUs with smaller variations for increas-
ing MUs. Straight-through linacs exhibit little or no field
uniformity changes immediately after turn-on. Bent-beam lin-
acs incorporate feedback stabilization circuits that need time to
operate properly. The asymmetries appear to affect the radial
(bending) plane and not the transverse plane. However, only
one unit showed a large (23 percent) deviation in symmetry for
the first 2 MUs as contrasted to a steady-state profile showing
a deviation of less than 1 percent.4
The stabilization of arc therapy may involve either a
constant or a variable output per degree of gantry arc rotation.
A constant dose per degree can be achieved by varying either
the output rate or the rotation speed in a compensatory manner.
A variable dose per degree; for example, to compensate for
changing thicknesses of overlying tissues, can be computer-
controlled as a function of gantry angle of rotation. The time
response of the system must be adequately fast to maintain
beam stability during arc therapy. Electron dosimetry for arc
therapy has been reviewed in the proceedings of a symposium
edited by Paliwal45 (see also Refs. 34, 35, and 45 in Chap. 2
and p 41).
ELECTRICAL AND MAGNETIC
INTERFERENCE
Ion chamber electronics incorporate high impedance input
circuits, which may be sensitive to electromagnetic interfer-
ence. Kopecky and Purdy29 report interference with dose mon-
itors from nearby microwave hyperthermia equipment at
microwave field levels of 0.1 mWlcm2, a value considerably
lower than an ANSI personnel safety standard of 10 mWlcm2
at 3000 MHz, the operating frequency of almost all linacs.3
Alternatively, van Rhoon et al.>3 found interference at 0.4
mWlcm2, from nearby hyperthermia equipment operating at
433 MHz with the beam energy determining electronics of
another linac, but not with its dosemeter system. Aelectrostat-
ically shielded room or a more distant location for hyperther-
mia equipment can provide solutions to these interference
problems. To reduce the likelihood of interference, all covers,
doors, and panels on radiotherapy equipment should be kept in
place, including keeping card-rack-housing drawers closed
during routine use.
Johnsen22 studied interference between MRI imaging sys-
tems and radiotherapy electron accelerators. Magnetic reso-
nance imaging units can produce a fringe field of 3 G up to 15
m and 1 G at distances as great as 20 m. The effect of such
magnetic fields on linacs is greatest in the regions of the gun
where electrons have minimal magnetic rigidity. Experiments
using a 3-G magnetic field resulted in less than 1/4 percent shift
in symmetry at the isocenter of a Clinac 4 accelerator. The
effect was greater for a Clinac 1800; 1*hpercent with servos
disconnected but no noticeable shift with servos enabled. Lin-
acs may also interfere with MRI units from fringe fields of their
magnets as well as from the perturbing effect of their many tons
of iron on the highly homogeneous magnetic fields of the MRI
system. The fringing fields of a Clinac 2500 were less than 5
mG at 4 m and less than 0.1 mG at 15 m. A gantry, with
approximately 6 tons of moving iron, creates a perturbing field
of the order 0.7 mG at a 15-m distance.
More than 100,000 new patients with heart disease have
cardiac pacemakers provided each year in the United States.
Lung and breast cancer together affect over 250,000 people per
year, so that encountering a patient with both cancer and an
implanted pacemaker in the same anatomic region is under-
standable. Pacemakers, usually implanted, serve as cardiac
pulse generators. They are susceptible to external electromag-
netic interference (EMI) as well as to damage from ionizing
radiation. Electromagnetic interference may cause intermittant
or transient malfunction while permanent malfunction might
occur from accumulated ionizing radiation damage. Early
pacemakers, which incorporated bipolar semiconductor de-
vices, were found more sensitive to EM1 than to ionizing
radiation based on a study of such devices in the field of
betatrons and linacs.33 Aconclusion was that patients who have
pacemakers implanted should not be treated with betatrons and
linacs should be employed only with due caution since varia-
tions from one therapy unit to another can play a very important
role in the type of interference exerted on the pacemaker.
Contemporary pacemakers employ complementary metal
oxide semiconductor (CMOS) for their integrated circuits be-
cause of the low power consumption, small size, reliability and
multiprogrammable capa~ity.1~13*30 The damage from ionizing
radiation in such devices is cumulative and failure may occur
for doses of 10 Gy or even as low as 2 Gy.34 Hence, the
pacemakers should not be irradiated; they should be placed
outside the radiation field. The pacemaker manufacturer should
be consulted if questions occur. The normal x-ray shielding of
a facility provides sufficient attenuation to protect pacemaker
wearers and patient monitoring equipment outside the treat-
ment room. Physician monitoring of a pacemaker patient's
pulse is recommended.
The American Association of Physicists in Medicine
(AAPM) has constituted a task group to report on relevant
 REFERENCES
aspects of pacemakers in the radiotherapy environment. Pre-
liminary recommended precautions in the management of ra-
diation oncology patients with implanted pacemakers have
been published34 and they follow below.
1. Have the patient's coronary and pacemaker status evalu-
ated by a cardiologist prior to and soon after completion
of therapy.
2. Never treat a pacemaker implanted patient with a betatron.
3. Always keep the pacemaker outside the machine colli-
mated radiation beam, both during treatment and during
machine portal filming.
4. Carefully observe the patient during the first therapy treat-
ment to verify that no transient malfunctions are occurring.
5 . Estimate and record the absorbed dose to be received by
the pacemaker (from scatter) before treatment. Locate the
treatment fields so that the accumulated dose does not
exceed approximately 2 Gy.
6. If treatment within these guidelines is not possible, have
the pacemaker either temporarily or permanently moved.
A detailed review of the pacemaker patient in the thera-
peutic and diagnostic device environment with extensive cita-
tions of the medical and electronic literature has been provided
by Hardage et al.13
There is insufficient information available in the literature
to allow detailed recommendations regarding the use of
hyperthermia on patients with implanted pacemakers. Until
such information is available, it is suggested that treatment be
approached with extreme caution. Under no circumstances
should the pacemaker or its leads be placed in the hyperthermia
field or allowed to be heated above normal body temperature.
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Damaging effect of therapeutic radiation on programmable
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3. American National Standards Institute: Safety levels with re-
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fields, 300kHz to 100 GHz. ANSI C95.1-1982 pp 1-24.
4. Barish RJ, RC Fleischman, YM Pipman: Teletherapy beam
characteristics: "The first second. Med Phys 14557-561, 1987.
5. Boese HR, DV Cormack: Detection of a leak in a "sealed"
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Clinac 20. Int J Radiat Oncol Biol Phys 6649, 1980.
30. Lewin AA, CF Serago, JG Schwade, AA Abitol, SC Margolis:
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 C H A P T E R 10

Accelerator Control and

Safety Interlocking

Safe and accurate operation of the accelerator for patient Interlocks, which are intimately concerned with the safety
treatment is implemented by the accelerator control and inter- of personnel and with the proper operation of accelerators, form
lock system. The control console provides a central location an integral part of the accelerator control system. Personnel in-
for presetting, monitoring, and controlling operation of the terlocks are concerned with the safe and accurate delivery of the
accelerator for an individual therapy treatment. It may also patient treatment prescription and the protection of radiother-
incorporate selection of operational mode among, for example; apy staff and the general public. Machine interlocks are con-
morning check out, clinical, special procedures, physics, and cerned with the safe operations of machines preventing damage
service. It may contain digital displays including those for to them. However, both personnel and machine interlocks per-
dose, beam-on time, as well as mechanical position readouts. form their function by control of the treatment unit, that is, the
Usually, it provides displays of dose rate and beam symmetry. machine. An interlock provides a means of preventing or termi-
The control console also provides: control of power to the nating an operation unless certain predetermined conditions are
accelerator, selection of radiation modality and energy, and fulfilled. Tert~zirlatingirradiatiorz requires stopping of irradia-
other treatment parameters, as well as an indication of the tion without the possibility of starting without reselection of all
status of various interlocks and subsystems. The console usu- operation conditions (that means return to the PREPARATORY
ally incorporates an illuminated panel display of interlock and STATE) (see p 173). Irzterruptirlg irradiation requires stopping
subsystem status. Such a panel can convey 50 or more discrete of irradiation and movements with the possibility of continuing
status messages. Alternatively, an increasing number of com- without reselecting operating conditions (that means return to
puterized treatment units incorporate a video display terminal the READY STATE) (see p 173). An abnormal or fault condi-
(VDT) to provide information concerning machine operation
and the patient treatment prescription. Two key boards are often
incorporated; one provides operational control of the treatment
unit, the other provides patient data recall and modification.
The console VDT provides an indication of normal operation
or alternatively, information concerning an abnormal condi-
tion.
Figure 10-1 shows a Clinac 1800 control console. It con-
sists of a sloped, lower control panel and mounted above, a
display panel of fault indicators, as well as digital and analog
displays. The lower console control panel is divided into five
(or six) groi~psof functional control and indicator modules.
From left to right these are wedge and control power, arc
therapy, x-ray therapy, beam control, and electron therapy. The
extreme right module is reserved for control of optional modal-
ities such as the high dose rate total skin electron therapy
option. The display panel, mounted above the control panel, FIGURE 10-1 . Clinac 1800 control console. Lower, control panel.
contains operational displays such as dose and dose rate to- Upper, interlock display panel, showing fault status indicators, radia-
gether with interlock status lamps. tion modality indicaton: together with digital and analog displays.
170 CHAPTER 10. SAFETY INTERLOCKING
tion, which terminates or interrupts a treatment, results in
illumination of an annunciator having a key word or abbrevia-
tion informing the operator where the interlock chain is inter-
rupted or which subsystem needs attention. Two examples of
personnel interlock, fault messages are: ARC-lights when gan-
try stop angle is reached in arc therapy mode; TARG-lights
when a discrepancy exists between the proper and actual target
position (the target is extended into the electron beam in x-ray
mode and retracted in electron mode). Two examples of ma-
chine interlock fault messages are VAC-lights when a signifi-
cant loss of vacuum occurs in the accelerator waveguide;
T/D-lights when a failure in the time delay circuitry occurs.
Linac control and interlock systems increasingly employ
integrated circuit (IC) electronics and digital circuitry in place
of analog methods. These changes have improved reliability,
decreased cost, improved performance, and reduced the dimen-
sions of electronic systems, the latter often by a factor as large
as 10. Replacement of discrete components within an IC is not
routinely undertaken in place since the printed circuit (PC)
boards, characteristic of the technology, can easily be removed
and a duplicate board can be installed. This approach mini-
mizes "down-time" and allows the defective board to be ser-
viced under more favorable conditions. The digital systems
interface more readily to computers than do analog systems.
Interface electronics, which couple analog detectorsltransduc-
ers to digital devices, are increasing integrated into the overall
electronics control system.
The IEC publication 601-2-118 revision provides a wealth
of technical recommendations for safe operations of radiother-
apy linacs, particularly radiation safety of patients and staff.
Greenel5 includes coverage of control and interlock systems.
Swanson36 treats control and interlock considerations of radio-
therapy linacs from the viewpoint of an overall safety program.
Karzmark22 calls attention to the need for procedural safe-
guards to augment safety measures implemented by hardware
or software.
COMPUTER CONTROL
Computer control and monitoring of accelerator operation can
provide many benefits. It can enhance safety by preventing
bypass of interlocks and can capture, for later analysis, machine
status, and operating conditions. Such information is valuable
for servicing especially for infrequent intermittent problems,
and can be interrogated remotely. It can provide the input data
for expert system analysis benefiting from collective experi-
ence as described on page 254. The particular accelerator
control system and operating program can be interrogated
remotely. The prompt availability of these expert system prob-
lem analysis techniques can minimize downtime and increase
machine availability. Computer control and monitoring can
simplify acceleratorfunctioning, implement fast shut down and
make it easier for the operators to carry out essential operations.
Using appropriate hardware, firmware and software, compo-
nent tasks of an operation can be combined, choices empha-
sized and operations limited to safe, logical procedures.
Hardware interlocks can be backed up with firmware. More
sophisticated and complex treatment techniques become feasi-
ble under computer control of treatment units such as: Dynamic
conformal therapy using multileaf collimators and/or indepen-
dent jaws, universal or dynamic wedge and on-line portal
imaging. Computer control of treatment units expands the
benefits from computer integration of radiotherapy as de-
scribed on pages 181-188. The computer based control system
for a Philips SL 25 accelerator is illustrated in Figure 10-5.
Computer network integration of radiotherapy is in an em-
bryonic stage. Integration of diagnostic radiology will provide a
solid basis of standards and techniques, from which methods for
the more specialized application to radiation therapy systems
can be developed. As examples of relevant conferences, a con-
ference38 on "networks and image handling" was held July 3-4,
1986at theuniversity ofWales. Ajoint U. S./Scandinaviancon-
ference on computer aided radiotherapy was held in San Anto-
nio, Texas, in 1988.20 A short course on computer management
systems was presented at the 1988 World Congress on Medical
Physics and Biological Engineering.30 Through the use of com-
puters in treatment planning and in record and verify systems, as
well as data base management functions, radiotherapy depart-
ments are already well advanced in the use of computers. It is a
natural progression to want to tie together the various radiother-
apy department functions by computer integration.
MINIATURIZATION
Some idea of the degree of miniaturization present in acceler-
ator control electronics may be gained from Figure 10-2; a PC
board for a gantry position readout amplifier, where two levels
of miniaturization are evident. Looking at the physical layout
of the PC board, one sees eight analog integrated circuits
(operational amplifiers and comparators) used for signal con-
ditioning, as well as seven digital logic chips (gates and multi-
vibrators) consolidated on a board measuring 6 X 4 in.
Moreover, examining the inset equivalent integrated circuit at
the level of a low power microscope, one finds that in each
3h -in. diameter operational amplifier "can," there is a sophis-
ticated 20 active element device. Thus, miniaturization now
permits techniques that would have been excluded from design
consideration two decades ago on the grounds of reliability,
physical size, heat dissipation, and cost. The diversity in appli-
cation of IC electronics to linacs continues to increase. Their
size continues to decrease, particularly, when viewed from the
standpoint of functions performed. As the size and complexity
of electronics systems grow, interfacing, interlocking, and sys-
tem communication can become a significant problem. A low
energy linac typically incorporates 20 PC cards, each associ-
 SEMICONDUCTOR DEVICES AND ELECTRICAL INTERFERENCE 171

EQUIVALENT CIRCUIT

COMPARATORS (4) OPERATIONAL

AMPLIFIERS (4)
MULTIVIBRATORS (4) /
CHOKE,
RESISTORS (29)
28 PIN CARD EDGE
CONNECTION
\
GATE LOGIC
(31 - 20 T U R N
POTENTIOMETER
(8)

TEST
POINTS (5)

CERAMIC
CAPACITORS -
(27)

POSITION READOUT AMPLIFIER BOARD

FIGURE 10-2 . Printed circuit card for position readout amplifier. This 6 X 4 in. card con-
tains tens of components. Some components, like the operational amplifier shown at the top,
themselves contain tens of smaller conlponents in the form of integrated circuits (ICs).

ated with a specific task so as to simplify service. A high energy
linac may incorporate 40 or more PC cards, several hundred
individual IC units, as well as discrete components such as
resistors and capacitors.
SEMICONDUCTOR DEVICES AND
ELECTRICAL INTERFERENCE
The potential for electromagnetic interference (EMI) around
linacs is threefold: linac generated EMI, which interferes with
internal linac circuits such as control and dosimetry; linac gen-
erated EMI, which interferes with external electronic devices
such as pacemakers and magnetic resonance imaging (MRI),
and finally, EM1 sources external to the linac, which interfere
with linac circuits. The internal sources are primarily the fast,
high current pulses for magnetrons and klystrons, as well as the
associated microwave bursts that may cause interference to
other devices. The former are wide frequency spectrum sources
with components up to about 50 MHz, and the latter, a single fre-
quency of about 3000 MHz. Good circuit design, shielding, and
grounding can minimize interference to linac circuits from both
internal and external EM1 sources. In this context, all linac cabi-
net covers, doors, and panels should be kept in place or closed
172 CHAPTER 10. SAFETY INTERLOCKING

during routine linac operation. Optical couplers are frequently

used for circuit isolation and simplification of grounding. Pro-
viding and maintaining a high quality,isolated ac power feed for
the linac is recommended. Potential external EM1 sources
should be adequately shielded and preferably located at a dis-
tance from the linac. Large scale integrated circuits, which in-
volve many signal conductors and components in close
proximity, are physically smaller than other devices, are more
susceptibleto internal coupling, and great care is thereforeexer-
cised in their design and layout. The dosimetry system itself
may be susceptible to moderate levels of EM1 from external
equipment such as microwave hyperthennia or diathermy
equipment. Interference of this type may result in spurious
counts on the integrated dose counters which could result in a
dose misadministration to patients, an underdose or an over-
dose. Magnetic resonance imaging equipment is very sensitive
to the presence of even small magnetic fields and nearby ferro-
magnetic material. Hence, such equipment and linacs should be
located far from each other. Other aspects of electrical and mag-
netic interference are elaborated in Chap. 9, pages 166-167.
The evolution of semiconductor devices has benefited
linac control. Many safety and control decisions have a binary,
digital nature; on and off, signal present or absent, and are often
represented by numbers (1) and (O), respectively. Relays, a tra- 0.4 V Noise lrnrnunkv
ditional binary device for control and interlocking, offer a high
open circuit and a low closed circuit resistance compared to
solid state devices, but have a higher failure rate. Relay coils are
more likely to fail open circuit rather than closed circuit with
solid state devices usually not exhibiting a preference for fail-
ure, either open or closed circuit. Although relays fail most often
from a nonenergized,open-circuited coil, they also fail by con-
tacts welding together. Contemporary miniature relays, .
FIGURE 10-3 Voltage reference diagram for 5-VTTL and 15-V
HiNIL logic. Note the significantly increased noise immunity band for
moulded into a 14-pin chip mounting, consume about 200 mW HiNIL at both the low (0) and high (1) state. Shading depicts input
of power. There has been a growing tendency to move away threshold range.
from relay control logic and to depend more on digital inte-
grated circuits. Many machines employ hybrid control systems; The noise environment carries great weight in the choice
a combinationof solid state logic and electromechanicalrelays. of a logic family for accelerator design. Not only are logic chips
The early logic family, transistor-transistor logic (TTL), vulnerable to noise input, they produce noise that, in accumu-
developed for computer use, was not suited for the high elec- lation on interconnections, affects unrelated chips. Conse-
trical noise levels found in linac environments. The margin quently, logic families have been developed, trading off various
between guaranteed output of one stage and acceptable input factors such as speed of response, power dissipation, and noise
for the following stage, called noise immunity margin, was too immunity. High noise immunity logic is costly, may be faster
small. A second family of logic was developed for high noise than needed, and dissipates significant heat. Where the noise
industrial environments called high noise immunity environment does not demand HiNIL logic, it is now popular
logic*(HiNIL), which operated at a higher voltage to improve to use low power l T L or complementary metallic oxide semi-
the noise immunity margin. Figure 10-3 illustrates the voltage conductor (CMOS) logic.
range of operation for 5 V TTL logic and 15 V HiNIL logic. Where possible, designers will consider using CMOS
The noise immunity range of HiNIL is approximately 10 times devices, which were originally developed for aerospace use.
that of TTL in the high (1) state and is about 5 times larger in Complementarymetallic oxide semiconductor logic offers low
the low (0) state. High noise immunity logic is particularly power drain, permitting medium and large scale integration of
effective in control applications where the ultrahigh speed of function in one logic chip. While older CMOS logic permits 12
computer logic is generally not required and 15-V operation is and 15-V operation and has a symmetry favoring low fre-
commonly used in instrumentationand control equipment.Fast quency noise immunity, the output is relatively high impedance
semiconductor devices have wide bandwidth with an attendant compared with HiNIL and is vulnerable to electrostatic pickup.
vulnerability to noise. The newer CMOS has speeds approaching the older
 INTERLOCK SYSTEM
HiNILlTTL logic families, requires only 5 V, but has the
symmetrical design of CMOS. It is much less vulnerable to
electrostatic interference and damage. Scanning one contem-
porary console with a cluster of about 170 logic chips, there is
only one CMOS chip; and even with so much solid state
electronics, there are 39 relays each packaged in a form approx-
imating the area of a chip.
The Clinac 18 uses HiNIL, with several exceptions, in 10
functional groups along with relay control. The logic groups
are divided as follows: mode select and release, energy select,
calibration and check, MU 1 display, MU 2 display, time
control, system timing control, dose rate servocontrol, arc
therapy, and interlock. The final interlock chain is based on
relays. However, many of the coils of the relays are activated
directly by integrated circuit logic.
ACCELERATOR OPERATIONAL STATES
An accelerator, in being readied for and delivering a treatment,
is carried through a hierarchical sequence of operational states:
STAND-BY, PREPARATORY, READY, BEAM-ON, and
COMPLETE or INTERLOCK. A medical electron accelerator,
at any one time, functions in one of these defined operational
states characterized by a varied and sequential readiness to
provide a treatment beam. These states are accessed and usually
displayed at the control console.
STAND-BY is the state in which an equipment can be
maintained for long periods, such as overnight and on week-
ends, and from which it is possible to move rapidly into
operation. It is the state in which a working level of vacuum,
temperature, and other parameters are maintained, but without
the possibility to select the essential operating conditions.
PREPARATORY is the state of equipment for setting
essential operating conditions. These conditions are associated
with a specific patient treatment and include setting the radia-
tion type, modality, nominal energy, dose monitor units, and
so. The setting of these conditions is precluded in the STAND-
BY state.
READY is the state of equipment in which all conditions,
such as the carrying out of confirming operations and any other
satisfaction of interlocks, prevail so that the intended operation
of such equipment can be initiated by a single action. An
example of a confirming action is a second independent oper-
ation action of confirmation of the prior selection of the number
of monitor units. The READY state is usually displayed on a
lighted pushbutton switch or VDT display when the READY
state is satisfied.
The BEAM-ON state is the state of the equipment when
delivering a radiation beam. The READY function is often
combined with a COMPLETE function. This latter COM-
PLETE function, lights when the dosemeter has delivered the
preset dose.
173
The INTERLOCK state indicates that an interlock fault is
present preventing initiation of operation or that an interlock
fault has occurred interrupting or terminating the exposure(see
p 169). When interlock faults are present the equipment is
moved to a lower hierarchical state requiring correction of the
fault and may require reentry of the treatment prescription
andlor other appropriate parameters. The particular operational
state to which the equipment is moved will depend on the nature
of the interrupt. An interruption of irradiation can, for example,
be associated with opening the therapy room door. Door closure
and confirmation of door closure at the console will restore the
equipment to the READY state without the need to reselect
operating conditions. A termination of irradiation fault inter-
rupt moves the equipment to the PREPARATORY state, which
requires resetting the specific patient treatment prescription
operating conditions. Any dose delivered prior to such a fault
interrupt is stored and accounted for in the reset operation
unless the prescribed dose has been delivered.
It will also be possible to terminate irradiation and machine
movements at any time by terminating mains power to the
equipment from EMERGENCY OFF switches, which may be
located on the control panel, on the accelerator, on the sides of
the treatment couch and equipment cabinets, and at strategic
points in the treatment room. An EMERGENCY OFF switch
interrupt disconnects all electrical power from the equipment
so that a complete start-up procedure is required.
INTERLOCK SYSTEM
The interlock system is designed to promote the safety of
patient, staff, and public (personnel interlocks) and to protect
equipment from damage during routine use (machine inter-
locks). The patient protection interlocks are designed to protect
patients against all hazards associated with machine opera-
tions, largely radiation and mechanical hazards, and to ensure
that the patient treatment prescription is accurately carried out.
Protection is provided by prevention or termination of irradia-
tion. The IEC publication 601-2-1'8 revision lists approxi-
mately 20 irradiation conditions that can initiate a patient
interlock fault. Some specific interlocks for patient safety relate
to: dose and dose rate monitoring, beam symmetry, beam
energy, beam defining accessories, and computer control.
Medical linacs employ extensive interlock and fail-safe
design features for personnel safety. Their objective is to min-
imize danger to the patient and staff in the event of failure or
malfunction of part of the system. Other interlocks enforce an
operator control procedure sequence that minimizes the possi-
bility of incorrect treatment of the patient due to operator error.
Still others, called machine interlocks, protect the equipment
from damage resulting from failure of a component or subsys-
tem by shutting the machine off in the event of a malfunction.
For example, the interlocks for the latter may be tied to mal-
174 CHAPTER 10. SAFETY INTERLOCKING

functions in the modulator, high voltage power supplies, the
accelerator vacuum system, cooling water flow and tempera-
ture conditions, line voltages excursions, or other specific
conditions. These equipment protection interlocks are incorpo-
rated into good design practices, but they are not required for
patient or operator safety. Equipment cabinet access doors and
protective covers are interlocked to protect staff from expo-
sures to high voltages. Interlock testing is included in the QA
program.
Early medical linacs used an interlock system based on
electromechanical relays with contacts in series to complete a
"chain", as shown in Figure 10-4a. Each link in the chain was
associated with a device or subsystem. Completing each link
was indicated by turning on an associated and sequential indi-
cator light on the console. By design, all fault indication lights
were lighted during normal fault-free operation and with one
or more lights extinguished to indicate a fault (s) when it
occurred. Extinguishing a light identifies a fault and is also
fail-safe against lamp filament failure. It was found more
useful, however, to have the fault light panel normally dark-
ened and to indicate the relative position of any break in the
chain with a single illuminated indicator light. In addition, relay
removal or failure turned on a fault light and inhibited opera-
tion. In such a system, a periodic manual lamp lighting check
is used to establish the integrity of all lamp filaments. Interre-
lated circuits affected by the fault, yet requiring electrical
isolation, were handled by auxiliary contacts on the activated
fault relays. As the complexity of accelerator control grew, it
was logical to move from the original 120 V ac relays to 24 V
dc relays that were smaller and that required less power, inter-
faced with semiconductor sensors better, and operated on dc
permitting use of semiconductor diodes as unilateral flow
elements in the control switching. Moreover, in cases of trou-
ble, the 120 V ac relays had the potential of releasing 120 V
into the console with serious consequences for many solid state
devices. Thus, it was a logical step in control circuit design to
move to a diode switching matrix with semiconductor drivers
such as transistors and silicon controlled rectifiers (see Fig.
10-4b).
The advent of multimodal accelerators increased demands
on the interlock system. During the same period, the reliability
of semiconductor devices surpassed that of ordinary relays.

lntlk B lntlk C

I Interlock

I I Aux. Function 1

Aux. Function 2

-
Sensor Sensor Sensor Sensor Sensor
A B C D E

FIGURE 10-4 . Examples of accelerator control interlock systems: (a) relay ladder inter-
lock and (6)diode matrix interlock.
 INTERLOCK SYSTEM
This confluence led to solid state interlock systems in the form
of computer logic components and diode switching matrices
permitting great flexibility in design. The matrix can be driven
with transistors able to follow rapid changes in the sensors or
with SCRs (silicon controlled rectifiers) to create a latch requir-
ing reset by the operator or auxiliary circuits. The diodes are
highly reliable and yet inexpensive. Although the fail-safe
nature of the design is somewhat compromised by transistors
and SCRs, the rapidity of response permits inclusion of the
matrix within a self-test cycle before operation. This self-test
feature demonstrates readiness without adding appreciably to
system delay. The interface to voltage comparators, to digital
logic, to power-up states, or to relay contact closure is readily
standardized. One standardized, general purpose hardware in-
terface, CAMAC, as adapted for a Clinac 18, has been de-
scribed.31
The example diode matrix interlock system sketched in
Figure 10-4b provides both operational status (see p 173) and
malfunction (fault) indication displays on the console concern-
ing various circuits within the machine. A fault lights the
appropriate lamp illuminating an abbreviated message identi-
fying the fault on the console interlock display panel or a VDT
(see Fig. 10-1). This system prevents beam initiation if an
incorrect status is detected, or if a malfunction is detected by
any of the sensors connected to the monitored circuits and to
the vertical bus lines A-E of Figure 10-4b. In addition, this
system causes immediate beam termination if the malfunction
occurs after commencement of beam-on operation. The status
signals from the sensors may denote an open switch on a
protective cover or access door, or a malfunction associated
with operator error or a linac operating parameter out of toler-
ance. A signal from a sensor causes the SCR (line A) or
transistor (lines B-E) to conduct, thus sending an activating
signal along its vertical bus. This signal is relayed by the cross
connected diodes shown in Figure 10-4b to every horizontal
interlock or auxiliary function circuit. The diodes serve to
isolate faults from one another. Note that every sensor can
interrupt the top interlock bus and its back-up (redundant) bus
just below. The two interlock buses connect to series relays
which, in turn, inhibit the beam, if any sensor sends an activat-
ing signal. Other sensor signals selectively activate the auxil-
iary function buses shown. These can inhibit beam-on and
relate to such functions as dosimetry fault and usually involve
complex conditional logic of specific subsystems. A sensor
signal also activates an associated lamp shown at the top of each
sensor bus. These lamps illuminate panel messages such as
DOOR, when the door interlock is open, or VAC, when there
is significant loss of vacuum in the accelerator waveguide. A
total of 84 such messages can be activated in the Varian Clinac
1800 treatment unit as displayed in Figure 10-1.
Many interlock functions are highly specialized as the
following examples indicate. An excess dose rate interlock,
defined at the normal treatment distance as more than twice the
specification maximum dose rate, ensures that the dose rate
does not significantly exceed the intended normal dose rate,
175
which could indicate a malfunction. This interlock is activated
if too many monitor units are counted during a short time
interval, or during a single pulse or a short pulse sequence, or
during lo, or in a few degrees, of gantry rotation in the arc
therapy mode. The excess-dose interlock is activated if the
difference in monitor units of the dual dosimetry readouts
exceed a predetermined value (e.g., 25 MU). The two dose
integrators are functionally, and as far as practical, physically
separate so that a failure in one system will not affect the other,
and accidental intercommunication between the two systems
cannot occur. Loss of delivered dose information, due to power
failure, is guarded against by use of a back up mechanical
counter or by auxiliary battery operation of the dosimetry
monitor unit display (see Chap. 9 for more details concerning
the dose monitoring system). The field symmetry interlock
turns the beam off if the preset asymmetry limit is exceeded in
either the radial or transverse planes of the radiation field. As
noted in Chap. 9, the sectored ion chamber provides signals for
beam steering designed to ensure operation within the preset
asymmetry limits. An energy interlock can establish energy
tolerance limits for both x-ray and electron beams using infor-
mation from a sectored monitoring ionization chamber.13 Here
the ion chamber has annular sectors arranged peripherally
around a circular section centered on the beam axis. An angular
distribution pattern of bremsstrahlung, originating in the x-ray
target and modified by the flattening filter, will provide an
energy-dependent signal based on the ratio of peak ion chamber
currentlpeak target current, the ratio being a constant value for
a given energy. Similarly, the angular distribution of electrons
from a scattering foil will provide a constant value of this ratio,
which is again a function of energy. Miller and van de Geijn26
describe a modification of the fault logic circuit for a Clinac 18
to accommodate large-field wedges. This circuit modification
permits customer supplied large-field wedges to properly inter-
act with the COLL fault interlock.
As noted earlier, some control sequences at the console are
designed to minimize the possibility of incorrect treatment of
the patient due to operator error. These include: a reset control
requiring important display readings (e.g., dose and time) be
reset to zero or moved off the previous treatment values and
then returned to the required values for the next treatment (even
though the value may be the same as for the previous treat-
ment), before a new treatment can begin. Several procedures
require the operator to select among choices; for example,
beam energy, electrons or x-rays, arc therapy, and wedged field.
To ensure safety, many device activations require two separate
and distinct actions called SELECT and CONFIRM. First, a
SELECT operation is initiated, such as selecting and inserting
the 30" wedge in the accessory mount in the treatment room.
Then a CONFIRM operation must follow at the console, con-
firming that the 30" wedge is intended, before treatment can
commence. The select and confirm operation can be extended
to automation of treatment wherein the parameters selected for
treating a patient must be confirmed by comparison with that
patient's computerrecord before treatment can commence. The
176 CHAPTER 10. SAFETY INTERLOCKING
console may incorporate several keyed lock switches corre-
sponding to the various treatment modes. The key serves a
safety function. When inserted in a lock and turned, it identifies
the treatment mode selected and allows the interlock chain to
be completed. When the key is removed, the accelerator is
rendered inoperable.
An innovative use of integrated circuit logic occurs in the
calibration and check cycle where a calibrate and functional
check of all analog and digital circuits comprising the dosim-
etry system are carried out prior to treatment from each field.
After the operator selects one of four different modes of clinical
operation (ARC CW, ARC CCW, FIXED X-RAY, E-BEAM),
a choice of energy is made, whereupon, an automatic calibra-
tion and check sequence is initiated. After a logic reset, a 6-s
calibration sequence occurs with both dose counters counting
to 100-109 MU, the timer counting to 0.1 minute, and the five
excess dose rate faults are all activated and checked. The excess
dose rate fault modes relate to exceeding specific preset limits:
MUIDEGREE, MU IITIME, MU 2/TJME, MU IPULSE, MU
2Pulse. A small electrical current is applied to the ion chamber
plates of each dosemeter for this latter check. The dosemeter
calibrate interlock check will be completed only for a consis-
tent set of integrated current readings from the two dosemeters.
After this calibration, the logic is again reset and both dose
counters and the time counter are fed 360-Hz signals and
allowed to count up to the dose indicated in the thumbwheel
dose settings as the check sequence. Then, the third reset
occurs, whereupon the arc therapy logic and both dose integra-
tors are enabled. Before treatment proceeds, the logic demands
a verification of the chosen energy by requiring the operator to
confirm by reselection of energy.
PROTECTION AGAINST EXTREME DOSE
Multimodality treatment units that provide both x-ray and
electron beams, potentially present a particular extreme dose
rate hazard in that the high electron beam currents needed for
x-ray production, especially 4-6 MV, can result in extremely
high dose rates if not intercepted by the x-ray target or flatten-
ing filter. Although the higher energy x-ray modalities entail
lower beam currents (but still higher than comparable electron
therapy energies) they too present a hazard because of less
scatter of the electron beam in the foil, window, and ion
chamber. An extreme dose rate hazard is defined as more than
10 times the vendor specified maximum dose rate at normal
treatment distance. For example, 100 pA of average beam
current may be employed for 6-MV x-rays but only 0.1 pA of
beam current for an equal dose rate of electrons at 4 Gylmin at
1 m (see Table 9-1). An abnormal fault condition could involve
machine operation in electron therapy mode but with 100 pA
beam current typically used for 6 MV x-ray therapy. Under this
fault condition electron dose rates of 4000 Gylmin are possible
and constitute an extreme hazard for patients. Such an electron
beam, particularly if unscanned or unscattered, can collapse to
a small diameter less than the central electrode diameter of the
monitor ionization chamber. In this circumstance its response
would erroneously indicate a much lower dose because of this
geometric anomaly as well as a likely lowered ion collection
efficiency.
Presently, IEC recommendations18 state that if treatment
units can deliver under any fault conditions a dose rate at
normal treatment distances more than 10 times the vendor
specified maximum dose rate, then the unit shall incorporate a
beam monitoring device, which is independent of the dose rate
monitoring system and located on the patient side of the x-ray
target and beam distributing system. This device shall prevent
the absorbed dose rate from exceeding twice the vendor spec-
ified maximum dose rate at normal treatment distance and will
limit this dose to less than 4 Gy anywhere in the radiation field.
The beam monitoring device must respond to failure of a
scattering foil or lack of movement of a scanned beam. To
accomplish these objectives, the device will need to monitor
the beam on a pulse-by-pulse basis and terminate the exposure
within a time on the order of lms. An additional IEC require-
ment for extreme dose rate interlock involves either: termina-
tion or prevention of irradiation when an interlock component
fails; or testing of interlocks between irradiations; or redundant
or continuously monitored diverse interlocks. An analysis of
IEC publication 601-2-118 lists approximately 30 interlock
fault conditions that can result in prevention or termination of
irradiation. Of these, roughly 20 can give rise to the extreme
dose hazard identified herein.
The radiotherapy beam characteristics of one multimodal-
ity 25-MeV scanned electron beam linac have been described
by O'Brien et al.29 For this linac in the extreme dose rate fault
condition with the abnormal unscanned electron beam inter-
cepting only the monitor ionization chamber, an extreme dose
of between 1 and 2 Gy per pulse was produced at normal treat-
ment distance at or near a depth of Dm,,More than 100 pulses
were emitted before the interlock interrupted the beam. This
scanned beam linac is computer controlled and the abnormalex-
treme dose fault involved software and system response time.
Loyd et al.25 assessed the dose monitor errors in the Philips
SL25 computer-controlled linac (see Fig. 10-5). They found
that for conditions that may be encountered during normal
treatment situations that the symmetry, flatness, and dose de-
livery errors were detected and the radiation beam was inter-
rupted relatively quickly. However, for extremely artificial
experimental situations with both the flattening filter and the
backscatter shield removed the fault detection system failed
(see Fig. 8-2). The current draft IEC safety standard18 requires
computer hardware and computer programs that control the
system to be capable of fulfilling all safety requirements of the
standard under all conditions, including transient or permanent
failure of the computer or related interface. Redundancy of
critical safety interlocks is essential with different physical
principles being employed in the sensor portion and different
 CONTROL CONSOLE
.I SL 25 Linear Accelerator
Monitor Display
Keypad I l~e~bcardl
I
I
I
C--_-_--,_--__I
-1-- r--l--
;Barcode;
1 Reader
; Printer
----J L---J
FIGURE 10-5 . Accelerator control system for an SL25 linac. (Courtesy of Philips Medical
Systems.)
logic being employed in the comparator and actuator portions
of each such interlock.
It should be noted that many conventional radiotherapy
calibration dosemeters are often inadequate for the extreme
dose rate measurements. One commonly used 0.5-cm3 ioniza-
tion chamber exhibited collection efficiencies of only 10 to 15
percent under these conditions.29 Additional aspects of beam
monitoring and control of multimodality treatment units under
normal and abnormal conditions18 are presented on pages
162-164.
CONTROL CONSOLE
The control console is designed to simplify ongoing operation
of the treatment unit. It is the central location for presetting,
monitoring, and controlling operation of the treatment unit. It
provides for selection of beam type and energy. It is equipped
with lighted indicators that show the status of equipment inter-
locks. It usually provides displays for dose rate, integrated dose
for both primary and secondary dosimetry channels, treatment
time, gantry angle, arc therapy and rotation direction (CW or
CCW), and operating mode (either x-ray or electron; and fixed,
full-field or arc therapy). In the fixed and full-field modes, the
gantry remains stationary. The full-field exposure is used to
provide anatomical references by superposing a maximum
collimator opening (full-field) exposure on a treatment port
film radiograph. In the arc therapy mode, the gantry rotates
177
I
3
I Streamer
_----I
during treatment. In multimodality units, additional displays
and controls pertain to radiation type (x rays or electrons) and
beam energy.
The console logic monitors and displays the status of
various circuits within the machine to provide both operational
status and malfunction (interlocWfault) indication. Beam acti-
vation is prevented if an incorrect status is detected or if a fault
is detected in one of the monitoring circuits. Immediate beam
termination ensues if the malfunction occurs after comrnence-
ment of "beam-on" operation. An interlock and status matrix
assembly provides monitoring and fault indication from a
sequence of labeled fault indicator lamps on the control console
as described on pages 173-176. These lamps are activated by
fault detectors placed in various locations throughout the ma-
chine including the console and various PC boards. Stevens et
al.34 describe a digital satellite addition for the Clinac 18, which
displays the gantry and collimator positions at the console, a
feature particularly valuable in setting the back-up x-rays col-
limator jaws 5 cm larger than the electron applicator selected
for use.
There is increasing use of computers and microprocessors
in linac control systems. In the late 1970s, the AECL Therac 6
treatment unit began to employ a Digital Equipment Corpora-
tion (DEC) PDP-11/05 computer to monitor and control ma-
chine operation.14 Its video display unit could display a clinical
treatment format of each patient's prescription or a mainte-
nance format of the current value of 64 linac operational
parameters. This latter display can be useful in rapidly diagnos-
ing or anticipating component failures, as well as in optimizing
performance. Computers can also be used to preset the treat-
178 CHAPTER 10. SAFETY INTERLOCKING
ment positional variables on a daily basis to the prescription
values. They can also provide the basis for dynamic treatment
via programmed dose, collimator jaw, and gantry motions, as
well as coordinated movement of the patient couch with respect
to the radiation beam during treatment (see Chap. 2, p 41-43).
A computer-controlled therapy accelerator must be exten-
sively tested to ensure that the specific hardwarelsoftware
system involved enhances safe operation and does not permit
unsafe practices or anomalies. An extensive testing procedure
for one prototype accelerator,a Varian 2100C, has been carried
0ut.39 The configuration of the 2100C at any time will depend
on the operational mode (e.g., morning checkout, clinical,
physics, and service), the radiation mode (x ray or electron and
energy) and the operational state (stand-by, ready, beam on,
etc.) (see p 173). The selected operational mode, radiation
mode, and operational state properly constrains how the accel-
erator can be operated. In clinical mode, the physicslservice
alphanumeric keyboard is rendered inoperative and the
operator's keyboard will respond only to an appropriate and
restricted set of commands associated with the operational state
as indicated by an on-screen display. The acceptance testing
procedure included mechanical systems, radiation parameters,
and manual safety systems, but the emphasis of this report was
on the computer control system (communications integrity,
state integrity, etc.) and the interlock systems (some 50 electri-
cal, mechanical and/or computer controlled interlocks). Spe-
cific tests were related to adherence to design specificationsfor
normal operations. Some tests constituted attempts to produce
abnormal operation and others to assess computer/interlock
interactions. An appendix contained in the above noted re-
port,39 provides details of procedures for testing interlocks to
assure safe operation for patient and machine. The procedures
relate to patient dose monitoring and other interlocks together
with the computer control system. All safety related interlocks
were tested in the clinical (patient treatment) mode. In clinical
mode, interlocks cannot be overridden.
Figure 10-5 is a functional block diagram of the accelera-
tor control system for a Philips SL25 treatment unit. The SL25
provides two selectable x-ray energies between 6 and 25 MV,
together with nine electron energy beams ranging in energy
from 4 to 22 MeV. The dashed blocks included in Figure 10-5
constitute the hardware associated with the record and verify
option. Much of the hardware, including three 16-bitmicropro-
cessors, common memory, and storage devices, is housed in
control cabinet "A" and interconnects with the accelerator and
console. The operator console is comprised of a video display
unit and associated keyboard, a TV room monitor, and a keypad
that directly controls the accelerator functions such as, start,
interrupt, and stop.
Processors 1 and 2 control data communication with the
accelerator and accelerator functions. Processor 3 controls
access to the Winchester disk and other peripherals. A35 Mbyte
Winchester disk forms the main storage for all programs,
patient data, and machine data. The 1 Mbyte floppy disk is used
for loading the operational and test software during the instal-
lation and maintenance of the accelerator, as well as for the
transfer of treatment prescription data.
The keyboard is used to enter a treatment prescription for
every new patient that includes: patient identification and
nonmechanical parameters (e.g., radiation type, energy, and
monitor units). Mechanical parameters (e.g., field size, gantry,
and collimator angles) can be entered manually or transferred
from the linac when the patient is correctly set up. This treat-
ment prescription is then stored on the Winchester disk for
future sessions, or'deleted if it is not to be used again. The
current patient prescription is displayed on the TV monitor in
the treatment room, as well as on the TV monitor at the console.
Patient treatment prescription verification with customized
tolerances together with updating of the patient record, both on
the Winchester disk and a hard copy record, are provided as
described on page 180.
Computer based accelerator control systems facilitate the
implementation of additional features that may include: Com-
puter-assisted setup of patients, remote-controlled, dual-expo-
sure check radiographs (6 MV) for port films, secondary
access of treatment data from a remote terminal, computer-as-
sisted service for maintenance including automatic self-log-
ging of machine data, self-diagnostic facility via phone line
communication using a modem, arc (moving beam) and dy-
namic therapy, and linkage with an external computer up to
1000-m distant. A current trend in treatment equipment design
is to incorporate ever larger numbers of microprocessors, each
with an assigned function. These function-assigned micropro-
cessors can operate under the jurisdiction of a master com-
puter. Protection against the extreme dose hazard of
dual-modality (x-ray and electron) linacs, which assumes a
larger role in computer-controlledunits, is described on pages
176177.
MOTION CONTROL SYSTEM
The Clinac 1800 motion control system is associated with
positioning the equipment for patient treatment; motions of the
gantry, collimator, patient support assembly (PSA), or couch
and beam stopper. In addition, it includes motions of subsys-
tems that are essential for operation of the accelerator to enable
the correct radiation treatment modality. These latter functions
are depicted in Figure 10-6, a motion system block diagram.
The associated motions are implemented by drive motors,
stepper motors, or pneumatic actuators. As shown in Figure
10-6, they affect the waveguide shorting tee (Chap. 5, p 98) the
x-ray target, as well as carousel and mirror positions. These
motions are activated when the beam energy and mode, (x rays
or electrons), are selected. Associated logic and interlock
blocks are also shown.
The treatment of patients involves motions of the gantry,
collimator, patient support assembly, and beamstopper. These
 MOTION CONTROL SYSTEM
BCD Log~c
L Mode Mode
Control 4 Select
Chassis System
FIGURE 10-6 . Motion system block diagram for accelerator operation.
motions are controlled by nine drive motors shown on the right
of Figure 10-7; the motor system block diagram.
+
The gantry can rotate through a range of 185" and has a
continuously variable rotation speed from approximately 0 to
1 rpm. The collimator assembly rotates around the central axis
of the beam through an angle of -+90°. The collimator field size
is continuously variable from 0 X 0 cm to 35 X 35 cm at the
isocenter at 1-m distance. The patient support assembly rotates
+ 95" around a vertical axis, which passes through the isocen-
ter. The couch translates laterally 5 2 5 cm, longitudinally a total
of 110 cm, and provides a couch table top vertical range from
82 to 135 cm above the floor (see chap. 12, pages 201-203 and
Figure 12-1). The beamstopper moves into and out of position
within 60 s.
The various position motors found in the stand, PSA and
gantry are controlled by circuitry located throughout the
system. However, these control functions are directed to the
motor control subchassis (see Figure 10-7) where the signals
interface and control the power to the individual drive motors.
The motors are dc operated for ease of control. Some motors
have permanent fields and others are energized from dc field
coils. The direction of rotation of the motors is altered by
reversing the polarity of a sinusoidal dc through the armature
of the motor. The speed of rotation is varied by the timing
of a silicon control rectifier SCR trigger pulse, which deter-
mines the time during the half-cycles at which the partial
sinusoid is applied.
The various motorized motions concerned with treatment
beam positioning are primarily controlled from a hand-held
179
II
-- BCD Logic
Encoder
Stepper
Motor +
Control
IIL Fault
X&E
Key Switch
pendant but some motion controls are duplicated at the radi-
ation head, the control console, or the patient support assem-
bly. The pendant has four thumb-wheel potentiometers, whose
displacement from their center resting (deactivated) position
determines the direction and speed of the motions they control.
In addition, there are three operational slide switches. One
switch controls pendant mode, directing control to the couch
or gantry. In couch mode, the thumbwheels control couch
lateral, longitudinal, vertical, and angular motions. In gantry
mode, the thumbwheels control gantry rotation as well as
collimator rotation and field size. The other two slide switches
control the radiation field and room lights. The pendant also
contains a dead-man switch, which must be closed for any
motion to occur. The PSA has duplicate controls on the couch
for lateral and longitudinal motions. The motor drive for these
latter motions may be unlocked for manual positioning of the
couch. The collimator assembly contains motor controls for
adjusting field size and collimator rotation angle together with
mechanical readonts. In addition, a large circular panel in the
yoke of the gantry displays both gantry and collimator position
data in digital form. Control of a full-field mode of the
collimator jaws for portal filming is located at the control
console.
An alternate pendant design employs membrane type
linear potentiometers. The latter takes the form of a flat,
normally open (deactivated) device and is configured as a
standard three-wire potentiometer. It is activated by pressing
the membranes and sliding one's thumb or finger laterally
across the pendant at the location of the potentionmeters.
180 CHAPTER 10. SAFETY INTERLOCKING

MOTOR CONTROL SUBCHASSIS

r---------------------------------'-------
I
I Gantry &
I Tach
I

-
I
I
7

-
I
Liftmeam Collimator
Card Rack
Trigger + Stopper Gantry Upper
Arc Control
I
I
1 A
P
SCR 86 I
I
I
Jaws

Motor I I
I
- '-C
Lower
Jaws
I

Power I I
Distribution ! I -
A

Power I
I
I
I
I
Pendant
Control
I
I
I
I ,r
console . I
-
Control j

Head
control
I-
I
I
I
I

I:
- -
Drive
D.C.
Motor
83
* InIOut
Couch

Rotate
Couch
I
L---------------------------------------l

FIGURE 10-7 . Motor system block diagram for machine positioning.

The analog output from the potentiometer signal may be
digitized or used directly.
RECORD AND VERIFY SYSTEM
Small computers and microprocessors can be used to monitor,
control, and place limits on linac operational parameters, as well
as store and manipulate information pertaining to patient treat-
ment. They can enter a record of an individual patient's treat-
ment prescription in computer memory, verify the correctness
of the daily sequence of treatments, as well as record the daily
treatment doses and their cumulative sums at specified anatom-
Table 10-1 lists 14 parameters moni-
ical sites. 638321224,27,28,32,33
tored in one record and verify system.33 Under each parameter
are given its range of adjustment and resolution. The resolution
of analog channels 1-8 refers to the potentiometer linearity and
does not include mechanical error. Unless the patient can be
reproducibly repositioned on the treatment couch on a daily
basis, a difficult and exacting requirement, it is not useful to
include such positioning parameters in the system. A further
extension of record and verify systems is dynamic therapy
under computer control as described in Chap. 2, pages 41-43.
Although the expression "record and verify" (R&V) is in wide-
spread use, it is a misnomer. The sequence "verify and r e c o r d
correctly describes the actual order of first verifying the treat-
ment prescription and individual daily doses prior to recording
them and their contributions to cumulative sums.
A number of centers have investigated such record and
verify systems, and they are now being offered as an option
by manufacturers. Their ability to identify errors in machine
setting of the treatment prescription, errors that can be cor-
rected prior to daily treatment, could be a significant benefit.
The types of errors found, their magnitude and frequency of
occurrence have varied at different centers and may be unique
to a particular center or a specific type of ma~hine.12.21~32~33
An early study of the automation of radiotherapy treatment
machines is that of Enviro-med.9 Their study looked at 4 levels
of automation and their effects on patient care, operational
efficiency, and costs. Early studies of the error rate in setting
treatment machine and couch parameters were carried out by
Kartha et al.21 who found timer or monitor unit setting respon-
sible for the largest component. The error rate will depend on
the preset tolerance values of treatment machine and couch
parameters, which allow treatment to begin and with small
errors predominating. The record and verify systems offered
by manufacturers differ significantly in their features and are
in general incompatible with each other. Mohan et a1.27,28
 COMPUTER INTEGRATION OF RADIOTHERAPY 181

TABLE 10-1 . Monitored parameters of maintaining the daily therapy record of treatment appears a
--- -
fruitful application, but there is limited experience. Certainly,
Parameters Range of adjustment Resolution
technologists, if freed of this responsibility, which includes
arithmetic aspects, would have more time for observing the
Gantry angle 0"-360"
patient and for patient concerns. However, it is essential that
Upper collimator jaws 0-32 cm
Lower collimator jaws 0-32 cm the patient's current record, which is stored in the computer, be
Collimator angle -C 90" available at all times and particularly, when the computer is
Vertical couch position 2 2 cm "down." At least one commercial system appears to have
Longitudinal couch solved this problem by employing a formatted and printed daily
position 0-141 cm therapy record form incorporating an integral magnetic strip
Transverse couch record and a terminal specifically designed to update it.8 For
position 225 cm 0.2% each treatment session or other entry, the individual patient's
Couch angle -C90° 0.2% record form is inserted into the terminal and automatically
Dose per degree 0.5-5 radP 2% quantization levels indexed to the appropriate printing position for updating it, the
Dose 0-999 rads 1cGy
magnetic strip, as well as the computer record. Normally, the
Time 0-9.9 min 0.1 min
patient's daily therapy record would be quickly viewed on a
Arc stop angle 0"-360" 1O

Wedge 0-7 1 video display unit. However, in the event of computer malfunc-
Shadow tray IN or OUT
describe a standardized interface, which facilitates treatment
monitoring of diverse accelerators on a single central com-
puter.
Large errors in field size, timer, or monitor setting, which
could significantly affect overall dose prescription, appear to
occur infrequently.12.21If so, they may have only a small effect
on the outcome when averaged over a course of therapy.
Therefore, the equipment and effort involved to identify and
correct such errors may not be justified, except in special cases,
for example, spinal blocks and lung blocks. However, with
treatment becoming increasingly complex and with the wider
use of dual x-ray energy and dual modality techniques, a record
and verify system, may become an essential ingredient of the
QA program of a treatment center. Alternatively, one may
incorporate the record and verify function into a larger com-
puter system which includes accelerator control and monitor-
ing, together with extensive record keeping.
The rapid advances in computer hardware and software
have benefited all radiotherapy computer applications. Com-
mercial record and verify systems are becoming more sophis-
ticated and may include extensive data management capability.
They often provide color window displays, popup menus, data
entry from simulators, remote review and editing workstations,
and incorporation in local area networks.
PATIENT RECORD KEEPING
A significant extension of the record and verify feature is to
replace entirely the manually kept daily therapy record and
concomitantly reduce the record keeping burden for technolo-
gists. Relieving treatment technologists from the responsibility
tion, the current printed record is still readily available. Another
difficulty in such computer based systems is designing software
programs that can handle all, or almost all, of the routine
entries, as well as contingencies that can modify the patient's
daily record during a course of therapy. Even a modest need for
manual intervention may render a record and verify system
more of a burden than a benefit.12 Software must also be readily
modifiable to accommodate changes in administrative proce-
dure of treatment technique. Patient record keeping involves
an essential core of information but it, together with any
extensions, depends a great deal on personal preference of
format, conventions and style.
COMPUTER INTEGRATION OF
RADIOTHERAPY
The term computer integrated radiotherapy can be defined as
the digital transfer of information among individual functions
(applications) under computer management. Individual appli-
cations require data input, often from another application, and
generate data output, which is often filed for later access or
transferred to another application. As opposed to manual meth-
ods, integrated therapy can facilitate the transfer of image and
other data with minimum distortion and can facilitate file
management and access. In order for different individual appli-
cations to communicate with each other, standardization of
transfer data format is essential, with interfaces to adapt the
communication system, to individual application equip-
ment.1.2J7 Horiil6 describes one example of such a format, the
(ACR-NEMA) American College of Radiology-National
Electrical Manufacturers Association standard for transfer of
diagnostic images.
Record and verify systems have been offered by most
manufacturers of radiotherapy machines. Such systems pro-
vide for storage and retrieval of patient and treatment informa-
182 CHAPTER 10. SAFETY INTERLOCKING
tion, prohibit treatment outside user-defined tolerances on ma-
chine settings, and provide for automatic setup of selected
machine positions and functions. l'j~picallyin the past, each
treatment machine had its own individualizedrecord and verify
system. Mohan et a1.28 describes a centralized record and verify
system, which serves four treatment machines of three different
manufacturers. Intelligent interfaces were developed to take
input from the machines in their different formats and commu-
nicate it digitally to a host computer in a standard format. The
host computer inhibits the beam until the parameters set on the
treatment machine agree with the prescribed parameters for
treatment within specified tolerances. Patient demographic
information, treatment prescriptions, individual treatments,
and verification failure out of tolerance data are recorded and
used to generate reports that are available for display or print-
out.
Record and verify systems are available that can serve
more than one treatment machine, provided they are by the
same manufacturer. Such systems employ a computer and hard
disk for verification, recording, and database management.
Manufacturers (e.g., see Ref 4.) are working on the develop
ment of systems of broader capability, in order to provide
digital transfer of patient treatment data among several func-
tions in the radiotherapy department, such as patient contour
sources, treatment planning system, simulator, treatment ma-
chine, physician work station for image display and manipula-
tion, and terminals for administrative tasks and office
automation activities. Table 10-2 lists a rationale for comput-
erization and some specific applications of computers in radio-
therapy.
A variety of local area network protocols are available for
communication among functions. One example is Ethemet.10 It
employs a coaxial cable to which all hosts connect through
interface boards. A machine wishing to communicate with an-
other waits a randomly chosen time (repetitively, if necessary)
for the cable to be free, then broadcasts its message on the cable.
The modulation rate is 10 Mbitsls, providing data rates of 0.5 to
5 Mbitsls. Cable length is limited to 500 m. Communication is
in "baseband" (direct pulsing). Some other systems operate in
"broadband" (modulation of a carrier, like radio transmission)
permitting higher data rates, but at greater expense for inter-
faces. The future development of fiber optics networks will
facilitate high speed transfer of high resolution images.
Diagnostic information from many sources is used for
radiotherapy treatment planning. Much of this diagnostic in-
formation is available in digital form, such as images from
x-ray computerized tomography (CT) scanners, MRI, digital
radiography (DR) systems, nuclear cameras and scanners, and
ultrasound scanners. It is essential that such image data be
provided to the radiotherapy treatment planning computer
without distortion. Adigital imaging and communicationsstan-
dard' developed by ACR and NEMA will:
1. Promote communication of digital image information re-
gardless of source format or device manufacturer,
2. Facilitate the development and expansion of picture ar-
chiving and communication system that can also interface
with other systems of hospital information,
3. Allow the creation of diagnostic information data bases
that can be interrogated by a wide variety of devices
distributed geographically.
A network may or may not be involved. The ACR-NEMA
standard specifies the hardware interface, certain software
commands, and a set of data formats for communication across
an interface between an imaging equipment and a network
interface unit or another imaging equipment. It is not an overall
picture archival and communication system (PACS) or work
station specification, nor a network standard.
The ACR-NEMA standardl.2.16 defines a point-to-point
hardware connection with protocol and data structure such that
two differing devices (e.g., imaging device, workstation, or
laser film writer) will be able to communicate with each other,
exchanging images and associated data. On each side of an
interface, the same layers are performing the same functions,
so the programmer views each layer as communicating with its
equivalent. The communication actually occurs in a vertical
direction in the layers and the true connection is only at the
TABLE 10-2 Computerization-rationale-specific applications
Rationale
I. Improve quality through improved treatment planning and
verification of set-up and dose delivered to the patient.
2. Perform tasks not possible manually (e.g., dynamic control.)
3. Increase the volume and type of data available by generating
data bases, for statistical analysis and control as well as patient
management such as scheduling and billing.
4. Create patient files with patient data, diagnosis, course plan, and
summary of treatment given.
5. Reduce the time needed for routine (but critical) data recording
and checking.
6. Include radiotherapy accelerator diagnostic information and
facilitate thorough rapid quality assurance checks.
7. Manufacturing upgrades become software rather than hardware
changes.
Some spectfic applications
Record and verify. (Enter patient data and course plan, compare
set-up parameters with plan, record results.)
Treatment planning.
Data management.
Radiotherapy accelerator control system.
Dynamic (conformation) therapy (advanced computerized
treatment planning; computer control of accelerator).
Automatic setup of accelerator (with record and verify system).
Automated dosimetry measurements, storage of data in
computer, and computer presentation of data through graphs or
printouts.
Dosimetry control through use of look-up tables containing
calibration and output factors.
 COMPUTER INTEGRATION OF RADIOTHERAPY 183

ELLa
wOrka
physical layer. The message format itself consists of data
elements collected into groups. Each data element (e.g., patient
name) consists of two numeric fields forming a key. This is
stations 0 0
followed by a length field and the element value. Once the
message is assembled, it is sent down to the session layer. The
transportlnetworklayer takes the message with the information
from the session layer and fragments the message packets. In
the data link layer each packet is enclosed by a frame descriptor Archive
word and a frame check sequence to form a frame. The frames
are sent to the physical layer, which handles transmission
across the interface. The physical interface consists of 16 Head-End
Cluster
asynchronous parallel lines with control signals. Figure 10-8 Control &
Support
NM
shows the data flow through the ACR-NEMA interface. Data Base
Figure 10-9 shows a schematic of a radiology storage PET Image
transfer analysis and reporting (Q-RSTAR) system employing
picture archiving and communicationssystem (PACS) technol- @ I
,IS
I
HIS

ogy in a department of radiology?' A dual local area network

(LAN) is employed, comprising Ethernet coax for command
and control information at data rates to 0.2 Mbytesls and an
optical LAN capable of sending high resolution images in a
Optical LAN
timely fashion at up to 100 Mbits (e.g., 12 Mbytes 8 bits deep). Cluster 12 MBls To
Figure 10-10 shows Ethernet system components.3

1
1F-I
Support Work-
Stations
In radiotherapy departments the volume of images is much
To
--Endki
Command
6.7 MBIs
APPLICATION
AND
PRESENTATION
.
FIGURE 10-9 Radiology storage transfer analysis and re-

I+ MESSAGE
TO DESTINATION
8
SESSION
porting system employing optical LAN and Ethernet and
PACS technology (from Ref. 37).

0-2048 WORD BLOCK less than in a radiology department so an optical LAN is not
I I DATA DESCRIPTOR
I
I essential for image transfer, such as from a simulator and
I
WORD
I
I
I
electronic portal imager to a workstation. However, compati-
I
bility with the radiology department in transfer of CT, MRI,
BLOCK SEQUENCE
NUMBER
A
&
N;T yT
I
and so on images for treatment planning may encourage use of
PACKET DESCRIPTOR I
I
optical LAN in the radiotherapy department; especially for the
WORD
BLOCKSEQUENCE
I
I
quantity of images needed for conformal therapy and 3-D
NUMBER I
I treatment planning.
0-2048 WORD BLOCK I
I In addition to the ACR-NEMA effort, which was initiated
4 primarily to serve the needs of diagnostic radiology, the IECl7
C FRAME DESCRIPTOR
WORD
I
I
has started work on standardization of data exchange for sys-

R i FRAME DESCRIPTOR
FRAME CHECK
SEQUENCE

DATA L~NK
I

I
tems in radiotherapy. This IEC effort is intended only to stan-
dardize the terms used in transmitting information and their
mnemonic abbreviations. Dahlins has reported the initiation of
a Nordic program among medical centers to develop an inte-
grated information system in radiotherapy, called CART (com-

-
BLOCK SEQUENCE I
I
puter assisted radiation therapy) (see Figs. 10-11 and 10-12). A
1 0-2048 WORD BLOCK I I
I
logical information flow is defined, which corresponds to the
I

SEQUENCE
I
I
standard sequence of radiotherapy procedures:

OVER PHYSICAL LINK 1. Image processing:

FIGURE 10-8 Data flow through the ACR-NEMA interface Localize tumor distributions.
(from Ref. 16). Define target volume.
184 CHAPTER 10. SAFETY INTERLOCKING

50 R Coaxial Cable
5. Oncological data base:
Transfer to hospital storage of all essential data to
permit long-term follow-up and statistical evaluation
of different treatment modalities.

Taprrransceiver
The sophistication of treatment planning will develop over
Transceiver Assembly time and any future integrated information system should be
planned to anticipate the following future treatment planning
capabilities:

True 3D beam model for each radiation quality.

Three-dimensional beam's eye view.
Interface
Three-dimensional display of anatomy and dose distribu-
tions. "
- Optimization programs, including radiobiological re-
sponse functions.
Display of digital port images for beam set-up verification.
Controller
Suntharalingam et al.35 discuss the potential for use of
Control computers and their mass storage media in radiation therapy
planning and delivery. They can provide the means for integra-
tion of the large amount of data that is related to treatment
planning, delivery, and follow-up.
Attached Dickof et al.7 describes an integrated radiotherapy com-
System puting system that provides for transfer of patient contour data
from various sources to the treatment planning system, and its
output to the verify and record system. This computing system
FIGURE 10-10 . Ethernet system components block sketch interfaces an active tumor registry system.
(from Ref. 3).
Fox et al.11 describes acomputer based information system
that schedules patient appointments at each patient care activity
in the radiation oncology department. Video displays in each
Define patient outline and organ contours. service area provide information on patients scheduled for that
Define physical properties of treatment beam. service. The system assists personnel in reacting to improve
Subsequent follow-up studies for tumor and organ patient flow.
response. Kijewski23 describes an information management system
2. Treatment modeling: for a radiation therapy facility in which the user responds to
Acquisition of dosimetric beam data for source to be menus and prompts in developing command procedures for
used. their application. This shifting of some of the programming
Obtaining of data for making patient individual beam burden to the user on an interactive basis permitted reduction
modifiers. of the system programming effort. The information system
3. Treatment verification: application areas include: administration, patient registration,
Treatment unit set-up parameters. biological laboratory, physics, clinical studies, program docu-
Patient specific devices, including beam modifiers. mentation, machine calibration, radiation safety, patient dosim-
Patient positioning. etry, and reprint library. It has been used on a daily basis for
Absorbed dose to the patient. patient records, dosimetry, treatment planning, patient studies,
Treatment unit electrical and dosimetric performance. and bibliographical retrieval.
Documentation of treatment prescription. The ICRU has issued a report19 on the use of computers in
Optional automatic set up of the treatment unit. treatment planning and recording and documentation proce-
Optional dynamic control for optimization of dose dures in external beam x-ray and electron radiotherapy. It
distribution. includes recommendations on quality assurance of the com-
4. Clinical register: puter system. Figure 10-13 is from this report and illustrates
Storage and ready daily access of treatment status for data flow within a department of radiotherapy. Figure 10-14
each patient, including diagnostic and treatment data, shows the pathways for beam data acquisition for treatment
patient administrative information and data from lab- planning and Figure 10-15 shows patient data acquisition for
oratory investigations and other treatment modalities. treatment planning.
 REFERENCES
FIGURE 10-11 . Information flow in the radiotherapy clinic as it is presented by the Nordic CART project. (from Helax, Box 1704, S-75147 U p
psala, Sweden).
REFERENCES
1. ACR-NEMA: Digital imaging and communications standard:
July 1, 1985.
2. ACR-NEMA: Digital imaging and communications standards
committee; Application guide: Minimum requirements for com-
patibility with the ACR-NEMA Digital Imaging and Communi-
cations Standard, 1987.
3. Cheong VE, RA Hirschheim: Local area nerworks. New York,
Wiley, 1983, p 39.
4. Coats JC: Current developments in radiation treatment of cancer
by integration of computer technology and the Clinac linear
accelerator: Varian Associates, Palo Alto, CA 94303, February
1985.
5. Dahlin H: Program CART-A Nordic challenge in medical com-
puting: Eighth International Conference on the Use of Computers
in Radiotherapy. IEEE 84 CH 2048-7. Toronto, July 9-12,1984,
pp 541-543.
6. Dickof P, P Morris, D Getz: Vrx: A verify-record system for
radiotherapy. Med Phys 11: 525-527, 1984.
7. Dickof P, P Morris: An integrated radiotherapy computing envi-
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186 CHAPTER 10. SAFETY INTERLOCKING

SERVICE STATION
CENTRAL
Magtape Printer

Video
scanner
Central
processor ---__,
Image display Image display
L
processor 2 16 MB processor .
Video 2 24 MB 2 24 MB Video

Ethernet

Trackball Mouse Mouse Trackball

FIGURE 10-12 Example of treatment management system configuration with Ethernet, providing3D mapping of patient anatomy and 3D dose
computation, including beam's eye view (from Helax).

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Identity Imaging Definition of Other Treatment Database

History (CT etc) Target Volume Modalities -
Status and Dose (Surgery, Clinical
Diagnosis Prescription Chemotherapy) Register
Follow-Up

Patient Data ? 0

Laboratory Results etc o

Diagnostic Images

Therapeutic Images w o

Treatment Reference Data

Treatment Documentation
T 0

Beam Data
T

Optimization Verification

FIGURE 10-13 - Schematic of data flow within a rediotherapy department (from Ref. 19).

(analogic) interface

Beam production
Off-line
f

-
-

Treatment
planning
computer
-
Dosimetry
system
I,,,II I,",
,,.,,
,.I..

111*11 1,111
,It.* ,,,,, I,..,

1 Keyboard
BEAM DATA ACQUISITION I I
Checking procedures or computer generated beam data

FIGURE 10-14 . Beam data acquisitionand input to a treatment planning system (from Ref. 19).
188 CHAPTER 10. SAFETY INTERLOCKING
MECHANICAL DEVICES
I PATIENT DATA ACQUISITION ] matrix
FIGURE 10-15 . Patient data acquisition and input to a treatment planning system (from Ref. 19).
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puter verification for radiation therapy treatment machines. Ra-
diology 131:258-262, 1979.
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Clinac 18. Med Phys 4:454-455,1977.
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son: Treatment planning and delivery. Cancer Treatment Symp
1:27-33, 1984.
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electron linear accelerators. IAEA Report 188 1-327, 1979.
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system: Technical overview, 317-323 and Q-RSTAR digital
image management and transmission, 432-438 in RL Arenson,
RM Friedenberg,(Ed): Computer applicationsto assist radiology.
Symposia Foundation, pp 432-438, 1990.
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Low Ousegate, York YO1 lQU, UK, The Institute of Physical
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accelerator's computer-control system. Med Phys 17:95-102,
1990.

Multi-X-Ray Energy Accelerators
DESIGN CHALLENGES
CLINICAL NEED
Radiation oncologists prefer use of a low energy x-ray mode
for the majority of patients, but a widely separated high energy
x-ray mode for about one-fourth of patients, and an electron
mode for about one-eigth of patients. A low energy x-ray beam
of 4 or 6 MV provides a desirable depth dose distribution for
treatment of tumors at moderate depth (e.g., in the head and
neck, breast, and lymphatics). The 6-MV depth dose distribu-
tion reaches a maximum at 1.5 cm below the surface, about
67% at 10 cm depth, and with parallel opposed fields the dose
distribution can be quite uniform through thinner sections of
the body. A high energy x-ray mode provides a clear advantage
in treating tumors in thick sections of the body. Examples of
appropriate clinical targets for such high energy mode are
tumors of the prostate, urinary bladder, cervix, esophagus, lung,
and sites deep in the brain. High energy x-ray mode is also
useful in protecting bone near the skin such as in treating the
nasopharanx and associated lymph system while protecting the
mandible. The 18-MV depth dose reaches maximum at about
3.5 cm below the surface, about 78% at 10 cm depth and with
parallel opposed fields the dose distribution can be quite uni-
form throughout thicker sections of the body.
By combinations of treatments with such low and high
x-ray energy beams, as well as electron boost fields, dose
distributions can be more precisely tailored to the individual
patient. With this range of modalities in a single accelerator,
moving the patient from machine to machine can be avoided.
This can expedite patient throughput by reducing total set-up
time and avoid proliferation of positional imprecision from the
additional patient setups that would otherwise be required. It
has been a challenge to accelerator designers to provide all
these capabilities in the same machine and still achieve uncom-
promised performance and beam stability for optimal patient
outcomes. Much of the discussion in this chapter applies as well
to single x-ray energy machines but multi-x-ray energy design
is more demanding.
C H A P T E R 11
PERFORMANCE REQUIREMENTS
One demanding requirement for the machine designer is to
achieve a high dose rate flattened to the corners of a quite
large field at low energy such as 6 MV and also to supply
a widely separated high energy x-ray mode (e.g., 18 MV)
with stable dose distribution in both modes over all gantry
angles. For patient comfort and reduced probability of patient
motion, as well as to allow for absorption in wedge filters
and for treatment at extended distances, high dose rate such
as 400 or more cGy lmin at 100 cm SAD should be available
at both energies.
Ideally, the distribution of dose over all field sizes from
small to large should be flat at all clinical depths and should
remain flat with rotation of the gantry and beam limiting
device. This requires that the electron beam be formed, accel-
erated, aimed, and controlled in ways that will minimize poten-
tial contributions to instability of the final treatment beam. Flat
distribution at all depths requires enough excess beam energy
at the x-ray target so that an optimal flattening filter construc-
tion (for shaping the x-ray spectrum over the field) can be used
and still achieve desired depth dose.
The ICRU Report No. 244 states that at the best level of
current practice, the uncertainty in calibration of dose with a
secondary standard ionization chamber in a phantom is k2.5
at 95 percent confidence limit. This is exclusive of uncertainties
related to the treatment machine. Even assuming complete
randomness in summation of errors, this leaves very little room
for machine performance tolerances if an overall dose precision
of 2 5 percent is to be met. Both the constancy of machine dose
versus calibration standard and constancy of dose spatial dis-
tribution versus time are essential. Define gamma as the slope
of the curve of tumor control probability (TCP) versus dose at
50 percent TCP. Assume a patient with a TCP of 50 percent and
gamma of 3. An underdose of 5 percent over the full-treatment
course will reduce the TCP by about 15 percentage points to 35
percent for this patient. Similarly, an overdose of 5 percent may
increase the probability of severe damage to normal tissue from
5 to perhaps 9 percent. Also, if the excess dose region of a 3
percent asymmetric field is in the region of a critical organ for
190 CHAPTER 11. MULTI-X-RAY ENERGY ACCLERATORS
the course of therapy, the excess dose can increase the proba-
bility of severe injury to that organ.
Perhaps even more important than beam symmetry is the
requirement for beam stability (e. g., avoidance of variations
in symmetrical flatness and penetrative quality) and this need
affects the selection among alternative technical approaches in
designing a medical accelerator. The design should anticipate
changes in performance of individual items over the life of the
machine and provide an adequate margin of performance.
In addition to providing a stable beam over all equipment
orientations, the machine must be reliable, safe, convenient to
use, and readily serviced. The machine must be compact for
convenient patient setup and this puts severe spatial constraints
on the permissible size and arrangement of major components.
ELECTRON BEAM DURING ACCELERATION
In order to reduce variation of beam symmetry with time and
equipment position, the variation of the convergence angles of
the electron rays at the x-ray target should be minimized.
Similarly, the variation in position of the centroid of the elec-
tron beam at the x-ray target should be minimized. The amount
of chaos of the electron rays making up the beam is called
transverse emittance. It is the product of displacement and
divergence of the electron rays making up the electron beam.
Minimizing the transverse emittance makes it easier to main-
tain the distribution of electron ray angles and positions in the
beam spot at the x-ray target. This need for maintaining a
precise beam spot distribution affects the choice of electron gun
design and the method of energy switching, as well as methods
for steering and beam transport. After initial bunching, the
electrons should pass through the middle of each cavity near or
at the peak of the oscillating rf electric field to optimize use of
rf power and minimize energy spread.
ENERGY STABILITY
The IEC3 Publication 977 suggests a tolerance value for stabil-
ity of depth dose in electron mode which corresponds to t1
percent energy stability at energies above 10 MeV. That is, the
deviation of the mean of the energy spectrum transmitted by
the energy slit should be limited to 2 1 percent. This is facili-
tated by accelerating a broad fairly uniform energy spectrum
(e.g., 20 percent) in electron mode and using a narrow energy
slit such as 6 percent to select out only a portion of this
spectrum. Some machines employ a 6 percent energy slit (i.e.,
2 3 percent), which is narrow enough to limit variation of the
mean energy to less than + 1 percent. Some machines reported
in the literature11 had energy slits as wide as 16 percent in older
designs and have slits much wider than 6 percent in more
current designs.
One way to meet this energy stability criterion is to use a
quite narrow energy slit in the bend magnet. However, this can
limit the dose rate in the x-ray mode if the same slit is used and
if the accelerated beam energy spread is not sufficiently narrow.
If high dose rate is to be achieved at low x-ray energy fully
flattened to the comers of a large x-ray field by a sufficiently
thick flattening filter, the percentage beam current transmission
through the bend magnet system to the x-ray target must be
relatively high. To pass through a narrow energy slit this
requires that the gun inject a beam with low transverse emit-
tance into the accelerator guide and that electrons ride the
accelerating wave in such a way as to avoid instabilities and
increases in energy spread. Also, high beam transmission
through the electron beam collimator and energy slit permits
thinner, lighter weight shielding in the radiation head because
less beam impinges on these components to produce stray
radiation. On the other hand, if a separate wider energy slit is
used for x-ray mode, it will permit larger variations in mean
energy at the x-ray target if the beam from the accelerator
structure is not stable in energy. This can result in larger
variations in field flatness (shape of dose profile across the
field), unless other means are used to stabilize this shape.
It is important to place the energy slit at the point in the
bend magnet where initially parallel electron rays cross over,
producing a radial focus for good energy discrimination (see
Chap. 7). In order to avoid adding shielding at the top of the
radiation head, with a consequent increase in isocenter height,
the energy slit is placed elsewhere in some machines. Mixing
of spatial and energy variations can then result, complicating
feedback control of field symmetry and beam energy.
Variations in the mean energy of the beam transmitted by
the energy slit in a doubly achromatic bend magnet will not af-
fect x-ray field symmetry but will affect the shape of the dose
profile across the field, increasing or decreasing the dose rate on
the beam axis relative to the periphery of the field. As Suther-
lands pointed out, this can also cause a dosimeter calibration
error in systems where the ion chamber dose rate electrodes re-
spond to the whole field and, hence, primarily to its periphery,
whereas external detectors for calibration are used on beam
axis. Feedback from dose rate can be used to control energy to
avoid this error. Variations in mean energy also make small vari-
ations in relative dose at depth, about V4 percent at 10 cm depth
per 1 percent change in mean energy around 6 MeV.
If the beam energy spectrum shape is quite peaked or
curved, changes in the position of this distribution in the energy
slit will cause variations in the mean energy of the energy band
transmitted by the slit. If the energy spectrumis quite broad and
relatively flat over the energy slit range, variations in the mean
energy out of the accelerator guide will be reduced in the beam
transmitted by the energy slit.
DOSE SPATIAL DISTRIBUTION AND
CALIBRATION IN INITIAL SECONDS
The beam energy, dose distribution, and dose calibration
should be within tight tolerances even during the initial seconds
 EQUIPMENT DESIGN ALTERNATIVES
of each portal treatment. In the future, conformal therapy may
call for say 10-port treatments of 5 s each. A 10 percent error
in field flatness through just the first second could add two
percentage points of error to the steady-state value of flatness.
Assuming a tumor dose of 200 cGy, a 0.1-cGy round-off error
or a depth dose error in the 20 cGy delivered by each of 10
portals could add another 0.5 percent dose error. These errors
could become significant if they add systematically. A similar
rationale applies with hyperfractionation where there are more
beam initiations in a course of treatment.
Movement of the electron beam centroid at the x-ray target
in the initial second(s) can contribute to poor spatial resolution
(geometric unsharpness) in portal images, especially pretreat-
ment images taken with geometric enlargement. Such pretreat-
ment open fields are taken in a time of order 1 s or less to
minimize patient dose outside the treatment field.
Fast rise and precisely controllable dose rate during treat-
ment can be essential in dynamic radiotherapy. Examples are
dynamic wedge with moving jaws, dynamic conformal arc
with moving leaves of multileaf collimator, dynamic compen-
sation, and scanned slit. These can be facilitated by avoiding
use of components with long thermal time constants (e.g., long
anode magnetron).
EQUIPMENT DESIGN ALTERNATIVES
In the following discussion, alternative designs for dual x-ray
energy accelerators will be compared, explaining the reasons
for particular design choices. Emphasis will be placed on
minimization of treatment beam instabilities and on having
adequate performance reserve to ensure long machine life with
minimal maintenance.
Although dual x-ray energy linacs had been available from
about 1970 [Varian Clinac 35; Philips (MEL) SL751201 (see
Appendix B), they had limitations that inhibited widespread
acceptance by the radiotherapy community. Since 1983, man-
ufacturers have been providing dual x-ray energy linacs, which
more properly fulfill the needs of radiotherapy. These machines
are economically justifiable and provide both low and high
energy x-ray modes as well as a full range of electron mode
energies. The machines are compact, permitting installation in
conventional size treatment rooms.
MICROWAVE POWER SOURCE-KLYSTRON
VERSUS MAGNETRON
A klystron is used in most dual high energy x-ray energy
machines because it provides high pulse power conservatively
and because it operates as an amplifier, being driven by a
separate frequency-stabilized oscillator. Thus, the phase and
amplitude of the rf output power are highly independent of
reflections from the accelerator guide. A klystron is preferred
191
for higher energy multimode accelerators because the high
pulse power permits a shorter accelerator guide for better beam
stability.
An alternative would be to use a magnetron. This is con-
ventional in low energy machines but is more difficult at 18
MV or higher x-ray energy. The magnetron is an oscillator and
its output power, phase, and frequency are highly dependent on
reflection from the accelerator guide. Also, because of its
compactness there is a limit to the maximum pulse and average
power that can be obtained reliably from amagnetron. Attempts
to exceed this limit can result in increased arcing, increased
frequency moding, and decreased operating life. Because the
pulse power is limited, achieving high energies with a magne-
tron requires a longer accelerator guide, with corresponding
potential for increased beam instabilities. Because magnetron
average power is limited, it is more difficult to achieve high
dose rate over large fields fully flattened to the comers in low
energy x-ray mode (such as 6 MV) in a dual x-ray energy
machine.
ELECTRON GUN-TRIODE VERSUS DIODE
A triode gun employs three electrodes+athode, grid, and
anode. Triode guns typically employ an impregnated cathode.
Operation in space charge limited mode provides a virtual
cathode, which minimizes transverse emittance of the electron
beam from the gun. In electron mode, the gridlcathode voltage
is automatically limited to a low or negative value to ensure
that abnormally high, hence unsafe, electron current cannot be
emitted. Dose per pulse can be regulated by the control grid
beam pulse length, clipping the end (not the beginning) of the
beam pulse so as to maintain constant beam acceptance by the
accelerating field. The ability to vary dose rate rapidly and
precisely is especially important in arc therapy with constant
gantry rotation rate. Care must be taken in designing the grid,
whether it be of the intercepting or nonintercepting type, to
ensure that it does not increase the beam emittance excessively,
such as by local transverse electric fields inside the beam.
Instead of a triode, a diode gun may be used, employing
only a cathode and an anode. A thoriated tungsten wire spiral
or circular type directly heated cathode may be used. Such
cathodes operate at much higher temperatures than im-
pregnated cathodes. Because of local electric and magnetic
fields at the wire, as well as their thermal energy, the electrons
leave over a spread in angles, increasing the transverse emit-
tance. Also, a wire spiral cathode can distort with time and
temperature.The emission current can be varied in temperature
limited mode by varying the heater current. However, this can
destroy the space charge virtual cathode and increase beam
emittance still further.
Instead of using temperature control, the diode gun emis-
sion current may be varied by variation of the cathodelanode
voltage. This can lead to instabilitiesand enlarged energy spread
192 CHAPTER 11. MULTI-X-RAY ENERGY ACCLERATORS

because of variation of injection energy and, hence, phase of the
electron bunch on the wave in the accelerator guide.
ACCELERATOR GUIDE-TRAVELING WAVE
VERSUS STANDING WAVE
One type of accelerating structure is traveling-wave (TW)
guide. The rf power is coupled from one cavity to the next
through a hole on the axis. The hole diameter must be quite
large, about one-fifth the cavity diameter, in order to provide
enough rf power flow. Hence, the rf electric field lines curve
away from axis to the hole periphery, providing a reduced longi-
tudinal component for acceleration of the electron bunch on the
axis. Optimum acceleration is obtained with three cavities per
wavelength in TW guide instead of the two cavities per wave-
length of standing-wave (SW) guide. The increased number of
cavity walls absorbs more rf power. The net result is that for a
given maximum no-load beam energy and rf pulse power from
the microwave source, a TW guide must be about 1.7 times as
long as a SW guide. With a drum type gantry, the accelerator
guide can extend back through the drum; hence, this extra length
is permissible. However, in the low energy x-ray mode, the elec-
trons are at low energy over a much longer distance and, hence,
are more sensitive to destabilizing transverse forces. For exam-
ple, unless carefully shielded, stray magnetic fields at the beam
can vary with angular position of the gantry.
Because of the much weaker coupling between cavities in
a TW guide, temperature variations can cause much greater
changes in phase over the guide length between the rf field and
the electron bunch, thereby contributing to instability of beam
energy. This can be especially important during the initial
seconds of beam on time.
In an SW guide, the peaks of the oscillating sine wave
electric field are located in each accelerating cavity and the
nodes of this wave are in the coupling cavities. Since the
electric field in these coupling cavities is near zero, they can
be made very small and can be placed on the side of the
guide or between accelerating cavities with little attendant
power loss.
In an SW type accelerator guide employing a microwave
energy switch, the lengths of the first few cavities are slightly
foreshortened. Electrons injected from the gun pass through
the midplane of each cavity at a time when the oscillating
rf electric field is rising (see Fig. 11-la, and b). Early
electrons see lower amplitude and late electrons see higher
amplitude electric field as it rises sinusoidally in time, hence
coalescing to a tight bunch as they gain velocity rapidly and
drift back toward the crest of the electric field wave. In the
remainder of the guide, the electron bunch passes through

Acceleration Portion Energy Acceleration Portion

Switch
0" From

Electron Bunch

Phase Spread
of Bunch

FIGURE 11-1 . Electron bunch phase with energy switch. The dashed wave is 180" of
phase later in time than the solid wave. (a) 18 MV x-ray mode and (h) 6 MV x-ray mode.
 EQUIPMENT DESIGIN ALTERNATIVES
the midplane of each cavity when the oscillating rf electric
field has reached approximately its peak. For example, with
cavities at 5 cm intervals, the electron bunches are 10 cm
apart. This SW guide design with microwave energy switch
has several beneficial attributes.
1. The beam energy spread is minimized. This permits use of
a narrow energy slit in the bend magnet to define the
centroid of the transmitted energy spectrum with better
precision and stability and reduces stray radiation due to
beam loss in the bend magnet chamber.
2. The sensitivity of the electron bunch energy to variations
in phase of the rf electric field is minimized.
3. The requirement for rf pulse power to establish the accel-
erating electric field is minimized, easing the demand on
the microwave source (i.e., copper losses are minimized,
saving more rf power to accelerate the beam).
Instead of off-axis (side-coupled) design, an alternate way
to build an SW accelerator guide is to make the coupling
cavities very short and put them on axis, alternating with each
accelerating cavity (bi-modal) or each pair of accelerating
cavities (tri-modal).' This permits using a smaller diameter
solenoid if one is used to confine the beam diameter. The
coupling cavities provide no acceleration, yet take up axial
space. Hence, for the same overall accelerator guide length and
basic cavity shape and the same maximum electron energy,
somewhat greater rf pulse power is required from the micro-
wave power source with on-axis coupling cavities. Also, the
beam can excite repelling fields in these cavities, disturbing the
phase distribution at high beam currents.
An SW type accelerator structure (side coupled, bi-modal,
tri-modal) has the following important characteristics, which
are superior to a TW guide.
1. The shape of the accelerating cavity (and especially near
the axis) can be optimized to concentrate the rf electric
field in time and space at the electron bunch to achieve a
given energy gain per cavity with minimum rf pulse power
loss to the cavity surface-and independently the coupling
cavity can be designed for optimum transfer of excitation
rf power between accelerating cavities. The shunt imped-
ance is thereby maximized. That is, efficiency of conver-
sion of rfpower to accelerating electric field is maximized,
permitting shorter accelerator guide length.
2. The accelerating cavities can be tightly coupled so that
they maintain a close rf phase relationship to each other
and the traveling electron bunch.
3. The use of half-wave accelerating cavities results in the
guide being inherently mode stable, suppressing potential
oscillation in nearest neighbor resonant modes, which are
about 1 percent away in frequency. Feeding the rf power
to the accelerating guide near its midlength instead of at
one end contributes to this mode stability. Avoidance of
193
excitation of neighboring resonant modes contributes to
stability of beam characteristics.
SWITCHING FROM HIGH TO LOW ENERGY IN A
TRAVELING WAVE GUIDE
Special techniques such as an energy switch are not needed in
a TW guide. The rf electric field can be high in the first portion
and can remain high in the second portion of a TW guide for a
high energy x-ray mode or can taper down to a low (or reverse)
field over the length of the second portion for a low energy
x-ray mode, with the electrons well bunched and riding the
crest (or valley) of the wave in either case. The switching from
a high to a low x-ray energy mode can be accomplished while
keeping the microwave source power and buncher electric field
constant simply by increasing the beam current, so it progres-
sively extracts an increasing fraction of the rfpower flow down
the TW guide. This is called beam loading. The beam energy
can also be varied by detuning the rf source, so that the electron
bunch drifts in phase over the accelerating rf sine wave field.
The rfpower travels only in the forward direction through
a TW guide. Radio frequency feedback through an external
circuit permits opening up the axial holes for tighter coupling,
in order to reduce phase instability. However, this reduces
efficiency of conversion of rf power to an accelerating electric
field and the system still ends up about 4 to 10 times less stable
in phase than an SW guide, with corresponding increased
energy instability, especially with a magnetron as microwave
power source.
SWITCHING FROM HIGH TO LOW X-RAY
ENERGY IN A STANDING WAVE GUIDE
Obtaining especially high dose rate at 4 or 6 MV in a multi-x-
ray energy accelerator requires optimal design. Such high dose
rate can be important for some applications, such as physiolog-
ical gating of the treatment beam to compensate for organ
motion and is facilitated by the SW guide design.
There are various techniques used for varying the output
electron energy of an SW linac. The simplest method is either
to vary the rf power into the accelerator or vary the injection
beam current and, hence, beam loading. However, this ap-
proach will provide only a narrow range of energy variation
beyond which the energy spectrum will rapidly degrade (see
Fig. 11-2).
Another technique is to detune the rf source frequency
and/or detune part of the accelerating cavities. In this case,
however, the energy range will be limited by the lack of
stability of the system as it is detuned from the stable condition.
One practical approach to vary the energy over a wide
range is to cascade sections of the accelerator that are indepen-
dently excited from a common rf source with independent
control of the phase and amplitude. However, the rf system and
194 CHAPTER 11. MULTI-X-RAY ENERGY ACCLERATORS

Energy (MeV)

Beam Loading: a, heavy; b, optimal; c, light

FIGURE 11-2 . Deterioration of energy spectrum of standing wave ac-

celerator optimized for 10 MeV when energy is varied siniply by vary-
ing rf power into the accelerator structure or varying the injected beam
current and, hence beam loading.

microwave structure of such an accelerator can get bulky,

complicated, and expensive.
Another method has been tried to achieve the equivalent
of a multiple section accelerator, namely, the double-pass sin-
gle-section linac. It uses a mechanically movable 180" reflect-
ing magnet to obtain the correct phase variation between the
beam passes. Energy can then be controlled by adjusting the
phase of the bunch on its return relative to the accelerating field.
This technique is complicated and moreover, the degradation
of the spectrum and the lack of system stability make it difficult
to implement the idea. It is especially difficult to obtain high
dose rate over large fields fully flattened to the comers at low
energy such as 6 MV because the poor energy spectrum causes
large loss of beam current on the energy slits in the bend
magnets and also large leakage radiation.
For the following discussion, the guide length is arbitrarily
divided into a first portion in which the major function is to
bunch the electrons and position them on the accelerating
wave, and a second portion in which the primary function is to
accelerate the electrons while minimizing their output energy
spread. In a high energy x-ray mode, the second portion of the
guide must be at a high rf field, with the electrons tightly
bunched and riding near or on the crest of the rf electric field
in order to minimize energy spread, energy instabilities, and
demands for pulse power from the microwave source. In a low
energy x-ray mode, the electrons must experience a low net
average rf electric field in the second portion of guide but still
be properly bunched and accelerated in the first portion. There
are two fundamentally different ways to do this in an SW guide.

1. One method is to use a compact microwave switch to

FIGURE 11-3 . Microwave energy switch types for an SW guide. (a)
reduce the rf power to the second portion of the guide, The noncontact method, (b)the single side cavity shorting method, and
thereby reducing the rf electric field so the electron bunch (c) the double side cavity shortinglopening method.
can ride the crest of a reduced wave. This method is
efficient in use of microwave pulse power and in attaining
minimum beam energy spread. (In Figure 11 -la and b, the
 EQUIPMENT DESIGN ALTERNATIVES
dashed wave represents the rf field during the time that the
cavities have oscillated into reverse phase, 180"later in the
time than the solid wave.)
The microwave energy switch may employ a noncon-
tact method9 (Fig. 11-3a) or a shorting method5'10 (Fig.
11-3b and c). The noncontact method is preferred because
it permits transmission of enough rf power to maintain a
desired low accelerating field in the second portion of the
guide. The shorting method in a single coupling cavity
results in the beam exciting the second portion of the guide,
building up a decelerating rf electric field over a second
filling time. This reduces the pulse time in which accept-
able beam energy spread is achieved, resulting in reduced
x-ray dose rate. Two side coupling cavities diametrically
opposite each other can be used to couple a single set of
on-axis cavities, using higher coupling coefficient slots for
one side cavity, lower coupling coefficient slots for the
other side cavity.5 By shorting one side cavity and unshort-
ing the other, and vice versa, the accelerating field in the
second portion of the accelerator guide can be switched
from high to low and vice versa from low to high (see Fig.
1I - 3 ~ ) .
Cell Number
Phase
Transition
Cavity
Broadband Bunching Portion
Electron Bunch Phase
(+I h
(-)
FIGURE 11-4 . Electron bunch phase with broadband buncher. The dashed wave is 180" of phase later in time than the solid wave. (a) 18 MV x-ray
mode and (b) 6 MV x-ray mode.
195
There were reliability problems with early versions of
microwave energy switches, related to the use of apart that
was moved in vacuum. Improvements have been achieved
via redesign.
A second method is to design the first portion of the guide
(the buncher) so that the electron bunch is formed even at
a reduced level of peak rf electric field and then simply
change rf power to change beam energy (see Fig. 11-4).
This has been called a broadband buncher. It avoids the
use of a part that moves in vacuum. In order to form an
electron bunch around a usable phase angle at widely
different rf peak electric field levels, the electrons would
spend considerable time slowly gaining energy at a syn-
chronous phase angle well forward of the crest in signifi-
cantly foreshortened cavities, gain only limited energy
while they bunch, and then be shifted in phase to near the
crest of the rf electric field for the rest of the guide. This
technique is wasteful of rf power in the buncher region, so
it requires higher peak power from the microwave source
to obtain a given maximum x-ray energy in a given guide
length. Figure 11-4 shows uniform field over the guide
length. Somewhat better results could be obtained by using
I
- 18" From
Crest
-
Acceleration Portion
of Bunch
196 CHAPTER 11. MULTI-X-RAY ENERGY ACCLERATORS
Phase of V, Ahead of V, By 0 \1-b +. (
+e!+
I I
Bunch Centroid
Beam Energy Spread
Opposing Field Generated By I
High Electron Beam Current I -
FIGURE 11-5 . Effect of beam bunch phase error on phase of net accelerating field and on energy spread with heavy beam loading.
a lower field in the first few cavities than in the rest of the
guide, but this is even more wasteful of rfpower. Changing
x-ray energy over a 3-1 range, from 18 to 6 MV, will
require a compromise in phase angle of the electron bunch,
being too far forward on the rf electric field wave at 18
MV and too far behind at 6 MV. This will result in
increased beam energy spread, hence reduced transrnis-
sion through the energy slit to the x-ray target in 6-MV
mode, hence reduced dose rate for equal maximum field
size flattened fully to the comers.
Running the electron bunch at a phase angle off the crest
results in increased sensitivity of electron energy to variations
in electron beam current loading and rf input power.' Figure
11-5 illustrates this point. For example, a sudden increase in
beam current increases VB,decreasing the net accelerating field
+
and shifting the phase of its crest from 0 to with respect to
the electron bunch. This perturbation (shift of net accelerating
field relative to the electron bunch) damps out with a time
constant of about 0.01 FS in an SW guide. In a TW guide, even
Net Field V, Shifts Ahead
I
of Electron Bunch By $
-
!
Unloaded Field Generated By
Klystron or Magnetron
Net Accelerating Field
with rf feedback, this effect is much larger because the damping
time constant is about 0.5 FS. In order to achieve useful (but
still marginal) dose rate in low energy x-ray mode with a
broadband buncher in an SW guide, it may be necessary to
make compromises such as:
1. Use of a thinner flattening filter, hence not flattening to the
comers of large fields (see Fig. 11-6).
2. Use of larger electron beam collimator holes. This permits
transmission of greater transverse emittance and, hence,
produces larger beam divergence angles at the x-ray target.
This can exacerbate beam symmetry instabilities.
3. Use of wider energy slit in the bend magnet system. This
can permit larger instabilities of depth dose curve in elec-
tron mode and larger instabilities of symmetrical field
flatness in x-ray mode.
4. Injection and acceleration of excess beam current and
wasting much of it on collimator holes and energy slit. This
exacerbates energy instability due to off-phase interaction
with the rfaccelerating electric field. Also, the requirement
 EQUIPMENT DESIGN ALTERNATIVES
/ /
40 cm x 40 cm Maximum Square Field
-----
FIGURE 11-6 . Flattened circle and size of square field flattened to cor-
ners for various thickness flattening filters.
for increased radiation shielding can affect the size and
weight of the radiation head and, consequently, the height
of the isocenter for clearance from the floor or, alterna-
tively, the location of the energy slit.
There are other methods that could be used to provide
operation at two widely separated x-ray energies with an SW
guide without using an energy switch. For example, with
appropriately tuned guide cavities, the guide could be powered
at one frequency to produce a uniform rf electric field over
the guide length for a high energy x-ray mode, and at a
different but closely neighboring frequency to produce a co-
sine-like distribution of rf electric field for low energy x-ray
mode, maintaining high field in the buncher in both cases.
However, such techniques are potentially unstable, being very
sensitive to thermal and frequency variations. The fundamental
problem still remains. The electron bunch is displaced some-
what from the rf electric field crest in the low energy x-ray
mode.
BEAM L O A D I N G
For an electron bunch of very short length, which rides the crest
of the fundamental space harmonic of the axial field in the
accelerator structure, load lines of beam energy Vversus beam
197
current i can be calculated using the equations of Table 11-1,
which are derived from Lapostolle6 and Neal.' Examples of
load lines are shown in Chap. 4. In essence, the net energy V =
Vo-AV, where Vo is the energy gain of an electron on the crest
at zero beam current and AVis the reduction in energy caused
by the beam load current i. Load lines are only a small part of
the story in estimating maximum dose rate at various energies.
Bunching, off-phase induced fields, radial divergence due to
space charge at injection, beam focusing, and so forth, are
important factors. Computer calculations are required to deter-
mine the beam intensity profile at the electron collimator and
the energy spectrum of the beam and its intensity profile at the
energy slit. Heavy beam loading exacerbates problems related
to bunching, off-phase transient induced fields, and resultant
spreading of the beam energy spectrum.
In T W structures of constant gradient design, the group
velocity of the rf wave decreases toward the exit end. That is,
the coupling between cavities is much lower toward the exit
end than near the entrance in order to tap off successively less
power from the preceding cavity. With heavy beamloading the
field induced by the beam increases toward the exit end,
increasing the tendency for the net accelerating field to slip out
of phase from the electron beam bunches, thereby tending to
induce beam energy spread and energy instability. Hence, a
small change in the temperature of the guide, of the rf source
frequency, or of the beam current can cause a tapered distribu-
tion of phase error of the rf field with respect to the beam bunch.
NON-CONTACT T Y P E SIDE CAVITY
E N E R G Y SWITCH
Figure 11-3a shows the simplest structure of a side-coupled SW
accelerator consisting of two centerline cavities and one cou-
pling side cavity used as an energy switch. Its equivalent circuit
leads to the relationships between coupling factors (KO]and
K,,) and accelerating field amplitudes (Eo and E2) in the cen-
terline cavities for the 1~12mode operation.
Since KQ is much larger than unity, the second term is
small. Hence, accelerating fields can be inversely varied by
varying the coupling factors Kol and K I 2between the acceler-
ating cavities and coupling side cavity. The negative sign
indicates that the phase between Eo and E2 is offset by 180".
If a longitudinal asymmetry is introduced by lengthening
one post and shortening the other (see Fig. 11-3a), a longitudi-
nally asymmetric field will be excited while the resonant fre-
quency is kept constant. With this asymmetric side cavity
coupled to the two centerline cavities, the magnetic coupling
of the short post will be significantly reduced and the coupling
of the longer post side will be increased. By introducing this
side cavity at a particular location along a side-coupled accel-
TABLE 11-1 . Equations for load lines
Traveling-wave guide without feedback:

Traveling-wave guide with feedback:

n
Standing-wave guide in - mode:
2

For an SW guide with an energy switch producing unequal fields over length L1 before and L2
after the switch, the effective shunt impedance rlL is substituted for rL, where:

Where (for all guide types) Abbreviation Units

Shunt impedance per unit length Mfllm
Accelerator guide length m
Resistive attenuation of rf field over length L nepers
Coupling coefficient of input coupler
Resistive power loss to guide at zero beam
Power incident on input coupler
Power reflected from input coupler
Power transmitted by input coupler
Power coupled to beam
Power from rf source into "lossless" bridge
of TW feedback network
Resistive power loss to guide when beam loaded
Ratio of first section length to total length
Ratio of first section energy to total energy
Effective shunt impedance due to (Y and 5
 REFERENCES 199

TABLE 11-2 . Clinac-1800 accelerator guide design parameters

Accelerator rf length (m) 1.47
Number of accelerating cavities 28 + V2
Frequency (MHz) 2856
Effective shunt Impedance (Mfllm) 102
Qo 15,200
Coupling factor, kl 0.04
Output energy (MeV)a 18 6
Radio frequency power into guide (MW) 3.8 1.2
Load line (MeV) V = 23.0 - 70i V = 9.8 - 30i

"Shows data for dual x-ray beams with widest energy spread. Other energies are available.

erator, one can vary the accelerating field ratio while maintain-
ing the 7r12 mode resonance. Thus, the accelerating field in the
second part of the accelerator guide can be shifted from high
to low while maintaining a constant field for bunching in the
first part, (see Fig. 11-1). Table 11-2 summarizes the Clinac
1800 accelerator design parameters. The variable coupling side
cavity is located between the rf coupler and the output acceler-
ator section. The buncher is designed to be optimized at an
accelerating field of 10 MVIm. The injected electrons will be
fully bunched and accelerated to 4 MeV at the point where the
fif !d is stepped.
Figure 1-24 shows the experimental results of the normal-
)zed output energy spectrum measured both at 6 and 18 MeV
fith a magnetic spectrometer using a 1 percent energy slit. The
measured fwhm energy spread for both modes is about 3
percent.
SYSTEM FEEDBACK CONTROL PHILOSOPHY
Each manufacturer has its own set of fundamental design
philosophies. One is to design each subsystem to be stable unto
itself, operate at only specifically selected steps of beam energy
and dose rate, and then use simple feedback control to stabilize
each step. A second approach would be to depend much more
heavily on feedback control via computer, using look-up tables
for each operating mode. A third approach is to align the
equipment well enough so that it can run with minimum feed-
back control, accelerate excess beam current, and waste an
oversized beam diameter and energy spread on shielded beam
collimators and energy slit so that deviations in mean beam
position and energy are reduced in the beam current reaching
the x-ray target.
REFERENCES
1. Arai S, E Katayama, E Tojyo, K Toshida: Beam loading effects
in a standing wave accelerator structure. Particle Accelerators
11:103-111, 1980.
2. Bensussan A, DT Tran, D Tronc: Standing wave triperiodic
structure for a 10 MeV medical accelerator. Nucl Instr Meth
140:231-235, 1977.
3. IEC Publication 977: Medical electrical equipment. Medical elec-
tron accelerators in the range 1 MeV to 50 MeV--Guidelines for
functional performance characteristics. IEC, 1 Rue Varembe,
Geneva, Switzerland, 1989.
4. InternationalCommissionon Radiationunits and Measurements:
Determination of absorbed dose in a patient irradiated by beams
of X or gamma rays in radiotherapy procedures. ICRU Sept. 15,
1976,7910Woodmont Ave.; Washington, DC 20014; ReportNo.
24.
5. Kazusa C, M Yoneda: Side coupled standing wave linear accel-
erator. U. S. Patent 4,746,839, issued 24 May 1988.
6. Lapostolle PM, AL Septier: Linear accelerators, New York,
Wiley, 1970.
7. Neal RB (ed.): The Stanford two-mile accelerator, New York, W.
A. Benjamin, 1968.
8. Sutherland, WH: Dose monitoring methods in medical linear
accelerators. Br J Rndiol43: 864, 1969.
9. Tanabe E, R Hamm: Compact multi-energy electron linear accel-
erator. Nucl Instr Meth B10/11:871-876, 1985.
10. Uetomi I: Standing wave accelerator. U. S. Patent 4,651,057,
issued 1987.
11. Whitham K: 20 MeV S-band standing waveguide. IEEE NS-22
(3), 1328-1333,1975.

Patient Support Assembly and
Treatment Accessories
PATIENT SUPPORT ASSEMBLY
The patient support assembly (PSA), be it treatment table
(couch) or treatment chair, fills a central role in supporting,
positioning, and facilitating immobilizion of the patient in a
readily implemented and comfortable manner. The PSA must
be constructed with high standards for safety, accuracy, rigidity,
reproducibility, reliability, maintainability, together with flex-
ibility in use for patient treatment and portal imaging. The need
for reproducible positioning of the patient during the entire
course of radiation therapy, which ensures directing the beam
accurately on the target volume, has been demonstrated by
Kartha et al.,23 as well as by Marks et al.40 Ideally, one uses the
same PSAon the simulator to facilitate duplication of position-
ing for therapy. Figure 12-1 illustrates an elementary treatment
couch for an isocentric linac and emphasizes the geometrical
relationship of the linac and treatment couch motions. The
couch support must be offset from the isocenter and the couch
cantilevered to allow the radiation head to pass underneath the
couch in 360" gantry designs (early machines did not rotate
360"). Patient chairs may be attached to the end of the couch
for positioning and make use of the coordinate motions of the
couch. They are used infrequently, typically for 30 or fewer
patients per year, less than 10% of patient load.
PATIENT TABLE SUPPORT TYPES
Treatment couches are mounted on a pedestal (see Fig. 12-1) or
on a vertical column called a ram (see Fig. 12-2).Couches incor-
porate motorized control of longitudinal, lateral, vertical, and
angularpositions usually via a lightweight,hand-held or ceiling
mounted pendant. Such controls may be duplicated on the
couch. The longitudinal and lateral motions of the couch top
may also be positioned manually. Some couch tops provide an
auxilliary rotation about a vertical axis displaced from the
isocenter as well as roll and pitch angular motions about lateral
C H A P T E R 12
and longitudinal couch axes respectively.21 The couch may in-
corporate pushbutton controls for room, field, rangefinder, and
laser positioning lights, as well as for retractable beam stopper
positioning and for emergency machine off. The couch rotates
about a vertical axis, passing through the isocenter normal to the
gantry axis (see Figs. 12-1). Couch rotation facilitates certain
techniques such as stereotactic radiosurgery, wherein multiple
arcs of the gantry are spaced over the patient's head by rotating
the couch to a number of discrete couch rotation angles16 (see
Figs. 2-12 and 2-13). Couch rotation is also used in contempo-
rary breast treatment with complex 3-D positioning tech-
niques.35.57 It is important that this rotation have an easily read
angular scale, a secure position lock, and a true vertical axis.
The pedestal vertical motion (Fig 12-1) is powered by a
contoured scissors-jack mechanism contained in the base that
gives uniform lift speed for a constant motor drive speed. The
pedestal style couch is largely self-contained above the floor
but often has a high minimum height position above the floor,
which precludes the use of large SSD values and treatment field
sizes. Recently, extended range, double-scissor-jack couches
have been introduced with more than lOOcm of travel and
having both high and low height capability. This permits large
field treatments from both above and below arecumbent supine
patient, through large openings in the couch top, eliminating
the internal organ shift when changing between the supine and
the prone position, a change usually necessitated if vertical
couch travel is limited.
Usually the ram style couch can be positioned nearer the
floor to permit large treatment field sizes and SSD distances as
large as 150 cm from above and below the patient. However,
such a couch may require a deep pit, up to 6 ft, in the floor with
attendant cost, maintenance inconvenience and vulnerability to
flooding from both hospital and machine water supply. The ram
vertical motion is powered by a long, motor driven lead screw.
The couch itself may be detachable from the lifting ram,
leaving a clear floor area for special patient setups and to
facilitate the use of dosimetry apparatus. Couch motions are
202 CHAPTER 12. PATIENT SUPPORT ASSEMBLY AND TREATMENT ACCESSORIES

X-RAY TARGET
GANTRY

\ P CEILING LASER

COLLIMATOR ROTATION

GANTRY
ROTATION
DIGITAL POSITION
INDICATORS

BEAM
CENTRAL AXlS
STAND

SlDE LASER SlDE LASER

I
1
/ - \ / \\\\A
\\\\. \

AXlS , ISOCENTER

TRANSLATIONS

TREATMENT .COUCH
COUCH ROTATION
/
HAND
CONTROL

FIGURE 12-1 . Schematic view of a treatment unit emphasizing the geometric relationship of the linac and treatment couch motions. A pedestal type
couch is illusTrated.

usually equipped with electrically released brakes. Drive mo-

tors are provided with slip clutches to prevent inadvertent
application of excessive torques.
The isocenter height of a treatment unit is determined by
the length of the radiation head on the beam axis and the
target-skin distance. Operationally, a low isocenter height is
favored for the convenience of technologists, but it may be
associated with more restricted, vertical couch travel and col-
limator clearances. Vertical couch motion is always powered,
preferably variable in speed and interlocked with a safety
enable bar "deadman" switch on the couch control pendant. If
not powered, lateral and longitudinal motions of the couch are
provided with locks that facilitate orderly setup procedures.
Flexible couch positioning aids both ambulatory and gurney
patients in mounting and dismounting or transference to and
FIGURE 12-2 . Ran1type patient couch. (Courtesy of Philips.) from the patient couch (table top).
 PATIENT SUPPORT ASSEMBLY 203

Several modifications have been developed to overcome couch dual-side-rails, and often along their ends, to attach
some of the limitations of early couch designs. Gillen et al.13 patient positioning and immobilization devices, as well as field
constructed a vertical couch extender that overcomes the limi- modification accessories and cassette holders. These and other
tations of some couches in permitting the use of large anterior accessories are treated on pages 204, 208. Simulators should
and posterior fields while keeping the patient in the supine be equipped with therapy style couches having similar tops and
position during the entire course of treatment. Biggs and attachable accessories. However, simulator couches may be
Leong3 describe an attachment for an existing couch to extend fitted with a carbon fiber couch top, a plastic composite featur-
the range of SSDs at which patients can be treated with a ing strength, lightness, and translucency to diagnostic energy
downward directed beam. It attaches perpendicular to the end x-rays.19
of the existing couch and makes use of all the latter's motions.
A heavy patient may exert significant stress on the treat-
ment couch, particularly, if supported in extreme positions. The
IEC has established positioning range and scale standards, TREATMENT CHAIR
deflection tolerances under specified loading conditions, as Some lesions may be advantageously treated with the patient
well as specifications for the parallelism of vertical motion and seated. These include pituitary and other brain tumors, as well
rotation axes.21 If the possibility exists that failure of a motor- as other head and neck sites and particularly, central lesions of
ized movement during normal use of the equipment might the head. Treatments carried out with the patient seated may be
result in a patient becoming trapped, means shall be provided particularly valuable for a small group 'of patients unable to lie
to permit the release of the patient.21 Simulator couches should down and for treatment areas more accessible with the patient
incorporate similar standards and tolerances. in an upright position. Immobilization of the patient's head
using a bite block is often used in conjunction with chair
treatments.24 A chair described by Karzmark et a1.,*5.26 accom-
modates both sitting and standing patients. Drive mechanisms
TABLE TOP for this chair are located in a floor pit with the chair detachable,
The couch top is often constructed of smooth, hard panel leaving a smooth floor for patients wheeled on a gurney. The
sections, for example, Benelex (Masonite) plastic, or carbon chair itself is mounted on casters to facilitate its attachment,
fiber for strength and x-ray transmission which attenuates the removal, and storage. The powered motions include horizontal
treatment beam minimally. An early finding was that deeply X and Y translations; two concentric rotation axes about the
upholstered couch tops, although more comfortable for the vertical and two SAD positions along the horizontal axis of the
patient, were unsatisfactory for reliable, reproducible patient treatment beam.
positioning. Couch sections are of standard width, typically A commercial chair is described by Mulkerin and shown
about 50 cm, of variable lengths, and are removable and inter- in Figure 12-3.4The chair is fixed to the end of the treatment
changeable to best accommodate the treatment beams and
patient anatomy. Often, one section of the couch top is con-
structed of a nylon "tennis racket" grid (covered with Mylar for
comfort) or a thin Mylar film to facilitate observation for
treatment procedures from below and for port film exposures,
as well as for marking the skin from below (through the tennis
racket)? Treatment planning must take cognizance of possible
patient sag between different CT, simulator, and treatment table
top surfaces. When port films are needed, the couch should
accommodate film cassette holders for films as large as 14 X
17 in. between rails or the cassette supported from ancillary
devices. Some couches incorporate a center spine section,
which facilitates the placement of angled posterior fields with-
out attenuation of the beam by the couch rails.
Many couch tops may be rotated end-for-end about a
central vertical axis. Such a couch is constructed with an outer,
dual-side-rail structure on one end and a single center spine on
the other end. This feature provides flexibility in the treatment
field and portal film orientation. To avoid interference from the
couch rail (s), central lesions irradiated with anterior-posterior
fields make use of the dual-side-rail end of the couch and
lesions employing angled fields often make use of the single FIGURE 12-3 . Tkeatment chair shown attached to end of treatment
center spine end. Accessory rails are usually provided along the couch. (Courtesy of Varian.)
204 CHAPTER 12. PATIENT SUPPORT ASSEMBLY AND TREATMENT ACCESSORIES
couch with locking pins placed through the dual-rail structural
members. Casters on the chair permit technologists to easily
roll the chair aside. Such a chair makes use of the couch
motions for positioning the patient. The permitted gantry an-
gles for treatment with isocentric linacs will be limited by the
chair, particularly, in beamstopper equipped treatment units.
Compared with a couch, a treatment chair is more cumbersome,
the chair patients will often require more setup time and often,
no provision is made for simulation in a chair.
TREATMENT ACCESSORIES
Radiotherapy treatment procedures have become more com-
plex and precise in the continuing effort to accurately deliver a
prescribed dose to a specified target volume. Increasingly, so-
phisticated accessories are incorporated into such procedures
and the simulation of them. Historically, a small number of
treatment centers designed and constructed accessories to fit
their own individual needs, often with the assistance of an
on-site or a local machine shop. At times, a descriptive publica-
tion ensued and other centers adopted or modified the original
design. Infrequently, an enterprising manufacturer would pro-
duce and market these innovative devices. The adoption of
accessories that could enjoy wide usage was slowed by the
variability of treatment procedures between centers, by a lack
of standardsand agreement as to what was needed, as well as the
relatively small market that discouraged commercial produc-
tion. Over the years, a growing awareness of the importance of
accessories in treatment procedures became apparent. This
awareness gave rise to the development of new and better
accessories.It emphasized the need for their interchangeability
between treatment units and simulators, as well as among treat-
ment units themselves. There was also increased agreement as
to what accessories were needed and their characteristics. Sev-
eral manufacturers now cater to these needs independently and
increasingly accelerator manufacturers incorporate functional
accessories into their patient treatment systems.
Accessories may be categorized in terms of their function
or their usage. Some accessories, such as shadow blocks,
wedge filters, and tissue compensators, function in modifying
the radiation beam spatial dose distribution. Others are con-
cerned with patient immobilization, patient alignment, or po-
sitioning. Accessories such as wedge filters are mounted in the
accessory holder on the radiation head, and others elsewhere
on the gantry, the couch, or the floor. Few standards presently
exist for accessories. When adopted, they may involve such
considerations as: handling aspects (e.g., weight and handles),
indicators and scales, interchangeability, mechanical interfer-
ence between accessories, alignment, interlocking, radiation,
and mechanical safety (attachment security and collision
avoidance), as well as positioning tolerances. The development
of functional performance standards for medical linacs has
served to focus attention on the need for standards for treatment
accessories.2l Recently, the IEC has developed standard terrni-
nology for several accessories such as field blocks and tissue
compensators, and is working toward a format specificationfor
accessory holders, accessory rails, and shadow trays.
As treatments become more complex and large accessory
trays are attached to the radiation head, collisions between
these accessories and the patient, couch, or couch attachments
become more probable. The incident treatment beam should
not intersect the couch accessory holders or rails, which may
attenuate the beam by more than 40 percent. Such geometric
problems can be expressed in terms of field sizes and gantry
avoidance angles for specified treatment setups. These and
other parameters have been incorporated into a brief computer
program for planning treatments by Yorke.61
In the sections that follow, accessories are categorized by
usage. They encompass both x-ray and electron therapy treat-
ment modalities. References that pertain to several categories
are listed under their primary usage. Goerl4 reviewed the role
of treatment aids and accessories in radiation therapy treatment
with emphasis on port films, electron arc therapy, patient
immobilization and positioning, as well as record and verify
systems. A comprehensive and well-illustrated exposition of
radiotherapy accessories has been provided by hrdy.51 The
recommendations and background considerations of a work-
shop on geometric accuracy and reproducibility in radiation
therapy have been published.56 The 14recommendations of the
workshop are divided into three categories: the significance of
treatment accuracy, the achievement of accurate treatment, and
the verification and evaluation of treatment accuracy. Boyers
has reviewed patient positioning and immobilization devices,
and their effect on radiotherapy treatment.
FIELD SHAPING SYSTEMS
Most tumors are irregular in shape. Therefore, auxiliary absorb-
ing shadow blocks are frequently used to modify the customary
rectangular shaped x-ray fields provided by the conventional
adjustable beam limiting collimator. Alternatively, a multileaf
collimator having (e.g., multiple leaves of 1-cmeffective width
or less at 100-cm SAD) can be used to approximate an irregu-
larly shaped field. (see Chapter 2, pp41-43). Heavy metals such
as tungsten, lead, or low melting point lead alloys (Lipowitz
metals), such as Cerrobend, in lead equivalent thicknesses of
7.5 to 10 cm are needed to reduce the transmission of high en-
ergy x-rays to 5 percent or less for shadow blocks. Thicker
shielding shadow blocks are often not warranted because of the
limiting effects of penumbra and scatter from the irradiated vol-
ume into the shielded tissues. It is impractical to reduce trans-
mission through a shielding block to 1 percent, for example, by
increasing its thickness if scatter and penumbra already contrib-
ute 3 percent. The narrow beam transmission thicknesses of
Lipowitz metal to the 1 percent level at 2,4,10, and 18 MV and
for 60C0 has been reported.18 Lead or tungsten field blocks are
frequently provided in an assortment of useful cross-sectional
 TREATMENT ACCESSORIES
shapes (e.g., rectangles, triangles, and arcs of circles) for repeti-
tive use. They are positioned on an accessory holder placed on
the radiation head. Lipowitz metal blocks have become increas-
ingly popular since they have a high physical density, a low
melting point temperature, and can be cast in high density Styro-
foam molds into irregular shapes to completely define an irregu-
larly shaped field for an individual patient and provide for beam
divergence.49 For supine orprone patients, a position used in the
treatment of lymphomas, field blocks may be placed on a tray
supported over the patient.45 Figure 12-4 shows the arrange-
ment of shadow blocks employed for such treatments. Once a
patient has completed treatment, these blocks are conveniently
melted and recast into new shapes for patients treated at a later
date. Several centers have described systems having automatic
cutting machines for the molds and for casting and using such
b1ocks.22.37.49.54
Thinner transmission blocks, which transmit 30-50 per-
cent dose, are often used to reduce dose to sensitive treated
tissues such as lung, while preserving the dose fractionation
schedule.44.46 Their use insures an optimal radiobiological ef-
fect for such tissues as well as for nearby tissues irradiated to
a larger dose. This regime is preferable radiobiologically to
using 5 percent transmission blocks and removing them for
one-half of the treatment days, for example.
An ingenious, synchronous protection and field shaping
system employing a curved absorber has been described for
rotation therapy.5oUsing such a system, the curved spinal cord
-
FIGURE 12-4 Typical lymphoma treatment region showing the area
covered by two adjoining fields, the mantle and inverted-Y fields, and
the arrangement of shielding blocks needed.
205
of an individual can be protected by rotating an appropriately
shaped shield, placed in the beam between the patient and x-ray
target, so as to accurately shadow the continuously changing
spine outline during rotation therapy.
The plastic acrylic trays used to mount shielding blocks
degrade the x-ray buildup region by contributing low energy
electrons to the patient skin surface. The attendant, undesirable
increase in skin dose can be reduced, by as much as 15 percent
for large fields by substituting a clear leaded acrylic in the tray.4
Complex treatments, such as breast, entail the use of abut-
ting fields with the attendant hazards of underdose and overdose
associated with their divergence at the junction of the fields. In-
creasingly, such techniques incorporate field half-blocks in
which one-half of the treatment field is blocked by placing one
edge of the half-block along the beam central axis, thereby elim-
inating the divergence at the field edge near the ribs.35 The half-
block is by necessity, inconveniently large and heavy, and may
restrict simultaneoususe of other accessories. Several treatment
units now provide field half-blocking by the use of indepen-
dently positioned beam limiting collimatorjaws.33Here, one or
both pair of collimator jaws is constructed to provide either
symmetric or asymmetric fields with respect to the central axis
of the beam. For such fields, the asymmetric effects of flattening
filter and scatter in the patient influence beam quality and the
shape of isodose curves. The dosimetry of such asymmetric
fields has been studied by Khan et al.29and Palta et a1.47
Electron fields are shaped with adjustable collimators or
detachable applicators providing a small number of square or
irregular field inserts. Thinner absorbers, typically of 1 to 2-cm
equivalent lead thickness, can be used for irregularly shaped
electron fields. They may be cast in thin, tailored Styrofoam
molds as for high energy x-ray blocks. A technique for con-
structing square field or irregularly shaped field Cerrobend
inserts has been described.52 The electron beam defining aper-
ture is usually positioned at a small distance (e.g., 5 cm) from
the incident skin surface. This separation allows for an unflat
patient surface and permits observation of the light field on the
patient's skin. The x-ray collimators provide "backup" periph-
eral shielding for electron treatment apertures and usually, are
positioned automatically to a slightly larger (e.g., 5-cm extra
added) field dimension.
WEDGE FILTERS AND TISSUE COMPENSATORS
Anatomical body surfaces are often nonplanar and irregular; an
incident beam uniform in cross section would result in a non-
uniform distribution of dose at tumor depth in a plane orthog-
onal to the beam axis. Wedge filters and tissue compensators
are employed in such situations to modify the incident beam
and to provide a more uniform dose distribution at the tumor
depth. Wedge filters are usually in the form of 1-D absorbing
wedges, which tilt the isodose distribution through a given
angle (e.g., 30") at 10 cm depth. Pairs of wedges are often
needed when adding fields at angles less than 180". Wedges are
206 CHAPTER 12. PATIENT SUPPORT ASSEMBLY AND TREATMENT ACCESSORIES
commonly used for two fields at 90' to each other but at larger
and smaller angles as well.
In one wedge accessory system, the wedges slide into a slot
of the accessory holder placed close to the collimators at the
front of the radiation head. A second adjacent slot is provided
for attaching other accessories, such as shadow blocks. At the
isocenter, wedged fields typically cover 15-20 cm in the
wedged dimension and 3040-cm perpendicular to the wedged
dimension. The wedge factor, that is, the fraction of incident
dose transmitted on the central axis, will vary with beam en-
ergy, wedge material, and wedge angle. Representative wedge
factor values at 10MV are about 0.90 at 15"and 0.50 at 60". The
wedge becomes thicker and the wedge factor is decreased if the
wedge is designed to cover a wider field in the wedged dimen-
sion. There is need for high machine dose rates to compensate
for the marked attenuation of large angle, large field wedges.
Wedges are electrically interlocked to insure complete inser-
tion into the wedge slot and are labeled and individually coded
to identify the particular wedge angle and direction of insertion,
that is, 0" or 180" at the console. Miller and van de Geijn41 de-
scribed a modification of the wedge fault logic to accommodate
and code additional large field wedges in a Clinac 18/20.
Most treatment units are provided with a selection of
wedge filters that are mounted externally. A single 60" wedge,
mounted inside the head and remotely positioned by motor
control, may also be used as a universal wedge. Beams with
effective wedge angles less than 60" are obtained by delivering
an appropriate portion of the dose with the 60" wedged field and
the remaining portion with an open (unwedged) field. Measure-
ments of such a wedge by Petti and Siddon48 agree well with the
model proposed by the manufacturer. The feasibility of provid-
ing wedge-shaped dose distributions by computered-controlled
collimator jaw motion has been demonstrated by Kijewski et
al.30 and has been called dynamic wedge. By adjusting the
velocity of the jaw, one can produce fields with any wedge
angle less than 60". The isodose curve in the principal plane can
be made into a straight line of a predetermined angle at any
desired depth and for an arbitrary field size.
FIGURE 12-5 . Tissue compensation. (a) The principle of shrinking the area of the tissue compensator, and (b)typical compensator
constructed of aluminum square columns for 6 X 8-cm anterior field applied to the neck. (Courtesy of Ellis, from Ref. 10.)
The availability of independent jaw collimater systems
and computer control has made the dynamic wedge an attrac-
tive option. As with the universal wedge", the technique sim-
plifies wedge treatment setup since one no longer has to handle
and install a physical wedge. Moreover, unlike physical
wedges, the dynamic wedge delivers wedged-dose distribu-
tions that have a constant wedge angle over a larger portion of
the radiation field with smaller effective perembra.32a Beam
characteristics of wedged fields can be optimized indepen-
dently for different wedge angles, field sizes, tissue depths, and
x-ray beam energies. A dynamic wedge field may employ two
adjacent segments having different wedge angles. A dual-pass
technique, in which the dose is delivered by traveling the
wedge field in both directions, provides isodose distributions
adhering closely to the idealized prescription. A closed loop,
servo-controlled computer system modulates the jaw speed and
dose rate simultaneously to optimize and customize the dose
distribution. An extention of this procedure will also incorpo-
rate the shape of the patient contour into the treatment planning
system.
Tissue compensators are employed for individual patients
and provide 2-D dose modification by the use of shaped ab-
sorbers of wax, aluminum, brass, lead sheets, or lead alloys.
The compensator is a 2D absorber constructed to compensate
for missing tissue defined between a plane perpendicular to the
beam axis and the patient's skin surface over the treatment area.
Its affect is to provide a flat field over a plane perpendicular to
the beam axis through the target volume at the tumor depth.
Large field compensators do not compensate perfectly at other
than one selected depth and can introduce hot spots at thinner
body sections. The compensator is mounted on a plastic lamina
that slides into an accessory slot. Placed between the target and
skin surface, it takes the shape of a minified contour, which is
the inverse of the incident skin surface (Fig. 12-5a). In one early
compensator, aluminum columns of square I-cm cross section
and various lengths were assembled into a 2D absorber matrix.
It is convenient to vary the absorber length in multiples of 1-cm
tissue equivalent,lo (see Fig. 12-5b).
 TREATMENTACCESSORIES 207

An apparatus to measure the missing tissue depths at the
patient by measuring the variation in distance of representative
rays over a treatment field grid of 1-cm squares has been
described.28 Another method involves plaster casts and photo-
graphs of successive contours, which are fabricated from lead
sheets cut to the same shape with proper demagnification.31 In
an alternative optical technique using lead sheet, a Moire'
topographical photograph is obtained on the simulator.6 This is
then employed to transform the depth of missing tissue con-
tours in the photograph to a lead sheet compensating filter
equivalent.
One versatile and elaborate compensator system employs
a contour milling machine design principle. In it, a stylus is
moved over the treatment area while it simultaneously cuts out
a 3-D Styrofoam mold using appropriate linkages. This mold
is used to cast a Cen-obend compensator for the prescribed
treatment geometry.l7,28,53
X-ray filters and compensators must be positioned at least
20 cm from the patient skin surface to limit the dose contribu-
tion from secondary electrons originating in them. Similarly,
the use of lead acrylic accessory holder mounting plates limits
secondary electron production and, hence, skin dose compared
to materials such as Lucite.4 Filters designed to flatten the
angular distribution of megavoltage x-ray beams are treated in
Chapter 8, pages 147-148.
CT data for internal anatomical structures, as well as contours
from a number of slices. Contour devices are frequently incor-
porated into simulators where they conveniently contribute to
treatment planning information.
One representative electromechanical contouring system
is suspended above the patient on a telescopic support (see
Figure 12-6).9 A system of two articulated arms and three
precision potentiometers teminate in a probe arm contacting
the patient's skin surface. The X-Y cartesian coordinates of the
contour are obtained from the trigonometric based logic of the
associated electronics. The contour coordinates for any number
of cross sections are stored on tape and fed to the treatment
planning computer. A similar system makes use of a graphics
digitizer to provide computer compatible coordinates of patient
contours.58 In another approach, an optical system, consisting
of a light source, mirrors, and photomultiplier tube, is mounted
on the simulator gantry.36 An associated feedback system and
computer are used to calculate the distance from the isocenter
of a slit of light reaching the patient in a sequence of angular
positions of the gantry. The ultrasonic scanner has also been
used for contour acquisition.

PATIENT CONTOUR SYSTEMS

Patient contour systems are used to obtain a full scale, cross-
section outline, usually a transverse section, of the patient's
body surface for treatment planning. Frequently, this contour
is limited to a central plane containing the beam axes, and
usually containing the width or length of the field. Treatment
planning is usually confined to this 2-D plane. However, sev-
eral adjacent planes are needed for more complex treatments
and a larger number when 3-D treatment planning is employed.
Patient contours and the position of body organs can be ob- Carriage -
tained from CT scans, but substantial indexing and patient
positioning problems are involved.
Many patient contour devices are for use with the patient
lying on the treatment couch in the prone or supine position.
One of the earliest and simplest methods of contour acquisition
is to shape one or more lengths of lead solder wire to approxi-
mate the patient contour and trace the outline(s) onto paper.
This method and an alternative circular device, which incorpo-
rates a sequence of adjustable radial rods, are described by
Lanzl et al.32
Contouring devices may be a simple mechanical rho-theta
combination involving a variable length arm (rho), which can Oigin of Coordinates
move through a variable angle (theta) about a fixed point of
attachment. The sequence of rho-theta values traced out by the
distal point of the arm can be translated tox-y coordinate points
-
FIGURE 12-6 Schematic representationof patient contouring de-
vices. Pi, Pz,and P3 are potentiometers that measure the vertical height
defining the patient contour. More sophisticated optical and of the carriage, the angle 0, and the angle 4, respectively. (Courtesy of
x-ray systems are also employed. The latter may incorporate Doolittle, from Ref. 9.)
208 CHAPTER 12. PATIENT SUPPORT ASSEMBLY AND TREATMENT ACCESSORIES
PATIENT IMMOBILIZATION DEVICES
Many radiation treatment procedures are predicated on spatial
accuracies of 3 to 5 mm and some to 1 mrn.15,16,38 Patients are
usually unable to maintain the position of the relevant body
anatomy to this accuracy during treatment without auxiliary
immobilization devices. Many treatment fields incorporate a
I-cm border around the tumor to account for breathing dis-
placements, assumed tumor spread, inaccuracies of CT, and so
on. Hence, such devices are often used to simplify a procedure
and insure accuracy on a daily basis during a course of therapy.
Boyers has recently reviewed patient positioning and im-
mobilization. He discusses the consequences of malpositioning
and the need for frequent position verification. Immobilization
devices are frequently used in conjunction with head and neck
treatments, which often involve normal tissue structures in
close proximity to the tumor, with an attendant need for spatial
accuracy. They include bite blocks,24 as shown in Figure 12-7,
molds, and other devices incorporating a wide variety of ap-
proaches. Such devices are constructed or adjusted for the
individual patient and resewed for their exclusive use during a
course of therapy. A reduction from 16 to 1 percent in signifi-
cant localization error (a shift of 1 cm or more of the treatment
portal in any direction compared to the original localization
FIGURE 12-7 . Rite-block mounted at end of treatnlent couch for su-
pine patients. The patient's head rest in the plastic head i n ~ n ~ o b i l ~he.r ,
The bite-block assembly a and bracket c are readily detachable.
film) was found in one head and neck study when immobiliza-
tion was employed.39
Plaster casts were one of the earliest immobilization de-
vices. They have largely been supplanted by thermal-setting or
vacuumcast plastic lamina or meshes and more recently, by
light-cast plastics,34 which set with the application of UV
light.8,12,42,60Vacuum-activated sand blankets and tailored Sty-
rofoam molds can be employed in a wide variety of proce-
dures.42The vacuum-activated sand blanket is especially useful
with infants and small children. Individualized plastic im-
mobilization devices are used where precise alignment is im-
portant, often with tremorous patients. Treatment couches and
chairs often incorporate arm supports, hand grips, and leg
supports.
MECHANICAL AND OPTICAL POINTERS
The positions of radiation treatment field axes on the patient are
often established by the coincidence of skin marks placedon the
patient with the central axes of the entrant and exit fields. At-
tachable front and back mechanical pointers, together with the
image of an optical fiducial cross projected on the beam axis,
were among the earliest devices employed to establish beam en-
trant and exit axes. Since such skin marks canmove with respect
tointernal anatomy due to weight loss, hanging fatty tissues, and
so on, distances from bony landmarks must be used to confirm
the location of axes through a deep seated tumor. Direct use of
skin marks for positioning tumors of the lower abdomen is not
recommended, especially for obese patients.
Isocentric treatment procedures, wherein the tumor is cen-
tered at isocenter, lend themselves to optical pointing methods.
Here, auxiliary wall and ceiling mounted lasers project fiducial
crosses or fan beams through the isocenter (see Figure 12-
8)20,59 Their intercepts are marked on the patient's skin and
provide a convenient reference for daily setup. Simulation
procedures and the easy transfer of coordinate information are
enhanced by providing a duplicate group of such lasers and a
mechanical front pointer in the simulator facility. The use of
CT images in providing anatomical information required for
radiotherapy treatment planning is well established but the
procedure is often indirect. Endo et al.11 describes an auxiliary
optical system attached to the CT unit, which provides patient
treatment beam positioning information and makes direct use
of the CT images.
PATIENT POSITIONING AND MOTION
DETECTION
An early patient motion detection system incorporated a com-
parison of orthovoltage or megavoltage port films taken just be-
fore and just after treatment.' Although megavoltage film
contrast is low, a dual exposure technique that superimposes an
over-sized or maximum field exposure onto the smaller treat-
 REFERENCES 209

Ceiling
Laser

! Accelerator Rotation
I Angle Indicator Side
Lasers

rce

Vertical Scale

FIGURE 12-8 . Location of the iscocenter, gantry rotation axis, treatment couch, and positioning lasers
on a &MeV linac.

ment portal exposure can provide useful anatomical informa-
tion at lower megavoltage energies. Visualizing anatomical dif-
ferences with film becomes increasingly difficult at 10 MV and
above. Several high energy accelerators now incorporate a low
energy (e.g., 6 MV) x-ray port filmmode. More complex and so-
phisticated motion detection procedures make use of a transmit-
ted fluoroscopic image and video cancellation techniques by
image subtraction, which portray differences in the observed
image that change with time.
An early study of continuous visual monitoring of the
treatment beam relative to the anatomy and contrast media,
such as air or mercury, involved a 2-MV Van de Graaff beam.'
The ~ransmittedimage was viewed on a fluorescent screen with
a television pickup system, amplified and reproduced on a
monitor at the control console. It was possible to make minor
position corrections during treatment in the case of rotation
therapy. Kelsey et al.27 adapted a closed circuit television
(CCTV) system for the measurement of patient motion during
therapy. A preliminary study showed that patients remain
within ? 2.5 mm of treatment positions during 90 percent of
treatments. Patient repositioning and motion detection have
also been studied using a video cancellation system.7 Here, the
correct position is stored on a video disk and compared with the
live image from a CCTV using a video subtraction technique.
Repositioning and patient movements of 1 mm are detectable.
The effect of position errors in the radiotherapy of head and
neck cancer has been assessed by Marks and Haus.39
Rabinowitz et al.55 examined the accuracy of radiation field
alignment in clinical practices by comparing treatment-to-
treatment variations in anatomy with respect to the field by
comparing sequential portal films. They found a normally dis-
tributed standard deviation of 3-mm independent of site and
field shaping technique. Discrepancies between the portal and
simulator films were considerably greater and depended on the
site of treatment. The mean worst-case discrepancy averaged
over all sites was 7.7 mm. This suggests that random uncertain-
ties in treatment setup were not responsible for the discrepan-
cies and they are more likely due to systematic errors in the
treatment relative to the treatment simulation. An extensive de-
scription of portal imaging may be found in Chap. 13, pages
224-237.
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50. Priomos BS: Synchronous protection and field shaping in
cyclotherapy. Radiology 77591-599, 1961.
5 1. Purdy, JA: Radiotherapy accessories. Encyclopedia of Medical
Devices and Instrumentation, in John G. Webster, (Ed) New
York, Wiley-interscience, 1988 IV pp 2466-2483.
52. Purdy JA: Electron beam simulation applicators. Med Phys
10:911-912, 1983.
211
53. Purdy JA, SD Henderson, WB Harms: Compensating filter
system design and use in radiotherapy. Proceedings of the Tenth
Varian Users Meeting, Palm Springs, CA, April 15-17, 1984,
pp 3 8 4 5 .
54. Purdy JA, A Sorenson,J Eisenhoffer: A combination Styrofoam
cutter/block checker for fabricating field shaping blocks. Int J
Radiat Oncol Biol Phys 2:1209-1211,1977.
55. Rabinowitz I, J Broomberg, M Goitein, K McCarthy, and J
Leong: Accuracy of radiation field alignment in clinical practice.
Inter J Radiol Oncol Biol Phys 11:1857-1867,1985.
56. Reinstein LE; Recommendationsof the workshop on geometric
accuracy and reproducibility in radiation therapy. Med Dos
12:27-33, 1987.
57. Siddon RL, GL Tonnesen, GK Svensson: Three-field technique
for breast treatment using a rotatable half-beam block. Int J
Radiat Oncol Biol Phys 7:1473-1477, 1981.
58. Simpson LD, R Mohan: Computer compatible patient contour
plotter. Med Phys 4:215-219, 1977.
59. Thomadsen BR: Principles in positioning cross-projecting la-
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60. Verhey LJ, M Goitein, P McNulty, JE Munzenrider, HD Suit:
Precise positioning of patients for radiation therapy. lnt J Radiat
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61. Yorke, ED: The geometry of avoiding beam intersections and
blocking tray collisions. Med Phys 16:288-291, 1989.
 Treatment Simulators, Treatment
Planning and Portal Imaging
TREATMENT SIMULATORS
"The simulator is and has been a radiotherapy aid for one-quar-
ter of a century and yet, to many, its purpose and use are still
undefined. The simulator is a different aid to each clinician who
sets out to use it, and the use they make of it changes and grows
with experience." This observation appears in the introduction
to a report entitled: Treatment Simulators.l7 The BIR Supple-
ment 2316 with this same title describes recent developments
and perspectives concerning simulators that include imaging
and computer aspects. These are excellent, general references
on simulators which, in addition to design aspects, identify their
value and use and indicate how they are incorporated into
radiotherapy treatment planning facilities. Design considera-
tions find their expression in performance specifications and
the quality assessment and assurance of them.16.69.85
McCullough and Earlegs provide an extensive assessment of
the latter aspects, often with somewhat tighter tolerances and
from the perspective of American equipment and practice.
Considerations in selecting related x-ray equipment, generator,
tube, and image amplifier are included. Figure 13-1 illustrates
a contemporary radiotherapy simulator providing both radiog-
raphy and fluoroscopy. A quasisimulator alternative, which
provides x-ray field verification, has been demonstrated by
mounting a diagnostic x-ray source on the side of a linic.9
The results of diagnostic x-ray examinations have tradi-
tionally been incorporated into radiotherapy treatment plan-
ning, but a full awareness of the differing perspectives and
needs of therapeutic and diagnostic radiology is a relatively
recent perception. Conventional, diagnostic radiographic pro-
cedures play an important role in identifying and defining the
nature and extent of disease. However, the difficulty of obtain-
ing accurate, quantitative, reproducible, spatial information
from radiographs using conventional diagnostic x-ray equip-
ment largely precludes its use. This quantitative information is
not readily and accurately transferable from such equipment to
the x-ray treatment unit nor is it verifiable.22 The radiotherapy
treatment simulator was developed in response to these limita-
tions. The CT images provide additional information but again
accurate transfer of spatial data to the simulator may not be
readily accomplished.22
Traditionally, diagnostic radiology has been concerned
with qualitative, planar information obtained from views of
anatomy positioned optimally for a particular diagnostic study.
In contrast, radiotherapy planning requires quantitative, volu-
metric information obtained with the patient in a treatment
position on a patient support assembly, usually a treatment
couch. Accurate knowledge of field size and placement is
crucial in radiotherapy, but of lesser interest in diagnostic
radiology. Megavoltage port films, albeit of poor quality, pro-
vide information on the patient in a treatment position. The
advent of CT and MRI, with their expanded tumor localization
capabilities, has dramatized the differences in need and our
perception of them. It has brought home two important tenets:
(a) Ordinary diagnostic x-ray equipment and procedures are
inadequate for obtaining treatment planning information. (b)
Radiologists are needed who are aware of the special needs of
radiotherapy treatment planning. As a result, there has been a
dramatic increase in the development and use of simulators
during the past decade, and diagnostic radiologists with an
oncology interest have become an emerging subspecialty. As
usually employed, the CT unit supplements the simulator and
provides transverse (cross-section) images of the anatomy in
which treatments are often planned. When the treatment plan
is agreed upon, it is verified on the simulator using the treatment
fields prescribed. Several developments have demonstrated
that CT can be incorporated into simulators.45,72.97.99~111a~121~122
Alternatively, simulation can be incorporated into a CT scanner
and integrated with software into a comprehensive treatment
planning ~ystem.97,99J22~133 In one such system this includes
interactive 3-D irregular field software and a software con-
214 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING
FIGURE 13-1 . Treatn~entsin~ulatorproviding radiography and fluroscopy. (Courtesy of Varian)
trolled laser located in the gantry for localization and transfer
of treatment portal information to the patient's skin.45 Other
contemporary developments pertaining to simulation are re-
viewed on pages 219-220.
Data obtained from simulation is first used in planning the
individual patient's treatment. Simulator originated data to-
gether with data from the treatment plan selected can be used for
initiating a patient's daily therapy record used during treatment,
for a record and verify function, and as the first step in establish-
ing a more comprehensive computer based archival rec0rd.~0,69
New imaging methods, particularly CT and MRI, have added
significant anatomic information for treatment planning. The
simulator, however, remains central to the localization of the
target volume and the verification of the planned treatment.
MECHANICAL FEATURES
High energy megavoltage x-rays, with their penetrating and
sharply delineated beams, characterize modern radiotherapy.
Their ability to deliver a high and uniform dose to a deep seated
tumor, while avoiding a nearby sensitive organ, is a hallmark.
A radiotherapy simulator, which provides readily accessible
and transferable quantitative tumor localization information, is
essential to the planning process that exploits this capability.
Where incorporated, CT and anatomical coordinate informa-
tion must also be transferred." To simplify the transfer of
information, a simulator should duplicate the treatment setting
in significant detail, particularly the spatial, mechanical, radi-
ation and optical aspects, and incorporate identical or similar
accessories. The patient setup procedure for therapy is thereby
facilitated by a simple, 1:l transfer of information using high
quality radiographs, guided by fluoroscopy if desired. Such an
implementation will best fulfill the twin goals of simulation:
(a) Provision, for plaizizirzg purposes, of accurate localization
of the target voluine with respect to scirrounding anatonzy. (b)
Verijkatioiz, after planniizg, of the prescribed treatnzentfield
size andpositioniizg. These are the goals that motivate simula-
tor design. The related procedures of treatment planning and
portal imaging are treated on pages 220-237.
Simulators are designed to simulate a number of different
treatment units employing a wide variety of treatment tech-
niques. Many simulator performance specifications can be
described in terms of x-ray characteristics, mechanical param-
eters, and their tolerances. Stringent mechanical tolerances are
needed to obtain the requisite spatial accuracy and to ensure
reproducible setup of patients. Mechanical specifications such
as field size range, SAD, SSD, isocenter height, and minimum
and maximum couch top height, are important specifications.
The simulator couch should duplicate the treatment couch as
closely as possible, including removable panels and Mylar or
"tennis racket" inserts, to simulate the sag of the patient on
the treatment couch. Similarly, the accessories should be
duplicates of those employed on the treatment unit. Accessory
tray distance positioning on simulators must be compatible
with the positioning on associated treatment units. Mechanical
tolerances of simulators must be fully as strict (or possibly
more strict) as those for treatment units as specified in the IEC
standard.65.66 The lighter weight components of simulators can
help ensure stricter mechanical tolerances so that simulation
is unlikely to contribute significantly to overall error. How-
 TREATMENT SIMULATORS 215

ever, the simulator must be designed to accurately position the TABLE 13-1 - Summary of the simulator specifications
heavy Cerrobend blocks used in treatment. Moreover, rigorous
alignment 58 and quality assurance procedures '6,19.84-85 similar
to those for linacs are needed. Often, tolerances are signifi- Height of isocentre
cantly more stringent than those for conventional diagnostic above floor 5 1 1 5 cm
Angle of rotation at
equipment from which they were developed. Several early
5 100-cm SAD >360° 0.03-1.0 rpm
simulators performed poorly through failure to meet these Angle of rotation at
requirements. >100-cm SAD +- 90"
Mechanical and x-ray specifications suggested by a task Isocentre accuracy,
group of the BIR may be found in Supplement 2316 and are diameter 2 mm
reproduced in Table 13-1. This table is a summary of simulator Clearance between
specifications pertaining to: the gantry, the x-ray head and gantry and isocentre ZllOcm
collimators, the x-ray tube and generator, the imaging device X-ray head and collimators
and the couch. These 1989 BIR recommendations were
Source-axis distance 80-100 cma 0.5-5 cm/s
updated from an earlier 1981 tabulation.17 Some mechanical, Beam limiting
as well as x-ray specifications, are discussed in more detail diaphragms at 100 cm 50 X 50 cm max
by McCullough, Blackwell, and Earle.84.85 The IEC standard Diaphragm rotation > 220" 0.01 rpm
conventions for linear and angular scale placement, direction Beam delineating wires
of increasing values, and zero location for treatment units at 100 cm 50 X 50 cm max
are recommended for simulators, as well as for treatment Source-skin distance
units.65 For convenience, both manual and motorized control indicator 60-150 cm
of certain motions are suggested. The variable speed and X-ray tube and generator
powered motions specified in BIR Supplement 23 allow Focal spot size 0.3 X 0.3 mm
rapid, precise setting of these parameters. Digital readout of Target angle 520"
significant parameters is highly desirable. The BIR specifi- Continuous rating of
cations, which involve anteroposterior (AP) and lateral ex- target 500 HUIs
posures, are for a representative patient 25 X 45 cm in cross Generator 3 phase
section with the image receptor 10-cm distal from the patient Radiographic output
(see Figure 13-2). (minimum) 500 mA, 90 kV
The design of the x-ray head and collimators (Table 13-1) Fluoroscopic output
is of major importance for simulation and treatment proce- (minimum) 6 mA, 125 kV
Imaging device
Film cassette and grid 2 3 5 cm sq Manual rotation
Image intensifier 12 in.
Scanning movements of
the image intensifier t 2 0 cm 3cds
Radial movement of
the image intensifier -1Oto-60cm 3cds
Couch
Couch top 220 X 45 cm
Rotation about
couch support 360" Manual rotation
Rotation about isocentre t 100 0.003-0.05 rpm
Vertical movement +2 to -50 cm 0.1-3.0 c d s
Minimum couch height <50 cm
Longitudinal movement -30 to + 100 cm Manual, 2 cm/s
Lateral movement ?20 cm Manual 2 cm/s

T h e source-to-couch distance extends to 175 cm when the beam is vertical.

(Courtesy British Institute of Radiology.)

FIGURE 13-2 . Limiting geometry for radiography for a patient 25 X

45 cm in cross section for the design of a simulator. (Courtesy British In-
stitute of Radiology.)
216 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING
dures. Good design of this assembly can serve to implement
and simplify a wide variety of treatment procedures. The ad-
justable delineators (usually field defining wires) located in the
collimator serve two purposes: (a) using a double-exposure
technique they identify the treatment field against a back-
ground view of the surrounding anatomy, and (b) they can, by
positioning, be used to identify the location of various anatom-
ical sites with respect to the central axis. In contrast to diagnos-
tic radiology, field size specification for radiotherapy must be
accurate, and numerical indication of field size to + 2 mm is
recommended.65 A digital indication of field size and SSD is
usually provided. Simulators that provide asymmetric fields by
independent movement of delineators or diaphragms can facil-
itate planning contemporary field-abutment methods. Figure
13-2 and Table 13-1 include couch specifications and design. A
couch top, 45 cm wide and 220 cm long with a long transparent
section, has been recomrnended.16.n It is necessary to have the
simulator couch, or at least its top and accessory rails, similar if
not identical to the treatment unit couch. The carbon fiber
couch, popular in diagnostic radiology, is appearing on simula-
tors and a few treatment units.59 It features strong, lightweight
radiotranslucent panels. A rotatable simulator couch designed
with a "tuning fork" frame and removable panels provides good
flexibility as it does on the treatment unit. The dual-rail end
facilitates four-port (AP, PA, and lateral) treatments, and the
center spine end, the angled beam treatments. A low minimum
couch height, which may be restricted by fluoroscopy appara-
tus, facilitates large field irradiations such as for mantle and
hemibody treatment. A high maximum couch height provides
upward directed treatment beams at SSD distances of 100 cm or
greater. Table 13-1 lists gantry specifications. A low isocenter
height improves the view of the patient's upper skin surface and
facilitates setup procedures, especially for technologists of
short stature. No commercial simulator satisfies a BIR recom-
mendation that the height of the isocenter be equal or less than
115 cm above the floor. Note that the SAD values greater than
100 cm impose restrictions in minimal simulator room height
and width. A 2-mm diameter spherical isocenter tolerance cor-
responds to that of the treatment unit.65
Contemporary commercial simulators provide increased
flexibility in adapting to the needs of a wide variety of treat-
ment units. These new developments, together with acceptance
testing and a tabulation of these units, have been reviewed by
Doppke.35 The strict requirements on simulator performance
entail a rigorous, continuing QA program. A detailed QA
program specifying tolerances and test methods for periodic
tests is described by the BIR.16 McCullough and Blackwell 84
summarize a simulator QA program involving biweekly and a
6-monthly sequence of tests.
RADIOGRAPHY AND FLUOROSCOPY
A significant difference in radiographic technique, using a
simulator in contrast to a conventional diagnostic x-ray unit,
results because of the large distance from focus-to-image re-
ceptor for the former. Typically, this distance is 70 cm for the
diagnostic unit and 135 cm for the simulator with a range of
100 to 200 cm for the latter. Hence, an eight times larger
exposure, measured in milliampere seconds (mAs), may be
required on this basis, with additional capacity needed for the
large body thicknesses encountered, that is, up to 45 cm for a
lateral pelvis. These requirements necessitate a high voltage
and high current x-ray generator with a maximum power output
of 300 mA at 150 kV (500 mA at 90 kV) for radiography, and
6 rnA at 125 kV for fluoroscopy (see Table 13-1). Asmall focal
spot x-ray tube to minimize geometric unsharpness would be
preferable because the film is far from the patient, a require-
ment in conflict with reducing exposure time and thereby
stopping motion by use of a large focal spot. A high speed target
rotor is desirable, since it permits high anode currents and short
exposure times for a given mAs without overloading. Fluoros-
copy requires only a small focal spot, but its usefulness is
impaired if its position differs from that of the second focal spot
used for radiography. A nominal 0.3 X 0.3 mm focal spot tube
may satisfy this requirement, but a 0.6 X 0 . 6 - d 1 . 0 X 1.0-
mm focal spot is more often chosen. The magnification and
blurring of the delineators, which depend on their relative
position and the focal spot size, should be considered in select-
ing an x-ray tube. X-ray and mechanical console controls
should be simple and clearly grouped from an operational,
"human engineering" viewpoint. Certain couch controls and
indicators should be duplicated at the simulator console loca-
tion. A nearby rapid film processor is essential. An image
amplifier (IA), or other intensifier system help assure rapid,
precise localization of treatment fields and anatomic land-
marks, and reduce the need for repeat radiographs. Most image
amplifier (IA) systems incorporate television viewing and ac-
commodate dynamic procedures, for example, contrast me-
dium visualization passing through a constricted esophagus. A
9-in IA is considered minimal but a 12 in. IA is recommended
and a smooth-working, positioning system over a projected 50
X 50-cm area at isocenter is needed (Table 13-1). The IA and
couch support mechanisms should be coordinated with gantry
motion to maximize the available angular orientation of the
treatment field, with the IA under the couch when the couch
longitudinal axis is positioned parallel and transverse to the
gantry axis. Fluoroscopy can provide real-time imaging infor-
mation, albeit of poorer quality than radiography, but whose
parameters, such as field size and orientation, kilovoltage and
brightness, can readily be changed. A bulky image amplifier
for fluoroscopy frequently limits the angular positions of the
gantry by interference with the couch or floor. Fluoroscopy is
employed to localize the majority of tumor volumes. It is
essential for all staff involved to know at all times whether
tumor volume, or the somewhat larger target volume, is being
employed. Radiographs can be taken once pertinent parameters
are decided from fluoroscopic images. Fluoroscopy requires
the presence of the radiation therapist; radiography permits
assessment at a later time and provides a permanent record.
 TREATMENT SIMULATORS
SIMULATION ACCESSORIES
Radiotherapy simulation is aided by a wide variety of accesso-
ries such as those listed in Table 13-2. Included are devices that
aid tumor localization, anatomical measurement, patient im-
mobilization, x-ray procedures, and interfacing-to-external
systems. As treatment techniques become more complex, they
increasingly employ multiple accessories attached to the treat-
ment head, and an extended accessory tray or mount is required.
At times, accessories are specifically designed for simulation
procedures only. At other times, a duplicate device is employed
in conjunction with the treatment. It has been found expedient
to duplicate the latter devices in detail such that they are
exchangeable between simulator and treatment unit. Standard-
ization helps, such as having standard accessory rails on all
couches and employing the same clamping devices with them.
Attention to such detail not only simplifies simulation and
treatment, but facilitates the communication of information and
the exchange of technologists between simulator and treatment
units. The rapid growth in microprocessor based data acquisi-
tion and control systems suggests that simulators be equipped
with appropriate transducers designed to interface with con-
temporary digital electronics.
OPERATIONAL ORGANIZATION
Simulation is one of a combination of activities surrounding
the radiotherapy patient, which starts with clinical assessment
and ends with follow-up evaluations. Figure 13-3 illustrates
this sequence and emphasizes information flow and documen-
tation. Simulation and its operational organization fill a central
role.34 It is here that the ensemble of diagnostic information,
including tumor size, converges into a specific treatment plan.
TABLE 13-2 . Accessories Used in Siniulation
Rulers and tapes Magnification rulers
Magnification rings Protractors and calipers
Spirit levels Front and back pointers
Optical distance indicator Breast bridge
Lead wire and markers Laddersa
Templates Vclcro straps
Accessory trays Accessory clamps
Bite blocks Head holder
Shielding blocks Film holders
Contouring devices Interfacing devices
Video recorder Polaroid camera
Optical alignment Sponges
aLadders refer to strips of thin lead foil sandwiched between strips of plastic
tape. The random, irregular, scalloped shapes of the ladders assist in uniquely
identifying a specific anatomical site. Optical alignment devices include laser
projected spots or lines, incandescent lamp projected cross-hair images together
with coordinate projections such as an array of dots or lines on 2-cm centers at
100-cm SAD. Some items listed as accessories nlay be integrally
- - incorporated
into the sirnolator and are included for the sake of completeness.
217
The tumor is localized on the simulator for treatment planning
purposes and later, confirmed on the simulator as to how the
treatment prescription will be carried out on a specific treat-
ment unit. A number of ingredients are essential if this process
is to function smoothly. The scheduling of simulation and
treatment should be carried out by someone thoroughly fa-
miliar with the functioning of the department. Cognizance of
the radiotherapist's schedule, as it pertains to simulation, is
essential. The simulator is a local point in planning treatments
and should be centrally located, preferably near the treatment
planning group. A large simulator room is needed to accom-
modate the many staff often involved: physicians and phys-
icists; simulator, mold room, and treatment technologists;
dosimetrists as well as students. The simulator room should
be equipped with the necessary ancillary aids including im-
mobilization and alignment devices, which duplicate those in
the treatment room. The availability of written protocols
describing all standard treatment techniques can simplify
simulation procedures.91 A patient conference or planning
session will review each new patient and adopt an appropriate
treatment plan. Accessories of all types serve a vital role in
simulation and in treatment. It is vital that there be a 1:l
correspondence of accessories in simulation and treatment,
and the simulator and treatment technologists have good
communication as to how a specific patient will be positioned,
immobilized, and treated. The patient's contour will be ob-
tained during simulation, and selections will be made for
tissue compensators and wedges, if any. These accessories,
as well as others relating to field blocking, alignment and
patient positioning, are discussed in more detail in Chap. 12,
pages 204-209. Typically, 30 treatments are involved in a
course of therapy. It is important that the patient be positioned
and immobilized in a comfortable and reproducible manner.
Polaroid photographs showing the patient in treatment posi-
tion are particularly useful and become part of the daily
therapy record (chart). Simulation procedures involve diag-
nostic radiographs. Therefore, familiarity with film character-
istics, screens, contrast agents, and film processing is
essential. Simulator technologists should have training in
diagnostic radiology, as well as training in therapeutic radi-
ology. Such training is included in contemporary curricula for
radiation therapy technologists.
REGULATORY REQUIREMENTS
Simulators provide a radiographic and fluoroscopic x-ray fa-
cility. As such, they come under the purview of Federal and
State regulatory agencies for diagnostic x-ray systems. Such
agencies promulgate, as statutory requirements, many of the
recommendations of national and international bodies con-
cerned with radiation, such as the United States Center for
Devices and Radiological Health (CDRH) and formerly the
Bureau of Radiological Health (BRH), the National Council on
Radiation Protection (NCRP), the International Commission
218 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING

-
Complete Clinical Work-up
(Extent of Tumour, Staging, -Record --t
Histology, Grading, ---)
D
Optimization
Criteria $-
Record +0
Beam Therapy
r.-.-.-.-.-.-.
Treatment Record -+ c
! Planning
I
Medical Prescription: (Target
I Volume, Target Absorbed Dose)
fRecord --t
I t I
Provisional Selection of M
I
Beam Arrangements and Com- -
I
putation of Corresponding I
Dose Distribution E
I - I
I t I
Comparison of Dose Distribu- . N
tions and Selection of Opti- I

-
ma1 Treatment Plan
I I
I A Computation
/ and Display of T
I the Selected Treatment Plan
7Record
A

T
I
Record --t

Monitoring I
Verification
In Vivo Dosimetry
0
4 Record +

t
Record +

F'IGURE 13-3 - Steps in radiotherapy procedures; information flow and docunlentation. (From Ref. 62)

on Radiological Protection (ICRP), and the International Elec-
trotechnical Commission (IEC). Because of the specialized and
restricted use of simulators, the BRH has enacted a number of
specific amendments to the general provisions for diagnostic
x-ray facilities.1921 The motivation for enacting these amend-
ments is an awareness that compliance with the general diag-
nostic x-ray facility provisions would impair the accuracy and
effectiveness of simulation while the additional dose to the
patient, resulting from the relaxed requirements, would not be
significant when compared to the dose received from the
radiation therapy treatment itself. Note that more tissue is
exposed during simulation and when obtaining port films than
that subtended by the treatment field.
The definition of the radiation therapy simulator system
has been revised to include radiographic, as well as fluoro-
scopic, capability. Regulatory agencies acknowledged the
growing radiographic role of simulators, and have exempted
them from the positive beam limitation requirement imposed
on stationary, general purpose x-ray systems. Raising the max-
imum aluminum equivalent thickness for radiation therapy
simulator tabletops from 1.5 to 5.0 rnrn will ensure the requisite
positional stability of the cantilevered tabletop. Exemption
from the minimum field illumination requirement (15 fc at 100
cm) relates to the need in radiotherapy to accurately define
treatment field size. Illumination brightness could be improved
with a larger filament bulb. However, because of penumbra
effects, a loss of accuracy for scales and delineators would
result. Exemption from the maximum fluoroscopic exposure
rate requirement (10 Rlmin at the beam entrant point on the
patient) acknowledges the need for simulators to simulate a
large range of SSDs and yet provide adequate fluoroscopic
image brightness in a simple manner.
 TREATMENT SIMULATORS
The laser light sources used in conjunction with simulators
for patient alignment are low power, Class 2, devices wherein
the maximum power level is 1 mW. Such visible light lasers do
not have enough output power to injure a person accidentally,
but could cause eye damage from chronic exposure. Personnel
must be cautioned not to purposefully stare directly into the
beam of such a laser.20
SIMULATOR USAGE
Although radiotherapy simulators have been in use for one-
quarter of a century in major centers, their widespread adoption
did not begin until the late 1970s, and an expansion in this
growth continues. A simulator is now deemed essential to
radiotherapy patient care, based on the improvement of overall
efficiency, which results from its use by specially trained staff,
as well as from the benefits that accrue from rapid and accurate
tumor localization. AU.S. Patterns of Care Study30 found 268
therapy facilities (25 percent) with simulators as of January
1978. By January 1980, this number had increased to 424 (39
percent), and to 69 percent (1984) among 1,098-MV facilities
responding. There is growing recognition and acceptance that
a simulator is required for "state-of-the-art" radiation therapy.
A report of the Committee on Radiation Oncology Studies
(CROS) recognizes the need for simulators, each having one
or two staffing technologists depending on usage.27.64 Radia-
tion oncologists acknowledge the need for one simulator per
two treatment units. The 1981 BIR report recommends that
every facility with a megavoltage treatment unit be equipped
with a simulator. A 1986 survey tallies almost 2000-megavolt-
age treatment units in the United States and approximately
one-half as many simulators and access to treatment planning
services. Two summaries of changing treatment practices in the
United States include data on simulators, treatment planning
computers, treatment machines, staff, and patients.26.32 In Brit-
ain, radiotherapy centers find that one simulator properly
staffed can serve the planning needs of 2- or 3-megavoltage
units, but much depends on the use made of the simulator, such
as the proportion of multifield treatment plans, the various
types of tumors treated, as well as the total number of patients
treated per year. Large departments having three or more
megavoltage units, as well as orthovoltage units, will need at
least two properly staffed simulator units. It is recommended
that the treatment unit itself not be used as a simulator. In
departments where the patient load is increasing and treatment
units are used for planning purposes, it is preferable to install
a simulator rather than an additional treatment unit, so that
more time is available for the treatment of patients.55 The
economic argument for installing a simulator hinges on the
number of patients, as well as relative costs of simulators and
treatment units.l7.70 Agreed international conventions, stan-
dards, and tolerances for simulators, treatment units and their
accessories, will help promote accurate, effective radiotherapy
on a worldwide basis.
219
CONTEMPORARY DEVELOPMENTS
Advances in digital computing, imaging, and display have
affected simulation as well as the related aspects pertinent to
treatment; treatment planning and portal imaging that are cov-
ered On pages 220-237. The associated
both hardware and software, is changing rapidly. Hence, the
optimum system for simulation, treatment planning, and portal
imaging will likely be redefined. Certaln of these develop-
ments, which relate to simulation, are described herein, others
are in Chap. 10, pages 181-188.
~omedevelb~ments have challenged the necessity of pro-
viding a conventional simulator, which provides fluoroscopy
and radiographs for treatment planning, verification, and com-
parison with treatment portal films. Nishidai et a1.99 and Nagata
et a1.97 describe a CT simulator and 3-D planning system and
its clinical application for 72 patients. Their system combines
a CT simulator, a multi-image display component, a treatment
planning device with real time visual optimization, and a laser
beam projecting component. It does not include a conventional
simulator. All components are connected on line. The system
can be used for 3-D planning and simulation for radiotherapy
with more than one-half of the patient plans finished in 30 to
40 rnin after the start of simulation. A CT simulator provides
the discrimination for distinguishing soft tissue structures, a
capability lacking in conventional simulators. Integrating the
CT scanner into 3-D treatment planning simplifies the spatial
registration problem and can improve the outcome of treatment
through accurate localization of the tumor and normal struc-
tures. The laser beam projects the field outline as well as other
pertinent points or lines on the patient's skin within 3-rnm
accuracy. This CT based simulator and planning system has
been found particularly useful for cases where the target vol-
ume is adjacent to dose limiting organs, for complicated target
shapes, or dose distributions, and for tangential fields. Using
CT data scanned projection radiographs (scannograms) of A-P
and lateral views can be assembled with superimposed target
and organ outlines. These radiographs substitute for the con-
ventional simulator films and are to be compared with portal
imaging films obtained during treatment. Other beams eye
views and images of oblique slices can be provided (see pages
220-223). The system requires the patient to lie still for 30 rnin
and their position must be checked at least three times; before
and after CT scanning and before field projection. Alterna-
tively, immobilization devices are employed to prevent move-
ment. The CT simulator was developed to be conveniently
operated by a radiotherapist, not a medical physicist or techni-
cian, because the operations involve determining the outlines
of the target volume and important organs, and optimizing the
planning results.
A sophisticated method for computation of digitally recon-
structed radiographs (DRR) for use in radiotherapy treatment
design has been described by Sherouse et al.118 Using CT data
the reconstructed radiographs correspond to conventional sim-
ulation films and provide reference images for verification of
220 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING
computer-designed treatments as outlined earlier. The empha-
sis is on high quality reconstructions that take advantage of the
contrast and spatial detail inherent in the original CT data. For
superior image quality the reconstruction involves trilinear
interpolation of each voxel along a ray (using eight comers of
the voxel) and attenuation based on weighted photoelectric and
Compton interactions. The desired resolution and pixel count
of the output image can be specified in terms of film size and
TFD (target film distance). The pixel size is 0.7 X 0.7 mm for
a 36-cm square film size, a 140-cm TFD, and a 512 X 512
matrix. For a 20 million instruction per second (MIPS) work-
station, a 256 X 256 X 50 CT data, a 512 X 512 DRR with
trilinear interpolation requires about 20 min to complete a
treatment plan. The system accurately registers graphic over-
lays of target and anatomic structures from CT to DRRs, which
are important considerations in the design of treatment portals
(fields). Computation times are expected to decrease using the
emerging parallel computing architectures while retaining the
high quality images favored by radiotherapists.
Sherouse and Chaneyll7 describe a portable virtual simu-
lator, which may substitute for a conventional physical simu-
lator. It is a software tool for support and management of the
geometric component of treatment planning in contrast to the
dose computation aspects. Like the CT based system of
Nishidai, et al.?7$99it defines a virtual patient from CT or other
source data and operates in the same way that a physical patient
is operated on by a physical simulator. The ability to rotate
one's perspective around the viewing axis of any of the three
patient views combined with coordinate motions of the virtual
simulator can represent a feature not available in a physical
simulator. Combining this feature with some combination of
table, gantry, and collimator rotations one can explore helpful
options for the placement of treatment fields. Once the treat-
ment prescription is decided it provides input parameters for
the computation of DRRs, the analog of the physical simulator
film as described above. Portability is enhanced by employing
the "C" programming language, the " X window system, and
a generic UNIX workstation with the goal of applicability to
various commercial workstations and other clinical environ-
ments. Approximately 50 patients have undergone virtual sim-
ulation.
TREATMENT PLANNING
The treatment of cancer involves a complex series of proce-
dures, consultations, and decisions. This extended sequential
process is illustrated in the simplified flow charts of Table
13-3(A and B) for external beam radiation therapy, once this
modality is adopted. The emphasis in these tables is on proce-
dures and staff roles in them. The sequence is individualized
for each patient with specific diagnostic and other assessment
and planning procedures being invoked for particular cancer
sites. The report, from which Table 13-3 is adapted, provides
an overview of radiation treatment in the management of
cancer.64 Another view of this process, Figure 13-3 emphasizes
information flow and documentation, aspects that increasingly
involve computers.62 After clinical evaluation of the patient
and a decision on choice of the type of therapy, tumor localiza-
tion is performed. This involves the use of diagnostic images,
mechanical aids, and additional x-ray views to define and
outline contours of the patient's anatomical body, sensitive
organs in the area of treatment, and the proposed target volume.
The target volume is somewhat larger than the tumor to be
irradiated, in order to provide a margin of safety. Target volume
localization is aided and refined during simulation, a procedure
already described on pages 213-214, wherein the target vol-
ume is visualized radiographically, and often fluoroscopically,
using equipment that simulates the treatment unit itself. The
input data for treatment planning computation of an individual
patient treatment plan consists of beam data and patient data.
Block diagrams of beam and patient data acquisition systems
are illustrated in Figures 10-14 and 10-15, respectively.
Treatment planning is the process of selecting and com-
bining a number of radiation beams so as to deliver a high,
uniform, tumoricidal dose to the target volume, minimizing the
dose to nearby sensitive organs and generally delivering a dose
as low as reasonably achievable to all tissue external to the
target volume. Often, a number of alternative treatment plans
are developed and considered prior to selecting the optimal
plan. The current availability of improved diagnostic imaging
techniques, such as x-ray CT and MRI, provides increasingly
accurate and detailed patient anatomical information in the
cross-sectional planes where treatments are planned. The treat-
ment planning process includes simulation, computation of
beams, analysis of alternatives, choice of the therapy plan,
verification films, and dose calculations. Treatment planning
follows tumor localization and, in turn, is followed by selection
of ancillary aids and the treatment itself.
The core of the treatment planning process involves selec-
tion, orientation, and detailed computation of the dose contribu-
tions of the individual treatment beams to a large number of
anatomical points within and outside the tumor as well as to crit-
ical organs. Assessment of the adequacy of an individual plan
can be best judged from this large body of dosimetric informa-
tion, which is normalized and presented graphically as isodose
contours overlaid on an anatomical cross section of the pa-
tient.109 The labor intensive manual computational methods,
which characterized early treatment planning, have been
supplanted by modern computer techniques, which rapidly per-
form the requisite comp~tations29.56~63.115~127 A number of the
patient handling and treatment planning procedures are itera-
tive and are repeated until a satisfactory outcome is achieved.
Treatment planning procedures involve many detailed consid-
erations. Incorporation of these detailed considerations in the
planning process may significantly expand the computation.
The modem treatment planning system built around the digital
computer not only accommodates this expansion, but encour-
 TREATMENT PLANNING 221

TABLE 13-3 - Procedures and staffing functions for radiation therapy (from Ref. 64)

A. Process of radiation therapy (external beam) B. Key staff function in radiation therapy

Function Key staff Supportive role

Clinical Evaluation Clinical Evaluation Rad. oncologist

Initial evaluation Therapeutic Decision Rad. oncologist
Assessment of pathobiology of tumor Target Volume Localization
Staging Tumor volume Rad. oncologist Sim. tech.ldosimetrist
Therapeutic Decision Making Sensitive critical organs Rad. oncologist Sim. tech.1dosimetrist
Patient contour Dosimetrist Sim. tech.ldosimetrist
Selection of treatment goals-curelpalliation
Choice of modalities of treatment Treatment Planning
Target Volume Localization Beam data-computerization Physicist
Computation of beams Physicist Dosimetrist
Definition of tumor
Shielding blocks, DosimetrisV Rad. oncologist/
Identification of sensitive organs and tissues
treatment aids, etc. mold room tech. Physicist
Measurement of patient
Analysis of alternate Rad. oncologist/ Dosimetrist
Construction of patient contours
plans Physicist
Shaping of field
Selection of treatment Rad. oncologist/
Treatment Planning plan Physicist
Selection of treatment technique Dose calculation Dosimetrist Physicist
Computation of dose distribution SimulationNerification Dosimetrist
Calculation of doseltimelvolumerelationship Of Treatment Plan Sim tech. Rad. Oncologist/
Simulation OfTreatment Physicist
Verification of adopted treatment technique
Fabrication OfTreatment Aids Treatment
Construction of custom blocks, compensating filters First day setup Rad. oncologist/ Dosimetrist/
Selection of immobilization devices Physicist Physicist
therapy techs.1
Treatment Localization films Rad. oncologist/
Initial verification of treatment setup therapy techs.
Verification of accuracy of repeated treatments Dosimetry checks1 Physicist/ DosimetrisV
Continual assessment of equipment performance initial chart review Rad. oncologist/ chief tech.
Periodic checks of dosimetry, record keeping chief tech.
Repositioninglretreatment Therapy techs. Dosimetristl
Patient Evaluation During Treatment
chief tech.
Assessment of tolerance to treatment
Evaluation of tumor response Periodic Evaluation
Assessment of complications of treatment (during treatment)
Tumor responseltolerance Rad. oncologist Nurses1
Follow-up Evaluation
therapy techs.
Evaluation of tumor control
Assessment of treatment-related complications Follow-ccp Evaluation Rad. oncologist Nurses

ages the exploration of new and different plans, which were
hitherto not considered because of the large computational ef-
forts required.115 The details of the treatment plan selected are
incorporated into a written treatment prescription for the pa-
tient. An example treatment prescription is shown in Figure 13-
4, page 1of a patient's daily therapy record. This prescription is
for treatment of a stageA2prostate tumor positioned at isocenter
on linear acceleratorv. It combines a 20 X 18-cm four-field irra-
diation of the pelvis (anterior, posterior, left, and right laterals)
with lateral arc therapy (9 X 9 cm field with left and right 120"
lateral arcs). The prescription provides daily fractions of 200
cGy at isocenter in three sequences of 2600,2000, and 2400cGy
yielding a total of 7000 cGy to the prostate in 35 fractions.
After prescribing the treatment plan, the patient is again
simulated and verification radiographs obtained before the
treatment plan is adopted. The goal of the simulator verifica-
tion procedure is to ensure that the treatment fields selected
encompass the tumor volume and spare the nearby critical
organs. The correct positioning of radiation beams during the
sequence of treatments is assessed by portal imaging, a
procedure described on pages 224-227.
Traditionally, treatment planning has been 2-D.48 The im-
222 CHAPTER 13. TREATMENT SIMULATORS,TREATMENT PLANNING AND PORTAL IMAGING

which can be used to confirm accuracy of treatment with the

DIVISIONOF FADKITHERhPY
STANFORDUNIVERSITY SCHOOL OF MEDICINE accelerator port film. A BEV display is helpful in interpreting
Dally menpy Rkord Linear Accelerator NO. % the familiar anatomy of AP and Lat views; it is indispensable
for oblique projections. Combining the data from multiple CT
and MRI slices using a large computer memory and fast hard-
ware can allow shifting the BEV rapidly; at times on-line, in
real time.
Modem computer treatment planning systems offer an
increasing amount of computational power, which must be
used with caution. The results depend significantly on the
quality of beam and patient data input, as well as the computa-
tional algorithm(s).29 Hence, quality assurance in treatment
planning is essential, although difficult to implement in a
comprehensive manner. This topic has been addressed in a
number of studies.64?90,92A large treatment planning computa-
tional capacity can generate a number of alternative treatment
plans. A method of choice can be implemented by an optirni-
zation algorithm wherein criteria such as minimal dose to
specific sites and high uniform dose to the tumor are in-
VOked.90,92,129,137
Treatment planning is undergoing rapid change; from 2-D
to 3-D, additional diagnostic imaging information, improved
and expanded computer hardware (workstations,3-D displays)
which run more sophisticated treatment planning programs.
Additional aspects of this changing environment are outlined in
wrnt F ~ $29
SIIIPl ,mi
W IS s w f l s d a me size m e sso or sro vsad the following section and others found in the current literature.

FIGURE 13-4 - Example treatment prescription for cancer of the pros-

tate.
RESOURCES
The literature concerning treatment planning is extensive with
proved visualization of tumors using CT and MRI imaging varied emphasis. In addition to the archival literature and the
techniques has encouraged 3-D treatment planning, which has several texts and reports cited herein, a resume of ongoing
been made feasible by more powerful treatment planning com- developments is documented in the proceedings of a series of
puters, taking into account the effect on absorption of in- international conferences on the use of computers in radiation
homogeneous structures (lung, bone, etc.) as related to CT therapy, of which the Ninth is cited.101 Typically, these pro-
n~mberS.22,109,110;5116,120 ceedings contain more than 100 reports and cover several
The limitations of 2-D treatment planning programs have computer applications in contemporary radiation therapy, with
been discussed by Goitein,4*,49who makes a strong argument the majority concerned with treatment planning. Some general
for 3-D treatment planning and for what is known as a beam's and specific literature resources follow.
eye view (BEV) of the anatomy transversed by the diverging An AAPM monograph reviews many aspects of radiation
treatment beam as observed from the radiation source. The therapy treatment planning including: target volume localiza-
BEV has become a very useful 3-D concept. It allows one to, tion, simulation, dosimetry, CT, brachytherapy, and treatment
in effect, move one's head around the patient to optimize the strategies.' Central axis depth dose values are tabulated by
placement of beams, separating the target volume and critical the BIR.18 This reference contains a wealth of basic data,
normal structures. It makes use of interactive computer-graph- formalism, and a glossary of terms used for planning x-ray,
ics display. Unlike 2-D planning, it allows noncoplanar beams. electron, and neutron treatments over a wide range of energies.
Figure 13-5 illustrates the geometry for constructing the BEV A critique by LaRiviere76 of this reference suggest an alternate
from perspective projections of anatomic features of CT sec- definition of x-ray beam quality (see also Chap. 8 p 146).
tions.50 The distance of the viewing plane from the source, for The ICRU Report No. 2461 contains treatment planning in-
example, at the plane of a field-defining aperture, is selected formation related to single x-ray beams and patient data,
by the observer with automatic scaling of the image. Back-pro- combinations of beams, the planning and delivery of radiation,
jection of such an aperture shows anatomic areas of the original dosimetric errors, together with a glossary of terms. In the
or reconstructed CT sections covered by the beam. Projection ICRU Report No. 42, use of computers in external beam
through the CT data provides an alignment film simulation, radiotherapy procedures with high energy photons and elec-
 TREATMENT PLANNING
Patient's
, , 1 7k-)
Coordinate
System
s
i/\tance:
A
x~
CT Sections
=P
I Anatomic
Feature
FIGURE 13-5 . Schematic diagram of the geometry involved in computing a beam's eye view (BEV) of
anatomic structurrs. (From Ref. 50)
trons>2 is primarily concerned with treatment planning con-
siderations. This review includes: representation and modifi-
cation of photon and electron beams, acquisition and
representation of patient data, computation of the absorbed
dose distribution in a patient, and presentation of the results
of calculation. The basic physical and clinical considerations
in treatment planning are described in textbooks by Bental et
al.,g and Mould.93 A similar, but more general coverage is
provided by Bleehan et al.,l2 who include chapters on beam
modification, alignment, immobilization, planning for electron
and neutron beam therapy, together with detailed planning
considerations for a number of specific anatomical sites such
as head and neck tumors. A brief introduction to computer
principles and techniques, including medical physics applica-
tions, has been given by Vickery.133 A short survey of devel-
opments in computer based treatment planning systems has
been provided by Leavitt,77 who reviews advances in software
applications and hardware implementation. A review by Purdy
et al.103 of present and projected treatment planning computers
compares the hardware and software features of commercial
systems. The capabilities of radiation treatment planning were
greatly enhanced by the imaging techniques of CT and MRI.
Goitein47 pointed out the need of CT scanning the patient in
treatment position, for accurately delineating tumors and
adjacent normal structures, and of using CT scans to assist
in the calculation of dose. A 1981 symposiumgo reported the
223
Beam
Coordinate
System
I
Source to
viewing plane
I
Perspective
Projection
contributions of CT in radiation therapy including technical
aspects of utilization, dosimetry, and clinical considerations
in the treatment planning of specific tumors. Spanos and
Hogstroml23 give an overview of trends in radiation therapy
planning systems, particularly, where CT is involved. A CT
slice can provide an accurate definition of the skin contour,
as well as internal organs and inhomogeneities. It can lead to
graphical portrayal of tumor extent in relation to superimposed
dosimetry. Patient positioning is of crucial importance in
transferring CT information to the treatment plan.22.116.120
Some CT equipment may not permit obtaining data with the
patient in treatment position due to restrictions imposed by a
small CT patient aperture size. A typical problem is positioning
of the arm, in the treatment of breast cancer, with tangential
fields. Here, accurate reproduction of patient leveling between
treatment table and CT table is very important, since differing
arm positions can translate into erroneous beam angulation.
The use of similar arrangements of lasers for treatment,
simulation, and for CT can be used to best define the lateral,
transverse, and sagittal planes of the patient on both units,
and be very useful for patient alignment.
The number of U. S. treatment facilities having access to
computerized treatment has been reported by two American
College of Radiology studies.30.31 The number now totals al-
most 1000, with only dedicated systems exhibiting substantial
growth (see Table 134).
224 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING
TABLE 13-4 . Treatment planning computers in the United States
Dedicated 507
Time share (in-house) 56
Time share (external) 223
Total 786
RADIOGRAPHIC (FILM) PORTAL
IMAGING
At the beginning of a course of treatment and periodically (e.g.,
weekly) throughout the treatment, portal verification films are
taken to check for alignment of the beam with the clinical target
volume. Reinstein reports that 90 percent of institutions take
portal films (presumably localization radiographs) on the first
day of treatment for more than 75 percent of patients but repeat
weekly films are taken at only 40 percent of institutions. Thirty
percent of institutions take verification radiographs with the
treatment unit, but only 10 percent use it on a regular basis,
probably because of poor image quality. Regular and frequent
filming should be done for noncooperative patients, for critical
sites where millimeter accuracy is required, and for obese
patients with unstable skin marks.
Various techniques employed in obtaining useful portal
images, by nonelectronic as well as electronic means, are
discussed in this and the following sections.
The AAPM2 and Reinsteinlo5 present the following defi-
nitions of conventional portal imaging:
1. Portal radiograph. Any radiograph taken with the treat-
ment unit beam.
2. Localization radiograph (often called port film). Taken
with a small dose prior to the daily treatment (pretreat-
ment).
3. Verification radiograph. Taken during the entire treatment
fraction, with low sensitivity film.
4. Double exposure technique. Localization film exposed to
the shaped treatment field and then again to a larger
rectangular field to show surrounding anatomy.
The optimum optical density for viewing the radiograph
is 1.6-2.0. Densities down to 1.2 and up to 2.3 are acceptable.
The port film is compared with the simulator film (or BEV).
Unintended shielding of the tumor or unnecessary irradiation
of normal structure may be corrected by modifying the shape
of the shadow block (e.g., Cerrobend) or its location on the
shadow tray (by changing the screw locations) or by changing
the multileaf collimator if available. In addition to providing
quality assurance in the course of radiotherapy, portal image
records can sometimes be invaluable for medical-legal pur-
poses. Because the reference anatomical landmarks &e often
well outside the treatment field, the jaws are opened for a
pretreatment localization radiograph. If this open field is large
enough and the anatomical landmarks are suitably situated
outside the blocks, it is frequently not necessary to remove the
shadow blocks or Cerrobend block for this image. If the blocks
are removed, then a second or superimposed image will be
taken with the blocks in place. When verification radiographs
of the actual treatment are taken, much slower film is used than
for pretreatment radiographs.
In the following sections the physical principles and tech-
niques affecting image quality are discussed. In addition to the
list of directly relevant referenced articles, a bibliography is
included of texts that address broader aspects of radiographic
imaging.13,33,68.73.74,87,126,132
PHYSICS OF CONVENTIONAL PORT FILMING
Cassette and metal screens
A film cassette is mounted close to the patient, such as in or on
the patient table top, or on a floor stand that is rolled up to the
patient. For example, a sandwich of 0.6-mm lead in front, film,
and perhaps 0.3-mm lead in back may be used with 6-MV x
rays. The front lead screen shields the film from electrons
produced in the patient by the x-ray beam and creates new
electrons to expose the film. The electrons from x-ray scatter-
ing in the patient do not provide useful image information since
they spread broadly before reaching the cassette and would
reduce image contrast by adding a background of spatially
noisy exposure (quantum mottle) to the film image, if they were
not stopped in the metal screen. Compton scatter x-rays from
the patient do add a background of spatially noisy exposure,
reducing image contrast. The primary x-ray photons, which
pass through the patient without being scattered, carry the
useful image information. Their spatial intensity pattern con-
veys the anatomical detail, with regions of reduced film expo-
sure corresponding to anatomical regions of increased
absorption and scattering of x-rays. Electron equilibrium is
reached and the film exposure is proportional to x-ray photon
intensity (number of photons per energy interval times their
energy, hence dose). The back lead screen shields the film from
electrons back scattered from material beyond the cassette and
also intensifies the film image, by producing back-scattered
electrons. Better spatial resolution can be obtained without the
back screen but a longer exposure is required so patient motion
may determine the overall image unsharpness.
Hammoudah, et a1.,52 shows relative dose in the film
versus thickness of the front lead foil. The number of x-ray
photons interacting with the metal screen increases as the
screen is made thicker but ceases to increase when the electrons
generated in the portion of increased thickness cannot escape
the screen to expose the film. One way to minimize background
 RADIOGRAPHIC (FILM) PORTAL IMAGING 225

exposure of the film by x-ray scatter from the patient is to move T A B L E 13-5a. Exposure and resolution in diagnostic
the cassette away from the patient, so that much of the scatter radiography. Trade-off of speed and spatial resolution
x rays can spread outside the primary image area. Droege et Relative Qpical resolution
a1.36 shows the reduction in the ratio of scattered to primary Technique exposure limits
photons obtained with front metal screens with the screedfilm
sandwich 25 cm behind the patient vs in contact. Nonscreen 10 60 lp/mma
Galkin et a1.4 shows optical density (darkening) of film Detail screens 2 1OC
versus x-ray exposure. The "gamma" (slope), hence sensitivity Par speed screens lb 7
to object contrast, increases with increase in x-ray exposure. High speed screens 0.25-0.5 3
However, port films become more difficult to interpret above
optical density of approximately 2.0. Galkin et al.4 used fluo- aThe largest number of high contrast line pairs per millimeter which will be
rescent screens instead of metal screens, providing increased reproduced with relative contrast of at least 4 percent.
bl mR (3 X lo7 photonslcm 2, at the film produces an optical density (OD)
film exposure and contrast sensitivity,but Hammoudah et al.,52 = 1.
Droege et a1.,36 and Munro et a1.,95 report loss of spatial CAboutequal to the resolution of the eye at normal viewing distances.
resolution due to light spread in the fluorescent screen.

Diagnostic dose and
photon flux
In diagnostic radiology,83 Par speed screen technique has been
assigned a relative exposure rating of 1. An exposure of 1 rnR
(10-3 cGy) (- 3 X 105 photodmm;? at about 80 kVp x-ray
energy) will produce an optical density of 1.O, resulting in 10
percent light transmission. Optical density of 2.0 corresponds
to 1 percent light transmission; 3.0,O.l percent light transmis-
sion through the developed film. Spatial resolution limit is
defined as the largest number of 100 percent, object contrast
line pairslmm (lplmm), which will be reproduced with relative
film contrast of at least 4 percent. This value of 4 percent
corresponds to about the limit of contrast detectability of the
human eye under normal viewing conditions.
Apair of fluorescent screens has about 50 percent quantum
detection efficiency (QDE, ratio of interacting photons to input
photons). Without prior knowledge of the anatomical regions
of interest, its detection requires that its signal be three times
noise (i.e., three times the deviation of the detected x-ray flux).
For 4 percent contrast of a pixel (a typical visual limit) the
standard deviation of detected x-ray photons in that pixel
should not exceed 1.33 percent. This corresponds to a detected
x-ray flux of 1.8 X 104 photons per pixel, 3.6 X 104 input
photons per pixel at 50 percent QDE.
At 1 mR, 3 X 10s input photonslmm2, the corresponding
limiting pixel size is 0.35 X 0.35 mm, giving 1.4 lplmm
resolution with Par speed dual screen technique. (llplmm
corresponds to 2 pixelslmm). Table 13-5 from McCullough,83
lists typical patient entrance exposures for various diagnostic
examinations and lists typical x-ray exposures at the imaging
medium and limiting spatial resolution values for various im-
aging techniques.
T A B L E 13-56 -
Exposure and resolution in diagnostic
radiography. Patient entrance exposure per radiograph
Examination mR/Film
Chest film
Pelvimetry (AP)
Skull
Spine (lumbar lateral)
AP spine (cervical)
IVP
Mammography (CC view)
Industrial (SO-146)
Lo-dose
Xeroradiography
Source: From Ref. 83.
Iplmm at 8 MV at 50 percent MTF. Hamrnoudah et a1.52 found
that spatial resolution was poorer with the cassette at a distance
from the patient than if it was in contact, using lead foils and
regular diagnostic films. Because the major limitation of port
film images is in contrast sensitivity, subjective comparison of
images of actual anatomy is a better indicator of q~ality.107~111
Medical linacs have a typical x-ray source diameter of 3
rnm (e.g., 1.5 mm fwhm Gaussian profile). Spatial resolution
in line pairs per millimeter is defined along a given direction.
Taking account of this and the spatial distribution of electron
intensity over the x-ray source area, the effective x-ray source
size is about 2 mm. Hence, geometric image unsharpness of
patient anatomy with the patient tumor at 100 cm from the
source is 0.4 mm with the film at 120cm, correspondingto 0.29
mm referred back to the patient, limiting spatial resolution to
about 1.5 lplmm.

Geometric unsharpness versus cassette location
Droege et al.37 and Munro et al.95 show curves of modulation
transfer function (MTF) for various screens in patient-contact
geometry. The spatial resolution is about 2 lplmm at 4 MV, 1
6 Megavolt x-rays-required photon flux and dose
versus quantum mottle
The pretreatment type portal exposure is usually given with
6-MV x-rays to an unattenuated dose at isocenter of about 4
226 CHAPTER 13. TREATMENT SIMULATORS,TREATMENT PLANNING AND PORTAL IMAGING
cGy (1 cGy at the cassette, accounting for attenuation in the
patient and assuming 140-cm source-film distance). The dose
equivalent mean photon energy is about 2.5 MeV, at which
there are 9.4 X 106 photonslmm2 in 1 cGy. One millimeter
pixels correspond to about 0.5 lplmm spatial resolution, which
is desirable to identify the edges of low contrast objects. The
narrow beam mass attenuation coefficient of lead at 2.5 MeV
is 0.044 cmVg and 0.7 of the photon interactions are compton,
emitting electrons forwardly. Thus, 1.13 X 0.044 X 0.7 X 9.4
X 106 = 0.33 X 106 photonslmm2 convert to electrons in a
1-mm front lead screen, (i.e., 3.5 percent of incident photons).
One-third of these electrons escape to expose the film. The
standard deviation is 0.3 percent. Threshold of contrast detect-
ability in a single pixel is three standard deviations,hence about
0.9 percent, due to quantum mottle.
Quantum mottle limited anatomical contrast
sensitivity
Assuming a 20-cm thick fairly uniform section of patient, the
narrow beam attenuation at 6-MV x-ray energy is about
O.S%lmm of depth at unit density. Thus, a 1-cm cube section of
tissue differing in density by 18percent would be at the quantum
mottle threshold of contrast detectabilityif the 0.5 lplmm spatial
resolution was also required to distinguish its edges. Some typi-
cal densities in grams per cubic centimeter are lung, 0.32; fat,
0.92; lung carcinoma, 0.86 to 1.05;muscle and body fluids, 1.O;
bone, 1.65to 1.85.Thus, even withnoloss of contrast sensitivity
in the detector medium (e.g., film), contrast sensitivitywith use-
ful discrimination of edges in portal images at megavoltage x-
ray energies is limited to discrimination of major changes in
density, such as bone, lung, air pockets, and material added to
the patient (e.g., barium internally). By identifying such land-
marks in the portal films and comparing them with the simulator
films (diagnostic quality 100-kVpx-rays), the radiotherapist is
able to verify patient and shadow block positioning. Double ex-
posure check films at limited dose are often used, one an en-
larged area to include surrounding anatomy for orientation, the
other being the actual treatment field.
Treatment verification image quality
Some clinics image the actual treatment, using slower speed
film. Exit doses and resulting film exposure vary over a wide
range, depending on the number of portals, so achieving ap-
proximate film optimal density can be difficult. Haus et al.53
recorded patient exit doses ranging from 28 to 135 cGy but
found that overexposed films could easily be viewed with a
bright light. Surrounding anatomy cannot be imaged, so images
can be hard to read. The exposure at the film will be perhaps
30 times that of a pretreatment exposure. Quantum mottle will
become inconsequentialbut the image spatial resolution can be
significantly degraded by patient motion unsharpness because
of the long exposure time, exceeding breath holding time.
PORTAL FILM ENHANCEMENT TECHNIQUES
Contrast enhancement by film gamma
multiplication
Methodsl~Joghave been tried to enhance the gray scale of port
film images, such as by double or triple development to multi-
ply the film gammas (slope of curve of light density versus
x-ray dose). However, this restricts the film dose window (film
latitude) and, hence, the useful image to more uniform thick-
nesses (glcmz) of the anatomy. Double or triple development
increases artifacts and image noise. Also, the procedure is time
consuming and very sensitive to development techniques. A
sandwich of two light emitting screens with film has been
shown to give improved contrast, but with loss of spatial
resolution.36
High contrast film-limited latitude-long exposure
A sandwich111 called PMCI system has been tried, employing
sequentially: (a) lead front screen, (b) single emulsion very
high contrast graphics or line-type film, (c) high quality fluo-
rescent screen. Contrast was twice as good as conventional
sandwiches of lead foil-x-ray film-lead foil. However, ex-
posure latitude is limited (good images were obtained over a
2 2 0 percent dose range). Also, the required patient dose is
about 20 to 30 cGy. If area pretreatment exposure were used to
orient the treatment field to surrounding anatomy, this sur-
rounding anatomy would receive an undesirably high dose.
Digital enhancement of film images
A more desirable method of image enhancement involves
digitizing the fi1m.28,78,86-1123119
The gray scale window and
gamma within the window can then be varied over the image
by computer. Spatial averaging and edge sharpening tech-
niques can be used. Superposition of portal and simulator
images can be facilitated. Film digitizing equipment is com-
mercially available with film scan times of a few (e.g., 6)
seconds. However, the overall process of inserting the cassette,
taking the film to a processor, developing, and digitizing is still
time consuming, and labor intensive.
Nonfilm radiographic techniques
Instead of a sandwich of metal screens and film, a 1-mm thick
photostimulable phosphor sheet134 has been used as the detec-
tor. The phosphor sheet stores the x-ray image. Subsequent
scanning by a laser beam causes the phosphors to emit light,
which is detected by a photomultiplier, as illustrated by Figure
13-6. The resulting electrical signals are digitized, stored, and
subsequently image enhanced by computer and output to film
or optical disk storage and CRT display. A similar techniques1
has been used with an experimental storage phosphor sheet that
was laser scanned, image processed, and displayed on a laser-
 ELECTRONIC PORTAL IMAGING 227

X-Ray Quanta

Exposure Scanning Mirror

I
Laser Beam Scanning
-I- +c I
1

Reading
P

Imaging Plate
Light 1

FIGURE 13-6 . Photostimulable phosphor imaging technique (from Ref. 134).

printed film. These images were found to be superior to con-
ventional portal film images. Selenium plates7l7ll0have been
used at diagnostic x-ray energies but might be considered for
megavoltage x-ray energies. The selenium plate is electrically
charged, exposed to the x-ray beam, laser-scanned, and the
resulting change in charge detected by a photomultiplier or by
an electrostatic probe.
verification of patient setup and of multileaf field shape. To
avoid expending excessive time and labor, an electronic imag-
ing system, which rotates with the gantry, seems essential. In
order to limit patient exposure with open fields, the associated
TABLE 13-Q . Errors in patient setup. Field-placement errors
detected using localization films

Site of tumor Errors" Total films %

ELECTRONIC PORTAL IMAGING Ear, nose, and throat 73 434 17

Brain and pituitary 12 163 7
Chest 41 317 13
VALUE OF ELECTRONIC IMAGING Pelvis 40 153 26
Upper abdomen 12 61 20
Ideally, each portal should be verified every treatment day. Bone metastases 9 83 11
There is considerable data82 on magnitude and frequency of
position errors in patient setups. Table 13-6 shows that about
50 percent of fields exceed 5-mm error. Marks et a1.82 showed
some data on the effects of such errors on clinical outcomes aErrors represent a displacement of 0.5 cm or more from planned field.
(e.g., tumor recurrence increased from 55 to 77 percent with Source: From Ref. 83.
major errors in treating lung cancer). Pseudoreal time portal
imaging (e.g., integrated images at 1 second intervals) is dra- TABLE 13-6b . Errors in patient setup. Type of field-placement
matic in its display of organ motion. For example, even with errors detected using weekly localization films
shallow breathing the chest wall can move 2 5 mm during
breast treatment. Field-placement error %
There is a desire, in contemporary practice, to employ
Field malposition 74
more portals in order to conform the high dose region closely
Field malrotation 14
around the clinical target volume and to follow changes in this Patient malposition 8
volume and the patient anatomical shape throughout the treat- Block misplacement 4
ment course. This suggests use of multileaf collimators, to -
facilitate following changes in anatomy over the course of Total 100
treatments and perhaps even dynamically during an individual
portal treatment. This in turn increases the need for x-ray Source: FromRef. 82.
228 CHAPTER 13. TREATMENT SIMULATORS,TREATMENT PLANNING AND PORTAL IMAGING

TABLE 13-6c . Errors in patient setup. Degree of variation order of 1 to a few centigray for enlarged area view and 1 to a
between simulator and portal films few centigray for actual field in pretreatment checks, ensuring
an adequate view of surrounding anatomy. It can be used to
Field Field Field
exceeding exceeding exceeding image actual treatments over a widerange of patient tumor dose
5 mm 10 mm 15 mm per portal, such as 20 cGyIporta1 in a 10 portal conformation
Site of n m o r (%I (%I (%I therapy treatment, or 200 cGy in a single portal treatment.
Figure 13-7 from Leong,79 shows response of an electronic
Brain 58 17 3 system that is linear over a range from 5 to 350 cGy at machine
Head and neck 17 0 0 dose rates from 100 to 500 cGytmin. The system can be used
Thorax 77 32 15 for dosimetric confirmation of wedge filter orientation and for
Abdomen 35 11 2 comparison of actual versus planned patient exit dose distribu-
Pelvis 65 24 11 tion to confirm positioning of shadow blocks. Wong et al.136
Extremeties 47 15 0 and Ying et al.138 describe use of portal dose images to verify
Average 50 20 8 patient positioning and delivery of planned dose.
In a 6000-cGy tumor dose course of treatment with 6-MV
Source: from Ref. 82.
x-rays in 30 daily treatments, the daily exposure in the
treatment field is about 300 cGy at D-max. The allowed
localization images would perhaps be taken at only two portals, leakage through the jaws of the beam limited device for
which are nearest to orthogonal in multiport therapy, but the accelerators capable of large fields is limited by IEC to about
actual treatment fields could be imaged at every portal, either 0.5 percent; that is, daily 1.5 cGy at D-max, a total of 45
before or during treatment. Since about two-thirds of conven- cGy in the course of treatment. Scatter radiation in the patient
tional treatments are done at about 6 MV, the time to switch adds considerably to this leakage dose, depending on field
from a higher x-ray energy (e.g., 18-6 MV) for pretreatment size. It is important that the dose to the patient in openfield
imaging need not make a major impact on daily schedules. (e.g., jaws fully open; or jaws set several cm larger than the
Motorized multileaf collimators and automatic wedges will treatment field) portal imaging not exceed collimator jaw
facilitate speedy setting of open fields for pretreatment imag- leakage; that is, about 1.5 cGylday if done daily, to limit total
ing. Based on analysis of various combinations of screens, exposure of critical normal tissue outside the treatment field.
films and x-ray energy, Munro et a1.95 state some requirements Although open field portal imaging with film is conventionally
for an electronic imaging system: done once perlweek at most, daily pretreatment open field
electronic imaging would be desirable for some patients to
1. It should be able to visualize the entire treatment field at avoid the errors in patient setup that might otherwise occur
one time and should be able to record for the duration of between weekly film localization images. A dose of 2 to 6
treatment, thereby using all of the available quanta. It must cGy is typically employed in weekly open field localization
have a high signal-to-noise (SIN) ratio. imaging. An even lower dose of 1.5 cGy would be desired
2. A thin heavy metal screen should be used to absorb comp for daily open field electronic imaging. This necessitates high
ton and pair produced electrons emitted from the patient utilization efficiency of the available 6 MV x-ray flux in
and to convert the transmitted x-rays to electrons. A mod- electronic portal imaging to avoid limitation of image contrast
ulation transfer function (MTF) of 50 percent up to 1 to 2 by x-ray photon quantum statistics.
lplmm is desirable. (This corresponds to pixel size less
than 0.5 X 0.5 mm to 0.25 X 0.25 mm referred to isocenter
and a 700 X 700 to 1400 X 1400 pixel array for 35 X 35 ONE-DIMENSIONAL VERSUS
cm field at isocenter.) TWO-DIMENSIONAL DETECTORS
Both mechanically scanned and electronically scanned linear
Taborsky et a1.125 take a quite different view from Munro et detector arrays have been developed. Their usefulness has been
al.95 Since in portal imaging, the viewer has prior knowledge of primarily for verification of actual treatment fields. Since the
what to look for by comparison with the simulator film an SIN active linear array detector in these systems sees only a small
ratio of only 2: 1 (instead of conventional 3: 1) can be tolerated. fraction of the field at any one time and converts only a small
Also, since tumor margins for treatment portals are normally 5 fraction of the x-ray flux it does see, large total dose and
mm, pixel intervals could be slightly more than 1 rnrn and still exposure time are required to limit quantum mottle. For exam-
achieve adequate spatial resolution. (Taborsky uses "spatial ple, even using a I-D linear array of thick crystals with 60
resolution" of 1 rnm and detector intervals of 1 mm as though percent x-ray conversion efficiency instead of the typical 1
they were the same.) By "spatial resolution" in this case, percent x-ray conversion efficiency of a metal-fluorescent
Taborsky really means precision of location of an edge. screen with 2-D 256 X 256 pixel detector, the I-D linear array
Compared with film an electronic detector can have wide would detect only 601256 = 23 percent as many x-ray photons
latitude. It can be used to image patient delivered doses of the as the 2-D array. Too much time and patient exposure would
 ELECTRONIC PORTAL IMAGING 229

lmaaina Section lrnaae Processina Section

F-3
E-2
.--.- - - - ... A
.Fluorescent
Screen
- I
Image
Processor
rrocessor
TRAPIX
VAX 1lff80
Mirror
Monitor
Camera

3 0 -8 1 1 -6 1 1 -4 1 1 -21 1 1
0 1 12 1 r4 l l 6 l l 8J
crn
(4

-
FIGURE 13-7 Dose distribution verification with fluorescent screen viewed by SIT type W camera
(from Ref. 79), (a) equipment arrangement, (b)measured wedged field dose profiles.

be required for high quality images with the I-D scanned array
in pretreatment localization use, especially since such fields are
usually much larger than the treatment field. In addition veri-
fication images will have very poorcontrast when a high energy
x-ray mode, such as 18 MV, is being used for patient treatment.
Examples of such scanned systems are discussed in the follow-
ing subsections, including silicon diode linear arrays and a
multiwire liquid ionization chamber, which is physically 2-D,
but only one linear array is activated at a time.
For pretreatment localization portal imaging of open fields
with high image quality, 2-D arrays (or a multiple linear array
with high x-ray conversion efficiency) would be desired. Alow
dose to the patient could be used for fields larger than the
treatment field in order to see bony landmarks, with acceptable
230 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING

low quantum mottle at this low dose. Examples of such 2-D isooctane was injected between two 1.5-mm thick glass fiber
systems are described later. printed circuit boards on each of which 128 copper strips 1.27
mm wide on 2.5-mm centers were printed. The field of view
was 32 X 32 cm. A voltage of 300 V is applied sequentially to
the "X" set of strips, stepping each 2.5 ms. Electrometers
SILICON DIODE LINEAR
ARRAY-MECHANICALLY SCANNED measure the ionization current of each "Y" cross strip 10 times
to obtain an average. The time to scan 128 "Y" strips at a given
In an early experiment125 with an 80-cm SAD 4 MV medical
linac, a linear array of 16 pairs of scintillator crystal plus silicon
diode detectors on 4-mm centers was placed in a plane at 95
cm from a 4 MV x-ray source. The diameter of the sensitive
region of each detector was 2 mm. In each pair, one diode was
mounted above the other. A 1-mm lead sheet was mounted
above and another below the linear array.
A system,75 Figure 13-8, has been developed for portal
imaging employing a linear array of 256 silicon diode detec-
tors, spaced at 2-mm intervals in a plane at 150 cm from the
x-ray source, overlaid with 1.1-mm lead. The array is scanned
through the field by a stepper motor in 2-mm steps. The
maximum field is 3 4 mm wide X 30 cm long at isocenter
(100-cm SAD), corresponding to 1.3 X 1.3-mm pixels in a 256
X 256 image array. Typical accelerator operation was at 200
pulses/s. At 100-cGy tumor dose per portal at 200 cGy/min at
tumor depth, there would be 6000 pulses per portal, 27 pulses
per scan step. A 1.0-cm diameter 1.5-mm thick poly(styrene)
disk on a 7-cm thick poly(styrene) phantom was clearly visible
(2 percent density contrast).
Brahmel5 mentions development of a linear array detector
employing calcium tungstate crystals coupled to photodiodes
and its use for CT imaging and as a transit dose detector, as well
as for verification type portal images.

MULTIWIRE SEQUENTIALLY PULSED

(ELECTRONICALLY SCANNED) LIQUID
IONIZATION CHAMBER
A small multiwire liquid ionization chamber has been experi-
mented with (see Fig. 13-9 a-c).13'.]" A I-mm thick layer of

I Motor
Control
- 101 0 0

Motor
.f 1
Pulse Video
110 Electronic Imaging Device
I Control
Control
Board
-
r0 (4
-
C .

a,
a,
D
Detector
Amplifiers
and
-+ AID 2 LSI-11123
FIGURE 13-9 . Multiwire liquid ionization chamber (from Ref. 131).
Computer
Multiplexer (a) A view inside the nlegavoltage camera cassette. (1) ionization cham-
a ber matrix; (2) 128 channel electron~eter;(3) 128 channel high voltage
switch; (4) control electronics; (5)line-driver amplifier; (6) cable to con-
FIGURE 13-8 . Block diagrani of electronic portal imaging systenl tml unit. (h) A typical radiotherapy treatment setup, and (c) a sche-
with 256 silicon diode linear array (from Ref. 75). nlatic diagram.
 ELECTRONIC PORTAL IMAGING
Accelerator
Sync Pulse
I
FIGURE 13-9 - (Continued)
"X" position to detect the ionization at each cell is 20 ms. After
5 ms to let the electrometer decay, the next "X" position is
scan'ned. The full " X Y matrix is scanned in 3.1 s. The noise
at 200 cGy1min was 0.13 percent. Decreasing the averaging to
4 instead of 10 measurementsper pixel increases the noise level
to 0.25 percent (1 std dev). The spatial resolution (line spread
function) was 2-mm fwhm (- 0.25 lplmm). The ionization
current is about 100 pA and the electrometer electronic noise
level is 0.5 PA. The published figures illustrate the value of
computer enhanced portal images, even with limited spatial
resolution. The array has been increased6.88.89.132 to 256 X 256
ionization chambers in 32 X 32 cm, within overall housing
dimensions of 52 X 52 X 4 cm. Image acquisition time is 5.88
s for a raw image, 6-10 s for a processed image. Typical patient
exposure per image is about 20 cGy.
The ion mobility in isooctane is extremely low. Van
Herkl30 measured 8.1 X 10-3 mmls per voltlmm of electric
field, hence 2.4 mmls with 300 V across a 1-rnrn gap. Thus only
about 5 percent of the ions in a detector element are collected
during the 20 ms that the corresponding electrode is switched
on in each 25-ms interval. At 200 cGyImin, the ionization
charge rate generated per detector element is 2.5 PA. But the
actual electrometer current is 50 PA. This occurs because a
latent image charge is built up in the isooctane by the radiation
during a period of about 0.2 to 0.5 before the electrode is
switched on.131 The latent period of image charge storage is
shorter at high dose rate because of ion recombination. Signal-
to-noise ratio is determined by the statistics of the latent image.
The x-ray photon quantum noise is comparable to the
electrometer random electronic noise at typical dose rates
without patient. The quantum noise predominates with typical
patient thickness, detector position, and treatment machine
231
(c)
dose rate. Van Herkl30 found that the collected charge per unit
time is proportional to the square root of dose rate at the
detector. This implies that the contrast sensitivity will be cut in
half for low contrast anatomy compared to the contrast sensi-
tivity of a linear response detection system, assuming it had
equal dynamic range. For example, a 2 percent difference in
transmission in an otherwise uniform phantom will provide
1.020.5 - 1.000.5 = 1 percent signal difference. The loss of
signal difference is due to increased ion recombination in the
liquid as the x-ray flux rate is increased. Thus, S/N might be
500: 1 without patient, but 250:1 with thick patient region,
corresponding to 125:1 in the actual anatomical image due to
square root response of the liquid.
In order to improve the contrast of portal images, the gray
scale level and window can be selected and the slope of signal
versus x-ray intensity made steeper. However, different selec-
tions can produce changes in the apparent edge of the field
relative to anatomy in the image. This could lead to serious
clinical errors. Therefore, Bijhold et al.10 developed an auto-
mated technique for detecting and displaying the true position
of the field edge, consistent with the 50 percent isodose line. A
histogram of the image is calculated and used to produce a
binary image, one inside the high dose region, zero outside.
This image is automatically traced to display a line representing
the field edge.
Image smoothing is achieved by switching on two wires
at a time, then shifting by one wire (1 and 2, 2 and 3, etc.).
Digital spatial filtering is used. Displayed images of actual
fields during treatment are averaged over four scans, for total
delivered dose at isocenter of about 80 cGy per image.
Pretreatment images of fields larger than the treatment
field are taken in 1.5 s with patient exposure of 5 cGy, shifting
232 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING
by two wires each switch time (1 + 2, 3 + 4, etc.). This gives
one-half spatial resolution in the scan direction. Because of the
large pixel size, the quantum mottle is only 40 percent greater
than with 6-s scans of every wire.
About 2 s is needed between portal field measurements for
the ions in the isooctane to clear by recombination. Movement
of the ion chamber can cause severe microphonics due to
variation of the capacity between opposing electrode planes,
hence preventing imaging during motion of the gantry, unless
the chamber planes are rigidly supported. For example, a
bulging of only 10pm at one pixel region would cause a 1
percent change in ion collecting electric field and a correspond-
ing 1 percent change in ion flow at that pixel.
Holroyd57 states that about 10 molecules of a hydrocarbon
liquid react per 100 eV of ionizing radiation absorbed in the
liquid, for example, a G value of 10. This means that about 1
percent of the liquid will be converted into various products by
a dose of 107 cGy, corresponding to about 10 years of 60
patients per day verification imaging. This might conceivably
be important if an extremely pure organic liquid were used, as
proposed by Antonuk et al.4 However, the isooctane used by
Meertens et al.88 and van Herkl3l is far from pure, fortuitously
for optimal ion mobility.130 However, van Herk has observed
thermal currents induced by repeated exposure of fields cover-
ing only a part of the chamber. These and other effects make
the chamber inadequate for precise spatial dosimetry.
In order to obtain faster imaging with the multiwire liquid
ionization chamber approach, a chamber has been developed4
which uses an ultrapure liquid (parts per billion) so that the
electrons do not recombine on contaminants and can be col-
lected. Free electron transport is about 105 faster than ion
transport, hence permitting electron collection in about 1 ps.
The purity achieved provided an electron lifetime of about 100
ps, SO it was proposed to scan about one-sixth of the chamber
electrodes in 100ps, covering the full chamber in 0.6 ms, then
repeating and integrating the image. A separate high voltage
electrode will be used to sweep out the positive ions to clear
the space charge left by the fast scan of the free electrons.
Conventional amplifiers will be used instead of electrometers,
since the electron current is so much higher than the ion current
of the previously described chamber. In order to maintain
purity of the liquid, the chamber enclosure is made of laser
welded stainless steel. The flash point of the liquid is below
room temperature, so it is cooled while filling the chamber.
van Herkl30 points out that with a pulsed x-ray source such
as a linac, the S/N at practical data rates (e.g., 10 MHz) is no
better with the ultrapure liquid electron collection technique
than with the conventional liquid ion collection technique.
MECHANICALLY ROTATED MULTICHANNEL
IONIZATION CHAMBER
An experimental model of a gas filled ionization chambers]has
been built, employing 64 linear anodes on 1-mm centers, each
connected to 1 of 64 electrometers. With each anode 6.4 cm
long, this forms a 6.4 X 6.4 cm2 active detector area. The
anode-to-cathode gap was 4 mm. A lead screen was used for
enhancementof sensitivity. The chamber was rotated in a 4 MV
x-ray beam. The profile formed by the electrometer signals at
each of 100 angles was filtered and back projected (as in CT)
to form an image. The image reconstruction time was 2 min
using an IBM PC type model AT computer but it could be much
faster using an array processor. The measured line spread
function was 2 mm for a slit in a 4 MV x-ray beam. A similar
technique has been employed by Bova,l4 but using a liquid
(similar to carbon tetrachloride) in a 1-mm gap and high dc
voltage such as 30 kV to extract the ions.
TAPERED FIBER OPTICS TO TV CAMERA
Small scale tests have been made with a system23 in which each
2.5 X 2.5-cm area of a fluorescent screen is coupled via a
bundle of plastic tapered fiber optics to a 2 X 2-mm area of a
charge coupled device (CCD) detector. The CCD detector
could be located remotely and fed through a fiber optic cable,
which could have a rotating fiber opticjoint at the gantry-stand
interface.
Binns et al.11 state in their patent application that commer-
cially available plastic fibers have an acceptance angle of about
10". This presumably means the maximum meridian angle in
the core (not in air) at the output end of the tapered fiber. Wong
et all35 describes fiber-optic reducers made of poly(styrene)
core and acrylic cladding. The refractive index is no = 1.59-
1.60 for poly(styrene); n' = 1.48-1.50 for methyl methacry-
late, giving an average numerical aperture (NA) in air of NA
= (1.5952 - 1.492)0.5= 0.569 for meridional rays. Accounting
for skew rays, this increases to (NA),= 0.68. The equivalent
acceptance angle in air is 43" at the tapered fiber output, 2.44"
at the 16 to 1 tapered fiber input. An equivalent lens at 100 cm
from a 40 X 40cm screen minifying to 2.5 X 2.5 mm would
have a focal length of 6.25 cm, an aperture diameter of 2 X 100
tan 2.44" = 8.5 cm and speed offl(6.2518.5) =f/0.74. Account-
ing for ratio of core to total area, interface losses, and internal
losses in the fiber optics and for reflection, transmission and
vignetting losses in the mirror-lens system, the fraction of light
photons reaching the TV pickup tube from the fluorescent
screen could be quite similar for the two systems. However, the
vertical height of a 45" mirror for a 40 X 40 cm screen would
be 29 cm (1 1.4), whereas the tapered fiber bundle height could
be approximately 10 cm (4 in), a height saving of 19 cm (7.4
in.).
The technique has been used to build a full size camera,
with 40 X 40-cm area 240 mgIcm2 gadolinium oxysulfide
(GOS) fluorescent screen.135 A 256 X 256 array of 1.6 X
1.6-mm fibers in 16 X 16 fibers array 1 X 1-in. bundles is
tapered down to the fiber optic face plate of a 1-in. Hamamatsu
Nuvacon TV tube. Slit tests are reported to give a spatial
resolution of 2 mm fwhm when the slit is aligned with the fibers
 ELECTRONIC PORTAL IMAGING
and 3.5 mm when straddling the fibers. (This corresponds to -
0.18 lplmm spatial resolution.) The image is integrated on the
TV tube target for 0.25 s and averaged in digital memory for 4
s of exposure. Considerable smoothing of the image was done
electronically to compensate for light transmission variations
from pixel to pixel in prototype versions of the fiber optics,
thereby detracting from crisp spatial resolution.
LENS TO TV CAMERA
Various kinds of TV cameras [image orthicon, Multichannel
Image Intensifier38 (MCII)] followed by CCD, silicon intensi-
fied vidicon (SIT)7.79 have been used to view a fluorescent
screen via a lens and 45" mirror, as depicted in Figure 13-5from
Leong.79 Such systems by Munro et a1.94.96 and Shalev et
a1.113.114 approach the image quality of digitally enhanced film
cassettes described above. Because of the 45" mirror, the min-
imum thickness of such systems is about 75 percent the length
of the phosphor screen, making them quite bulky.
Emberson et al.38 shows the modulation transfer function
(MTF) of a MCII with 20 pm channel pitch (50 channelslmm)
18-mm diameter screen as 17.5 lplmm at 50 percent MTF. This
corresponds to 225 line pairs across a 13-mm square, hence
0.75 lplmm projected to a 30 X 30-cm field at isocenter. When
the MTFs of the metal screenlfluorescent sandwich, lens (if
used), MCII, CCD, and display system are multiplied, the total
system spatial resolution at 50 percent MTF is probably one-
half the MCII resolution. This is to be compared with the 2
lplmm spatial resolution at 50 percent MTF reported by
Droege37 for metal screens on film at 4-MV x-ray energy, about
1 lplmm at 8 MV, and the 1.2 lplmm at 6 MV reported by
Munro.89 A 25-mm SIT tube with 18-mm diameter target has a
limiting resolution (4 percent MTF) of 680 TV lines at 10-fc
illuminance. Assuming one-half of this, 340 TV lines, 170 line
pairs over the 18-mm screen diameter, 9.4 lplmm, this is about
one-half the resolution of an 18-mm diameter MCII.
Instead of using a TV camera system sensitive to very low
light levels, such as a SIT tube or an MCII plus conventional
TV tube, it is possible to use a Plumbicon TV camera tube by
integrating the light image on the tube target. A portal imaging
system has been built, which employs a thick metal converter
screen, a 0.4-gIcm2 thick 40 X 40-cm GOS fluorescent screen,
lens, and Plumbicon camera tube.39.94.96 The light image is
integrated for 0.2 to 2 s on the Plumbicon target. Using a
uniform phantom and plastic penetrarneter, 0.35 percent image
contrast has been obtained with 2-s exposure of 7 cGy at 6 MV.
The measured spatial resolution was 0.7 lplmm at 10 percent
MTF.
Munro et a1.w measured the MTF, noise power spectrum
(NPS), and detection quantum efficiency (DQE) of a complete
mirror-lens type fluoroscopic system and of just the x-rayllight
converter. The system employed a 1-mm thick copper sheet
coated with up to 400 mglcm2 of terbium doped gadolinium
oxysulfide (GOS), a 45" mirror, 55-mm focal lengthp0.95 lens,
233
20-mm active diameter plumbicon TV pickup tube, &bit frame
grabber and IBM-PCIAT. By taking the difference in perfor-
mance between the total system and just the x rayllight con-
verter, Munro determined that total system quantum efficiency
would continue to improve with improvement up to a factor of
10 in quantum efficiency of the optical link. Munro suggested
gaining a factor of 6 in this optical quantum efficiency by
doubling the GOS thickness to 800 mglcm2, increasing the lens
speed toj70.75, and increasing the Plumbicon active diameter
to 28-mm. Munro et a1.N had previously calculated that be-
tween 1 and 5 light photons were detected per x-ray photon
interaction in the metal converter plate and was not able to
explain this large discrepancy of order 10:l in optical quantum
efficiency in Munro et a1.94.
By comparing video signals from a calibrated light source
and from a 400-mglcm2 GOS screen, Munro et al.96 calculated
that 2.5 X 104 light photons are emitted (into air) per high
energy electron from x-ray conversion, assuming 20 percent of
such electrons escape the metal and pass through the GOS
screen (but that the actual light emission per electron might be
up to five times smaller than this).
Shalev et al.113 states that the emitted light quanta (into air)
per incident electron will be about 1.5 X 104 for a 4 MV linac
and finds that the system quantum efficiency will be degraded
to 40 percent of its theoretical value if anfl1.4 lens is used.
However, faster lenses are typically positioned further from the
fluorescent screen to limit vignetting and aberrations, so the
lenses and the light tight enclosure become larger.
Monte Carlo calculations by Huntzingefio show that 3
percent of a narrow 6 MV x-ray beam is absorbed in a 1-mm
thick steel converter plate but only 0.8 percent of the incident
primary (information carrying) x-ray photons produce elec-
trons that escape the metal and transit a 400-mgIcm2 GOS
screen, each electron depositing 0.8 MeV of energy. The quan-
tum efficiency of GOS is 19 percent and the light transmission
of a thick screen is about 80 percent. The emitted light photon
energy is 2.28 eV. Because of diffraction at the GOS to air
interface, only rays emitted within a core half-angle of about
50" from the normal to the interface can escape the GOS into
air, a solid angle of only 18 percent of the 4.rr steradians of
emission (0.19 X 0.8 X 0.18 X 8 X 10512.28 = 9.6 X 103light
photons into air per transiting electron. Assuming minification
from 45-cm diameter at the 40 X 40-cm screen to 28-mm
diameter at the TV pickup tube screen with anf10.75 lens at 90
cm from the screen, the lens focal length would be 90 (2.8145)
= 5.6 cm and the lens aperture would be 5.610.75 = 7.5 cm,
encompassing 8.7 X 10-4 of the hemisphere of fluorescent
screen emission. Allowing for 0.8 mirror-lens transmission, 0.7
lens vignetting, 0.3 TV pickup tube response gives 1.46 X 10-4
photon acceptance and 1.4 events at the TV pickup tube per
high energy electron transiting the GOS screen. This shows that
for these conditions the quantum sink is not in the optics.
However, some degradation (about 40 percent) would occur in
total system quantum efficiency due to statistical loss of pho-
tons in this optics. A slower lens, such asf.0.95 orfll.4 instead
234 CHAPTER 13. TREATMENT SIMULATORS,TREATMENT PLANNING AND PORTAL IMAGING

of them.75 chosen in this example would significantlyreduce

total system quantum efficiency.
A 1-cGy dose with 6-MV x rays will produce 11.5 X 106 t
----------
+I+ Radiation
Source

x-ray photonslmm2, 11.5 X 104 electrons/mm2 transiting the

GOS. If there were no degradation of quantum efficiency in the
optical system, the standard deviation (quantum mottle) would
be 0.34 percent per 1-mm2 pixel. The threshold of anatomical 100 cm

I-.:
contrast detectability would be three times this, or 1 percent
corresponding to 2.5 mm thickness of tissue, hence 1 percent RF Shielding Box
of the thickness of a 25-cm thick patient region.
1 mm Copper Converter 1

TWO-DIMENSIONAL ARRAY OF SILICON

DETECTORS
++++++++
------
Intensifying Screen

IT0
P '
:;Ael
r
L

Signal
A 17 X 17 array of 289 silicon diodes128 on 1-cm centers has +1.6 V I
been used to verify the dose distribution exiting the patient. Bias -
N
Changes in patient thickness can be estimated from the exit Cr
dose pattern. Patient movement and the motion of internal
anatomy can be detected. This is really not an imaging system Glass Substrate
because of the sparseness of the array. The experimentersfound I
I 1
that the 1-cm spacing of diodes was too large to give adequate LeCroy 9400
Digital Oscilloscope
verification of placement of shadow blocks.

TWO-DIMENSIONAL AMORPHOUS SILICON

-
Flze?@L
I
CHI-

CH2.
1
Trigger from
Accelerator
ARRAY
The potential of hydrogenated amorphous silicon (a-Si:H) is
being explored for radiation dete~tion.4.5.41.42~1~~'24.'39
Silane,
doped with gases such as diborane or phosphine, is deposited
in a reactor on a thin substrate such as metal or glass to form
the detector. For imaging of megavoltagex-rays, the a-Si:Hcan
be used like an array of photodiode solar cells, replacing the
film in an x-ray cassette. A fluorescent screen (e.g., Gd0S:Tb
Kodak Lanex Fast B) emits light that produces ions in the
intrinsic layer of the array of a-Si:H photodiode cells. A bias
voltage of about 300 V causes ion flow to charge the capaci-
tance of each photocell. A pair of thin-film transistors (TFT)
(also of amorphous silicon deposited at each photocell) permits
sequential switching along a row to detect the charge voltage
at each cell in that row and switching from row to row to scan
the detector area.
The advantages of amorphous silicon over crystalline sil-
icon are (a) it has so many defects already that it is not
damaged100 significantly further by radiation and (b) it can be FIGURE 13-10 . Amorphous silicon photodiode experimental configu-
deposited over large areas on an inexpensivesubstrate.4.5 Much ration for 6 MV pulsed x-ray beam measumments (fmm Ref. 5).
larger areas than conventional wafers for semiconductor pro-
duction are possible, for example, of order 50 X 50 cm with a
cell every millimeter. Street124reported 4 X 6 cm arrays in 1990 pulsed beam measurements.5The sensor cell was fabricated by
andAntonuk4reported 11 X 11cmarrays in 1991.Amajor area plasma-enhanced chemical vapor deposition (PECVD). The
of research is in minimizing noise in the TFTswitches in a large n-doped layer (40 nm thick) is deposited first, then 1000-nm
array, and in obtaining uniformity from pixel to pixel. intrinsic layer, then 20-nm p-doped layer, hence termed by
Figure 13-10 shows a single a-Si:H cell with intensifying convention an n-i-p device. A chrome strip at the bottom and
screen and signal detection electronics, used in 6-MV x-ray an optically transparent metal (indium tin oxide, ITO) at the
 PHOTON SPECTRUM IN PORTAL IMAGING
top provide dielectrical contact to the cell. The cell area was
0.6 mm. With a Lanex screen, 6.4 X 107 signal electrons (-
10-11 Coulomb) were collected in 3 ms of signal decay follow-
ing a 0.028-cGy single pulse of 6-MV x rays (240 cGylmin at
143 Hz beam pulse rate) at the detector 100 cm from the source.
The noise was comparable to the signal, but this was attributed
to poor definition of the boundaries of the amorphous layers
due to using shadow masks, instead of photoresist methods that
would be expected to provide noise levels of less than 10-11 A.
The detector material itself generates noise, primarily due
to the fluctuations in the capture and release of the electrons
and holes traversing the detector material (shot noise). The TFT
noise has two primary components: Nyquist noise, due to the
finite channel resistance of the front end of the TFT, and flicker
noise (llf noise), due to the fluctuation of electron density in
the channel. Cho et a1.24.25 found llfnoise to predominate for
the entire system, obtaining SIN of about 10 with shaping times
of 1 to 20 ps for detection of single minimum ionizing particle
(MIP), such as individual Compton electrons, producing ion-
ization of about 3000 electrons in a 50- pm thick detector. The
physical origin of the llf noise appears to be the random
trapping and detrapping of channel electrons at the interface
traps between silicon and silicon nitride at the front end of the
TF.
The signal found by Antonuk et al.5 was 2.1 X 104 times
as high as Cho's signal. Hence one might assume a SIN of 1000
with a single linac pulse producing 0.028 cGy at a single cell
detector. The capacitance of a 1 X 1 X 1 pm thick detector
intrinsic layer is about 100 pF. A row of 256 detector cells
would have a capacitance of 25 nF. Accessing a row of 256 or
512 detector cells via TFT switches will add capacitance,
reducing signal voltage and adding switching noise. However,
integration over 1 s of x-ray exposure will gain back SIN. This
illustrates the need for continued research, especially on large
arrays, to reduce a-Si:H detector and TFT noise for megavolt-
age x-ray portal imaging applications, where S/N of at least 5 12
is desired so that signal quality is maintained in digitization.
Perez-Mendez et al.100 proposes using 100-400-pm layers
of CsI (TI) evaporated onto the a-Si:H detector for enhanced
scintillation efficiency with x rays. Heat treatment of the CsI
would produce columnar structures, which would pipe the light
with enhanced spatial resolution, similarly to conventional
x-ray image intensifier.
Fujieda et al.42 mentions use of glass fiber optic panels
with the core glass doped with scintillating rare earth elements.
Fujieda42 also mentions preliminary success in producing thick
faceplates with a larger columnar diameter by melting and
recrystallizing CsI inside a honeycomb structure (presumably
fused glass tubes). Puseljic et a1.104 mentions use of a fused
array of glass capillaries (e.g., 0.6 mrn diameter) filled with
scintillator liquid such as 1-phenylnapathalene.The refractive
indices of the liquid core (1.46-1.49) and capillary glass (1.66)
provide good fiber optic light transmission.
Naruse et al.98 describes a detector comprised of several
alternating layers of metal and amorphous silicon, intended to
235
increase the quantum detection efficiency of x rays in the
diagnostic energy range. A five-layered detector was fabricated
on a 1.5 X 4-cm glass plate, each layer comprising 0.5-pm of
molybdenum. An output current of 10-loA/cm2 was obtained
at an exposure rate of 700 cGylmin of 70 kV x-rays. Instead of
producing light in a fluorescent screen to expose the amorphous
silicon photodetectors or photoconducters, the electrons from
x-ray interactions in the metal develop charge in the amorphous
silicon directly.
MOUNTING A DETECTOR ON A LINAC
Assuming the Clinac 61100 and Clinac 1800 with beamstopper
as examples for discussion, the clearance from isocenter to
beamstopper is about 59 cm. A clearance from isocenter of 37
cm is required to clear the rails and under support of the table
top of the extended range patient table assembly, with full
gantry rotation. This leaves a 22-cm (8.7 in.) space for insertion
of an electronic image detector. This would be enough height
for the mechanically rotated multiwire ionization chamber, the
tapered fiber optics technique, the liquid ionization chamber,
and so on, but not enough for the lens TV camera systems. In
order to provide clearance for full lowering of the patient table
for extended SSD treatments and for patient convenience in
getting on and off the table top, the detector in any of these
systems should be fully retractable or removable. In machines
without beamstopper, this would also keep the space clear to
facilitate patient setup before portal imaging. The detector
could be mounted on a bearing at the side of the gantry and
could be swung either forward through about 180" to position
it on beam axis or back totally away from the region involved
for patient setup. A second bearing would permit swinging the
detector vertically through about 90" into a storage position
against the side of the gantry. A flexible cable would transmit
signals from the image pickup devices in the detector to the
gantry and on to a display terminal.
PHOTON SPECTRUM IN PORTAL
IMAGING
The basic problem of low contrast in portal images is due to the
small differential absorption of megavoltage x-ray spectra in
the patient. This can be improved by reducing the energy of the
x-ray spectrum, and by enhancing the response of the detector
to the low energy end of the photon spectrum. This is especially
important in detecting bone.
Also, improving spatial resolution will improve visual
detection of anatomical edges and, hence, visual detection of
contrast. This can be done by improving geometric and motion
unsharpness. Techniques for achieving these improvementsare
discussed below.
236 CHAPTER 13. TREATMENT SIMULATORS, TREATMENT PLANNING AND PORTAL IMAGING

DEPENDENCE OF I M A G E C O N T R A S T ON X-RAY the low photon energy component would fall off more slowly
ENERGY versus angle than the high photon energy component.)
This technique could not be used for verification films of
Amols et a1.3 compares calculated and measured portal film
the actual treatment with the therapy beam (high Z target, flat-
contrast for various x-ray energies. The test setup comprised a
tening filter in the beam), but it could be used for pretreatment
1.2-cm thick 5-cm square block of aluminum placed on the axis
localization images, including double exposure technique.
of a 10 X 10-cm field on a 7.8-cm thick Lucite phantom with
It is worth noting that the number of photons per cGy of
a cassette of 1eadlfi1m10.5-mm lead placed at various dose falls almost linearly with energy above 6 MV x-ray
air-ga~distances the phantom' Talung MV as a
energy. Hence, at low dose levels the quantum mottle in the
for and an air gap of 30 cm. the contrast image will be greater at higher x-ray energy for a given dose.
values were 1.36 at 4 MV, 1.00 at 6 MV, 0.46 at 10 MV, and
0.27 at 15 MV. Amols explains this steep dependence of con-
trast on x-ray energy as due to two aspects of attenuation by OFF-AXIS PORTAL X-RAY TUBE
Compton scatter: (a) The Compton effect decreases with the
two-thirds power of photon energy. (b) The Compton scatter An x-ray tube is commercially available54 that can be mounted
angle decreases with an increase in photon energy, increasing on the side of the radiation head, at about 45" to the therapy
the chance that a scattered photon will still be in the field at the beam axis (see Fig. 13-11). With diaphragm and shadow plates,
cassette. Purdy et al.103 obtained improved localization films it can function as a simulator, with the gantry angle offset by a
by operating an 18-MV x-ray machine in electron mode at 6 fixed angle. In one model, the x-ray tube uses a fixed anode
MeV, with an x-ray flattening filter retracted but with the x-ray and the generator is low powered, so relatively long exposures
target left in place. are required. Biggs et al.9 describes a hospital built system in
Galbraith43 describes a technique for enhancing the low which a rotating anode x-ray tube is mounted on the side of the
radiation head. The 100-kV type x rays provide much better
end of a megavoltage x-ray spectrum, by using a low Z target
contrast than megavoltage x rays. However, these off-axis type
and removing the flattening filter. The incident electron beam
systems do not solve the important problem of errors in setting
is scattered less in a beryllium target (Z = 4) than in a tungsten
up the patient to the outline of the therapy beam, either pretreat-
target (Z = 73), each thick enough to stop the electrons. The
ment or during treatment.
lower energy photons produced as the electron energy is ab-
sorbed in a thick target will be more forwardly directed from
the beryllium target than from the tungsten target. Stated dif-
ferently, with tungsten the low energy rays are spread out of the ON-AXIS PORTAL X-RAY T U B E
useful forward lobe. Thus, in a + 12" maximum diameter 6-MV
The first radiotherapy cobalt unit67 employed a diagnostic
beam lobe with the flattening filter removed, the ratio of
x-ray tube in the radiation head about 12 cm above the retract-
photons in the diagnostic range (to 150 keV) to total photons
able cobalt source. The first medical linac in the United States,
will be higher with a beryllium target than with a tungsten
at Stanford,46 employed a 150-kV rod-anode industrial x-ray
target, about twice as high according to Galbraith.43 The ratio
of photons below 150 keV to total photons at 6-MV x-ray
energy is about 17 percent with thick beryllium target, 5-13
percent with tungsten target, for unfiltered photons. By elimi-
nating the metal screen and using a rare earth fluorescent screen
and single emulsion film, the detection of photons below 150
keV is emphasized while minimizing the response to higher
energy photons. Improved contrast and detection of bone re-
sults for patient thicknesses up to about 20 cm. For thicker
patient sections, such as 25-30 cm in the mediastinum, abdo-
men, and pelvic regions, because the low energy photons do
not penetrate the patient adequately, conventional high Z target
and metal screen-film would be superior.
With a gamma of 1.8 the film optical density varies from
1.6 at the center to 1.0 at the corner of a 40 X 40-cm field. For
a machine with a 5-cGy/s output at 6 MV with a flattening filter,
the output on the axis without a flattening filter was measured
as 11 cGy/s with a beryllium target, about 15 cGy/s with a high
Z target. (The dose rate at the comers of a 40 X 40-cm field
would be about 3 cGy/s with a beryllium target, about 7 cGy/s FIGURE 13-11 X-ray tube mounted on side of radiation head (from
with a high Z target, both without a flattening filter. However, Ref. 54).
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18.
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cation error could be compensated in the displayed image.
20.
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 Radiotherapy Accelerator Facilities
A megavoltage radiotherapy facility, consisting of one or more
heavily shielded treatment rooms, ancillary facilities and asso-
ciated equipment, is one of the most complex and costly units
in a modem medical center. Its design must incorporate safety
for patients, staff, and the public. Its plan must facilitate the
flow of patients, as well as buffer them from physicians, staff,
and related services. It must accomplish these objectives within
a cost-effectivebudget. A 1986survey by the American College
of Radiology (ACR)? lists 1144 responding radiotherapy cen-
ters in the United States having 1264 linacs, 671 cobalt units,
and 30 betatrons. The radiotherapy facility may be free-stand-
ing, but more frequently, it is located in a medical center or
hospital.
The radiotherapy facility associated with a university will
have attendant educational and research responsibilities. Often,
such centers incorporate the cancer treatment modalities of
surgery and chemotherapy, as well as radiotherapy. Individual
patient treatment decisions are arrived at jointly by physicians
from each of the three specialties, as well as from other dis-
ciplines such as pathology, in what is termed a tumor board in
the light of all findings. Their decisions will incorporate other
diagnostic information such as pathology and imaging data, as
well as referring physician information. Complex irradiation
procedures such as for bone marrow transplantation involve a
large number of medical specialists, hospital departments, and
services.
The primary objective of curative radiation therapy is to
deliver a precisely measured dose of radiation to a defined
clinical target volume. This volume will encompass the observ-
able and predicted extent of the tumor, plus a safety zone for
patient movement, beam misalignment, and so on. The goal is
eradication of the tumor with minimal damage to surrounding
healthy tissue while maintaining a high quality of life. In
addition to curative efforts, effective palliation or the reduction
of the symptoms of the disease, such as the alleviation of pain,
may be involved. A minority, perhaps one-third, of patient
treatments in the United States are for palliation, the disease
having disseminated beyond a region sufficiently localized for
curative therapy.
The facility must be designed to treat patients in a safe,
comfortable, and pleasant environment. It must limit the radi-
ation exposure of occupationally exposed personnel, as well as
to transient personnel, and those located adjacent to the radio-
therapy facility. This chapter is concerned with the planning
and features of megavoltage treatment facilities with these
objectives.
FACILITY PLANNING AND
OPERATIONAL RESOURCES
Many decisions that will influence optimal patient care are
made at the planning stage for the treatment facility. These
decisions can inhibit or enhance optimal patient care for many
years into the future. For example, they will include such items
as the traffic flow patterns of patients and staff, the design of
treatment rooms, the arrangement and proximity of ancillary
supporting facilities, and the choice of equipment. There is a
significant group of books, manuals, and other publications that
provide guidance on these and other associated facility plan-
ning topics. Such resources are most valuable in the early
planning stage. The content of certain of these references, not
explicitly cited in the text, is conveyed by their titles. A brief
description of the content of major references follows.
The Committee on Radiation Oncology Studies (CROS),l3
provides a contemporary description of the role of radiation
oncology in cancer treatment, flow-chart overviews of the
process, requisite staffing, and an outline of a program having
both clinical and physics components. Quality assurance in
radiation therapy includes those procedures that insure a con-
sistent and safe fulfillment of the dose prescription to the target
volume, with minimal dose to normal tissues, and minimal
exposure to personnel.
The book Planning Guide for Radiologic Installations,
edited by Scott,TI is an early and comprehensive radiology
planning guide. One chapter by King et a1.37 covers radiation
therapy and others treat physics, radioisotopes, and radiobiol-
ogy facilities. Scott cites the importance of establishing a
242 CHAPTER 14. PLANNING AND OPERATIONAL RESOURCES
Planning Cornrnittee with the responsibility of making recom-
mendations early in the process. For radiation therapy facility
planning, this committee would include the radiotherapist,
architect, physicist, chief technologist, administrator and per-
haps a trustee, and others. The architect must become inti-
mately acquainted with how patients are handled in order to
develop an optimal plan. The evolving plan must incorporate
the experience of the therapistts), their likes, and dislikes. The
committee should consult with interested members of the med-
ical and nursing staffs, and it should take advantage of the great
amount of sound advice and know-how to be gotten from the
planning section of some manufacturers of radiotherapy equip-
ment. The large manufacturers of such equipment often main-
tain well-organized planning sections that are ready to assist
and participate in planning. They can bring a wealth of experi-
ence with specific treatment units and different facility envi-
ronments to the planning process. In addition, the committee
should visit other facilities of like character and observe the
flow of patients through the system. The WHO publication,
Planning of Radiotherapy Facilities covers department orga-
nization, staffing, choice of equipment, and building layout.80
The American College of Radiology has published two
radiotherapy planning manual.3.4 The Planning Guidefor Corn-
tizunity Radiation Oncology Facilities, edited by Parker? is a
collection of papers by individual experts pertinent to commu-
nity facilities. Parker emphasizes that such facilities, requiring
highly trained personnel who are in short supply and sophisti-
cated equipment, must be carefully related to the needs of the
community. The Planning Guide for Radiologic bzstallarions4
contains recommendations for the design of a variety of types
of radiation therapy installations: the university center, the
free-standing private oncology center and the community hos-
pital radiation therapy department. An increasingly relevant
topic, which is introduced, is the incorporation of appropriate
computer facilities for treatment planning, patient records, as
well as for administrative tasks.
The British Journal of Radiology (BJR) Report, edited by
Deeley,lo The Planning of Radiotherapy Deparhnents is a
compendium of edited papers representing the extensive Brit-
ish experience. It has the perspective of their nationalized
health care system with its careful allocation of resources.
Planning from this perspective will likely become of increasing
concern to most countries and constituencies. The need for a
department coordinator to occupy a central role in the planning
team is emphasized as is the need for early involvement of
equipment manufacturers. Another British publication, Radia-
tion Protection in Radiotherapy27 reviews the physical, organ-
izational, and administrative approaches that may be used to
control the hazards arising from the use of ionizing radiation
in radiotherapy. A major section on external beam therapy
elucidates the protection measures incorporated into equip
ment design, into room design, interlocks and warning systems,
and administrative procedures.
As noted, one of the most experienced and helpful re-
sources is the assistance provided by planning sections of
accelerator manufacturers. They often have been involved with
a wide variety of situations and are cognizant of the changing
factors that influence facility design (including planning of an
entire radiotherapy center). They make available to potential
users a wide variety of architectural plans that make use of their
equipment. Low energy treatment rooms, which admit natural
light and provide an atrium with plantings, dramatically en-
hance the aesthetic appeal of a treatment room and may be
economically provided in certain situations. Space should be
allocated for plants and, where needed, artificial growing
lights. A circular room with a dome ceiling is an attractive
combination. On the other hand, and depending on individual
conditions, such "Creative rooms" may add substantially to
cost but offer intangible values.
In addition to architectural support, many manufacturers
offer installation data packages keyed to specific machines.
These outline the sequence of procedures and material needs
for the installation of equipment on a timely basis. Typically,
this package contains basic architectural plans, installation
drawings, and specifications for power requirements, conduits,
utilities, and items of this nature, which are then developed by
the owner's architect and engineers into construction docu-
ments. These documents indicate work to be performed by
others under separate contracts with the owner prior to the
installation of the accelerator. Usually, therapy room prepara-
tion will include the shielding structure and door, or maze,
installation of the base frame in the floor to anchor the accel-
erator and treatment couch as well as provision of compressed
air, cooling water, electrical power, door interlocks, emergency
off-switches, warning lights, and patient alignment lights. Al-
though some manufacturers may offer "turn-key" installation,
customers must usually arrange for rigging services to transport
and position the machine in the treatment location. This may
involve leaving a temporary opening in a therapy room wall or
ceiling, which is later closed if access through the door is
restricted. The machine can be partially disassembled at the
factory when required to facilitate movement through con-
stricted access in hospitals. The manufacturer's representative
aligns and tests components and subsystems prior to accep-
tance testing of the equipment with the user's representative.
The acceptance tests are designed to demonstrate that the
equipment meets the stated performance specifications. Im-
mediately after a radiation beam is available, the owner is
responsible for conducting and reporting the results of a radia-
tion shielding survey to the appropriate regulatory agency to
ensure adequate shielding of the treatment room. In addition,
calibration and radiation field data must be obtained for all
treatment beam modalities, energies, and field sizes. The ef-
fects of all beam modifying accessories must be evaluated prior
to use. Some manufacturers can provide specific project pre-
liminary planning layouts for treatment room and for full
oncology department facilities.
The National Council on Radiation Protection and Mea-
surements (NCRP) Report No. 39,s' outlines the background
for the development of contemporary radiation protection stan-
 PLANNING AND OPERATIONAL RESOURCES
dards. Treatment room design is governed by these standards.
The perspective of radiation protection is to restrict exposure
of all individuals to a value as low as reasonably achievable.
With this approach the average exposure of less than 0.5
remlyear can usually be maintained, even for radiation work-
ers.38 Occupationally exposed personnel in a controlled and
monitored area shall not be exposed to more than 5.0 rem
(centigray normalized to biological effect) per year and those
normally outside the controlled area, noncontrolled personnel,
shall not be exposed to more than 0.5 redyear. These expo-
sures are total body, and there are variations in this value related
to, for example, the particular body organ involved, age, fre-
quency of exposure, and whether it affects the whole popula-
tion.
Radiation protection regulations often employ the itali-
cized words shall and should with a specified meaning. When
so employed shall indicates a recommendation that is neces-
sary to meet the currently accepted standards of practice.
Should indicates an advisory recommendation that is to be
applied when practical. The responsibility for radiation safety
must reside at any given time with a single, designated and
qualified individual, the radiation safety officer.
The exposure an individual receives depends on the dis-
tance from the source, the time of exposure, the nature of
shielding barriers, as well as dose rate from the source. Since
exposure usually depends on the inverse square of the distance
from the source, locating personnel at a greater distance rapidly
reduces exposure. Incorporating as much shielding as possible
in the radiation head is desirable because of the saving in
thickness of the large treatment room secondary barrier walls.
Several NCRP reports are concerned with details of the
treatment room design and construction. The NCRPReport No.
49,52 contains recommendations and technical information, as
well as a discussion of the various factors that must be consid-
eredin the selection of appropriate shielding materials and in the
calculation of the barrier thicknesses. The primary consider-
ation in the design of radiotherapy treatment rooms is safety. Lo-
cation of a therapy installation should be based on operational
efficiency and initial cost as well as the feasibility of future ex-
pansion. However, other factors, such as proximity to adjunct
facilities, easy access for in-patients and out-patients, may be
more important than costs. The cost and inconvenienceof future
alterations may be reduced by constructing sufficiently large
treatment rooms initially to accommodate future replacement
equipment of greater size, higher energy and flexibility, and
with increased workload. Contiguous expansion at or below
ground level onto the surrounding area is usually most econom-
ical, requiring significant shielding only for some walls, possi-
bly the ceiling, but with no need for floor shielding. At times, an
additional unfinished treatment room is constructed initially at
reduced cost in preparation for future expansion.
The NCRP report No. 5 1,53 extends the scope of NCRP
Report No. 49 to higher energies and to other types of particle
accelerators, taking into consideration their broad application
in research, medicine, and industry.
243
The NCRP Report No. 102,56deals with radiation protec-
tion as a factor in equipment design, performance, and use.56It
includes recommendations for a wide variety of specialized
diagnostic imaging equipment; for example, in digital subtrac-
tion and CT installations. Included are imaging characteristics
and patient dose for these specialized equipments. Radiation
therapy recommendations cover both photon and particle beam
systems, simulators, calibration guides, radiation protection
surveys together with important administrative and personnel
monitoring requirements placed on working conditions in a
radiation facility
Neutrons may become a significant source of leakage
radiation with x-ray beams above approximately 10 MeV.
National Bureau of Standards (NBS) special publication No.
554.50 is a collection of papers presented at this conference. In
part, the conference arose from ambiguity in methods of neu-
tron measurement and lack of agreement on the biological
effect of neutrons. The major topics addressed were character-
istics of the radiation beams, regulations, biological interpreta-
tion, measurements and calculations, and neutron reduction
techniques. The NCRP Report No. 79,wfollowed some 5 years
after the NBS conference. By this time, there was considerable
clarification both in the interpretation of measurements and of
biological effect. The report is concerned with neutron produc-
tion and transport both in the radiation head and shielding
barriers of the treatment room. It also discusses relative neutron
hazards and neutron measurements.
Two publications are primarily concerned with the safety
aspects of accelerator operation. Brobeck's Particle Accelera-
tor Safety Manual covers hazards and safety considerations for
various accelerator types including electron linacs.11 It de-
scribes radiation as well as nonradiation hazards and an accel-
erator safety program. It appendices quantitate the production
of x rays by klystrons and the production of ozone by electron
beams. The Federal Occupational Health and Safety Adminis-
tration (OSHA) has classified certain materials and chemicals
as "hazardous." Accelerator manufacturers make data sheets
available on such materials and chemicals and their safe han-
dling where incorporated in their equipment. Swanson's pub-
lication Radiological Safety Aspects of the Operation of Linear
Accelerators,75 as its title indicates, is specific to electron
linacs. It contains a wealth of information on electron linacs
including medical linacs operating in the range 4-40 MeV. One
appendix provides 15 convenient "Rules of Thumb" for esti-
mating many quantities pertinent to radiation safety.
The International Electrotechnical Commission (IEC) de-
velops safety standards and performance specifications for a
wide variety of electrical equipment. Its scientific committee
SC62C is concerned with high energy radiation equipment.
Their developing documents include requirements and tests of
electrical, mechanical, and radiation safety, as well as defini-
tions and tests of functional performance characteristics of
radiotherapy equipment. The IEC documents often comprise
the basis for the ongoing quality assurance of radiotherapy
equipment. See IEC references 26a, b and c.
244 CHAPTER 14. MEGAVOLTAGETHERAPY ACCELERATORS AND TREATMENTFACILITIES
Once operational, the QA of equipment and procedures
becomes an important concern. An extensive and well-refer-
enced report on physics QA is the AAPM report No.13.' It
covers: radiation safety, treatment planning, dosimetric accu-
racy and equipment tolerances, measurement equipment, t~
gether with simulation and external beam treatment equipment
QA specifics. An AAPM publication No. 3,2 contains a wealth
of detailed information on the equipment aspects of QA.
The IPSM Report No. 54.28 provides a wealth of detailed
information on linac QA, the subject being addressed. This
publication portrays British practice but also reflects IEC stan-
dards for the parameters of concern: their tests, tolerances, and
frequency of assessment. It encompasses electrical and me-
chanical safety, radiation protection, mechanical and optical
tests, dosimetric measurements, and tests for commissioning
as well as periodic tests for quality assurance. These topics are
addressed in five self-contained chapters, a format that facili-
tates easy reference and use.
The ACR publication, Quality Assurance in Radiation
Therapy, A Manualfor Technologists,5 provides a comprehens-
ive and well-illustrated description of ongoing QA concerns
and procedures that can be carried out by radiation therapy
technologists. It serves as a reference and as an instruction
manual augmented by an instructor's supplement.
MEGAVOLTAGE THERAPY
ACCELERATORS AND TREATMENT
FACILITIES
A radiotherapy cancer treatment center consists of one or more
treatment units and the supporting facilities. An example of
such a center is shown in Figure 14-1. Although some cancers
may be treated with low energy (100-150 kV) or orthovoltage
(200-300 kV) x rays, the majority of tumors are irradiated with
megavoltage x rays. For tumors extending to the skin surface,
electrons are used, ranging in energy from about 6 to 35 MeV.
The 8000-ft2 center shown in Figure 14-1 has two accelerators,
a low energy 4 or 6 MV x-ray unit, and a high-energy multi-
modality unit that can provide two x-ray energies between 6
and 18 MV together with a number of electron beams ranging
from about 4 to 20 MeV in energy. Such a center might treat
500-800 or more new patients per year with lesions of varied
complexity.
The main entrance of this center opens into a large family
waiting room and continues with a direct flow path to the
central patient area. Consultation and office rooms are located
on the left. The central group of rooms provide for the routine
handling of patients and consist of examining and dressing
rooms, together with patient treatment rooms. The group of
rooms on the upper periphery of Figure 14-1 provides technical
support for radiotherapy. Included here are mechanical and
electronic services, together with treatment planning facilities
and offices for the physicist(s) and chief technologist. The
simulator, a Ximatron, is conveniently located not far from a
dark room for developing treatment planning and verification
radiographs from the simulator and port radiographs from the
treatment units. The spacious control area provides for the
steady flow of ambulatory and gurney (bed) patients, as well
as for physicians, staff, and the treatment technologists who
work with the individual patients. The function of the above
noted rooms, and others not individually cited, are identified in
more detail in Figures 14-1. Aradiotherapy treatment center is
usually best sited on the periphery of a hospital or medical
center with some treatment walls surrounded by earth to sim-
plify and lower the cost of constructing external bamers. Such
a location permits less costly future expansion, while being
close to other clinical departments and supporting hospital
services. Figure 14-1 is an outpatient free-standing facility.
This same plan within a hospital would require 8-ft wide
corridors for hospital patients. Therapy rooms should not be
located adjacent to high occupancy areas such as lobbies or
hospital emergency rooms. The primary design considerations
for radiotherapy facilities are radiation safety, operational con-
venience, and cost.
A representative treatment room incorporating a high en-
ergy multimodality x-ray and electron accelerator, is described
in several sections that follow. Such a room, with its massive
shielding bamers, is the central focus of a treatment facility.
The entry maze or door, which must function reliably and
provide radiation protection is described on page 253. Patient
intercom and closed-circuit television systems (or a window at
lower energies) provide for requisite communication and are
described on page 253-254.
MULTIMODALITY THERAPY INSTALLATION
Figure 14-2a shows the plan view and 14-2b shows a section
view of a representativemultimodalitytreatment room to house
a Clinac 1800. The Clinac 1800 is similar in external appear-
ance to the Clinac 18 shown in Figure 2-3. It provides dual
x-ray energies in a single treatment unit. The Clinac 1800
provides several treatment modality options: dual x-ray ener-
gies, a low energy of 6 or 8 MV, and a high energy of 10, 15,
or 18 MV. In addition, five electron energies are provided
ranging form 6 to 20 MeV. The gantry houses the dual x-ray
energy accelerator, the radiation head, and other components.
A description of the dual energy accelerator may be found in
Chap. 11 and the radiation head in Chap. 8.
The gantry is equipped with a retractable beam stopper,
which is shown in the retracted position, in Figure 2-3a. When
extended to intercept the beam transmitted through the patient,
it provides an attenuation factor of about 1000 for all field
sizes up to the maximum of 40 X 40 cm at isocenter with
clipped corners, 35 X 35 cm without. As a result, a thinner
primary beam shielding barrier is sufficient and the wall can
be reduced about 3 ft in thickness of concrete. In addition,
 MEGAVOLTAGE THERAPY ACCELERATORS AND TREATMENT FACILITIES 245

.
FIGURE 14-1 Free-standing radiotherapy treatment center consisting of two megavoltage treatment units, a sinlulator, and supporting facilities. If
located within a hospital, 841. wide corridors would be required for hospital patients. (Courtesy of Varian.)

the beam stopper intercepts radiation scattered from the patient
up to angles of 30" from the isocenter. An extendible beam
stopper may be interlocked with the angular orientation of
the gantry, so as to be in the extended position only where
needed during the treatment. The stand, on which the gantry
is mounted, contains the klystron microwave power source
and gantry drive hardware. The gantry rotates about the patient
lying on the treatment table (sometimes called the treatment
couch or patient support assembly), so as to direct the radiation
beam at the treatment target volume from one or more discrete
gantry angles (ports) or continuously over an arc of travel.
The modulator cabinet houses auxiliary electronics including
the klystron power supply. The modulator cabinet may be
located inside the treatment room as shown in Figure 14-1,
or outside near the console as shown in Figure 14-2a. The
latter location is more convenient for maintenance and trouble
shooting.
The control console and card rack cabinet are located at
the desk shown in Figure 2-3c. The console provides opera-
tional controls, as well as monitoring and interlock status
information concerning operation of the treatment unit. The
card rack has 21 plug-in, printed circuit boards for electronic
subsystems such as dosimetry channels and the digital readout
circuits. This modular design facilitates trouble shooting and
servicing, since spare boards can be readily inserted to isolate
and identify problems and quickly resume operation. Figure
14-3 shows a patient being set up for electron treatment on a
Clinac 1800, which has a counterweight for an accelerator not
equipped with a beam stopper.
Figure 12-1 in Chap. 12 provides a schematic view of a
treatment unit, such as the Clinac 18 or 1800. It emphasizes the
geometric relationship of the linac and treatment couch mo-
tions. The isocenter is a point in space defined by the intersec-
tion of the beam central axis, the gantry axis of rotation, and
the vertical axis of couch rotation. Optical lasers positioned on
the ceiling and two opposite walls project fiducial images,
which intersect at the isocenter and facilitate patient setup.
Often, the tumor center is positioned at the isocenter during
patient setup procedures with the aid of skin marks and the laser
positioning lights. The gantry is then rotated to the angular
 CONTROL CONSOLE 7

O S A F E ~ YINTERLO
@ DISABLING STAT1
@WARNING LIGHT
@ LASER POSITION
LIGHT

DASHED LlNE INDICATES

WALL THICKNESS WHEN
BEAMSTOPPER IS USED.

(a)

DASHED LlNE INDICATES

WALL THICKNESS WHEN
BEAMSTOPPER USED.

(b) ISOCENTER --/

FIGURE 14-2 . A high energy Clinac 1800 multimodality x-ray and electron treatment unit room. (a)Plain view (b) Section view. (Courtesy of
Varian.)
246
 MEGAVOLTAGETHERAPY ACCELER ATORS AND TREATMENT FACILITIES 247

ing barriers, together with placement of equipment and details

pertaining to operational and safety features.
The facility shown is adequately shielded for 100 percent
occupancy of all adjacent areas. It is likely that shielding could
be reduced for actual adjacent occupancies (see following sec-
tion). Radiation leakage in noncontrolled areas shall not exceed
10 mrerntweek, assuming 100 percent occupancy in areas be-
yond the immediate shielding barriers. All final room designs
must be approved by a qualified radiological physicist and a
radiation survey conducted prior to normal operation of a treat-
ment unit. Preliminary approval of shielding design may also
be required by federal, state, or local agencies. The shielding
shown is typical for a Clinac 1800 equipped with and without a
beam stopper for a head leakage radiation of 0.1 percent at 1 m
of the useful beam at Dm,, at the nominal treatment distance as
defined in IEC 601-2- 1.'6a The demarcation between shielding
with and without a beam stopper is shown by dashed lines.
Without a beamstopper, thicker primary wall and ceiling bar-
FIGURE 14-3 . Supine patient set up for treatment on Clinac 1800. riers are needed in addition to those provided by the nominal
(Courtesy of Varian.) wall and ceiling secondary barriers. All shielding is based on a
workload of 100,000 cGyIweek at isocenter, and primary beam
positions prescribed by the treatment plan, with the patient use factors of 20 percent for ceiling, 20 percent for walls, and 40
lying comfortably in the prone or supine position as shown in percent for the floor. Where electrical junction boxes must be
Figure 14-4. This set-up procedure facilitates accurately posi- set into barrier walls, a llh-in. thick steel plate with 1-in.
tioning the patient for treatment, with the likelihood of a margin is placed behind such boxes.
significant geometric miss greatly reduced. A sink for clinical use, with provision for filling and
draining of a water phantom, is provided. A 3-in. diameter
TREATMENT ROOM DESIGN experimental access conduit from control area to treatment
room should be located conveniently to needs, and oriented
The plan and section views of Figure 14-2a and b illustrate diagonally to minimize leakage. The closed-circuit TV system
many of the salient features of a treatment room housing a high camera for patient observation is preferably located above and
energy multimodality treatment unit. It includes typical shield- approximately 15" off the gantry axis of the accelerator. The
two-way intercom system for communication with the patient
should be oriented to enhance pickup from the patient. Three
A Laser Ceiling laser positioning lights, two on opposite walls and one on the
ceiling, project small fiducial points or lines intersecting at the
isocenter. A fourth laser, placed high on the wall at the target
. \
end of the linac, projects a vertical fan beam through the gantry
\
\ axis and isocenter. Leaving laser lights on continuously has
\
\ been found to prolong their life. Safety-off (SCRAM) large-
\
red-mushroom-head switches are placed at several convenient
locations on the walls and at the console, modulator, couch, and
Centered at \
lsocenter \
accelerator. The "thin" door at the maze entry consists of 4-in.
thick borated poly(ethy1ene) layer (minimun 2 percent borated
for 15 MV or greater) facing into the maze, a %-in. thick lead
facing outside with esthetic wood or plastic coverings. Addi-
' Lights tional notes on treatment room planning may be supplied by
equipment manufacturers pertaining to shielding, architectural,
structural, mechanical and electrical details.

,
X-Skin Marks
SHIELDING BARRIER DESIGN
FIGURE 14-4 . Treatment geometry showing tumor centered at isocen-
ter, laser positioning lights, and gantry positions for three treatment An individual's exposure to radiation at a given dose rate
fields. depends on three factors: the time of exposure, the distance
248 CHAPTER 14. MEGAVOLTAGE THERAPY ACCELERATORS AND TREATMENT FACILITIES
from the source, and the shielding barriers through which the
radiation must pass. The attenuating effect of barriers depends
on the material of which they are constructed, their thickness,
and the effective energy of the incident radiation. Unless oth-
erwise restricted, a 40-h work week is assumed. Often, radia-
tion emanates from what can be considered a point source, the
x-ray target, and is attenuated inversely as the square of the
distance from it. Bamer design considerations herein are for
megavoltage x-ray therapy. A facility so designed will invari-
ably be more than adequate for that portion of the workload
devoted to electron therapy.
Radiation areas are categorized as controlled or noncon-
trolled. Controlled areas entail restrictions on access and occu-
pancy which primarily concern radiotherapy staff, that is, the
radiation workers. Such workers are monitored for radiation
exposure, usually with film badges.39 Their maximum permis-
sible annual dose of 5.0 rem is a factor of 10 larger than that
for the general public and nonradiation workers who have
access only to noncontrolled areas. References 16,27,40,51,
52,53,54,56,75, and 76 provide guidelines for barrier design.
In addition to time, distance, and shielding, three derived
factors are customarily used to express radiation exposures
from x-ray generators. They are workload (W), use(U), and oc-
cupancy (2). Aworkload Wof 103Gy week at 1 m from the tar-
get is usually assumed for a busy department providing 50
treatments of 4 Gy at Dm,, each day to 50 patients covering a 5-
day week. For accelerators with x-ray energies above 10 MeV,
NCRP 51 recommends a workload of 5 X 102 Gylweek for the
highest x-ray energy. The remaining time will be spent in the
electron or "lower" x-ray energy mode for which the existing
shielding will be more than adequate. The use factor, U de-
scribes the fraction of the workload to which a barrier is ex-
posed. Primary bamers, at which the useful treatment beam
may be directed, are generally assumed to have a U factor of 1
for the floor and usually 0.25 for walls and ceiling. Clearly,
these are conservative estimates and can be modified, depend-
ing on experience as noted on page 250. A U factor of 1 is ap-
plied for leakage and large (>30°) angle scatter radiation.
Scatter radiation is less penetrating than primary or leakage ra-
diation and decreases rapidly with the angle of scatter.33 Bar-
riers that provide adequate protection for primary and leakage
radiation often need little or no additional thickness to protect
against the scatter component. The occupancy factor T corrects
for the degree of occupancy of an area while the beam is on. It is
assumed to be 1 for occupationally controlled areas, but non-
controlled areas, such as corridors, outside areas and waiting
rooms, and so on, may be assigned values less than unity.
For a given barrier, the necessary attenuation factor B, to
limit the permissible weekly exposure to a value P, is given by
B = - ~d
WUT
where d is the distance in meters from the source.
It is convenient to measure barrier attenuation in tenth
value layers (TVL); thicknesses of material that attenuate a
broad beam of x rays by a factor of 10. The attenuation factor
B for a barrier of thickness x (cm or inches) becomes
Combining and rearranging equations. (14-1) and (14-2)
. [=I
= T"L log,,
WUT
Aconvenient tabulation of bamer thicknesses in inches of
concrete versus distance in feet, based on eq. (14-3), has been
provided by Tochilin78 and is reproduced in Tables 14-la and
b. Information presented in this form is often termed a look-up
table as compared to where the input goes into a programmable
calculator or computer.
Table 14-la covers six primary x-ray energies from 4 to
24 MV at distances from the x-ray target of 10 to 30 ft. It lists
the number of TVLs at these distances for U = 0.25, T = 1,
and a transmitted weekly exposure of 10 mRlweek. The work-
load is 8 X 102W Gylweek 4 and 6 MV and 103 Gylweek at 10
to 24 MV. This table also lists the TVL in concrete for the
energy range, 4 to 24 MV. For example, a 15-MV primary
radiation barrier would require 82 in. of concrete at a distance
of 20 ft from the x-ray target.
Table 14-1b covers leakage x-ray energies from 4 to 24MV
at distances from the isocenter from 6 to 30 ft. It lists the TVLs
needed at these distances for U = 1, and a transmitted weekly
exposure of 10 W w e e k . A workload of 8 X 102Gylweek with
leakage of 0.05 per cent is employed at 4 and 6 MV, and 103
Gylweek at 10 to 24 MV with leakage of 0.1 percent. This table
also lists the TVLinconcrete for the energy range, 4-24MV. The
TVL for leakage x rays varies with angle and is less than the pri-
mary TVL. The 90" data listed are believed representative and
can be used in calculations.58 For example, a 15-MV leakage ra-
diation barrier would require 32 in. of concrete at 20 ft from the
isocenter. Typical minimum barrier thicknessesrepresent archi-
tectural practice. Distances, at which these data apply, are con-
ventionally measured to a point 1-ft outside shielding walls, 2 ft
above the floor, and 6 ft above the floor of a room beneath the
treatment room. These values assume that therelevant exposure
will be at these distances from the shielding barrier.
Table 14-1 provides a wealth of easy-to-use information
in a compact form. It is use is illustrated in Table 14-2 for eight
locations, A-1 through E-2, shown on the treatment room plan
and elevation views of Figure 14-2. These values are for an
18-MV x-ray beam, where the primary TVL = 17.5 in., and the
leakage TVL = 13.0 in. of ordinary concrete. The treatment
and leakage beam characteristics, their transmission in con-
crete and neutron energies in the treatment for a 24 MV linac,
Clinac 2500, have been studied by Barnes et al.8 and by
LaRiviere.40.42 The transmission in concrete and the scatter
angular distribution of 25-MV x rays from a betatron and alinac
have been reported earlier by de Almeida et a1.16 Treatment
room and barrier design for lower energy (e.g., 4-6-MV linacs)
TABLE 14-la Radiation shielding data. Primary beam requirementsa

Distance
from Number 4MV 6MV Number 10MV 15MV 18 MV 24MV
target of xrays xrays of xrays xrays xrays x rays
(ft) TVL (A)b Concrete (in.) TVL (BY Concrete (in.)

10 5.33 60.8 72.1 5.43 83.1 93 95 101

11 5.25 59.9 71.4 5.35 81.8 91 93.6 99
12 5.18 59.1 70.1 5.28 80.6 90 92.2 97.7
13 5.11 58.3 69.1 5.21 79.5 89 91.1 96.4
14 5.04 57.5 67.9 5.14 78.6 88 89.9 95.1
15 4.98 56.8 67.2 5.08 77.7 87 88.9 94.1
16 4.93 56.2 66.6 5.03 76.8 86 87.9 93.1
17 4.87 55.5 65.8 4.97 75.9 85 87.1 92.1
18 4.82 55.1 65.1 4.92 75.3 84 86.1 90.9
19 4.78 54.5 64.5 4.88 74.6 83 85.1 90.3
20 4.73 53.9 63.9 4.83 73.8 82 84.5 89.4
21 4.69 53.5 63.3 4.79 73.7 81 83.8 88.6
23 4.61 52.6 62.2 4.71 71.9 80 82.2 87.1
25 4.54 51.8 61.3 4.64 71.1 79 81.2 85.8
30 4.38 49.9 59.1 4.48 68.5 76 78.4 82.8

Primary TVL 11.4 13.6 15.3 17 17.5 18.5

"In inches of concrete versus distance.

bTenth value layer required to attenuate primary beam from 80,000 cGy1week to 0.01 cGy1week for use factor of 0.25.
Tenth value layer required to attenuate primary beam from 100,000 cGy1week to 0.01 cGy1week for a use factor of 0.25.

TABLE 14-lb . Radiation shielding data. Leakage beam requirementsa

4-6 MV X-rays ;Workload = 80,000 cGy / week-leakage = 0.05 %
10-24 MV X-rays :Workload = 100,000 cGy /week -leakage = 0.10%

Distance
from Number 4MV 6MV Number 10MV 15MV 18MV 24MV
target of x rays x rays of x rays x rays x rays xrays
(ft) TVL (A)b Concrete (in.) TVL (B)' Concrete (in.)

6 3.08 30.8 33.9 3.48 41.8 45.2 45.2 48.7

7 2.94 29.4 32.3 3.34 40.1 43.3 43.3 46.8
8 2.83 28.3 31.1 3.23 38.8 42.1 42.1 45.2
9 2.72 27.2 29.9 3.12 37.4 40.6 40.6 43.7
10 2.63 26.3 28.9 3.03 36.4 39.4 39.4 42.4
11 2.55 25.5 28.1 2.95 35.4 38.6 38.6 41.3
12 2.47 24.7 27.1 2.87 34.4 37.3 37.3 40.2
13 2.41 24.1 26.4 2.81 33.6 36.4 36.4 39.2
14 2.34 23.4 25.7 2.74 32.9 35.6 35.6 38.4
15 2.28 22.8 25.1 2.68 32.2 34.9 34.9 37.5
16 2.22 22.2 24.4 2.62 31.4 34.1 34.1 36.7
17 2.17 2.17 23.9 2.57 30.8 33.4 33.4 36.1
18 2.12 21.2 23.3 2.52 30.2 32.8 32.8 35.3
19 2.08 20.8 22.9 2.48 29.8 32.2 32.2 34.8
20 2.03 20.3 22.3 2.43 29.2 31.6 31.6 34.1
21 1.99 19.9 21.9 2.39 28.7 31.1 31.1 33.5
23 1.91 10.1 20.9 2.31 27.6 30.1 30.1 32.1
25 1.84 18.4 20.3 2.24 26.9 29.1 29.1 31.4
30 1.68 16.8 18.5 2.08 24.9 27.1 27.1 29.2
LEAKAGE TVL 10 11 12 13 13 14

"In inches of concrete versus distance

qenth value layer required to attenuate 90° leakage x rays from 80,000 to 0.01 cGylweek. Leakage = 0.05%.
Tenth value layer required to attenuate 90' leakage x rays from 100,000 to 0.01 cGylweek. Leakage = 0.10%.
250 CHAPTER 14. MEGAVOLTAGE THERAPY ACCELERATORS AND TREATMENT FACILITIES
TABLE 14-2 . Representative shielding requirements for Clinac 18 treatment room illustrated in Figure 14.2
Unit : Clinac 1800
Hospital : 18 M V x rays
Primary TVL :1-7.5in. concrete
Leakage TVL : 13.0 in. concrete
1-in. Steel = 4.0 in. concrete
1-in. Lead = -
8.0 in. concrete
Dist TVLa concrete" concretea mR
Wall U {ft} P/Lb required required
W L and inches of concrete required for 10 mR/week for occupancy factor T = 1 .O.
*P-primarybeam, L-leakage beam
are less complex but only marginally. A comparison of the two
megavoltage rooms of Figure 14-1 and the TVL and bamer
thickness values of Table 14-1 (6- vs. 18-MV x rays) shows
that, typically, primary barriers are reduced in thickness by
about 2 ft, and 1 ft for secondary barriers. However, at 15 MV
and above, the neutron component accompanying high energy
x rays can complicate the maze and entry door design. The
discussion and literature citations in Chap 8, on radiation
shielding and neutron leakage in the radiation head provide
additional information relevant to shielding barrier design.
Treatment beam-on time, gantry angle, and field size usage
for treatments can influence barrier designs. In one study
employing a Clinac 4 accelerator, M0yeI.4~finds a beam-on
time fraction of 0.13 for a dose rate at isocenter of 200 radmin,
a weighted mean field area of 147 cmz, and gantry quadrant use
factors of 0.23 for left and right, 0.42 down and 0.12 up. Cobb
and Bjarngardl2 extended the study in a center employing three
Clinac 4 accelerators. They find an average field area of 253
cmz and gantry quadrant use factors of 0.06 for right and left,
0.48 down and 0.29 up. They suggest that the angular distribu-
tion and quality of radiation scattered from the patient can be
an important consideration in the design of secondary barriers.
These values can be compared to conservative NCRP recom-
mendations of 400-cm2 field size, use factors for primary
radiation of 0.25 for walls, 1.00 for floor, and approximately
0.25 for ceiling. Farrow has surveyed the distribution of gantry
angle orientations and field sizes employed for treatment with
an 8 MV x-ray unit.19 The survey shows that a greater than
expected fraction of treatments are camed out with the beam
pointing downward (58 percent) and that an assumption that
Date : 15 Oct. 90
FigNo : 14-2
Leakage : 0.001
Workload : lo8cGy/wk
Beamstopper
Yes No - J
used week Remarks
maximum field sizes are always used is overcautions. How-
ever, rotation of the diaphragm can make the diagonal dimen-
sion of the field the most important dimension at a bamer.
Ordinary concrete, weighing approximately 147 IbIft3
(2.35 g/cm3) is the most commonly used material for construct-
ing the shielding baniers of treatment rooms. It is a readily
available structural material and can be easily cast into the
desired thicknesses and shapes. The attenuation of megavolt-
age x-rays is primarily via Compton interactions, and which
occur closely proportional to a material's physical density,
particularly at lower megavoltage energies. To save space,
higher density materials can be introduced into concrete to
increase their composite density.65 Barytes concrete containing
a barium ore has a nominal density of 3.1 gIcm3, while loading
concrete with steel or lead shot may increase the density to
values of 5 to 6 g/cm3. Careful mixing and pouring of heavy
concrete are important to ensure uniformity and to prevent
settling of the high density filler.
Primary concrete barrier thicknesses range from about 5 to
8 ft in thickness, depending on the energy and distance from the
source (see Table 14-la). To reduce this thickness, layers of
steel plate or lead are sometimes substituted or combined with
concrete. The steeVconcrete linear attenuation ratio varies from
3.2-4.4, and for lead, from 5.4-9.0 over the energy range 4-24
MV. At higher energies, pair production becomes a significant
factor and serves to increase the ratio, especially for lead.
The use of steel or lead for shielding is especially advan-
tageous where space is limited. For energies to 6 MV, a compact
"lead brick" room can be constructed by using structural steel
for retaining lead brick walls and a roof supported by steel
 MEGAVOLTAGE THERAPY ACCELERATORSAND TREATMENT FACILITIES
beams and covered with steel plates, plus lead bricks. Offered
as a single source, "turnkey" installation, this room may be
quickly assembled or dismantled when circumstances change.
Fitzgerald20 describes a relatively inexpensive treatment room
constructed of concrete, concrete blocks and largely, dry sand.
The walls are constructed of two rows of parallel concrete
blocks whose voids are filled with concrete and the space
between filled with sand. Slabs of reinforced concrete, 6 in.
thick, are used to cover the vault, and the exterior walls ex-
tended upward to form a basin to hold sand for the roof
shielding. Means must be incorporated to prevent the shift or
flow of the sand in such rooms and to meet seismic require-
ments in earthquake areas.
ENTRY DOORS AND MAZES
Entry doors provide access for staff, as well as ambulatory and
gurney patients, to the therapy room. The door may open
directly into the therapy room or provide entry via a maze,
which itself connects to the therapy room. Doors associated
with mazes require significantly less shielding, since only
scattered radiation, considerably reduced in energy and inten-
sity, is incident upon them.
A shielded door, opening directly into the treatment room,
conserves floor area and is most satisfactory when protection
requirements are moderate. However, for most megavoltage
installations, an adequately shielded door, permitting direct
access to the treatment room, will weigh several tons and
require an expensive mounting and motor drive mechanism.
Such doors must be interlocked and reliable in operation, since
their failure renders therapy inoperative. A second smaller
access door, or auxiliary means of opening the primary door, is
needed in case of power failure or mechanical breakdown.
One motorized door design for 6-MV x rays consists of a
welded rectangular box of 0.5-in. steel plate that encloses lead
sheets.30 The overhead door hangers run on a hardened steel
"l" beam track, whose position is adjustable.In this installation,
a large cross-section steel threshold is cast flush with the
concrete floor, and the door is adjusted to provide a narrow gap
between the bottom of the door and the steel threshold. Push-
button switches, providing both half-open and full-open posi-
tions, speed entry for personnel and beds, respectively. An
automatic,half-open door position can save significanttime for
slow-moving, heavily shielded doors, since it accommodates
almost all of the traffic. A pneumatic safety edge acts so as to
automatically open the door if activated. Ruddy70 described
several types of radiation shielding doors, that is, hinged, lift,
hanging, and rolling; and Wadey79 gives details for a hinged
design. If a heavy door is employed, lasting mechanical and
structural integrity are essential to avoid interruption of treat-
ments.
One commercial supplier (among others) of roller-sup-
ported and hinged radiation shielding doors features a rectan-
gular steel box construction filled with lead and plywood as
251
well as sheets of borated poly(ethy1ene) when required for
neutron protection.64Their rolling doors overlap the door open-
ing and move on a chrome plated steel plate embedded in the
floor using a series of tapered-rollerbearings. Such commercial
doors are finding wide acceptance.
Arelatively thin door suffices with a maze that allows only
multiple-scattered radiation to reach the door. The shielding
requirement for such a door will be minimized but the maze
requires more floor area and reduces the convenience of access,
especially for beds and equipment. Height and width of door-
ways, mazes, and elevators must be adequate to permit delivery
of equipment if intended.
As x-ray energies rise above 10MeV, neutrons are increas-
ingly present. This latter component may require doors or
mazes to be faced with hydrogenous material [e.g., poly(ethy1-
ene)] for photoneutron absorption. The poly(ethy1ene) may be
loaded with boron or lithium to enhance thermal neutron c a p
ture. Such captures may give rise to energetic capture gamma
rays, which are best absorbed by high Z materials (e.g., lead),
which are placed distal to the poly(ethy1ene).
X-ray transmission in lead at the entrance of therapy room
doors has been studied at 6 and 18 MV.41 In this study, inner
hinged doors in the maze having 2-in. thick poly(ethy1ene)
could be left open or closed, thereby varying neutron fluences at
the outer door. At 6 MV, the measured broad-beam TVL in con-
crete at the door was about 2.5 cm, the result of single Compton
scattering of leakage x rays. At 18 MV, the measured broad-
beam TVL in concrete at the door was 5.8 cm and appears to be
associated with a radiative capture gamma ray source spectrum
from neutrons originating in concrete in the entrance way de-
scribed. For protection purposes, such gamma rays completely
overwhelm leakage x-rays scattered to the doorway.
For medical accelerators, there is no simple method for
determining neutron transmission through a maze and the
resulting dose equivalent at the door. The NCRP Report No.
7954 summarizes a number of empirical solutions that have
been used to determine the thickness and material composition
of doors where shielding from fast neutrons, thermal neutrons,
and neutron capture gamma rays (TVL, 6 cm of lead) is
required. Tochilin76 describes a modified version of a method,
originally proposed by Kersey,36 for determining the neutron
dose equivalent at the door. For a typical treatment room maze,
the first tenth value distance (TVD) is 3 m, and all subsequent
TVDs are 5 m. Muller-Runkel et a1.49 discuss maze design and
neutron measurements for a 20-MV Therac 20 accelerator.
They conclude that a compact L-shaped maze design allows
use of a single, relatively light door at the end of the maze. Two
radiation survey reports for high energy accelerator facilities
emphasize neutron protection requirements and findings.60.63
PATIENT OBSERVATION AND COMMUNICATION
Good visual observation and aural communication with the
patient is essential. The operator shall be able to view the
252 CHAPTER 14. ACCELERATOR MAINTENANCE AND USAGE
patient while operating the control console from the same
position. Direct window viewing and megavoltage radiation
entails the use of costly, high density lead glass, whose optical
transmission decreases and coloration increases both with
thickness and with exposure to radiation. Radiation leakage
through gaps around shielding windows may also present
problems, particularly for single element windows in contrast
to stepped two and three-element types.17 Hence, shielding
windows for megavoltage therapy rooms have largely been
supplanted by closed-circuit television viewing, which is less
costly and provides considerable flexibility in locating both
camera and TV monitor. Two cameras can expand coverage,
provide backup, and convenience in servicing. A remotely
controlled camera can be directed where required on the pa-
tient. It is usually equipped with motorized zoom, focus, and
iris controls and can operate under a wide range of lighting
conditions.
Means for aural communication between patient and mon-
itoring staff shall be provided along with a patient-activated
signaling buzzer. Means for dimming the treatment room lights
from both inside the room and at the control position shall be
provided. This greatly facilitates the placement of treatment
fields with the aid of skin markings and the field light.
RADIOACTIVE AND TOXIC GAS PRODUCTION
The production of radioactive and toxic gases in the air by
radiotherapy beams in the treatment room has been st~died26~47
as has activation produced within the irradiated tissue volume
of the patient.18 The two radioisotopes of concern in the atmo-
sphere around the medical accelerator are 13N and BO, which
are produced by the (yn) reactions in 14N and ' 6 0 with thresh-
olds of 10.5 and 15.7 MeV and half-lives of 10 min and 122 s,
respectively. The production of the toxic gas ozone has also
been studied.26Within the patient, the positron emitters ' 5 0 and
11C (20.5 min half-life) are produced from the abundant 1 6 0
and 12C radionuclides present in the tissue. The calculations
were performed and most irradiations were carried out with a
25-MV x-ray beam from a medical betatron or a linac. Earlier
work employed electron accelerators used for research pur-
poses wherein the limitations of radiotherapy usage involved
with dose rate, total dose, and interval between treatments,
which reduce the concentrations of radionuclides produced,
were not present.
The calculations of Holloway and Cormack26 for the pro-
duction of 13N and 1 5 0 led to the conclusion that only in
exceptionalcircumstancesinvolving high dose-rates,poor ven-
tilation, and long treatment distances would any significant
hazard arise. Exceptional circumstances arise when accelera-
tors are designed to give high dose rates to large fields at a long on the mechanical, electronic, and radiation specialist skills of
SSD for whole body irradiation by either penetrating x-rays or
superficial electron (TSET) therapy. In this situation adequate
ventilation such as eight air changes per hour may be required
to restrict radioactive gas concentrations to within their maxi-
mum permissible concentration (MPC) values. The production
of ozone, using a half-value reduction time of 35 min, a dose
rate of 4 Gylmin at 1 m, a beam length of 2 m, and no room air
changes, approaches a concentration of 5 X 10-3 ppm com-
pared to the MPC value of 0.1 ppm.
McGinley47 directly measured the activity of 1 5 0 and 13N
per unit volume of air produced by a 25 and a 45 MeV medical
accelerator. The accelerators were operated without room ven-
tilation so as to produce maximum activation of the treatment
room air. Levels of the order of 1 percent or less of the MPC in
air for 1 5 0 and 13N were found immediately after accelerator
shutdown. These findings are within an order of magnitude
agreement with the theoretical values of Holloway and
Cormack, a reasonable agreement considering the large num-
ber of assumptions utilized to evaluate levels of activity.
RADIOACTIVATION OF PATIENT
Dunscornbe et a1.18 examined the activity induced in patients
from a 25-MV therapeutic x-ray beam. For a photon dose of 2
Gy to a patient volume of 4 X 10-3 m3, a mean dose to the
irradiated region as a consequence of activation may be calcu-
lated to be 50 F G ~ a, value negligible in comparison with the
dose delivered by the external photon beam. The dose equiva-
lent rate within 10cm of the patient surface 150s after receiving
+
2 Gy is 2 1p Svlhr. In view of the very short half-lives of the
radionuclides involved, this figure confirms the absence of a
radiation hazard to individuals in the neighborhood of a radio-
therapy patient.
ACCELERATOR MAINTENANCE AND
USAGE
CONVENTIONAL MAINTENANCE
Good maintenance is essential in order to fully exploit the
capabilities of modern equipment. Inadequate maintenance
will eventually result in excessive downtime and decreased
usage because of more limited availability. These dictums
apply to all equipment involved in radiotherapy and especially
to accelerators that employ a wide variety of sophisticated
mechanical, electrical, and electronic systems.
Frequently, maintenance and QA measures are comple-
mentary or even synonymous. Maintenance can be provided
either by in-house personnel or external service organizations,
which may include the original equipment manufacturer. What
in-house maintenanceresponsibilities are assumed will depend
the hospital staff. In any case, up-to-date documentation to-
gether with agreed equipment performance standards are
needed for all equipment. Access to adequate spare parts and
bound chronological archival records of equipment perfor-
 ACCELERATOR MAINTENANCEAND USAGE
mance and problems are essential. Periodic inspection of equip-
ment and scheduled preventive maintenance can reveal incip-
ient problems and minimize their interference with treatment
schedules.67 There is no substitute for the acute observations of
a concerned user where maintenance is concerned. The user's
sense of sight, hearing, and smell will often alert them to
incipient problems. Many problems are electronic in nature. An
oscilloscope and multimeter are essential tools in identifying
and analyzing such problems. Some manufacturers offer basic
and advanced maintenance education courses covering their
various accelerators. These courses stress important aspects of
equipment operation, periodic maintenance, troubleshooting,
and repair procedures.
Specific recommendations and some generalizations con-
cerning linac maintenance have been presented by Karzmark.31
Periodic scheduled preventive maintenance is essential for
optimum performance. Maintenance scheduling experience
has been reported using Presdwood pegboards, magnetic
boards, and a computerized maintenance program, including
maintenance schedule generation on a minicomputer.34.35 The
relation of quality assurance in radiotherapy to IEC specifica-
tions for equipment has be outlined by Rassow and Klieber.69
The test methods and numerical guidelines found in IEC doc-
uments concerning standards for radiation, mechanical, and
electrical safety as well as equipment performance standards
can form a basis for a quality assurance program. Relevant IEC
documents are cited by Rassow and Klieber.69
Large maintenance organizations can provide a variety of
services and are widely used. They offer a number of service
contracts under different response time-cost options, which can
include full service, periodic maintenance inspections, recourse
to product specialists and often spare parts. Such organizations
can extend worldwide service. Their collective maintenance
knowledge, often coupled with original equipment manufac-
turer experience, can be most effective in solving abstruse prob-
lems. Where maintenance is camed out by third party or inhouse
technical staff it is essential that the safety of equipment not be
compromised because of poor or variable quality maintenance.
The associated compromises could include use of unauthorized
parts or consumables, failure to document changes, and failure
to remove an interlock jumper by-passed during maintenance.
Appropriate training is strongly recommended for in-house
maintenance staff. Note that inadequate power lines supplying
the accelerator can cause reliability problems at any time.
In addition to the periodic testing of machines to confirm
their functional performance, scheduled preventive mainte-
nance of equipment is needed to ensure reliable operation.
Manufacturers furnish suggested schedules of routine preven-
tive maintenance for their various machine types, based on
average usage under average conditions. These involve peri-
odic inspection, lubrication of certain moving parts, checking
torque of threaded fasteners, replacement of filters in the water,
air and dielectric gas systems and general cleaning. A typical
schedule for routine preventive maintenance is given in Table
14-3.67 (See also IEC Pub 977, ref 26b.)
253
TABLE 14-3 Typical schedule of routine maintenance of
accelerators (From Purdy et al. Ref. 67)
Daily 1. Replace any faulty indicator lights at control console.
Weekly 2. Check operation of blower fans in electronics cabinets.
3. Lightly oil any moving parts in high power microwave
system and carousel.
4. Check water cooling system reservoir water level and
gauge pressure.
Monthly 5. Lightly oil moving parts in rf driver assembly if used
and the beam limiting system drive mechanisms.
6. Remove accumulated dust on component surfaces that
hold off high voltage (e.g., vacuum power supply,
high power modulator)
7. Check all water flow interlocks by restricting the water
flow such as by using a clamp on hoses.
3 Months 8. Clean air filters on blower fans.
9. Clean printed circuit board cards with clean acetone
and a soft brush.
10. Remove a sample of oil from the bottom of the pulse
transformer tank, test for breakdown strength, and
replace or refilter oil if indicated.
11. Check operation of waveguide under-pressure inter-
lock by using the manual bleed valve. Check opera-
tion of waveguide overpressure interlock by energiz-
ing the fill valve temporarily, using a clip lead.
12. Remove connections to each flow interlock, inspect for
deposits, clean out as necessary, check all moving parts.
13. Change the water in the recirculating system, using
deionized water.
14. Visually inspect water cooling pipes inside the gantry
for signs of a developing slow leak.
15. Visually inspect the high current connections on mag-
nets inside the gantry for any signs of working loose.
12 Months 16. Replace any hoses and electrical wiring that
have hardened or cracked due to radiation damage.
Especially, check in high radiation areas, such as ion
chambers, radiation head cables.
At times, a machine will require the immediate attention
of a service engineer or equivalent for replacement of a
significant component or for repair, adjustment, or recalibra-
tion of a subsystem or component. The average frequency with
which such service is needed is typically at about 6-week
intervals for low energy machines and at about 3-week inter-
vals for high energy machines. The average machine time
required to perform such service is several hours. Often,
treatments for the day can be completed and the service
performed before the next scheduled treatment day. For ma-
chines operated an average of 2400 Myear (filament hours),
unplanned machine downtime (during the treatment day) av-
erages about 1 to 2 percent (30 Nyear) for low energy ma-
chines, about 3 to 4 percent (80 Myear) for high energy
machines. Actual experience will vary with individual ma-
chine type and with individual user.
254 CHAPTER 14. ACCELERATOR MAINTENANCE AND USAGE
A term in common usage is "mean time between failures,"
or MTBF. For example, the MTBF for a component might be
5 years. It would be improper to assume that such a component
will probably not fail during the first 5 years of machine
operation. On the contrary, there is a 50 percent probability that
the component will fail during the first 5 years.
EXPERT SYSTEMS
The search for providing continually improved service for
accelerators has led manufacturers to the field of artificial
intelligence (AI) and a subset of it, expert systems (ES).
Artificial intelligence is concerned with identifying and using
tools and techniques that allow machines to exhibit behavior
that emulates intelligent human behavior. An expert system
is composed of computer based reasoning systems, which
offer advice or solutions to difficult problems in very narrow
problem areas. They solve practical problems by offering
advice comparable to that which would be offered by a
human expert in that problem area. They provide assistance
in the maintenance, troubleshooting, and repair of complex
equipment.
As illustrated in Figure 14-5, an expert system consists of
three major components: a user interface, an inference engine,
and stored expertise. The user interface usually consists of a
keyboard (and mouse) to allow the user to input problem
information to the system and a monitor (and printer) to provide
response information from the system to the user. The system's
inference engine is the problem solving software that receives
user input, draws from the stored expertise, and uses reasoning
knowledge about the problem to reach a conclusion and present
it to the user. The stored expertise within the system is the rule
set, a collection of rules that contain pieces of knowledge about
how to reason in specific problem areas. For a specific problem,
the objective of an expert reasoning system is to examine
relevant facts in a logical sequence that results in a solution to
that problem. As implemented for the Clinac 1800, the knowl-
edge base includes more than 800 rules, 500 questions, and
1000 informational screens occupying 3.5 Mbytes. It is able to
diagnose more than 700 problems. This software expert sys-
Expert System
Interference
Problem Interface
.
FIGURE 14-5 Block diagram of expert system designed to offer com-
puter-based assistance in maintenance, troubleshooting,and repair of
the Varian Clinac 1800. (Courtesy of Varian.)
tem, called Perfix 1800, is specific for the Clinac 1800. It
operates on the user's IBM Personal Computer. It can assist
experienced service personnel as well as trained in-house tech-
nical staff in the repair and maintenance of the Clinac 1800. It
seems likely that other expert systems will be developed for
other equipments.
The use of A1 to aid in the diagnosis and repair of complex
electronic equipment can have its greatest impact on furthered
up-time improvement through reduced time to diagnose prob-
lems and increased accuracy of the solutions reached. It can
make troubleshooting expertise available for immediate, on-
site access 24 h a day, every day. Correctly diagnosed and
repaired equipment is also expected to further increase the
mean time between failures (MTBF) since partial or im-
properly diagnosed problems may fix symptoms without rec-
ognizing the source of the original problem, causing recurrent
failures.
TEST EQUIPMENT AND INSTRUMENTATION
Accelerator tests and maintenance requires an appropriate ar-
mamentarium of equipment and instruments. Table 14-4 lists
test equipment suggested by the E C to be made available for
site tests and subsequent periodic tests. This special equipment,
together with an assortment of hand tools, a multimeter, and an
oscilloscope, can be used for other equipment maintenance. The
test equipment selected should have ranges, tolerances, and
sensitivities suitable for measurement of the functional perfor-
mance values and tolerances of the medical electron accelera-
tor. This test equipment should be available for periodic tests
TABLE 14-4 . IEC suggested equipment for site tests and for
subsequent periodic tests
Water phantom
Radiation field scanner
A field detector, not more than 6-mm active dimension in the
direction of scan, for use with the radiation field scanner; a
second detector; dual channel electrometer or two independent
electrometers
Means for mounting radiation field scanner on radiation head
X-Y plotter
Reference standard dosemeter with buildup caps
Film processor access
Film densitometer
Adjustable mechanical pointer with means for support
independently of the gantry for isocentre tests
Mechanical front pointer
Solid phantom for attachment to radiation head
Solid phantom block for isocentre spot check
Solid buildup material
Miscellaneous tools (e.g., machinists metric scale, square,
protractor, spirit level, clinometer, plumb bob, calipers, stop
watch, retort stands to clamp and position equipment.
 ACCELERATOR MA1[NTENANCEAND USAGE
during the working life of the accelerator. Expendable items
such as film, graph paper, and so on, are not included in this list.
Several authors have described devices, instrumentation, and
techniques for simplified periodic checking of the constancy of
radiation beam penetrative quality and field uniformity or sym-
metry. Haskard2Jdescribes a technique employing 16ion cham-
bers in a solid phantom to display the dose profile across the
treatment field in real time. Jones et al.29 describes a technique
employing two silicon diodes in a solid phantom to check depth
dose and field symmetry. Padikal et al.61 describes a system
employing two detectors, electrometers, and an X-Y recorder to
plot field symmetry as a function of gantry angle. Sutherland74
presents results of measurements of field dose profile for vari-
ous gantry angles at the time of machine installation and at a
single gantry angle over 2 years of machine operation. This was
for a machine operated at 4 MeV and with a 270' achromatic
magnet. Lutz et al.44 describe a device employing a solid phan-
tom and three diode detectors to check machine dosemeter
calibration, field symmetry and flatness, and beam penetrative
quality for both x-ray and electron beams. It is suggested that
such checks be made on a daily basis. Lutz et a1.43 also describe
a device and test procedure for checking displacement of the
x-ray beam axis from gantry axis and for distinguishing be-
tween causes of such displacement (i.e., shift of focal spot,
asymmetric shift of collimator jaws).
PERIODIC TESTS OF FUNCTIONAL
PERFORMANCE
During the working life of the medical electron accelerator
periodic tests are conducted by the user to confirm the func-
tional performance characteristics of the machine. Relevant
tests are also performed following equipment adjustment, re-
pair, or component replacement, which could affect functional
performance characteristics or when the machine appears to be
performing improperly.
For periodic tests, concise test methods are needed. For
example, the test methods described by the IEC for site tests
can also be used for periodic tests but with a much more limited
set of test conditions each period, rotating through the full set
over a number of periods. In order to establish bases for
comparison, it would be desirable at the time of machine
installation to perform all periodic tests that employ methods
different from the site test methods. The IEC provides sug-
gested periodic tests by interval and applicable clause of the
IEC standards. The suggested frequencies of periodic tests are
presented only as a guide by the IEC in their documents and
may vary depending on experience.@Actual practice may also
vary during the service life of the machine and may also vary
with machine type and usage. Also, each institution is different
and the various factors that can impact on a QA program are
different. Thus, the QA program developed for an institution
will reflect the special needs of that institution. It will reflect
such factors as specific equipment performance specifications,
255
problems experienced, type and extent of usage, personnel,
relevant regulatory agencies, specific equipment manufactur-
ers and their service arrangements, and time and economic
aspects. Typical baseline data recorded at the time of accep-
tance tests for straight-through and bent-beam linacs and a
summary of subsequent periodic maintenance checks daily,
weekly, and so on, have been reported by Parrino, et al.62 for
the Mallinkrodt Institute of Radiology. Table 14-5 outlines their
quality assurance program.
The frequency with which tests should be performed is
dependent on the potential harm that might be done to patients
during the time that the parameter error can go undetected until
TABLE 14-5 . Accelerator quality assurance program at
Mallinkrodt Institute of Radiology
1. Daily checks, performed each morning by the radiation therapy
technologist who normally operates the machine. These checks
include:
a. Machine operating parameters
b. Radiation output constancy
c. Beam symmetry (machine meter)
d. Laser-isocenter lights (visual check)
e. Optical distance indicator (visual check)
f. Patient audiovisual communication
2. Weekly checks performed during the lunch hour or in the evening
by a dosimetrist or physicist. These checks include:
a. Light-radiation field congruence (examination of radiograph)
b. Electron beam radiation output constancy
c. Bend magnet settings for electron beam
3. Monthly checks performed on specific Friday afternoons set aside
for QA by a dosimetrist or physicist. These checks include:
a. Visual inspection of the mechanical parts of the accelerator
including the blocking tray assembly and treatment aids.
b. Test of safety devices
c. Optical range finder
d. Mechanical and digital indicators
e. Light-radiation field congruence (densitometer)
f. Isocenter
g. Beam symmetry
h. Checkof constancy of assigned dosimetry system and cGylMU
i. Beam energy (percent depth dose)
4. Annual full calibration performed on a weekend by a qualified
medical physicist. These tests include:
a. Alignment of the therapy beam, localizing light, collimator
b. Monitor linearity
c. Monitor end effect
d. Beam uniformity as a function of gantry angle
e. Calibration (cGy/MU)
f. Field size dependence
g. Dependence of dose calibration on machine orientation
h. Percentage depth dose factorsltissue-phantom ratios
i. Off-axis factors
j. Wedge transmission
k. Blocking tray attenuation
256 CHAPTER 14. SAFETY ASPECTSFACILITY AND MACHINE INTERLOCKS
the next test time. For example, dose errors are the most serious.
Spatial alignment errors can be serious for some treatments but,
being mechanical in nature, they tend to develop more slowly.
In addition to the IEC, several other organizations,l.5.59 and
individualsls.68.73have discussed QA programs and suggested
items to be tested, frequency of such tests, and in some cases
they have indicated acceptable tolerances on values measured
in these tests. The ACR has published a QA manual, for therapy
technologists, edited by Wizenberg.5 The AAPMl has prepared
a report on physical aspects of QA, which is intended primarily
for physicists and, which includes suggested tolerance values.
Table 14-5 lists an accelerator QA program reported by
Purdy, et al.,67 which has been employed for several years at
the Mallinkrodt Institute of Radiology. The time spent at
Mallinkrodt is about 10 min at the beginning of each morning
by a therapy technologist for a low energy machine; about 30
min by an electronics individual and a therapy technologist for
a high energy multimode machine of early vintage The Centers
for Radiological Physics (CRP) and RadiologicalPhysics Cen-
ter (RPC) have overseen the physics of QA of radiotherapy
centers in the United States participating in cooperative clinical
trials. The various machine parameters and corresponding ac-
ceptable tolerances (criteria) have been established under this
program. The compliance record of approximately 600 institu-
tions has been reported by Shalek.72 Typically, and depending
on the parameter selected, compliance ranges from 70 percent
to over 90 percent with continued improvement over time.
USAGE AND DOWNTIME EXPERIENCE
Accelerator usage has been examined from a number of view-
points, that is, time allocated to beam-on and other activities
related to individual patient treatment, influence on shielding
barrier design, (see p 250) as well as downtime affecting
long-term performance. A time and motion study of the deliv-
ery of radiation treatment in one environment found about 20
percent allocated to beam-on time, 50 percent to set up, and 30
percent to miscellaneous tasks.32 For a series of 179 treatment
sessions a mean time of 9.8 min was observed.
Improvementsin linac design and preventive maintenance
have resulted in less downtime, based on their available clinical
time. In an early study, Greene and Nelson22 describe technical
problems in the maintenance of a prototype 4-MV unit. Over a
5-year period, days per year lost from treatment (defined as days
when it was not possible to treat patients) increased to 3 and then
decreased to 0, although there were 4 further days when it was
not possible to complete all the treatments for that day. In a later
study of four low energy linacs, Greene and Fallas23 found a
scheduled total time out of service of 1 to 4 weeks per linac, and
an unscheduled total time out of service of 19 to 30 days over
machine lifetimes of 10 to 20 years, an average unscheduled
downtime of 1.6 dayslyear over an average of 16 years of ser-
vice per machine. However, the definition of an unscheduled
downtime day was a day in which it was not possible to treat the
scheduled patients because of machine failure. There were nu-
merous other days when machine faults occurred but were recti-
fied during that day and patient treatment continued. Parrino et
al.62 report a 0.3 and a 0.5 percent downtime for two low energy
accelerators, 4 percent for a high energy machine. Dawson and
Gribblel4 studied the unscheduled downtime for an early com-
puter-controlled 6-MV Therac 6 accelerator. They found, that
over a 7-year period following the initial year of clinical use, an
average unscheduled downtime of 2.4 percent with a corre-
sponding loss of 1.3 percent in patient treatments. In-house s u p
port for quality assurance, preventive maintenance, and repairs
averaged approximately 500 man-hours annually. In another
study, Bjarngard and McEwen9 found that, typically, time lost
decreased with time since acquisition, for the 5-year study of
four machines, and averaged 2 percent. The majority of inter-
ruptions had a duration of less than 1 h, occurred on an average
about once a month, and resulted primarily in inconveniencefor
patients and staff, but with no decrease in the number of treat-
ments given that day. The more complex, higher energy,
muiltimodalitylinacs will tend to have more downtime.
A feature of some contemporary linacs may contribute to
the downtime. The pulse repetition rate of these medical linacs
is automatically controlled to provide a constant dose rate
under various operating conditions. This feature can mask real
or incipient problems that are compensated for by abnormal
changes in dose rate. The addition of a simple, sample-and-dis-
play pulse rate counter has been shown to minimize rnisinter-
pretation and aid the diagnosis of malfunctions, as well as the
day-to-day setting of various operational parameters.46
SAFETY ASPECTS-FACILITY AND
MACHINE INTERLOCKS
Appropriate interlocks are provided in facilities and equipment
where radiation or other hazards could result in harm to patient,
personnel, or equipment. Afamiliar facility interlock is one that
controls access to a treatment room. If a treatment room access
door is opened when the machine is "ON," the interlock causes
the irradiation to be terminated and the machine placed in a safe
"READY" state. It is then possible to restore the machine to
full operation only from the control panel. Closing the treat-
ment door alone will not restore the machine to the " O N state.
Any interlock system should be so designed, so that the failure
of any one component will not jeopardize the safety of the
system; for example, by the use of two series-connected
switches at access doors and dual interlock relays.
The treatment room door or access maze constitutes a
critical element in the safe operation of a radiation facility. The
NCRP Report No 88,55 discusses such systems, which are
applicable to door and maze control, as well as elsewhere in
the equipment and facility. Alarms provide warnings and ac-
cess control promotes security, both ingredients of safe prac-
 HUMAN ENGINEERING ASPECTS
tice. Included in the discussion are radiation warning lights,
door interlocks, door key switches and emergency off-
switches. The safe access to a radiotherapy treatment roomcan
benefit from the use of a time-delay or a start-up switch, which
has to be activated and the door or barrier closed within a given
time interval (normally less than 20 s) before the beam can be
activated. Aldrich and Berkey7 describe a simple optical inter-
rupt time-delay which can be fitted or retrofitted in any treat-
ment room. The use of such a device ensures that the last act
performed by the operator before turning on the beam is to
check the room for other personnel.
Machine protection interlocks are designed to protect the
equipment from damage due to abnormal operating conditions.
These include interlocks for cooling water temperature and
flow rates, vacuum system pressure, air pressure for pneumatic
systems, waveguide insulating gas pressure, as well as appro-
priate under and over-voltage conditions.
Machine performance interlocks are those that ensure that
parameters which affect patient treatment are within perfor-
mance specifications.These include interlocks for high and low
dose rates, beam flatness/symmetry, agreement of the dual
dosemeters, and interlocks ensuring that beam modification
accessories, such as wedges and applicators, are correctly
inserted and identified. This latter operation is often ensured by
select and confirm procedures. In these, for example, the par-
ticular wedge selected and secured in position on the accelera-
tor in the treatment room must be confirmed by an action at the
treatment control console before that treatment can begin.
The status of the various access, machine protection, and
performance interlocks is usually displayed on the control
console, or, where appropriate, at other locations in the system.
Additional details concerning the interlock system are found in
Chap. 10.
Medical linacs require high power, pulsed microwave
energy sources. There is the possibility of significant electro-
magnetic (EM) interference from these sources with electronic
devices such as cardiac pacemakers. Marbach et al.45 suggest
that, for patients so equipped, the treatment can be first simu-
lated on a similar pacemaker. If this is not possible, one can
monitor the electrocardiogram of the patient during the actual
treatment, or use 60Co treatment quipment since therapeutic
doses of gamma radiation do not appear to affect pacemaker
function (Chapter 9, p 166).
Klystron powered, high energy linacs may present two
radiation hazards: (a) x-rays originating from energetic elec-
trons stopped in the collector or elsewhere in the klystron and
(b) x-rays from high field emission electrons originating in
evacuated microwave cavities or waveguides.21 Klystron col-
lectors often require several centimeters of lead shielding to
adequately attenuate x rays from operation at high voltages and
high average power levels.57.75 They must not be operated with
shielding removed. Note should be taken that the klystron
radiation hazard is also present when an accelerator beam is not
being transported as when the electron gun is turned off or when
klystrons are not amplifying, as when tuned off frequency or
257
the rf drive removed. Magnetrons, which usually operate at
potentials of 50 kV or less, produce softer X radiation. Such x
rays are likely to be adequately shielded by the magnetron
structure itself, but this expectation merits confirmation by
surveying with an appropriate instrument.
HUMAN ENGINEERING ASPECTS
The operation of particle accelerators for radiation treatment is
more complicated than in a physics research laboratory where
they originated and additional features must be added. It is
necessary to provide simplified controls, accurate dose moni-
toring, flexibility in beam directivity,accurate, adjustablebeam
collimation, a simplified vacuum system and functional, light-
weight accessories to ensure safe, precise, and reproducible
treatment procedures. This area of concern is encompassed by
an applied science, ergonomics, which involves the character-
istics of people that need to be considered in designing and
arranging things that they use in order that people and things
will interact most effectively and safely.
The design emphasis in treatment units has shifted over
time; first centering on improvementsin the acceleratorproper,
but now increasingly concerned with features that will enhance
its utility for patient treatment. Some of the most striking
improvements in contemporary radiotherapy linacs are found
in what may be called human engineering. Here, careful atten-
tion to the environment and details of treatment procedure have
resulted in improved esthetics and design features, accessories
and controls, which facilitate efficient, precise, comfortable,
and safe treatment in pleasant surroundings. The patient can
usually lie comfortably supine or prone and be readily posi-
tioned on the couch of an isocentric treatment unit. Contempo-
rary treatment couches, which are treated in Chap. 12 provide
both center-spine and dual-rail capability in a single unit, a
significant aid in treatment field visualization and placement
of fields that require particular gantry angles.
Treatment simulators are coming into widespread use and
are covered in Chap. 13.They are designed to closely duplicate
the treatment unit, and thereby facilitate tumor localization and
treatment portal verification. Manufacturers are providing im-
proved beam modification accessories: wedges, blocks, com-
pensators, shadow trays, and so on, which can be employed in
combinations with minimal perturbation to setup procedures.
Significant weight reductions have been made in accessories
that must be handled by staff. Patient positioning and im-
mobilization accessories are being designed to integrate into
the treatment couches with which they are used. Visual aids
include range finders, laser positioning markers and the alpha-
numeric displays of setup parameters in the treatment room. A
report by Goer reviews accessories for electron arc therapy,
patient immobilization, and positioning as well as record and
verify systems (Chap. 12, p 206).
258 CHAPTER 14. REFERENCES
X-ray beam energies of 10 MV and above result in poor
contrast port films. Hence, the provision of a low x-ray energy
(e.g., 4-6 MV) is advantageous, be it as a treatment modality
or, as in some units, available as a port film option.66
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Medical Microtron Accelerators
The microtron is a cyclic accelerator.It is called a microtron be-
cause it employs microwaves for acceleration. It was originally
proposed in 1944 by Vekslerls in the U.S.S.R. under the name
electron cyclotron as an application of his discovery of orbital
phase stability. It permitted repetitively returning the electron
beam to the same rf acceleration region, thereby attaining high
energy from a much lower energy single cavity accelerator. The
principle of phase stability discoveredby Veksler (and indepen-
dently by McMillan9) meant that early electrons, gaining too
much energy on the rf sine wave, would follow a longer path in
the magnetic field, returning late, and gaining too little energy
on the rf sine wave in the next pass through the acceleration re-
gion. Thus, the electrons oscillated around a stable phase angle
on the late side of the rf sine wave. The phase stable region is rel-
atively small, so electrons off too far in energy and phase are lost
in the first few orbits and only electrons in a narrow energy bin
survive to be accelerated to full energy. Thus, unless 10ps pulse
type emission is employed the injected current from the gun
must be much higher than the microtron output beam current. In
essence, the microtron magnet acts as an energy spectrometer.
Original interest in development of microtrons related to
physics research. Experimenters were interested in using the
narrow energy spread, tightly bunched, high energy electrons
to generate submillimeter radio waves.
The development of the microtron was slow compared to
the microwave linac, primarily because the early versions
produced quite low beam current and because these early
machines had limited reliability. It is an axiom of accelerator
technology that the beam injectionlacceptance process is the
Achilles heel in attaining reliable high beam performance. This
has certainly been true over the decades of development of the
microtron, first the circular type and then the racetrack type.
The circular microtron requires an extremely small high
brightness gun cathode to be positioned at the accelerating
cavity within the magnetic field and inside the first circular
orbit. In the racetrack microtron a multicavity accelerator struc-
ture is positioned in the field-free region between magnets, so
the gun could be reasonably large and be positioned away from
the accelerator structure and beam orbits. Small inflector mag-
nets are then required to clear the first racetrack orbit and the
C H A P T E R 15
beam extraction orbit. The beam emittance of the injected beam
from the gun must be quite good because the phase acceptance
of the microtron is small. One way to meet this requirement is
to use a small high brightness cathode such as lanthanum
hexaboride, but such cathodes have to date had limited life.
The tight energy spread and low emittance of the output
electron beam from a microtron permits use of rather simple
magnets for transport of the beam. This facilitates transporting
the beam from one microtron to two or more gantries in
separate treatment rooms. It also permits using a simple 90" non
achromatic bend magnet in the radiation head and facilitates
scanning of the beam with simple magnets for both electron
and x-ray modes.
The injection scheme invented by Kapitza and Melekhing
in the U.S.S.R. to achieve 1-MeV gain per orbit in the circular
microtron permits use of an especially compact magnet. For
example, 20 MeV could be achieved with a magnet of a little
more than 1 m diameter and 30 cm thickness. A machine of this
general type has been developed for radiotherapy in the
U.S.S.R. and has been used to treat patients.
The racetrack microtron becomes interesting as a compet-
itor to the linac for energies above about 25 MeV. There are
interesting industrial and scientific applications of a machine
that can be compact and achieve energies above 25 MeV, even
to 100 or more million electron volts. For treatment of patients,
such higher energy beams have not been found to be needed to
date, but clinical research is proceeding with 50-MeV racetrack
rnirotrons. Brahme2 describes the design and beam character-
istics of such a machine.
In the following two sections, circular and racetrack
microtrons for radiotherapy and other applications are dis-
cussed in more detail.
CIRCULAR MICROTRON
CAVITY POWER REQUIREMENTS
The beam passes through a number of accelerating cavities
only once in nonrecirculating linacs. For example, a 20 cavity
262 CHAPTER 15. MEDICAL MICROTRON ACCELERATORS
1-m long SW structure might be used at 10-cm wavelength to
produce 20 MeV. Assuming 100-MWm shunt impedance, the
total power loss to the structure would be P = W L = 4 MW.
The energy gain and power loss per cavity are, respectively, 1
MeV and 0.2 MW. (Additional rf power from the source is
converted into beam power.)
The beam passes through a single cavity a number of times
in the circular microtron. This single microwave cavity, typi-
cally resonant at 10-cm wavelength, is placed between the
poles of a uniform field dc magnet. Assuming 1/2 MeV gain per
transit and a 2.5-cm long cavity at 50-MSZIm shunt impedance,
power loss to the cavity would be P = (0.5)2/(50 X 0.025) =
0.2 MW. This is only 5 per cent of the cavity power loss of the
above linac example. By recirculating the electron bunch
through the cavity 40 times, an output energy of about 20 MeV
could be obtained. Assuming 0.5-MW source power is coupled
into the beam, the total pulse power at 20 MeV would be 4.5
MW for the linac and 0.7 MW for the circulator microtron,
based on the above example.
The basic conditions for synchronous acceleration in the
circular microtron are given by Rand.10
MAGNET SIZE
For typical values of orbit synchronism the radius of the last
orbit of a 42 orbit, 21-MeV microtron is 68.44 cm and the
magnetic field is about 0.11 T (1.1 kG). The magnet gap is about
11 cm to clear the cavity. A magnetic field uniformity of about
10-4 is required to avoid sidewise (in the orbit plane) drift of
the orbits. Adding two gap dimensions to the maximum orbit
radius to reduce fringe field effects, the magnet pole diameter
becomes about 1.8 m. Allowing for magnet coils and return
yoke, the outside diameter of the magnet becomes about 2.2 m
and its thickness becomes about 0.5 m. This is a relatively large
heavy magnet with stringent field uniformity requirements.
INJECTION METHODS FOR INCREASED
ENERGY PER ORBIT
For a given maximum energy, the final orbit diameter can be
reduced to about one half by gaining about 1 MeV instead of
112 MeV per orbit and using twice the magnetic field intensity.
The magnet pole diameter does not decrease proportionately
because of the need for a margin to avoid fringe field effects.
The 153-cm pole diameter calculated for a 42 orbit 21-MeV
microtron would reduce to 85 cm and the magnet outer diam-
eter would reduce from about 2.2 to about 1.5 ms, thereby
making the accelerator more compact and lighter.
In order for the first orbit to clear the cavity while bending
in this increased magnetic field, the electrons entering this
first orbit must have an energy of about 1 MeV. Melekhin
and co-workers in the U.S.S.R. invented a method for achiev-
ing this effect in which electrons from the cathode enter
directly into the cavity from a point off axis and follow a
curved path inside the cavity in the forward and then reverse
directions as the rf field reverses (see Figure 15-la). In another
Melekhin technique (see Figure 15-lb), the electrons make a
second pass through the cavity before entering the first orbit
around the cavity. The cathode must be quite small to meet
the orbit dimensional criteria. This U.S.S.R. team7 was the
first to use the uniquely high emission properties of lanthanum
hexaboride cathodes for this purpose. However, Kapitza et
al.8 state that such cathodes required replacement at intervals
of about 100 h in their early accelerators. (Recent experience
suggests much longer life.) In addition, the extracted electron
beam current is much less than with conventional medical
linacs. A medical accelerator has been developed in the
U.S.S.R. in which the microtron is mounted in the gantry and
rotates with it.
PHASE STABILITY
The phase stable region of the microtron is on the falling side
of the sinusoidal rf oscillation. An early electron transits the
cavity nearer the crest of the oscillation, gains more than
synchronous energy, follows a larger than synchronous radius
orbit in the magnetic field, returns to the cavity later than the
synchronous phase, gains less than the synchronous energy,
and so on. These oscillations about synchronous phase are
stable over the range from 0"(i.e. crest) to
2
tan-' <D - -
zb
where @ is the phase angle and b is the extra number of rf
periods per successive orbit. For b = 1, the stable range is
0"-32.5". This finite range of phase corresponds to a finite
range of deviation from synchronous orbit radius and, hence, a
finite range of energy deviation. For example, in an orbit of 44
CAVITY
.
FIGURE 15-1 Injection orbits for high energy gain per cavity transit
in circular microtron (fmm Ref. 8).
 RACETRACKMICROTRON 263

rf periods (15,840") long at 21 MeV, 32.5"/15,840°corresponds EXTRACTION

to 0.25 percent (43-keV) energy spread. It is also a 43-keV ; /cHmNEL

energy spread in each of the preceding orbits, since the stable

range of 32.5" is a constant. Thus, the percentage energy spread
is inversely proportional to beam energy. This narrow energy
spread simplifies beam transport from the stationary microtron
to the radiation head in the treatment gantry.

BEAM CURRENT AND FOCUSING

To produce a dose rate of 3 Gylmin at 100 cm SSD with an
x-ray beam flattened over 50 cm diameter, the required pulse
beam current at the x-ray target is about 90 mA at 6 MeV, 14
mA at 20 MeV, assuming 0.001 beam duty cycle. At 1l2-MeV
energy gain per orbit, the beam passes through the cavity 12
times to reach 6 MeV, representing a total cavity beam load
current of 1080 mA; 40 times to reach 20 MeV, a total cavity
beam load current of 560 mA. Focusing forces are required to
limit the beam transverse dimensions as it passes and repasses
through the cavity. The 360" circular bend results in natural
radial focusing; rays of a given energy that are parallel at the FIGURE 15-2 . Electron bunches and orbits in circular microtron.
Movable magnetic shunt permits extraction from various orbits at cor-
cavity cross at 90" and 270" of the orbit path. Radio frequency responding energies for transport to radiation therapy gantry (from
focusing at the cavity is used to provide beam focusing in the Ref. lo).
transverse (magnetic field) direction. The cavity entrance ap-
erture is made small in the transverse direction to provide
electrons follow a small radius path in the magnetic field,
transverse electric focusing forces and the cavity exit aperture
enter the cavity, and gain lh MeV per orbit. One model is
is made large in the transverse direction to minimize transverse
rated 21-MeV x-ray energy, employing 42 orbits. The first
electric defocusing forces.
orbit corresponds to two rf periods and each successive orbit
is one period longer. Electrons from the 10th orbit (, 5 MeV)
GANTRY to the 42nd orbit can be deflected out of the circular orbit by
passage through the field free region of a movable steel tube,
As described by Svensson et a1.,14 the electronbeam is extracted
oriented such that the electrons subsequently enter a stationary
from the microtron along the rotational axis of the gantry and steel tube leading to a beam transport system in a treatment
focused by quadrupoles to match the acceptance of three suc- gantry (see Figure 15-2). The geometry is such that the beam
ceeding bend magnets. These bend the beam - 90°, + 82", and
at any of the selected energies leaves the microtron along a
+98" to align the beam with the rotational axis of the radiation
fixed trajectory.
head in an isocentric system (see Figure 15-2). A quadrupole
triplet combines with the 98" magnet to focus the beam to about
2-mm diameter and 5" angular divergence at the x-ray target
location just outside the vacuum window and 100 cm from the
isocenter. The x-ray target and electron scattering foils are RACETRACK MICROTRON
mounted on a carousel. Multiple x-ray and electron energy
treatment beams are available. By use of a switching magnet it CONFIGURATION
is possible to arrange for one microtron to feed the beam to two
separate gantries in their respective treatment rooms. This may The circular microtron is a bulky structure for two reasons:
prove useful for intraoperative radiotherapy, permitting a rela-
tively light weight gantry in one or more operating rooms, fed 1. The magnet gap must be large enough to accommodatethe
by a microtron located elsewhere in the hospital. accelerating cavity and this in turn requires large magnet
coils and a large magnet yoke. The large magnet gap also
necessitates increased magnet pole diameter to avoid non-
MACHINES FOR RADIOTHERAPY uniformity of the magnetic field at the beam orbits due to
About 10 circular microtrons have been manufactured by fringing of the field.
Instrument AB Scanditronix in Sweden for use in radiotherapy 2. The uniform part of the magnetic field must have a large
(e.g., see Refs. 3,11,12 and 14). The electrons are emitted enough diameter to accommodate the large number of
from a small cathode located just outside the cavity. The spaced orbits corresponding to the limited energy gain per
264 CHAPTER 15. MEDICAL MICROTRON ACCELERATORS
orbit. Energy gain per orbit is limited by possible arcing in
the single cavity, which must fit inside the first orbit. Space
for the gun is also severely limited.
Such constraints of the circular microtron are removed in
the racetrack microtron by separating the functions of beam
bending and acceleration. Although several geometries have
been proposed for doing this, only the so-called standard race-
track mircotron will be discussed here. An SW linac structure
(instead of a single cavity) is placed in the field free region
between two 180" bend magnets (see Figure 15-3). Reverse
field auxiliary magnets and injection chicane magnets are also
located in this space, so the distance between 180" magnets is
considerably greater than the accelerator structure length. The
parameters of a nominally 50-MeV racetrack microtron devel-
oped by Wernholm's group at the Royal Institute of Technol-
ogy, Stockholm are given by Rosander et al.13
The same conditions for synchronism apply to the race-
track microtron as to the circular microtron, resulting in the
same phase stable region of 0" to -32.5".
FOCUSING
Without correction, the bending of the beam in the fringe field
at entrance to and exit from each 180" magnet in each orbit
would cause excessive transverse (normal-to-orbit plane)
defocusing of the beam. The Wernholm group compensated
this effect by adding auxiliary reversed field poles along the
edge of each 180" pole, as proposed by Babic and Sedlacek.1
Figure 15-4 shows a similar magnet design for a 100-MeV
racetrack rnicrotron. The entrant electron ray bends outward a
few degrees, then bends inward slightly more than 180°, then
bends back outward a few degrees for a net turn of 180" and
net zero transverse focusing force. An added advantage is that
the path length of the first orbit is slightly less than would match
a velocity of light particle, satisfying the resonance conditions
for the electron energy of the first orbit. For example, the
FIGURE 15-3 - Perspective view of 50 MeV racetrack microtron (from
Ref. 13).
electron energy in this first orbit may be 3 MeV, at which P
=0.99c. Subsequentorbit path lengths are less affected because
of their larger radii of curvature and resonance conditions are
maintained for their higher energies. As in the circular microt-
ron, the 180" magnets provide radial focusing from entrance to
exit. The accelerator cavity apertures can be shaped to provide
some electrostatic focusing.
ACCELERATOR STRUCTURE POWER
In order to accommodate the lateral spread from accelerator
axis of recirculated electrons at the accelerator, the cavity drift
tube aperture is made about 10 rnm in diameter, whereas
apertures of 5 mm can be used in medical linacs. To provide a
path for the first orbit a return tube is located in the accelerator
wall. These two factors result in lower shunt impedance for
racetrack microtron accelerator structures, about 75 Mfllm,
than for medical linacs, about 100 or more Mfllm. Assuming
18" synchronous phase angle, 3.7 MeV gain per orbit, 0.25-m
accelerator structure, the power to the structure is A P =
(3.71~0~ 18")2/(75 X 0.25) = 0.81 MW. Allowing for other
losses and for rf power to the beam, a 2-MW magnetron could
be used as the microwave source.
The electron flight time through 15 orbits is about 1/4ps.
The accelerator guide fill time is about Ips. Some care in
injection timing and injection pulse current shape may be
required to stay well within the phase stable region at heavy
beam loading of the accelerator structure.
INJECTION
The phase space admittance of the racetrack microtron is
relatively small, about 2% mm-rnrad normalized to the rest
energy of the electron, correspondingto a 1-mm radius, 1-rnrad
divergence beam at 12 MeV. It would be most convenient to
use a hollow gun on the axis of the accelerator structure and let
the return orbits pass through it. Hutcheon et al.6 describes a
gun with a 301~ mm-mrad normalized emittance. Ahollow core
version of this gun was subsequently developed for a 2-pass
linac, with about 3-mm aperture for the reflected beam. How-
ever, the racetrack rnicrotron requires an aperture of about 10
mm in the hollow gun. Wernholm's group, after many tries,
abandoned the hollow gun approach as having improper beam
emittance for a racetrack microtron. Therefore, a solid gun at
about 30 kV was offset at 33" from the accelerator axis and two
small magnets on the accelerator axis were used, one to inflect
the gun beam into the accelerator and the other to compensate
for its small deflection of the megavoltage beam returning from
its orbits. The gun cathode was a 2.5-mm diameter lanthanum
hexaboride button, emitting up to 1 Aof current. High injection
current is needed because there is a large loss of current from
the first two or three orbits due to off-phase off-energy elec-
trons leaving the accelerator structure.
 RACETRACK MICROTRON 265

Mai
Coi
Common Coil
for Reverse
Field

Iron .
Tube

Reverse Field Assembly

0
I
CM 1 0 .

(a)
High Field Circuit
, 0
I I I
CM
I I 5P
(4
-
Reverse Field Assembly

FIGURE 15-4 - (a) Cross-section and (b) plan view of 180"reverse field magnet design for the Wisconsin 100-MeV racetrack microtron (from
Ref. 4).

EXTRACTION
An arrangement originally proposed by Herminghaus et al.5
has been used in several racetrack microtrons for extraction of
the electron beam from any selected orbit (see Figure 15-5). A
small magnet placed near and after traversal of the first 180"
magnet is moved over the selected orbit in the drift space
between the two 180"magnets and powered to deflect the beam
a few degrees in the direction toward the previous orbit. The
extracted beam is displaced by one orbit at entrance to the
second 180" magnet and is displaced similarly beyond the
accelerator axis at the exit from the second 180" magnet. The
beam clears the accelerator structure exterior and enters a beam
transport system. One advantage of this technique occurs be-
cause the electron rays that are displaced from the central ray
due to their energy spread and traversal of the first 180"magnet
are brought almost back together at the exit from the second
180" magnet. The remaining small beam chromaticity can be
canceled by an extra magnet outside the rnicrotron.
Since the extracted beam enters and leaves the second 180"
magnet at a small angle (see Figure 15-5), it experiences some
transverse defocusing, which is then accommodated in the
subsequent beam transport system.

FIGURE 15-5 . Electron orbits in a racetrack microtron. The extrac-
tion magnet can be moved to select various orbits for beam extraction
at various energies along the same output beam line (from Ref. 12).
ALIGNMENT PRECISION
If the two 180" magnets are not coplanar with edges parallel,
the electron beam will walk away, somewhat like a light beam
reflected between two tilted mirrors, with higher orbits missing
the axis of the accelerator structure. The permissible alignment
errors calculated by the Wemholm group for their 50-MeV
racetrack microtron are about 0.01 mrad, too small for remote
controlled mechanical correction. Similarly, a small gradient in
the field of the 180" magnets in the direction normal to the
accelerator axis will cause the beam to walk away; a tolerance
of about one part in 104has been calculated. The effects of these
errors have been compensated by the Wernholm group by using
electrical control of the distribution of the magnetic field along
the auxiliary magnets and by addition of a magnet array next
to one of the auxiliary magnets to permit individual correction
of each orbit.
266 CHAPTER 15. MEDICAL MICROTRON ACCELERATORS
MACHINE FOR RADIOTHERAPY
The first racetrack microtron for radiotherapy has been in-
stalled in Umea, Sweden. The extracted beam from the station-
ary microtron is directed and focused along the rotational axis
of a gantry. A sequence of -90°, +82", and +98" magnets
displace the beam and direct it into the radiation head. Electron
and x-ray energies up to 50 MeV are provided. Because of these
high energies, the beam is scanned in both the electron and
x-ray mode. This avoids excessive x-ray contamination that
would otherwise be produced from scattering foils in the elec-
tron mode at higher energies. It avoids excessive softening of
the x-ray spectrum and excessive sensitivity of field symmetry
to beam displacement that would otherwise be produced by a
flattening filter for large fields in x-ray mode at energies above
about 25 MeV. It also permits somewhat lower current for a
given dose rate. The scanning magnets and bend magnet in the
radiation head are described in earlier chapters.
REFERENCES
1. Babic H, M Sedlacek: A method for stabilizing orbits in the
racetrack microtron. Nucl Instr Methods 56: 170-172, 1967.
2. Brahme A: Design principles and clinical possibilities with a new
generation of radiation therapy equipment. Acta Oncologica
26:403412, 1987.
3. Brahme A: Microtrons: Development, principles, and applica-
tion in radiation therapy, in KR Das (Ed): Proceedings of a
Workshop in Bombay. Bombay, Assn. Med. Phys. India, Dec.
3-8,1982, pp 238-262.
4. Green MA, EM Rowe, WS Trzeciak, W R Winter: Design and
operation of the 100 MeV Aladdin microtron injector. IEEE
Trans NS-28 No. 3:2074-2076, 1981; 15.3.
5. Herminghaus H, A Feder, KH Kaiser, W Manz, H v. d. Schmitt:
The design of a cascaded 800 MeV normal conducting C. W.
racetrack microtron. Nucl Instr Meth 138: 1-12, 1976.
6. Hutcheon RM, LW Funk, BA Gillies, SB Hodge, PJ Metivier, SO
Schriber: A compact 6 MeV pulsed electron accelerator. IEEE
NS-30, NO. 2: 1418-1420, 1983.
7. Kapitza SP, VP Bykov, VN Melekhin: A high current microtron.
Sov Physics JETP 12 (No. 4):693-695, 1961. Translated from J
Exp Theor Phys (USSR) 39:997-1000,1960.
8. Kapitza SP, VN Melekhin: The Microtron: English ed. EM Rowe
(Ed), London, Harwood Academic Publishers, 1978 p 9.
9. McMillan EM: The synchrotron-a proposed high energy parti-
cle accelerator. Phvs Rev 68: 143-144. 1945.
10. Rand RE: Recirculating Electron Accelerators. New York, Har-
wood Academic Publishers, 1984.
11. Reistad D, A Brahme: The microtron, a new accelerator for
radiation therapy (Abstract, 3rd Int Conf Med Phys.) Phys Med
Biol 17:692, 1972.
12. Rosander S: The development of the microtron. Report 80-102.
Stockholm, Sweden, Royal Inst. Technology, Dept. Electron
Physics, 1980.
13. Rosander S, M Sedlacek, 0 Wemholm: The 50 MeV racetrack
microtron at the Royal Institute of Technology, Stockholm.Nucl
Inst Meth 204: 1-20, 1982.
14. Svensson H, L Jonsson, LG Larsson, A Brahme, B Lindberg, D
Reistad: A 22 MeV microtron for radiotherapy. Acta Radio1 Ther
Phys Biol16: 145, 1977.
15. Veksler VI: A new method of acceleration of relativistic particles.
USSRAcad Sci 43:346,1944 and J Phys USSR 9: 153,1945.
16. Wilson PB, CS Nunan: The racetrackmicrotronas anegativepion
source for radiotherapy. IEEE Trans on Nucl Sci NS-20, No. 3:
1018-1021,1973.
 Other Types of Medical Electron
Accelerators
HISTORY
The microwave linac is the most widely used machine for
x-ray and electron therapy. It is useful to review other
methods of electron acceleration to understand their place
in history and why they are not more widely used today for
radiotherapy. Various methods for electron acceleration to
megavoltage energies can be divided into three categories;
direct, magnetic induction, and ~nicrowaveacceleration. The
associated accelerators under these categories are described
in detail by Livingood and Blewett,23 Humpheries,lo Kapitza
and Melekhin,l4 Livingood,22 and Rand.27 Several of these
accelerators were used to a significant extent in earlier times
for radiotherapy and are described in this chapter. They are
the transformer-rectifier unit, resonant transformer, Van de
Graaff generator, betatron, and electron synchrotron. In ad-
dition, the microwave powered microtron's contemporary
development for radiotherapy is covered in detail in Chap.
15.
In a direct accelerator the entire accelerating potential is
held off over an insulating column, which forms the accelerator
tube. Examples are the transformer-rectifier units, the resonant
transformer, the Van de Graaff generator and the Dynamit-
ron.33a In a magnetic induction accelerator an electric field
induced by a changing magnetic field is used to accelerate the
electron beam. This is illustrated by the betatron described on
pages 273-275. The very high pulse power accelerators de-
scribed by Birx4 and Kulke20 are of this type. In microwave
accelerators the electron beam transits the electric field across
the gap of a resonant cavity or series of such resonators. These
accelerators are represented by the electron linac described
extensively in earlier chapters, and by the microtonl3.14.28 de-
scribed in Chap. 15 and a dual-pass, recirculation linac, the
Reflexotron, described by Schriber et a1.30 A precursor was the
rf generator described by Sloan.33
Of the three acceleration methods noted, the following
have been applied in machines for radiation therapy: Direct:
Cascade transformer; resonant transformer; Van de Graaff
generator. Magnetic induction: betatron. Microwave: synchro-
tron; linac; Reflexotron; circular microtron; racetrack microt-
ron. The machines for radiation therapy are described in
greater detail in the following and other sections. Although
commercial factors have been important, some technical rea-
sons for the lack of broad acceptance or obsolescence of
accelerator types other than linacs can be summarized as
follows:
Direct Inadequate energy. Large size. Limited maneu-
verability. Voltage breakdown. Difficult to service.
Betatron Inadequate beam current for high x-ray in-
tensity with large fields at moderate and low x-ray ener-
gies. Large size. Limited maneuverability. Complex beam
asymmetries between directions in and transverse to the
orbit.
Synchrotron Similar to betatron.
Reflexotron Limited current at low x-ray energy. Com-
plexity resulting in adverse manufacturing costs.
Circular microtron* Clinical desirability of feeding
more than one treatment room from one accelerator has
not been demonstrated. Need for large homogeneous field
magnet.
Racetrack microtron* Complexity is justified over linac
primarily only for energies well above 25 MeV, for which
need has not been demonstrated.
The Reflexotron (see Fig. 16-I), a microwave accelerator,
uses a short SW structure that can accelerate electrons in both
directions sequentially. By use of an isochronous achromatic
mirror magnet, the electron beam is reflected back through the
accelerator structure to obtain energy doubling.30See also p 15.
*Described in Chap. 15.
268 CHAPTER 16. OTHER TYPES OF MEDICAL ELECTRON ACCELERATORS

Reflecting Magnet
Double Pass
Accelerating Wave Guide
270 Bending Magnet

Gunllnjector

Beam Aperture

Coupling Slot
Machined Segment

Pancake Coupling
Cavity

Accelerating Cavity

t,.)

FIGURE 16-1 . Reilexotron,Therac 25, (a) Double pass linac incorporating a single reflecting magnet and a hollow cathode electron gun. (b)Half-
cavity machined segment showing beam aperture and coupling slots (c) Cross section of biperiodic cavity structure. (Courtesy of Atomic Energy of
Canada Ltd.).

single-pass (nonrecirculating)acceleration of an electron beam

TRANSFORMER-RECTIFIER UNITS
Direct accelerators are those in which the entire voltage at-
tained by the beam must be held off over the acceleration length
(excluding charge exchange). In almost all of these machines,
a charged particle is accelerated only once through a potential
difference.An elementary example is found in the conventional
diagnostic or therapeutic x-ray machine. Here, a high voltage
transformer-rectifiercombination provides a dc voltage for the
between filament and anode. Such equipment is currently
available at the 250- and 300-kV level for therapeutic applica-
tions. The term "orthovoltage therapy" is used to describe
treatment with x rays produced at voltages ranging from 150
to 500 kV, usually at currents of 10 to 20 mA. Orthovoltage
x-ray beam characteristics are described in Chap. 2. Orthovolt-
age energies superseded the less penetrating radiations pro-
duced earlier by lower voltages. Later orthovoltage was
extended to 400, 600, 800, and even 1000 kV by cascading
 TRANSFORMER-RECTIFIERUNITS 269

Water

Target

FIGURE 16-2 . A cascaded 800-kV x-ray tube and power supply (General Electric KXC-2).
(Courtesy of Charles Thomas, Supervoltage Roentgentherapy, 1950.)

200-kV transformer half-wave rectifier combinations and ex-
tending the accelerator tube, as shown in Figure 16-2.
This unit, operating at 800 kVp (or 0.8 MVp) and 10 mA,
employed two 60-Hz Villard voltage doubling circuits.6-1*,29
The abbreviation kVp refers to the peak voltage of the wave ex-
pressed in kilovolts, and MVp refers to the peak voltage of the
wave expressed in millions of volts. The x-ray tube is 14 ft long
in this air-insulated system. The electron emitting filament is at
800-kV peak voltage, and the x-ray target is at ground potential.
An electrically biased control grid suppresses the electron beam
from the filament until the rectified ac applied anode voltage at
each cycle exceeds a critical value. This feature produces an x-
ray beam of effectively higher quality for a given rectified ac ap-
plied potential and simultaneously increases the radiation yield
per unit energy input to the tube. The production, measurement
and insulation requirements of orthovoltage equipment domi-
nated research in the 1920s and 1930s. Although dry air with-
stands uniform electric fields of 30 kV/cm (over short distances)
270 CHAPTER 16. OTHER TYPES OF MEDICAL ELECTRON ACCELERATORS
before breakdown, moist air suffers breakdown at substantially
lower fields and is a significant factor in the 14 ft length of the
unit illustrated in Figure 16-2. Here the average electric field is
about 2 kV1cm. Later units were oil insulated to provide stable
orthovoltage equipment of reduced size.
Orthovoltage therapy is less used today because of the
clinical limitations of such low energy radiation and the tech-
nical difficulties encountered in such equipment beyond 300
kV. Primarily, these difficulties concern the ability of tubes,
transformers, cables, and auxiliary apparatus to withstand such
high voltages in reasonably compact units. Such equipment is
heavy and bulky. It was these limitations that first gave rise to
the resonant transformer x-ray unit and the Van de Graaff
generator described in the following sections. A guide to the
development and literature of these early accelerators used in
medicine can be found in the review articles by Schulz (1975)31
and Trout (1958)34.
RESONANT TRANSFORMER
The resonant transformer unit, (Fig. 16-3) employs frequencies
of typically 180-1200 Hz, and electrical resonance to achieve
high voltages without the use of heavy, bulky iron transformer
cores. These higher frequency resonant systems are more effi-
cient than the 60-Hz transformer-rectifier units described ear-
lier and make effective use of the energy stored in the
capacitance and inductance of the system. Such units have been
constructed over a voltage range from about 300 kVp to 2 MVp.
Most have been employed for industrial radiography or elec-
tron processing, but a number of therapy units were built and
a few may be still in service.'
Compactness is achieved by placing the x-ray tube coaxi-
ally within the cylindrical secondary winding of the air core
transformer as shown in Figure 16-3 and using an insulating
'Earthed' Transformer Steel Tank
Transformer Electr0des Filament
Primary Heating Current
Winding Transformer
FIGURE 16-3 . Resonant transformer x-ray unit with major compo-
nents identified. (Courtesy of Year Book Medical Publishers, Funda-
tion. Physics of Radiology 3rd ed, 1977.)
gas, such as SF6, at high pressure or oil to hold off the voltage
in a steel tank. The secondary winding is divided into many
sections that are connected to intermediate electrodes along the
tube to focus the electron beam and provide a uniform voltage
gradient along its length so as to best ensure freedom from
electrical breakdown. A line-operated, motor-generator set
powers the primary winding at the resonant frequency. The
filament is energized by the end section of the secondary
winding. The end-grounded anode is conveniently water
cooled and functions as a reflection target except in the higher
energy radiographic units where both a conically shaped trans-
mitted x-ray lobe and a narrower reflected x-ray lobe extending
circurnferentially around the beam axis are provided. These
resonant transformers function as a half-wave, self-rectified
unit and have the problems attendant to high inverse voltage
during the unused half-cycle interval. Here, the significant
problem is thermionic electron emission from the beam-heated
target and acceleration of these electrons to the filament, darn-
aging it during this interval. Various feedback systems are
incorporated to stabilize the tube voltage, beam current, and
the driving frequency. Constructing the individual secondary
windings to resonate at the design frequency is a major techni-
cal problem. The size of resonant transformer units becomes
impractically large above 2 MeV. Earlier, Sloan33 had devel-
oped a 6 MHz rf 800-kV x-ray generator built around vacuum
tube oscillators and resonant circuits.
VAN DE GRAAFF GENERATOR
An alternative contemporary of the resonant transformer unit
was the Van de Graaff generator (sometimes called the electro-
static generator), which is shown in Figure 16-4.31.35-38 In it,
the voltage generator and accelerating tube are separate and
placed alongside one another. The voltage generator has a small
stored energy, a small beam emittance, and the voltage is easily
stabilized. The Van de Graaff is a constant potential electro-
static generator developed around the physical principle
illustrated by the classical Faraday "ice bucket" experiment.
The hemispherical high voltage terminal dome is analogous to
the "ice bucket." In the ice bucket experiment, electrons depos-
ited inside the electrically conducting metal bucket (presum-
ably used for canying ice in earlier days) quickly move to the
outside because of repulsive forces between like charges. This
process can continue until a specific potential is attained or
until there is coronal breakdown to the air outside the bucket.
The space inside the bucket is essentially a field-free region.
Figure 16-4 is a schematic diagram of a 2-MeV Van de
Graaff generator employed for x-ray therapy. The enclosing
steel tank is about 3 ft in diameter and 5.5 ft in height, excluding
the radiation head. Electrons are introduced by a high voltage
coronal discharge from an array of needles, ionizing the en-
closed insulating gas and spraying electrons onto an insulating
 BETATRON AND ELECTRON SYNCHROTRON
Hemispherical Compressed
High Voltage Insulating Gas
Terminal (N, and C02)
Charge Steel Tank
Resistors
Moving Rings
Fabric Belt
Carrying Cylindrical
Electrons Accelerating
Electrodes
Electron Beam
Spray
Voltage Multisection
(5 kV)
Water Cooled
Grounded Target
Collimating
Assembly
FIGURE 1 6 4 . Schematic diagram of Van de Graaff generator with
major components identified. (Courtesy of Charles Thomas, from Ref. 12.)
moving fabric belt. A metallic screen removes the electrons
from the belt, transferring them to the high voltage terminal
dome as shown in Figure 16-4. Again, a high gradient electro-
static field associated with points of the screen is employed to
ionize the gas, and in this case, remove electrons from the belt.
Additional charge may be transferred by connecting a voltage
source between the screen and the dome with appropriate
polarity so that the belt returns with a net positive charge further
lowering the terminal potential. The belt-driven, charge-trans-
fer system substitutes for the transformer-rectifier system
found in orthovoltage units. The terminal voltage attained, V,
is a function of the accumulated charge, Q, and the capacity, C,
of the hemispherical terminal such that V = Q/C.
The multisection accelerating column consists of stacked-
metal, washerlike focusing electrodes separated by insulators.
This structure, which is placed adjacent and parallel to the
moving belt, is vacuum-baked and sealed, and constitutes the
x-ray tube. A long resistor chain distributes the overall voltage
uniformly along the accelerating column. Maintenance prob-
lems are associated with deterioration of the belts and electrical
breakdown of the accelerating column and belt. Accessibility
to the equipment is limited by the need to discharge and store
the insulating gas at 13-atm pressure before removing and
storing the steel tank. Vacuum integrity of the accelerating
column may be impaired by this high external pressure. The
principles of the Van de Graaff and other low energy generators
has been reviewed by Livingston and Blewett.23
The Pelletron, in some ways a successor to the Van de
Graaff generator, incorporates a segmented moving belt called
a "charging chain."24 The chain consists of a sequence of
alternating conductor-insulator segments, which are found
more resistant to deterioration and electrical breakdown than
271
the conventional fabric belts. However, the Pelletron has not
yet been used for therapy machines.
High voltage vacuum breakdown continued to be an oper-
ational problem and limited the attainable energy in direct ac-
celerators. Cranbergg suggested that the initiation of high
voltage breakdown in vacuum is due to traversal of the high
voltage gap by a "clump" of loosely adhering material. Aclump
is charged up and is detached by electrostatic repulsion when
the field strength is sufficiently high. The clump, striking the
opposing electrode, releases more electrons and the process es-
calates into an arc. For uniform field gaps, the breakdown volt-
age was found proportional to the square root of the gap length,
or conversely, the necessary gap length was proportional to the
square of the voltage, thus placing a severe voltage limitation
on direct accelerators. The individual sections of the multisec-
tion accelerating column are chosen to have an energy gain of
about 0.3 MeV. Therefore, 33 sections would be required for a
10-MeV direct accelerator, which results in an impracticably
long accelerator for radiotherapy. It is interesting to speculate
that a long ion transit time compared to the rf period appears to
exempt pulsed electron linacs, with their high gradients, from
this clump problem. In dc machines there is time for a cascade
of electrons and ions to develop into an arc (like lightning).
BETATRON AND ELECTRON
SYNCHROTRON
An alternative to attaining high energies by a single accelera-
tion through a large potential difference is by multiple acceler-
ation through a small potential difference.lO~l2.15-19-21One,
thereby, eliminates the need for producing a high voltage and
applying it to a high vacuum accelerating tube. In the betatron,
electrons are constrained to rotate and gain energy in circular
orbits of nearly constant radius. The energy gain is by magnetic
induction resulting from the magnetic flux change in the area
inscribed by the circular orbit. For example, an electron gaining
100 eV per revolution in a 45-cm diameter orbit executes
250,000 revolutions and about 250 miles of travel to reach 25
MeV.
Early experiments based on these ideas were frustrated by
lack of understanding of the injection and focusing require-
ments necessary to capture and guide the electron beam
through these many revolutions and miles of travel. The cyclo-
tron principle, which was developed earlier for the acceleration
of protons and other heavy ions at relatively low velocities, is
not useful for accelerating electrons that quickly attain relativ-
istic velocity and then gain energy above about 1 MeV almost
entirely by an increase in mass. For example, the mass of a
10-MeVelectron is more than 20 times its rest mass, while that
of a 10 MeV proton is only 1.01 times its rest mass.
Figure 16-5 illustrates the principle of the betatron and
pertinent features of this accelerator. The electron beam circu-
272 CHAPTER 16. OTHER TYPES O F MEDICAL ELECTRON ACCELERATORS

Changing Flux

Electrons Doughnut
Spiralling \ 1

Injection 180

Spiralling In

Highly Collimated
X- Ray Beam
Magnetic
Lines of
Force
I I ,EkElo"
1
FIGURE 16-5 Diagrams illustrating the construction and operation of the betatron. (Courtesy of
Charles Thomas, from Ref. 12.) (a) A cross-sectional diagram showing the ac magnet, the poles, the
doughnut, and injector. (b) The paths of the electrons within the doughnut and the method of production
of the x-rays (c) How an electric field is produced by a changing magnetic flux. (d) The cycle of operation
of the betatron showing the time of injection and orbit expansion. (e) The operation of the electron
"peeler" for obtaining an electron beam. The sketch showing the magnetic lines of force is a cross-sec-
tional view of the "peeler" device taken at right angles to the diagram through the center of the "peeler."

lates in an evacuated "doughnut" around an equilibrium orbit Integrating this expression over the acceleration interval
of radius r,,. A stable orbit requires that the force due to the and combining with eq. (16-1)results in the betatron "2:1" rule.
magnetic field Bo, at the equilibrium orbit ro, balances the
centrifugal force such that
mo = 2 [ n r i ] ~ ~ (16-3)
Bo=-=- P
ero ero (16-1) Here, the total flux linking- the orbit must at all times be
twice that obtained if the field inside the orbit were uniform
Here, u is the velocity of the electron of charge e, m is its
and equal to the field over the orbit, B,,. The filament and
relativistic mass, and p is its momentum. The electron orbit in
injector assembly lie just outside the equilibrium orbit and
the betatron can be thought of as a many turn, lossless, second-
inject a small solid angle cone of electrons directed towards
ary winding of a transformer, (see Figure 16-5c) with the
the equilibrium orbit at the start of the cycle, time zero in
induced voltage V per turn proportional to the rate of flux
Figure 16-5d. In the absence of acceleration, an electron
change per turn over the area of iron core inside the orbit. In
injected into a magnetic field would fly back out of the
terms of the momentum p and flux c$
magnetic field, hitting the back of the injector if it survived
360". Thus, a major problem of the betatron is to capture a
significant percentage of the electrons from the injector. This
 BETATRON AND ELECTRON SYNCHROTRON
is accomplished by shaping the magnetic field at the orbit to
provide focusing forces and by accelerating the electrons. The
injected electrons describe a set of orbits, which initially fill
a large cross section of the doughnut. As they gain energy,
their orbits shrink away from the injector and their oscillations
about the equilibrium orbit damp down, asymptotically sta-
bilizing at high energy in a small beam diameter at the
equilibrium orbit. They can be deflected out of the equilibrium
orbit by pulsing a soft iron "peeler" at time C, when they
have reached maximum energy, or earlier at some lower
energy, such as at time B. For x-ray production, a tungsten
target is located on the back of the injector (see Fig. 16-5b).
To extract the electron beam, a small auxiliary coil, not shown
in the figure, bucks out a portion of the magnetic field, causing
the electrons to spiral outward and intercept the target. At a
representative betatron energy of 22 MeV, the production of
x rays is an efficient process, and cooling the target, for the
small beam current involved, does not constitute a problem.
For electron therapy, the x-ray target is avoided and the
electron beam is extracted by a magnetic shunt, the soft iron
"peeler", shown in Figure 16-5e. Here, the orbit expansion
directs the spiraling electrons into the field-free region of the
"peeler." The electrons continue in a line through the peeler
and emerge from a thin window into the treatment head of
the equipment. Some betatrons circulate electrons in one sense
for x-ray therapy and, using a separate injector, circulate
electrons in the opposite sense for electron therapy.
During the capture and acceleration process, the electrons
"hunt" with both a radial and transverse (perpendicular to the
plane of the orbit) oscillation about the equilibrium orbit. Some
of the electrons are lost from the beam because of gas scatter-
ing. By shaping the horizontal and vertical faces of the magnet
poles to have magnet n values different from each other but
near 0.7, appropriate magnetic radial and transverse weak
focusing forces are provided. This limits the amplitude of radial
and transverse oscillations, as well as avoiding resonant
buildup of such oscillations. The increase of longitudinal mo-
mentum due to acceleration in the orbit quickly damps the
amplitude of oscillation about the equilibrium orbit. An under-
standing of this damped focusing phenomenon led to the design
and construction of the original betatron by Kerst.17.19
Space charge effects during injection limit the maximum
circulating current that can be accepted from the injector and
accelerated to high energy. Pavlovskii et a1.25 show the relation-
ship of this circulating current limit to injection energy for
optimized injection conditions. At 200-kV injection energy, the
limit on circulating current is about 2.3 A. In an orbit of 50 cm
diameter, the electron charge is circulating 1.91 X 108 times
per second, and the limit of 2.3-A circulating current would
correspond to 1.2 X 10-8 A per pass. At 180-Hz magnet
excitation frequency, the limit on maximum beam that could
be available for direction onto an x-ray target would be 2.2 pA
average, 55 W at 25 MeV. This beam could generate an un-
flattened and unattenuated central axis x-ray intensity of 650
cGy/min at 1 m. Flattening to the comers over a 35 X 35-cm
273
field would reduce this x-ray intensity to about 90 radlmin at 1
m. Routine reliable operating levels would be significantly less
than this maximum limit. Also, commercial betatrons used
much lower injection voltages. For example, the ATC Model
25 RTM betatron is rated 140 cGy/min at 100 cm at 25 MeV,
unflattened x-ray intensity.3 The Brown Boveri Asklepitron 45
is rated 250 Wmin at 100 cm at 45 MeV unflattened, 80 Wmin
flattened to a 15 cm diameter x-ray field.5
This space-charge limitation on accepted and accelerated
circulating current explains why, in order to achieve desired
clinical dose rates, betatrons have traditionally been operated
in the x-ray mode primarily at high x-ray energies and with thin
flattening filters suitable for much smaller fields than 35 X 35
cm. The space-charge limitation could be relieved by increas-
ing the injection voltage. For example, the circulating current
could be increased by a factor of about 4 by doubling the
injection voltage. However, this would seriously complicate
the injector.
Betatrons capture and transport a smaller average beam
current than linacs and are most often used for electron therapy,
particularly at the lower energies, where their low beam current
combined with lower x-ray production efficiency result in
unacceptably low x-ray dose rates. At higher energies, x-ray
production is enhanced although a complex shaped flattening
filter is needed to provide adequately large flattened fields,
hence, with an attendant reduction in dose rate. Often, asym-
metries related to the orthogonal radial and transverse direc-
tions of the field along the beam axis necessitates a complex
flattening filter shape that is not circularly symmetric. A num-
ber of investigators have reported on various aspects of the
application of betatrons to x-ray and electron radiother-
apy.l.9.Il921,26,32
In addition to medical uses, betatrons have been
employed for industrial radiography and were used extensively
during World War 11to radiograph thick castings and sections.
The principles of betatron accelerators have been reviewed by
Humpherieslo and by Livingston and Blewett.23
To achieve energies above about 25 MeV, the size of the
requisite magnet becomes large and cumbersome. As an alter-
native, the stable orbit aspect of the betatron can be used to
confine the beam, and additional energy can be imparted with
a resonant cavity in a manner much as in the linac or microtron.
The cavity is inserted into the doughnut, converting the beta-
tron into a weak focusing electron synchrotron. The cavity is
energized only after the initial betatron acceleration phase
described above. At this time, the magnetic field at the orbit
continues to increase and functions only to confine the beam
to the equilibrium orbit. The central core saturates and does not
continue to impart energy by magnetic induction. Electron
synchrotrons for radiotherapy have not been popular because
of their complexity, expense, and the clinical disadvantages of
energies above 25 MeV. A 70-MeV synchrotron was developed
by the General Electric Company for radiotherapy.2 It was a
large bulky unit with limited maneuverability and is no longer
in service. The principles and technical features of the electron
synchrotron have been treated by Livingston and Blewett.23
274 CHAPTER 16. OTHER TYPES OF MEDICAL ELECTRON ACCELERATORS
REFERENCES
1. Adams GD, GM Almy, SM Dancoff, A 0 Hanson, DW Kerst,
HW Koch, EF Lanzl, LH Lanzl, JS Laughlin, H Quastler, DE
Riesen, CS Robinson, LS Skaggs: Techniques for Application
of the Betatron to Medical Therapy. Am J Roentgenol Radium
Ther Nucl Med 60.153-157,1948.
2. Adams GD: The Use of a 70 MeV Synchrotron for Cancer
Therapy. Radiology 83:785-796, 1964.
3. ATC Betatron Corp (Successor to Allis Chalmers Betatron
Dept.) Performance Specification Brochure 1474 10 M-8-4.
4. Birx DL: Magnetic compressors: high power pulse sources.
Energy and Technology Review. Lawrence Livermore National
Laboratory, August 1983, 11-19.
5. Brown Boveri Corp., Asklepitron 45, Publication No. CH-E
6.0039.0E.
6. Buschke F, S T Cantril, H M Parker: Supervoltage
roentgentherapy. Springfield IL, Charles C. Thomas, 1950, pp
1-21.
7. Charlton EE, WF Westendorp, LE Dempster, G Hotaling: A
New Million-Volt X-Ray Outfit. J Appl Phys 10:374-385,
1939.
8. Cranberg L: The Initiation of Electrical Breakdown in Vacuum.
JAppl Phys 23518-522,1952.
9. de Almeida CE, PR Almond: Comparison of Electron Beams
from the Siemens Betatron and the Sagittaire Linear Accelera-
tor. Radiology 111:439445, 1974.
10. Humphries S, Jr: Principles of charged particle acceleration.
New York, Wiley, 1986, pp 1-573.
11. Jacobson A, B Birkhead, RM Scott: Practical Aspects of Beta-
tron Electron Beam Dosimetry. Am J Roentgenol Radium Ther
Nucl Med 111:607-612,1971.
12. Johns HA, JR Cunningham: The physics of radiology. 3rd ed,
Charles Thomas, Springfield, IL, 1969, p 800.
13. Kapitza SP, VP Bykov, VN Melekhin: A High Current Microt-
ron. Soviet Physics JETP 1961; 12(4):693-695. Translated from
J Exp Theor Phys (USSR) 39:997-1000,1960.
14. Kapitza SP, VN Melekhin: The Microtron. English ed, Rowe
EM, (Ed), Harwood Academic Pub, London 1989, pp 204.
15. Kerst DW: The Acceleration of Electrons by Magnetic Induc-
tion. Phys Rev 60:47-53, 1941.
16. Kerst DW: A 20-Million Electron-Volt Betatron or Induction
Accelerator.Rev Sci Instr 13:387-394, 1942.
17. Kerst DW, R Serber: Electronic Orbits in the Induction Accel-
erator. Phys Rev 6053-58, 1941.
18. Kerst DW, LS Skaggs: Medical Physics. 0 Glasser (Ed). Chi-
cago, IL, The Year Book Publishers, Inc., 1950, vol2, p 1227.
19. Kerst DW: Initial development of the betatron. In Proceedings
of the Symposium on Electron Beam Therapy, Memorial Sloan-
Kettering Cancer Center; New York. F Chu, JS Laughlin, (Eds),
1979, pp 1-5.
20. Kulke B: Validation of the pulsed-power design for FXR. En-
ergy and Technology Review, Lawrence Livermore National
Laboratory, May 1981, pp 1-8.
21. Laughlin JS: Physical aspects of betatron therapy. Springfield,
IL, Charles C. Thomas, 1954, p 98.
22. Livingood JJ: Principles of cyclic particle accelerators. New
York, D Van Nostrand Co., 1961, p 392.
23. Livingston MS, JP Blewett: Particle accelerators. New York,
McGraw-Hill, 1962, pp 1-666.
24. Norton GA, ML Sundquist, RE Daniel, RD Rathmell: Progress
on the 20UR Pellatron at the Japan Atomic Energy Research
Institute. Nucl Instr Methods 184:107-1 11, 1981.
25. Pavlovskii AI, GD Kuleskov, A1 Gerasimov, VO Klementev,
VA Kuznetsov, AD Tarasov: Injection of an Electron Beam into
a Betatron. Sov Phys Tech Phys 22:218-219,1977.
26. Quastler H, GD Adams, GM Almy, SM Dancoff, A 0 Hanson,
DW Kerst, HW Koch, LH Lanzl, JS Laughlin, DE Riesen, CS,
Jr., Robinson, VT Austin, TG Kerley, EF Lanzl, GY McClure,
EA Thompson, LS Skaggs: Techniques for Application of the
Betatron to Medical Therapy. Am J Roentgenol Radium Ther
Nucl Med 61:591-625,1949.
27. Rand RE: Recirculating elecrron accelerators. New York, Har-
wood Academic Publ., 1984, pp 1-236.
28. Reistad D, A Brahme: The Microtron, A New Accelerator for
Radiation Therapy. Phys Med Biol17:692, 1972.
29. Rose JE, DH Loughridge: Cathode Bias for a Supervoltage
Tube. Radiology 27:656-662, 1936.
30. Schriber SO, EA Heighway: Double pass linear accelerator-
Reflexotron. IEEE Trans on Nuc Sci NS-22 Nov. 3,1060-1064,
1975.
31. Schulz MD: The Supervoltage Story. Am J Roentgenol Radium
Ther Nucl Med 124541-559,1975.
32. Skaggs LS, GM Almy, DW Kerst, LH Lanzl: Development of
the Betatron for Electron Therapy. Radiology 50:167-173,
1948.
33. Sloan DH: A Radiofrequency High-Voltage Generator. Phys
Rev 47:62-71, 1935.
33a. Thompson CC, MR Cleland: High-power Dynarnitron acceler-
ators for x-ray processing. Nucl Instr Methods Phys Res
B40/41:1137-1141, 1989.
34. Trout ED: History of Radiation Sources for Cancer Therapy, in
F Buschke (Ed), Progress in radiation therapy. New York,
Grune & Stratton, 1958, pp 42-61.
35. Trump JG, RJ Van de Graaff, RW Cloud: Cathode Rays for
Radiation Therapy. Am J Roentgenol Radium Ther Nucl Med
43:728-734, 1940.
36. Trump JG, RW Cloud: The Production and Characteristics of
3,000 Kilovolt Roentgen Rays Am 3 Roentgenol Radium Ther
Nucl Med 49531-538,1943.
37. Van Atta LC, RJ Van de Graaff: A New Design for a High-Volt-
age Discharge Tube. Phys Rev 43:158-159,1933.
38. Van de Graaff RJ, KT Compton, LC Van Atta: The Electrostatic
Production of High Voltage for Nuclear Investigations. Phys
Rev 43:149-157,1933.

Generation of Radiation Beams
X-RAY BEAMS
PHOTON SPECTRA ON THE AXIS OF AN
UNFLATTENED LOBE
In x-ray therapy mode the accelerated electrons are directed
onto a target. As each negatively charged electron passes near
the positively charged nucleus of an atom of the target, the
Coulomb attraction of these two charges causes the nucleus to
pull (i.e., accelerate) the electron away from its original path.
This acceleration transverse to the electron path causes the
electron to radiate an x-ray photon (in quantum mechanical
terms, a change of state). This radiative process is termed
bremsstrahlung, meaning braking radiation. At very low elec-
tron energies the emission distribution looks something like a
thick donut with its axis coinciding with the direction of the
electron. [This is the radiation pattern of a radio or television
dipole antenna from electron current oscillations (sinusoidal
accelerations) in the antenna.] At high energies, relativistic
effects fold the emission distribution into a single forward lobe.
The energy of the emitted photon is dependent on the energy
of the electron and how close its path is to the nucleus. The
radius of the nucleus is approximately 1.5A113 X 10-13 cm. It
is 8.5 X 10-13 cm for A = 184, the atomic weight of tungsten.
The radius of the volume per atom in tungsten is 0.93 X 10-8
cm, giving a ratio of cross-sectional areas of atom to nucleus
of about 108. Thus, the vast majority of electrons miss the
nucleus by a large margin, experience a small deflection, and
emit a relatively low energy photon. X-ray spectra have been
calculated and in several cases measured for various electron
beam energies and targets.3,17,30,32-43.48,49,51
The dose produced in tissue can be calculated from the
photon energy spectrum by,
Dose (cGy) = 1.6 X (PE8Xo ('4-1)
where is the photon fluence in photonsfper square centime-
ter, E8 is the photon energy in megaelectron volts, Xo is the
mass-energy absorption coefficient in square centimeters per
gram and 1.6 X 10-8 is a constant to convert megaelectron volts
per gram to centigray, as described by Ing et a1.25
A P P E N D I X * A
ANGULAR DISTRIBUTION OF PHOTON
INTENSITY
The intrinsic angular distribution of x-ray photons emitted by
electrons deflected by a nucleus is dependent on the electron
energy. At megavoltage energies it has approximately a Gauss-
ian distribution with root mean square (rms) angle from inci-
dent electron beam axis of approximately,
where E, is the rest energy of the electron (0.511 MeV), E is
the kinetic energy of the incident electron, and 0.26 is a constant
obtained experimentally by Nordell et al.41 at 50 MeV. For
example, the x-ray lobe produced by a 20-MeV electron on an
infinitesimally thin target would have an rms angle of 0.024 rad
(1.4') from the axis, corresponding to a full width at half-max-
imum (fwhm) of 5.8 cm at 100-cm SSD.
In a target of practical thickness, the incident electron un-
dergoes single and multiple scattering by the Coulomb force of
the nuclei (partially shielded by the field of the atomic electrons)
and gives up energy by ionization of atomic electrons as well as
by radiation. Thus, the mean energy of electrons in the bre'ms-
strahlung process is much less than the incident electron energy
and the spread in angles of these scattered electrons spreads the
x-ray lobe. Assuming a Gaussian distribution for the electron
scattering angle and a relatively thin layer of material, the rms
scattering angle from axis is given26 approximately by
where t is the thickness of a layer in the target, E is the electron
energy in that layer, and Xo is the radiation length of the target
material and Oms is in radians.26 The parameter Xo is the thick-
ness of material in which high energy electrons lose lfe = 37
percent of their energy by radiation, exclusive of ionization loss
(see Table A-1).
The rms scattering angle increases almost linearly with tll2
but reaches an equilibrium value of approximately 0.8 rad (45')
at large depths. At depths beyond M-M of the practical range,
276 APPENDIX A. GENERATION OF RADIATION BEAMS

TABLE A-1 . Calculated radiation lengths

Radiation Length Thickness to stop
Atomic Atomic Density (XO) 10 MeV electrons
number weight (8)
Substance (a (A) &lcm3 g/cm2 cm glcm2 cm

Air (20°C) 0.001205 36.61 30380 5.44 451 1

Water 1.00 36.08 36.08 4.8 4.8
Beryllium 4 9.01 1.80 65.19 36.22 5.89 3.27
Carbon 6 12.01 1.88 42.70 22.71 5.34 2.84
Aluminum 13 26.98 2.70 24.01 8.89 5.89 2.18
Titanium 22 47.90 4.50 16.17 3.59
Iron 26 55.85 7.86 13.84 1.76
Nickel 28 58.71 8.90 12.70 1.43
Copper 29 63.54 8.94 12.86 1.44
Molybdenum 42 95.94 10.20 9.803 0.961
Silver 47 107.87 10.50 8.98 0.855
Tin 50 118.69 5.75 8.78 1.53
Tantalum 73 180.95 16.60 6.86 0.413
Tungsten 74 183.85 19.30 6.763 0.350
Platinum 78 195.09 21.37 6.56 0.307
Gold 79 196.97 19.32 6.47 0.335
Mercury 80 200.59 13.55 6.43 0.475
Lead 82 207.19 11.35 6.369 0.561
Uranium 92 238.03 18.68 5.999 0.321

Source: Reference 29.

the electrons reach a state of full diffusion where the rms width
of the angular distribution no longer increases.
Figure A-1 shows the angular distribution of the un-
flattened x-ray lobe for high Z targets of about 0.5 radiation
length thickness based on measurements by Lanz et al.33 at 17
MeV on gold targets and by Brynjolfsson et a1.16 at 8, 10, 12,
and 20 MeV on tungsten targets. Measurements at 25 MeV on
fully stopping targets by Hutcheon et al.23 are shown at 14" in
Figure A-1 for tantalum, copper, aluminum, and carbon, and
for a composite target of 0.3 radiation length tungsten backed
by about 0.5 radiation length aluminum.

CHOICE OF TARGET MATERIAL AND

THICKNESS
In radiotherapy machines, the x-ray treatment field is flattened
over a diameter of typically 5 0 cm at 100-cm SSD, correspond-
ing to an angle of 14" from the axis. This provides 35 X 35-cm
fields with square comers and typically 40 X 40-cm maximum
size fields with each corner clipped by 3.3 cm on the diagonal. l o t MeV x Degrees X-Ray Beam Energy x Angle
Since the rest of the field is flattened at a 10 cm depth in a
phantom to the dose at 14", and since there is limited filtration
in the flattening filter at this angle, the target material and
thickness can be chosen to maximize dose rate and mean FIGURE A-1 Calculated angular distribution of x-ray lobe. Relative
dose rate versus MeV degrees. Target material and thickness in radia-
photon energy at 14". Maximum dose rate at 14" is obtained tion lengths: (a) Au, 1.22; (b) Cu, 0.50; (c) Au, 0.16; (d) Au, 0.04; (e) Au
with less than 1 radiation length for all materials and for such or Be, 0.009; (A) Ta; (B) Cu; (C) W-AI; (D) Al; (E) C. (a)-(e) are from
lengths the mean photon energy and half-value layer in water data at low to medium energies. (A)-(E) are from 25 MV data.
 X-RAY BEAMS 277

at 14" are highest with high Ztarget material. Figure A-2 shows
the dose rate at 0" per pA of electron beam current versus beam
energy for ( a )fully stopping and ( b )optimum thickness tanta-
lum targets. Multiplying by the curves of Figure A-1, the dose
rate at 14"IpA on tantalum is shown in Figure A-3 for ( a )fully
stopping and ( b )for optimum thickness target. This shows that
the dose rate at 14" and, hence, the flattened dose rate, is nearly
independent of the thickness of the high Z target from 0.2 to
1.0 times the electron range. This is confirmed at high energy
by comparing the results of Lanzl et al.33 Figure A-4 shows the
total length along the electron path in various materials to fully
stop incident electrons versus their incident energy. This is
based on the tables in ICRU27 Report No. 37 and NBS39
Circular 577. Because inelastic scattering of electrons in-
creases markedly with increase in Z, the electron path is highly
jagged in tungsten. Fig. A-5 shows that about 75% of the
incident energy of a 4 MeV electron is deposited in a thickness

X-Ray Energy MeV

FIGURE A-3 . X-ray dose rate versus electron energy (a) at 14' with
fully stopping tantalum target (b) at 14' for optimum thickness tanta-
lum target (0.14 range).

X-Ray Energy MeV

FIGURE A-2 . X-ray dose rate versus electron energy (from Ref. 41).
(a) At 0" with fully stopping tantalum target. (b) At 0" for optimum -
FIGURE A-4 Fully stopping distance along electron path versus inci-
thickness tantalum target (0.14 range). dent electron energy. (a) Water, (b) Al, (c) Cu, and (d) W.
278 APPENDIX A. GENERATION OF RADIATION BEAMS

50 - -
MeV X-Ray Energy

401 1 A 5; A l b 1'5 2b 3b i0i060

FIGURE A-5 . Monte Carlo calculated paths in 0.76 mm tungsten
backed by 0.152 mm copper for 4 MeV incident electron beam from FIGURE A d Perrentage depth dose at 10 cm depth versus electron en-
Iinac. Solid jagged lines are electron paths. Dotted lines are energy d e p e ergy at x-ray target for 10 X 10-cm field at 1 W m SSD (from Ref. 34).
sition by x-rays produced in the metals. (From Varian).

of tungsten corresponding to only one-third of the total electron

path length given by Fig A-4.
Practical targets in medical electron accelerators are typi-
cally made of two layers. The first layer is a high Z material. It
is thick enough to provide a broad x-ray lobe without attenuat-
ing the mean photon energy. The second layer is of a lower Z
material such as copper or aluminum to stop the electrons and
to harden the x-ray spectrum over the full x-ray lobe.
(Taumannw used three layers: W, C, and Al.)

I MeV X-Ray Energy 1

CHOICE OF MATERIALS AND THEIR
DISTRIBUTION IN THE X-RAY
FLATTENING FILTER
X-ray scattering in the phantom makes a greater contribution
to total dose at the center of the field than near its edges, since
x-ray scatter contributes to the center from all directions but to
the edges only from inside the field. Since the scatter is pre-
dominantly forward, it causes the depth dose distributionto fall
off more slowly with depth at the center than near the edges of
the field. In addition, the mean energy of x-rays emitted from
the target decreases with angle from the axis. Assuming a field
flattened at 10 cm depth, these two effects cause the dose near
the field edge and comer to be high (sometimes termed
"horns") at Dm,,(the depth of dose maximum) and low at
depths significantly beyond 10 cm (convex isodose lines)
relative to the dose on the axis at the same depth. By choice of
material the x-ray spectrum can be hardened through one part
of the flattening filter and softened through another part.
Because of their smaller value of Dm,,,low x-ray energies
are often used to treat the lymphatics, since they extend to be
near the patient surface in some anatomical locations.The fields
can be quite large, as in mantle treatments. The variation in
mean energy with angle of the unflattened x-ray lobe is quite
small at low x-ray energies. A high Z target of sufficient thick-
ness to stop the incident electrons is normally used, maximizing
the x-ray lobe width and providing some filtration of lowest en-
-
FIGURE A-7 Depth to dose maximum versus electron energy at x-
ray target for 10 X 10-cm field at 100-cm SSD (from Ref 34).
ergy photons. The flattening filter is usually made of high Zma-
terial, with some thickness even at the edges of the field in order
to provide further filtration and to minimize the ratio of mean
photon energies at the center andedge of the flattened field. This
limits the magnitude of "horns", as described by Hansen et a1.21
By convention, accelerator x-ray beams have been character-
ized by the percentage depth dose at 10 cm depth and by the
depth to the dose maximum, both for 10 X 10-cm field size at
100-cm SSD. Figures A-6 and A-7 show these parameters as a
function of electron beam energy at the x-ray target for one
manufacturer's line ofmachine types, as measuredby LaRiviere.34
ELECTRON BEAMS
SPURIOUS SOURCES
Ideally, one would like to have the electrons all leave from a sin-
gle source point, all with the same energy, distributed almost
uniformly in angle, travel in straight lines from the source point
 RADIATION INTERACTIONS IN THE PATIENT 279

to the patient surface, and have sharp fall-off of flux at the field
edges. In practice, the electrons have a distributed virtual source
and do not travel in straight lines. This is due to the different po-
sitions of the electron beam window, multiple scattering foils or
scanning magnet, ionization chamber electrodes, light beam
mirror (if used), about 1 m of air, earth's and stray magnetic
fields, and due to scattering from outside the field back into the
field from the primary collimator, x-ray beam limiting device,
electron applicator, and air. All of this scattering results in a
multisource diffuse beam, with field edges becoming rounded
with distance from the applicator and with depth dose distribu-
tion being degraded by the electron rays arriving at any phantom
surface point over a spread in angle and energy.
Since the rms scattering angle is inversely proportional to
energy, scattering in air becomes a significant factor at low en-
ergies. For example, it produces a 20-cm rms spread of a 6-MeV
electron ray at lOOcm SSD, with the beam appearing to origi-
nate at 50 cm instead of 100 cm from the phantom surface. A
magnetic field of 1 G (comparable to the earth's field) over a 1-
m air path will bend a 6-MeV beam through an angle such as to
shift the rays by about 2.3 mm at 100-cm SSD, 5.2 mm at 150-
cm SSD. Primarily because of scatter, the isodose distribution
near the edges of the field in the phantom changes rapidly with
the distance of the electron applicator from the phantom sur-
face. This can be an important factor in anatomical regions such
as the chin-neck, where the distance from the applicator to the
Centimeters Depth
patient surface can vary by several centimeters.
FIGURE A-8 Comparison of electron depth dose curves from linac
SCATTERING FOILS and microtron (from Ref. 42).

The required total thickness t of thin electron scattering foils for

a given field size is approximately proportional to EZ, based on
eq. (A-3). The x-ray intensity at ' 0 due to the foil is approxi-
mately proportional to F.7t, hence to E4:7. X-ray contamination
of the electron beam precludes using foil scatterers for full-size
fields at electron energies above about 25 MeV. Scattering foils
were used in betatrons at electron energies up to 42 MeV, but at a
limited maximum field size. A scanning or defocusing magnet
has typically been used to provide large field sizes with linacs
capable of more than 25 MeV.2.22.50 Brahme et a1.10 proposed
scanning magnets for a 50-MeV microtron. X-ray contamina-
tion of less than 6 percent can be obtained using scattering foils
at energies to 25 MeV and fields to 25 X 25 cm, so such foils are
commonly used to avoid complexity.
In order to minimize total scattering foil thickness, the use
of two separated foils was developed for betatron beams. 19.31.52
A Gaussian distribution of intensity is produced by scattering
in the first foil. A second foil, a few centimeters from the first
foil, rescatters the central portion of this Gaussian distribution
to flatten the profile. Further improvements in dose distribution
were obtained by shaping the thickness contour of the second
foi1.5,7,8-11.13.47.s3This technique with shaped second foil was
developed independently by Bjarngard et al.4 Tauman45 also
shows the improvement in dose profiles obtained using a
shaped second foil technique.
EFFECT OF ENERGY SPECTRUM WIDTH ON
THE SLOPE OF DEPTH DOSE CURVE
The energy spectrum of the electron beam in a properly designed
multienergy linac can be quite narrow at each nominal energy
(e.g., 2.7 percent fwhm at 6 and at 18 MeV). This can be achieved
in an SW accelerator guide by employing a microwave switch to
maintain proper accelerating field in the early part of the acceler-
ator guide to achieve good beam bunching and phase position, and
reducing the accelerating field in the later part of the guide.
Although microtrons can produce a still narrower energy spec-
trum, it is not clinically significant.For example,Figure A-8 shows
that the depth to the clinically important 90 or 85 or 80 percent
depth dose is the same within 2 mm for the linac and the microtron
when their depth dose curves are selected to have the same depth at
20 percent depth dose. (For further discussion see Ref. 1,6,9,12.)
RADIATION INTERACTIONS IN THE
PATIENT
When megavoltage x-ray photons penetrate tissue they eject
electrons from atoms of the tissue primarily by Compton inter-
action (but also by photoelectric effect and electron-positron
280 APPENDIX A. GENERATION OF RADIATION BEAMS

pair production). Some of the photon energy is transferred to
the electron, which travels a short distance, of the order of a
few millimeters,ejecting electrons from additionalatoms of the
tissue, leaving them ionized. These ions are produced at inter-
vals of about 10-5 cm (, 50 times the 20-A spacing of the two
strands of the DNA double helix in the tissue cell nucleus).
These ions recombine in about 10-13 s, releasing energy, which
goes into the production of highly reactive chemical species,
such as the OH* radical. These chemicals can attack the DNA
and other critical structures of the cell nucleus.
The chemical process is enhanced by the presence of free
oxygen, which can diffuse through a fraction of a millimeter
from the blood capillaries in tumor or normal tissue. If not
repaired (e.g., enzymatically), the chemical damage can inter-
fere with subsequent cell reproduction, hence sterilizing the
cell. Note that only sterilization is required, not immediate
killing of the cell. Depending on the cell doubling time, it may
take many days or weeks for defective daughter cells to be
expressed and then cleared, such as by phagocytosis, resulting
in observable regression of tumor size.
In x-ray therapy, the energetic but short-range electrons
originate throughout the depth of tissue traversed by the x rays.
The mean photon energy of a 6-MV x-ray spectrum from a
thick high Z target after filtration by the flattening filter is
approximately 2.5 MeV at isocenter. From Figure A-9, essen-
tially all of the interactions of 2.5-MeV photons in a low Z
material, such as water or tissue, are Compton scattering events
and on average 56 percent (1.4 MeV) of the incident photon

100
MeV
Photon Energy -+

FIGURE A-9 . Cross sections per electron in aluminum and lead versus incident photon energy for photoabsorbtion, Compton scattering
and pair production. The energy absorbtion curve expresses the probability of transfer of energy from a photon to an electron by the Comp-
ton process (from Ref. 44).
 REFERENCES 281

TABLE A-2 . Energy of scattered photons versus their Compton in addition to those mentioned in the preceding sections of
scatter angle for various incident photon energies? this appendix. For convenience some of the more frequently
used information is excerpted, sometimes in abbreviated
Angle of Source energy, MeV
scattering 0 0.5 1.25 3.0 6.0 form, and presented here (e.g., Fig. A-11 and Tables A-l-
(de~es) Energy of scattered radiation MeV A-7). The depth dose values listed in Table A-4, extracted
from Ref. 14 and 15, have been found by La Rivieress to
be erratic when plotted versus rated machine x-ray energy.
The percentage depth dose on beam axis at 1 0 c m depth for
10 X 10-cm field at 100-cm SSD was found by La Riviere35
to form a smooth plot against dose weighted average energy
of the flattened beam photon spectrum (see Fig. A-10).

REFERENCES

1. Atherton L, FJ Coleman: Depth absorbed dose distributions for

"The Compton electron carries the difference energy at an angle corresponding
to equal but opposite transverse momentum.
Soume: From Ref. 44.
energy is transferred to an electron, 44 percent (1.1 MeV)
remaining in the scattered photon. From Table A-2 the mean
photon scatter angle is about 40". For equal and opposite
transverse momentum, the electron trajectory is at about 30°,
with a transverse range of about 3 mrn.
In electron therapy, more energetic, much longer range
electrons are delivered externally to the patient and produce a
shower of shorter range electrons in the tissue by ionization.
Subsequent interaction with the cell nucleus is similar to that
described above for x rays.
electrons. Phys Med Biol20:658-661, 1975.
2. AucouturierJ, HHuber, J Jaouen: Rev Tech Thomson-CSF2:655,
1970.
3. Berger MJ, SM Seltzer: Bremsstrahlung and photoneutrons from
thick tungsten and tantalum targets. Phys Rev C2:621431,1970.
4. Bjarngard BE, RW Pointek. GK Svensson: Electron scattering
and collimation system for a 12MeV linear accelerator.Med Phys
3:153-158, 1976.
5. Brahme A: Design principles of therapeutic electron andphoton
beams, in KR Das (Ed): Proceedings of the Workshop Bombay.
Bombay, India, Assn. Med. Phys., Dec. 3-8, 1982, pp 263-314.
6. Brahme A: Microtrons: development,principles and application
in radiation therapy, in KR Das (Ed): Proceedings of the Work-
shop Bombay. Bombay, India, Assn. Med. Phys., Dec. 3-8,1982,
pp 1-25.
7. Brahme A: Electron transport phenomena and absorbed dose
distributions in therapeutic electron beams: Livro de Resumos,
Abstract No. S 0348. Rio de Janeiro, Fourteenth International
Congress on Radiology, 1977, p 198.
8. Brahme A: On the optimal choice of scattering foils for electron
therapy. TRITA-EPP-72-17.Stockholm, Royal Institute of Tech-
nology, 1971.
9. Brahme A, G Hulten, H Svensson: Electron depth absorbed dose
distribution for a 10 MeV clinical microtron. Phys Med Biol
20:3946, 1975.
TABLE A-3 . Tenth-value layer (TVL) in g/cm2 suggested for
shieldingagainst scattered photons assuming each scattering angle
is about 908 or more
After 1 After 2 or More
Shielding material scattering Scatterings

Ordinary concrete (2.35g/cm3) 37 21

ADDITIONAL MATERIAL FOR Barytes concrete 29
RADIATION CALCULATIONS Iron (steel) 38
Lead glass 23
Lead 17 3.4
There are a number of publications, 24.29,37,38,40,44,46,56 which
contain information frequently used in radiation calculations, Source: Reference 24, Table XL.
 Dose Weighted Average Energy Ed(MeV)

.
FIGURE A-10 Depth dose at 10 cm depth in water versus dose weighted average photon energy of the x-ray spectrum for medical ac-
celerator x-ray energies from 4 to 24 MeV with target materials as noted. The notation, e.g., 15/W, denotes a 15 MeV electron beam on a
tungsten target. A 10 X 10-cm field at 100-cm source-surface distance (from Ref. 35).

TABLE A-4 Percentage depth dose."

Depth Energy Ob
(cm) 60~o 4 6* 6 8 10 16 21 25 30-
43

"A 10 X 10-cm field, 100-m SSD.

b ~ lcolumns
l are from Ref. 13b except column 6*, which is from Ref. 14 for a machine designated Clinac 6X.
 REFERENCES 283

TABLE A-5 . Electron physics table 13. Brahme A, H Svensson: Radiation beam characteristics of a 22
MeV microtron. Acta Radiol Oncol18:244-272, 1979.
Energy, Rigidity, Momentum, Velocity, 14. British Journal of Radiology Suppl. No. 11: Central axis depth
v HP P* P dose data for use in radiotherapy. British Institute of Radiology,
(MeV) (Oe cm) (Units of moc) (Units of c) 1972.
15. British Journal of Radiology Suppl. No. 17: Central axis depth
dose data for use in radiotherapy. British Institute of Radiology,
1983.
16. Brynjolfsson A, TG Martin 111: Bremsstrahlung production and
shielding of static and linear electron accelerators below 50 MeV,
Toxic gas production, required exhaust rates and radiation pro-
tection instrumentation. Int JAppl Rad Isotopes 22:29-40, 1971.
17. Calzado A, E Vano, V Delgado, L Gonzalez: 42 MeV bremsstrah-
lung spectrum analysis by a photoactivation method. Nucl Instru
Meth Phys Res 225232-239, 1984.
18. Chan KCD, MA Lone, SE Adams, PY Wong: Bremsstrahlung
and photoneutron yields from 5-25 MeV electrons on thin slabs
of Al, Fe, Cu and Pb. Eighth Conference on Applications of
Accelerators in Research and Industry. Poster Session P 2.26.
Denton, TX, Nov. 1984, pp 12-14.
19. Cova PL, G Botti, G Tosi: Strahlentherapi 133:7-12, 1967.
20. George RE, M Hartson-Eaton: Characteristics of an MM22 med-
ical microtron 21 MV photon beam: Int J Radiation Oncol Biol
Phys 11:1221-1224,1985.
21. Hansen HH, WG Connor, K Doppke, MML Boone: A new field
flattening filter for the Clinac-4. Radiology 1 0 3 : 4 4 3 4 6 , 1972.
22. Hsieh CL, EM Uhlmann: Radiology 67:263-272, 1956.
23. Hutcheon RM, SO Schriber, LW Funk, NH Sherman: Choosing
a therapy electron accelerator target. MedPhys 6:211-215,1979.
24. IAEA Technical Report Series No. 188: Biological safety aspects
of the operation of electron linear accelerators. IAEA, Vienna,
1979.
25. Ing H, WR Nelson, RA Shore: Unwanted photon and neutron
radiation resulting from collimated photon beams interacting with
the body of radiotherapy patients. Med Phys 9:27-33, 1982.
26. ICRU Report No. 35: Radiation dosimetry: Electron beams with
energies between I and 50 MeV. International Committee on
Radiation Units and Measurements, Bethesda, MD 208 14; 1984,
~ ~ 1 9 .
27. ICRU Report No 37: Stopping powers for electrons and posi-
trons. International Commission on Radiation Units and Mea-
surements, Bethesda, MD 20814, Oct. 1984.
28. Johnsen SW, PD La Rivere, E Tanabe: Electron depth-dose
dependence on energy spectral quality. Phys Med Biol28:1401-
1407,1983.
29. Knasel TM: Accurate calculation of radiation lengths: Labora-
tory for Nuclear Science; Massachusetts Institute of Technology;
Source: Reference 37. Cambridge, MA, 1965, pp 1-4.
30. Koch HW, JW Motz: Bremsstrahlung cross-section formulas and
related data. Rev Mod Phys 31:920-955, 1959.
10. Brahme A,TKraepelien, H Svensson: Electron and photon beams 31. Kozlov AP, VA Shishov: Forming of electron beams from a
from a 50 MeV racetrack microtron. Acta Radiol Oncol 19:305- betatron by foil scatterers. Acta Radiol Ther Phys Biol 15:493-
319,1980. 512,1976.
11. Brahme A, H Svensson: Digest 4th Int Conf Med Phys Canada, 32. Lambert RP, JW Jury, NK Sherman: Measurement ofbremsstrah-
32:283, 1976. lung spectra from 25 MeV electrons on Ta as a function of radiator
12. Brahme A, H Svensson: Electron beam quality parameters and thickness and emission angle. Nucl Instr Meth 214:349-360,
absorbed dose distributions from therapy accelerators, in A 1983.
Zuppinger, JP Bataini, JM Iragaray, F Chu, (Eds): High energy 33. Lanzl LH, A 0 Hanson: Z dependence and angular distribution of
electrons in radiation therapy. Berlin, Springer-Verlag, 1980, pp bremsstrahlung from 17 MeV electrons. Phys Rev 83:959-974,
12-19. 1951.
284 APPENDIX A. GENERATION OF RADIATION BEAMS

TABLE A d . Thickness (in.) of various parts of the human bodya

Adults 18 years and over

Children Females Males

17 years
Body part and under Small Medium Large Small Medium Large

Weightlheight ratio range

Antenor-
Posterior
Measurements
Head
Neck
Thorax-chest
Upper abdomen
Lower abdomen
Upper extremity
Upper arm
Elbow
Forearm
Wrist
Hand
Lower extremity
Thigh
Knee
Calf
Ankle
Foot

Lateral
Measurments
Head
Neck
Thorax-chest
Upper abdomen
Lower abdomen
Upper extremity
Upper arm
Elbow
Forearm
Wrist
Hand
Lower extremity
Thigh
Knee
Calf
Ankle
Foot

aAnthropometric Data, Composite, Body Part Thickness (in.), weight in pounds.

Source: From Ref. 46, Epithet 26.
 REFERENCES 285

TABLE A-7 . Thresholds for radiation damage to selected 34. La Riviere PD: Varian Report 2212A, March 22, 1985.
materials and systems 35. La Rivere PD: The quality of high energy x-ray beams. Br J
Radiol 62,473-481, 1989.
X-ray and electron 36. McCall RC, RD McIntyre, WG Turnbull: Improvement of linear
Material absorbed dose, cGy accelerator depth dose curves. Med Phys 5518-524, 1978.
37. National Bureau of Standards Circular 571: Electron physics
Transistor tables. US Gov printing office, March 30, 1956.
Potentiometer 38. National Bureau of Standards Circular 583: X-ray attenuation
Resistor coefficients from 10 keV to 100 keV. Issued April 30, 1957.
Diode 39. National Bureau of Standards Circular 577: Energy loss and range
Microcircuit of electrons and positrons. Issued July 26, 1956.
Glass changes color 40. NCRP Report No. 51: Radiation protection guidelines for 0.1-
Plastics lose tensile strength 100 MeV particle accelerator facilities. March 1, 1977.
Natural rubber loses elasticity 41. Nordell B, A Brahme: Angular distribution and yield from brems-
Polymers and oils unusable strahlung targets. Phys Med Biol29:797-810, 1984.
42. Nunan C: Design and performance criteria for medical electron
Disinfestation accelerators. Nucl Instr Methods Phys Res B10111, 881-887,
Pasteurization 1985.
Sterilization 43. O'Dell AA Jr, CW Sandifer, RB Knowlen, WD George: Mea-
surement of absolute thick-target bremsstrahlung spectra. Nucl
Source: Reference 40, Table B-4. Instr Meth 61:34&346, 1968.
44. Price BT, CC Horton, KT Spinney: Radiation shielding. New
York, Pergamon Press, 1957.
45. Podgorsak EB, JA Rawlinson, MI Glavinovic, HE Johns: Design
of x-ray targets for high energy linear accelerators in radiother-
apy. Aln J Roentgen01 1212373-882, 1974.
46. Public Health Service Publication No. 1519: Population exposure
to x-rays. U.S., 1970. DHEW Publication (FDA) 73-8047, No-
vember 1973.
47. Sandberg G: Electron beam flattening with an annular scattering
foil. IEEE NS-20 No. 3: 1025-1026, 1973.
48. Sandifer CW, M Taherzadeh: NaI spectrometer measurement of
thick-target bremsstrahlung at electron energies above 5 MeV.
AEC Contract (29-1)-1183. EG&G, Inc., 130 Robin Hill Rd.,
Goleta, CA, 1968.
49. Sherman NK, KH Lokan, RM Hutcheon, LW Funk, WR Brown,
P Brown: Bremsstrahlung radiators and beam filters for 25 MeV
cancer therapy. Med Phys 1: 185-192, 1974.
50. Shigematsu Y, A Hayami: Strahlentherapie 138:645-650, 1969.
51. Starfelt N, HW Koch: Differential cross-section measurements of
thin target bremsstrahlung produced by 2.7 to 9.7 MeV electrons.
Phys Rev 102:1598-1612,1956.
52. Svensson H: Influence of scattering foils, transmission monitors,
and collimating system on the absorbed dose distribution from 10
to 35 MeV electron radiation. Acta Radiol Ther Phys Biol10:443-
453,1971.
53. Svensson H, A Brahme: Electron beam parameters. Proceedings
AAPM Summer School. Burlington, MA, 1976.
54. Taumann L: Design criteria for x-ray beam exits on high energy
medical accelerators to minimize neutron production. Nut Bur
MeV Photon Energy Stand Rep NBS SP 554:139-144,1979.
55. Taumann L: The treatment head design of medical linear accel-
FIGURE A-11 . Photons/per square centimeter versus photon energy erators. IEEENS-28 No. 2:1895-1898, 1981.
to produce one centigray absorbed dose in water (derived from Ref. 56, 56. U.S. Dept. Health, Education and Welfare, Bureau of Radiolog-
correcting from roentgen to centigray). ical Health: Radiological health handbook. January, 1970, p 132.

Survey of Medical Linacs
HISTORICAL SUMMARY OF
MANUFACTURERS' TYPES
Over the past 35 years approximately 14 manufacturers have
produced isocentric microwave linacs for radiotherapy. Table
B-1 lists their machine models by year of introduction and
presents several major machine characteristics. Some of the
manufacturers' names have changed over this period, through
corporate acquisitions, and so on. The genealogy of these
names is listed as a note to Table B-1.
The numbers of various types of machines and facilities
stated below are estimates based on extrapolation from the fol-
lowing references: Hanson? IAEA,6 Patterns of Care Study
pr0grams.3~498There were 1144 radiotherapy facilities in the
United States in 1986 treating about 450,000 new patients per
year. These facilities employed approximately 700 60Co ma-
chines, 45 betatrons, 18 Van de Graaff accelerators,and approx-
imately 1200 microwave linacs, a total of nearly 2000
megavoltage treatment units. Essentially all of these facilities
had computerized treatment planning capability and over 80
percent had simulationcapabilities.
In the rest of the world, outside the United States, in 1986
there were about 1700 60C0 machines, 175 betatrons, 6 Van de
Graaff accelerators, and approximately 1000 microwave lin-
acs, a total of nearly 3000 megavoltage treatment units. Some
portions of the world have been slower than the United States
in replacing 60C0 machines with linacs. One reason may be the
more sophisticated national technological infrastructure
needed to maintain highly reliable operation of linacs distrib-
uted geographically throughout such regions.
CONTEMPORARY RADIOTHERAPY
ACCELERATORS
Tables B-2 and B-3 summarize some of the characteristics of
more modem single and dual x-ray energy radiotherapy linacs.
There are many additional specifications that are important in
comparing machine types. For example, the clearance from
A P P E N D I X - B
isocenter to the nearest accessory for x-ray mode, such as the
shadow tray mount, can affect convenience of patient setup.
There has also been a move to computerization of radiotherapy
accelerators but summarizing such features, their safety, and
their convenience is beyond the scope of this appendix.
Almond1 discusses considerations in selecting a machine
for purchase. The standardizedtable for functionalperformance
specifications developed by IEC7 should also prove useful in
comparing various machine types to determine suitability for
the clinical needs of the intended radiotherapy facility. An ab-
breviated version of this IEC table is presented in Table B-4. Al-
mond2 describes parameters for characterizingelectron treatment
beams and summarizesthe electron beamcharacteristics of sev-
eral machine types. Advances in the quality of electron treat-
ment beams have been made since that time and current depth
dose and isodose data shouldbe obtained for machine types now
being manufactured when selecting a machine for purchase.
REFERENCES
1. Almond PR: Considerations in the selection of a radiotherapy accel-
erator. IEEE Trans on Nucl Sci NS-28 No. 2:1933-1936,1981.
2. Almond PR: Characteristics of current medical electron accel-
erator beams. Proceedings of the Symposium on Electron Beam
Radiotherapy, 1979, pp 43-53.
3. Diamond JJ, GE Hanks, S Kramer: The structure of radiation
oncology practices in the continental United States. Int J Radi
Oncol Biol Phys 14547-548, 1988.
4. Hanks GE, S Kramer: The Patterns of Care Study. App Radio1
MayNune:69-75,1983.
5. Hanson W E The changing role of accelerators in radiation ther-
apy. IEEE Trans on Nucl Sci NS-30 No. 2: 1781-1783, 1983.
6. IAEA: Directory of high-energy radiotherapy centers. Interna-
tional Atomic Energy Agency, Vienna, 1976.
7. IEC Publication 977: Medical electrical equipment. Medical elec-
tron accelerators in the range 1 MeV to 50 MeV---Guidelines for
functional performance characteristics, 1989.
8. Kramer S, GE Hanks, DF Herring, LW Davis: Summary results
from the facilities master list surveys conducted by the Patterns
of Care Study. Int J Rad Oncol Biol Phys 8:883-888, 1982.
TABLE B-1 . Isocentric microwave electron linacs
~anufactud~
X-ray MV Elect. MeV Gantry Type Floor-Iso X Fielda f end^ Guide vpd Kly/Magnd
Model Yeaf (cGy/min) Foil/Scan SAW Head-Isoe DiagonaP Magnet Guide Lengtha MW

Mullard Double 240"

100
Met. Vick Single 240"
Orthotron 100
Mullard Double 240"
SL 48 100
Varian 8 Single 360"
Clinac 6 100
Vickers Single 240"
? 100

MEL 4-10 Drum 360"

SL75/10 Foil 100
U.S.S.R. Single 240"
LUE 5 100
CSF 7-32(40) Separate 2 10"
Sagittaire Scan 105
Toshiba 8-12 Single 360"
LME 13 Foil 100
Varian 360"
Clinac 4 80

Applied RAD 360"

Mevatron VI 69 100
Applied RAD 5-1 1 360"
Mevatron XI1 69 100
Mitsubishi 8-15 360"
ML-15 MIIB 70 Foil 100
Varian 7-28 360"
Clinac 35 70 Foil 100
RDL 360"
Dynaray 4 70 100

CGR (AECL)
Neptune
Therac (6) 71
RDL 3-10 360"
Dynaray 10 72 Foil 100
Toshiba 360"
LMR 4 72 100
Toshiba - 10-16 360"
LMR 15 72 Foil 110
SHM 360"
Therapi 400 72 110

CGR (AECL) 10,18 6-20 360"

Satume 400 Scan 100
Therac (l4,20) 73
MEL 8, 16 5-20 Drum 360"
SL 75/20 73 350,400 100
MEL 5 (4-6) Drum 360"
SL 7515 73 350 100
Mitsubishi 4 360"

ML-4M 73 350 80 0.30 2

Mitsubishi 2.8 360" 30 X 30 No SW M
ML-3M 74 160 80 0.25 2
Varian 10 6-18 360" 130 35 X 35 270°A SW K
TABLE B-1 . (Continued)
~anufactud~
X-ray M V Elect MeV Gantry 'Qpe Floor-Iso X Fielda f end^ Guide vp$
Model YearC (cGy/min) Foil/Scan SAD" Head-Isoe Diagonap Magnet Guide Lengtha MW

Clinac 18 74 500 Foil 100 48 1.4 5.5

RDL 6, 12 5-18 360" 122 35 X 35 266"A TW K
Dynaray 18 74 300 Foil 100 46 2.3 5
Varian 8 (6) 6-12 (4-9) 360" 126 35 X 35 270°A SW M
Clinac 12 75 350 Foil 100 48 1.2 2

Varian 360"
Clinac 6x 80
SHM 6-24 360"
Therapi 2000 Foil 100
CGRIAECL 6-10 360"
Therac 10 Scan 100
RDL 360"
Dynaray 6 100
U.S.S.R. 5-20 240"
LUE 15 Foil 100

Scanditronix Separate
MM 10 76 10 6-10 360"
MM 14 76 14 8-14 360"
MM 22 76 6 and 22 2-22 360"
300,500 Foil 100
Siemens 10,15 3-18 360"
Mevatron XX 77 300 Foil 100
Varian 4,6 360"
Clinac 4,61100 77 250 100
Varian 15 6-20 360"
Clinac 20 77 500 Foil 100

U.S.S.R. 4-5 4-5 240"

LUE 5M 78 200 Foil 100
MEL 8, 10 4-14 Drum 360"
SL 75114 78 350 Foil 100
Varian 6 and 24 6-22 360"
Clinac 2500 79 400 Foil 100
Siemens 10 5-12 360"
Mevatron 74 79 300 Foil 100
Siemens 10, 15,20 5-1 8 360"
Mevatron 77 79 300 Foil 100

AECL 5-25 360" 128 35 X 35 270°A SW M

Therac 25 80 Scan 100 43 180'1 2-pass 1.0 2.6
BBC 5-20 360" 122 35 X 35 264"A TW M, K
Dynaray 83 Foil 100 46 1.2-2.3 2,5
CH 4,6, 12, 18,20
Varian 6 & 10,12,15 4-16 360" 130 35 X 35 270°A SW K
Clinac 1800 83 8 & 15,18 6-20 100 48 1.4 5.5
400 Foil
Siemens 6 and 10 5-12 360" 132 40 X 40 270°A SW M

Mevatron MD 84 220 Foil 100 61 50 1.0-1.3 2

Siemens 6 & 15,20 6-2 1 360" 132 40 X 40 270°A SW K
Mevatron KD 84 8,lO & 20 6-2 1 100 61 42 1.3 7
220 Foil
MEL 6 and 25 4-22 Drum 360" 125 40 X 40 +So,-58" TW M
SL 25 85 300 & 400 Foil 100 45 +112" 2.5 5
Mitsubishi 2,8,4 360" 120 30 X 30 No SW M
EXL 3,4 85 160,350 80 2
TABLE B-1 . (Continued)

~anufactud'~
X-ray MV Elect. MeV Gantry Type Floor-Iso X Fielda end^ Guide ~ l ~ / M a ~ n
Model YeaP (cGy/min) FoillScan SAW Head-Isoe DiagonaP Magnet Guide Lengtha MW

Mitsubishi 6 6-8 360" 120 40 X 40 No SW M

EXL 8 85 250 Foil 100 2
Mitsubishi 10,15 8-17,22 Drum 360" 120 40 X 40 270" SW K
EXL 17,22 85 500 Foil 100 7
Scanditronix 5-50 2,s-50 Separate 360" 132 40 X 40 90" SW M
85 Scan Scan 100 30 Racetrack 0.25 2
500

aSAD and X field dimensions are in centimeters, guide length is in meters. Diagonal dimension at which comers of square field are clipped by primary x-ray
collimator. In some of the earliest medical accelerators (up to about 1%7), in order to avoid losing dose rate, the x-ray field was flattened only to a circle of diameter
equal to the width of the maximum square field size.
b~anufacturers-genealogy
1. Mullard = Mullard Research Laboratories, subsequently: MEL (Mullard Electronic Laboratories), Manor Royal, Crawley, Sussex RHlO 2PZ, United
Kingdom, subsidiary of N. V. Philips, Medical Systems Division, Eindhoven, Netherlands.
2. Met Vick = Metropolitan Vickers, Ltd., subsequently: AEI (AssociatedElectrical Industries) Ltd., Trafford park, Manchester, U.K. Manufacture of medical
accelerators discontinued in the 1%0s.
3. Varian = Varian Associates, Medical Equipment Operation, 3100 Hansen Way, Palo Alto, CA 94303.
4. Vickers = Vickers Research Ltd., Sunninghill, Ascot, Berks, U.K.; subsequently a subsidiary of Radiation Dynamics, which manufactured medical
accelerators under the name Dynaray; subsequently, the product line sold to BBC, which manufactured medical accelerators under the name Dynaray-CH.
5. BBC = BBC A. G. Brown, Boveri & Cie, CH-5401, Baden, Switzerland (see Vickers, Tables B-1, no.4). Combined with ASEA, forming ASEA Brown
Boveri (ABB), then sold to Varian in 1989.
6. MEL (Philips) (see Mullard, Table B-1, no.1).
7. U.S.S.R. = D. B. Efremov Scientific Research Institute of Electrophysical Apparatus, Leningrad, U.S.S.R.
8. NEC = Nippon Electric Company, Ltd., 10 Nisshin-Cho, 1-Chome, Fuchu City, Tokyo, Japan, which built Clinac 6,4,6/100,4/100 and Clinac 18 type
machines under the name NELAC-1006, and so on, under license from Varian in the period 1965-1980.
9. CSF = Compagnie Sans Fil, Courbeville, France, subsequently CGR-MeV, Route de Guyancourt, B. P. 34,78530 Buc, France, which cooperated with
Raytheon Corp. on production of Sagittaire accelerators for the United States and which cooperated with AECL in the 1970s on production of Neptune
(Therac 6) and Satume (Therac 14.20) accelerators. CGR-MeV purchased by General Electric in 1987.
Toshiba = Toshiba Corp., M~dicalDiv., 1-6 Uchisaiwai-Cho, 1-Chome Chiyoda-Ku, Tokyo 100, Japan.
Appl. Rad. = Applied Radiation Corp., previously ARCO, subsequently a subsidiary of High Voltage Engineering Corp., subsequently privately held,
subsequently Siemens Medical Laboratories, 4040 Nelson Ave., Concord, CA 94520, a subsidiary of Siemens A. G., Henke Str. 127, 8520 Erlangen,
Germany.
Mitsubishi. General office: 1700 Market St., Suite 2608, Philadelphia, PA 19103. Linac factory: Osaka, Japan.
RDL = Radiation Dynamics Laboratory, Swindon U. K. fsee Vickers, Table B-1, no.4g.
CGR-MeV (see CSF, Table B-1, no. 9).
SHM = SHM-Nuclear, subsequently EMI-therapy, subsequently ATC, 570 Del Rey, Sunnyvale, CA 94086.
AECL = Atomic Energy of Canada, Ltd., Medical Products, 413 March Rd., P.O. Box 13500, Kanata, Ontario, Canada K2K 1 x 8 (see CSF Table B-1, no.
9).
Scanditronix = Instrument AB-Scanditronix, Husbyborg, S-75590 Uppsala, Sweden.
Siemens = Siemens Medical Laboratories (see Appl. Rad. Table B-1, no. 11).
Beijing = Beijing Medical Equipment Institute, Beijing, China.
Shanghai = Shanghai Medical Nuclear Apparatus Manufacturer, 65 Nanhua Road, Shanghai, China.

AECL Therac 6, 14,25

ATC ATC 416
BBC Dynaray-CH 4,6, 12.18.20
CGR-MeV Sagittaire 32, Neptune 6, Saturne I, Saturne I1 +
MEL (Philips) SL7515, 10, 14, 20. SL25.
Mitsubishi EXL 3,4,6M, 8, 14, 17, 22
NEC NELAC-1006, etc.
Scanditronix MM10.14.22, MR50
Siemens Mevatron MD, KD
Shanghai 21-10
Toshiba LMR
USSR LUE 5.15
Varian Clinac 4/100,6/100, 18,20, 1800,2500

A = Achromatic bend magnet system.

I = Isochronous bend magnet system.
TW = Traveling-wave accelerator structure.
 CONTEMPORARYRADIOTHERAPYACCELERATORS 291

TABLE B-1 . (Continued)

SW = Standing-wave accelerator structure.
M = Magnetron
K = Klystron

eMiscellaneous
1. Introduction date is approximate, usually representing the date at which the manufacturer first announced readiness to accept orders, sometimes representing
the date of installation of the first machine at a user's site.
2. Dimension from isocenter-to-radiation head usually means with all attachments removed, such as shadow tray holder.

TABLE B-2 Specifications of modern single x-ray energy 100-cm SAD radiotherapy linacs

X-ray Field
MfP X-ray Electron Is0 Gantry Max Bend K/M Gun Guide
Mode MVPMU MeVF-S Height Type Wedge -xi-y Magnet MW T/D Mode

ABB
Dynaray
LA 6 Drum Auto 40140
- 151- 15
LA 16 Drum Auto 40140
-151-15
GWCGR
Orion Drum
Orion-6 Drum
Mitsubishi
EXL-8 Stand
EXL- 17 Drum
Philips
S L 7515 Stand

Siemens
6300 Stand
6700 Stand
6740 Stand

Varian Clinac
41100 Stand
61100 Stand
600C Stand

aAll manufacturers use:

100 cm source-axis distance

Gantry offset from stand
Standing-wave guide
270" achromatic bend magnet
Concave impregnated gun cathode

Except

1. Philips uses drum type gantry, TW guide, + 4.5'1 - 45"l + 112.5" bend magnet, spiral wire gun cathode.
2. Asea Brown Boveri uses drum type gantry, TW guide.
292 APPENDIX B. SURVEY OF MEDICAL LINACS

TABLE B-2 . (Continued)

3. Scanditronix uses independent gantry, separated from microtron, nonachromatic bend magnets, button type gun cathode. Scanditronix uses energy degrader
inbeam of MM50 to obtain electron energies intermediate to the 5-MeV steps. The isocenter clearance is to the enclosure of a multileaf collimator type radiation
head, without accessory shadow or block or compensator tray.

All manufacturers provide options of

Beam stopper
Record and verify system
. Electron arc

Some manufacturers provide options of

Retractable beam stopper

Independent jaw motion
Dynamic wedge by jaw motion
Variable electron collimator
Multileaf x-ray collimator
Multileaf electron collimator
Computer controlled equipment motions
Ram or pedestal patient table choices
Extended range of vertical travel patient table
Anticollision ring on radiation head

Abbreviations
DMU = Maximum cGy/min at i s ~ e n t e r
F-S = Electron foil(F) or Scan Magnet (S)
Iso Ht = Isocenterheight above floor in centimeters (cm)
Dish = Depth of depression in turntable floor plate (to reduce isocenter height) in centimeters (cm)
Auto = Wedge filter inside radiation head, remote controlled

X-ray field (cm)

Max = Maximum square, regardless of comer clipping
-x = Beyond center travel of one set ofjaws
-Y = Beyond center travel of other set of jaws
K/M MW = Klystron or magnetron and pulse power in MW
Gun T/D = Triode or diode gun

GuideIMode
Guide:

TW = Traveling-wave guide
SW = Standing-wave guide

Mode (to change x-ray energy)

B = Beam loading andlor phase shift in TW guide, special buncher in SW guide
C = Microwave switch in side cavity of SW guide
D = Microwave circuit between SW guide sections
P = Pipe in magnet field
M = Magnet on selected return path between 180" main magnets
 CONTEMPORARYRADIOTHERAPYACCELERATORS 293

TABLE B-3 - Specifications of modern dual x-ray energy radiotherapy linacs

Mfr X-ray Electron Iso Ht. IsoClr X-ray Field Bend KM Gun Guide An:
Model MVPMU MeV/F-S Dish Autowedge M ~ X / S & - X / - ~ Magnet MW T/D Mode D/+

Asea Brown
Boveri Dynaray
LA20

GE/CGR
Saturn
42

43
Mitsubishi
EXL17DP W200 6-15/F 1281 IN 401351-U-2 270" W5.5 D SWIC
& 101500
61200 6-~O/F 1291 m 401351 -u-2 270" ~ 5 . 5 D SWIC
& 181500
Philips SL
6/300 12510 45N- 401351- 12.51 Slalom MI5 D TW/B +
& 151300
& 181300
& 201300
& 251300 4-22/F
Scanditronix
Microtron
M22 10 10-21F 12510 30N
& 21
M50 5 5-501s 12510 30N
10 5MeV
15 Steps
to 50
Siemens Mevatron
MD 6/200 5-14/F 1311 43/N 401301-U-2 270" MI T SW/B +
& 10/300
& 151300
KD 6/200 6-21/F 1311 43/N 401301-U-2 270" W7 T SW/B +
& 101300
& 151300
& 231300
Varian CIinac
1800 and 2 100C 6/400 4-2O/F 12910 37m 401351- 101-0 270" W5.5 T SWIC D
& 101400
& 151400
& 181400
2100CD 6-1 81600
2500C 6/400 6-22/F 129110) 34N 401351- 101-0 270" W5.5 T SWIC D
& 241400
2 3 0 0 ~ ~ 61600 4-221~ 12910 37m 401351-1 01-2 270" W6 T SWIC D
& 151600
18/600
201600
294 APPENDIX B. SURVEY OF MEDICAL LINACS

TABLE B-3 . (Continued)

OAll manufacturers use:

100 cm source-axis distance

Gantry offset from stand
Standing-wave guide
270" achromatic bend magnet
Concave impregnated gun cathode

Except:

1. Philips uses drum type gantry, TW guide, + 45"l- 45"l + 112.5" bend magnet, spiral wire gun cathode.
2. Asea Brown Boveri uses dmm type gantry, TW guide.
3. Scanditronix uses independent gantry, separated from microtron, nonachromatic bend magnets, button type gun cathode. Scanditronix uses energy degrader in
beam of MM50 to obtain electron energies intermediate to the 5-MeV steps. The isocenter clearance is to the enclosure of a multileaf collimator type radiation
head, without accessory shadow or block or compensator tray.

All manufacturers provide options of:

Beam stopper
Record and verify system
Electron arc

Some manufacturers provide options of:

Retractable beam stopper

Variable electron collimator
Multileaf x-ray collimator
Multileaf electron collimator
Computer controlled equipment motions
Ram or pedestal patient table choices
Extended range of vertical travel patient table
Anticollision ring on radiation head
Dynamic wedge
Electronic portal imager
Radiotherapy management system

Abbreviations
DMUImin = Maximum cGy1min at isocenter
F S = Electron foil (F) or Scan Magnet (S)
Iso Ht = Isocenter height above floor in centimeters (cm)
Dish = Depth of depression in turntable floor plate (to reduce isocenter height) in centimeters (cm)
Iso-Clr = Clearance of nearest x-ray accessory from isocenter in centimeters (cm)
Auto Wedge = Wedge filter inside radiation head, remote controlled

X-ray field (cm)

Max = Maximum square, regardless of comer clipping
sq = Maximum square with no corner clipping
-X = Beyond center travel of one set of jaws
-Y = Beyond center travel of other set ofjaws
WM MW = Klystron or magnetron and pulse power in MW
Gun T/D = Triode or diode gun
GuideJMode
Guide:
TW = Traveling-wave guide
SW = Standing-wave guide

Mode (to change x-ray energy)

B = Beam loading andlor phase shift in TW guide, special buncher in SW guide
C = Microwave switch in side cavity of SW guide
D = Microwave circuit between SW guide sections
P = Pipe in magnet field
M = Magnet on selected return path between 180" main magnets
Arc Dl+ = Control of dose rate per degree with accelerator dose rate (e.g., gun) (D) or with gantry speed (4)
 CONTEMPORARYRADIOTHERAPYACCELERATORS 295

TABLE B-4 IEC377Suggested Values of Functional Performance

Dose monitoring system
Reproducibility
Proportionality (>1 Gy/< 1 Gy)
Dependence on equipment position (stationary)
Dependence on rotation of the gantry (moving)
Dependence on the shape of the radiation field
Stability of calibration
10,000 cGy delivery
One day
One week
Stability in moving beam therapy, preset versus delivered
Terminate irradiation by gantry angle; dose:
Terminate irradiation by dose monitor system; angle:
Depth absorbed dose characteristics
X-radiation
Nominal X-ray energy (mfr)
Relative surface absorbed dose (mfr)
Depth of maximum absorbed dose (mfr)
Penetrative quality: (mfr)
Deviation from stated value +3%, + 3 mm*
Electron radiation
Nominal electron energy (mfr)
Relative surface absorbed dose (mfr)
Depth of maximum' absorbed dose 20.1 cm
Ratio of practical range to depth of 80% absorbed dose 5 1.6
Penetrative quality: (mfr)
Deviation from stated value +3%, 2 2 mm*
Stability of penetrative quality, electrons, variation with
gantry angle and dose rate
Uniformity of radiation fields
X-radiation
Flatness (maxlmin ratio)
5X5to30X30cm
to maximum square
Stability of flatness with angular position of gantry
and beam limiting system
C 30 MeV
> 30 MeV
Symmetry (Ratio of symmetrical points)
Maximum ratio of absorbed dose (at D-max)
5X5to30X30cm
to maximum square
Wedge filtered x-ray fields
Wedge factor
Wedge angle
Electron radiation
Flatness (shape of isodose contours)
80% contour to geometric edge, at base depth
90% contour to geometric edgelcomer at SMD
Maximum ratio of absorbed dose at D-max to absorbed dose
on axis at SMD
Stability of flatness with angular position of gantry and
beam limiting system
Symmetry (ratio of symmetrical points)
Maximum ratio of absorbed dose at 0.5 mm depth to absorbed
dose on axis at SMD
Penumbra
296 APPENDIX B. SURVEY OF MEDICAL LJNACS

TABLE B-4 - (Continued)

Indication of radiation fields

X-radiation
Numerical field indication (% is of field size) 3 mrn, 1.5%*
Greater than 20 cm X 20 cm to maximum square 5 mm, 1.5%*
Light field indication:
Edges (% is of field size):
at normal treatment distance, 5 cm X 5 cm to 20 cm X 20 cm 2 mm, 1%*
at 1.5 X normal treatment distance, 5 cm X 5 cm to 20 cm X 20 cm 4mm, 2 %*
Center: NTDl 1.5 X NTD 214 mm
Reproducibility
Numerical field, light field edge
Electron radiation
Numerical field indication 2 rnm
Light field indication, edges 2 mm
Geometry of x-ray beam limiting systems + 0.5"
Illuminance and penumbra of light field
Average illuminance at NTD 40 lux
Edge contrast ratio 400%
Indication of radiation beam axis
+
Entry, x-radiation (NTD 25 cm range)
Entry, electron radiation (NTD ? 25 cm range)
+
Exit, x-radiation (NTD to NTD 50 cm)
Isocentre
Displacement of x-ray beam axis 2 2 mrn
Displacement of indication of isocentre +2 mm
Indication of distance along radiation beam axis from isocentre 2 2 mm
From radiation source +5 mm
Zero position of rotation scales
Gantry, beam limiting device, table, table top
Congruence of opposed radiation fields at isocentre
Movements of the patient table
Horizontal displacement for 20 cm vertical change
Displacement of rotation axis from isocentre
Angle between table and table top rotation axes
Table height: 30 kg, retracted to 135 kg, extended
Table top lateral tilt from horizontal
Deviation of table top height with lateral displacement

*=Whichever is greater
NTD=normal treatment distance (100 cm SAD)
SMD=standardmeasurement depth (10 cm, 90 cm SSD)
 Miscellaneous

C-1 ABBREVIATIONS AP Anterior posterior

BEV Beam's eye view
CART Computer assisted'radiation therapy
ORGANIZATIONS CCD Charge coupled device
AAPM American Association of Physicists in Medicine CCTV Closed circuit television
ACR American College of Radiology CMOS Complementary metallic oxide semiconductor
ANSI American National Standards Institute CRT Cathode ray tube (terminal)
ASTRO American Society of Therapeutic Radiology and CT Computerized tomography
Oncology CW Continuous wave
BIR British Institute of Radiology dc Direct current
BRH Bureau of Radiological Health De-Q Decreaser of Q
CDRH Center for Devices and Radiological Health dm Depth at dose maximum
CRCPD Conference of Radiation Control Program Directors Dm, Dose at d,
CROS Committee on Radiation Oncology Studies DR Digital radiography
Center for Radiological Physics DRR Digitally reconstructed radiograph
CRP
Department of Health and Human Services EMF Electromotive force
DHHS
EM1 Electromagnetic interference
EPA Environmental Protection Agency
ES Expert system
ICRP International Commission for Radiation Protection
fwhm Full width half-maximum
ICRU International Commission on Radiation Units
and Measurements EWTM Full width tenth maximum
GOS Gadolinium oxysulfide
IEC International Electrotechnical Commission
HBI Hemibody irradiation
IEEE Institute of Electrical and Electronic Engineers
HiNIL High noise immunity logic
IPSM Institute of Physical Sciences in Medicine
HVL Half-value layer
IS0 International Organization for Standards
IA Image amplifier
NBS National Bureau of Standards
IC Integrated circuit
NCRP National Council on Radiation Protection and
I1 Image intensifier
Measurements
IORT Intraoperative radiation therapy
NEMA National Electrical Manufacturers Association
LAN Local area network
NRC National Regulatory Commission
LAT Lateral
RPC Radiological Physics Center
MCII Multichannel image intensifier
SLAC Stanford Linear Accelerator Center
MLC Multileaf collimator
SSRCR Suggested State Regulations for Control of Radi-
MRI Magnetic resonance imaging
ation
MTBF Mean time between failures
MTF Modulation transfer function
MU Monitor units
TECHNICAL ACRONYMS NTP Normal temperature and pressure
ac Alternating current PA Posterior anterior
AFC Automatic frequency control PACS Picture archival and communications system
A1 Artificial intelligence PBI Partial body irradiation
 APPENDIX C . MISCELLANEOUS

PC Printed circuit, personal computer d Day

PET Positron emission tomography d Depth
PFN Pulse forming network D Absorbed dose
PLO Phase locked oscillator D Electric flux density
PRF Pulse repetition frequency e Electron
PRR Pulse repetition rate esu Electrostatic unit
PSA Patient support assembly eV Electron volt
PSIG Pounds per square inch guage E Electric field intensity
QA Quality assurance f Frequency
Quantum detection efficiency fc Cut-off frequency
QDE
RAM Random access memory fc Foot candle
rf Radio frequency F Farad
ROM Read only memory F Force
RPC Radiological physics center g Gram
RPM Revolutions per minute &! Magnetic field gradient
RTTP Radiotherapy treatment planning G Admittance
RV Record and verify G Gauss
SAD Source axis distance G Giga (109)
SCR Silicon controlled rectifier GY Gray
SIT Silicon intensified target vidicon h Hour
SSD Source skin distance H Henry
Standing wave H Magnetic field intensity
SW
Total body irradiation Hz Hertz
TBI
Tumor control probability I Electric current
TCP
Transverse electric J Current density
TE
Transverse electromagnetic J Joule
TEM
Target film distance k Kilo (103)
TFD
keV Kiloelectron volt
TLI Total lymphoid irradiation
kV Kilovolt
TM Transverse magnetic
~ V P Kilovolt peak
TNI Total nodal irradiation
kW Kilowatt
TSD Target skin distance
K Coupling factor
TSET Total skin electron therapy
OK Degrees kelvin
TTL Transistor transistor logic
1 Length
TV Television
lm Lumen
TVD Tenth value distance
Ix Lux
TVL Tenth value layer
L Inductance
TW Traveling wave
m Mass
VCO Voltage controlled oscillator
m Meter
VDT Video display terminal
m Milli (10-3)
VSWR Voltage standing-wave ratio
m Minute
mA Milliampere
mAs Milliampere seconds
C-2 SYMBOLS M Magnetic moment
M Mega (106)
A Ampere MV Megavolt
Atomic weight MeV Megaelectron volt
8, Angstrom MIPS Million instructions per second
B Magnetic flux density MVP Megavolt peak
c Velocity of light MW Megawatt
C Capacitance n Nano (10-9)
C Cosine-like trajectory n Neutron
C Coulomb n Magnetic field gradient index
OC Degrees Celsius n Turns ratio
~ G Y Radiation absorbed dose N Newton
 C-3 UNITS 299

Oe Oersted Permittivity
P Momentum Dielectric constant
P* Momentum in units of Zeta
P Power Eta Efficiency
4 Electric charge Instrinsic impedance of medium
Q Quality factor of resonant circuit Theta Angle
'
0 Range (continuous slowing down approximation) Iota
rad Radian Kappa Propagation wavenumber
rem Roentgen equivalent man (biological dose) Lambda Wavelength
rms Root mean square Cut-off wavelength
R Resistance Guide wavelength
R Roentgen Wavelength in free space
S Second Micro
sr Steradian Permeability (magnetic)
S Sine-like trajectory Micron
S Surface area Nu
S band 3000-MHz frequency region Xi
T Kinetic energy Omicron
T Temperature Pi Circle circumferenceldiameter
T Tesla Rho Radius of curvature
t Time Resistivity
T Transit time factor Reflection coefficient
U Stored energy Sigma Standard deviation of normal
v Velocity distribution
v Volt
Conductivity
W Watt
Tau Time constant
W Total energy (rest plus kinetic)
Upsilon Velocity
Rest energy
Phi Angle, phase
Radiation length
Chi
Atomic number
Psi Angle, phase
Impedance (to ac or rf)
Omega Angular frequency (21~8in radians
One-dimensional
Two-dimensional Omega Impedance
Three-dimensional Resistance

C-3 GREEK SYMBOLS C-4 UNITS

NAME TYPICAL USE In the portions of this book more related to engineering, such
as Chaps. 2 to 5, 1 0 , 11, the rational system of units is used as
a Alpha Attenuation constant introduced by Georgi. Lengths are in meters, mass in kilo-
Alpha particle grams, time in seconds. Its primary advantage in relation to
3
I Beta Velocity relative to light electricity and magnetism is that the units of all the primary
Beta particle (ray) electric quantities are those actually measured. Current is in
Phase velocity amperes, potential in volts, impedance in ohms, power in watts.
Coupling factor Force, in newtons, is the product of mass in kilograms and
Gamma Total energylrest energy acceleration in meters per (second).2 1 newton = 105 dynes.
Gamma ray Energy, in joules, is the product of force and distance. 1 joule
Propagation constant = 1 newton meter = 107 ergs. The unit of charge is the
Gamma Reflection coefficient Coulomb. Capacitance in farads = Ih (charge in Cou-
Delta Displacement lombs)2l(energy in joules). The dielectric constant of free space
Delta ray is eO =(!46~r) X 10-9 faradslmeter. Electric field is in volts
Skin depth per meter. Magnetic field intensity, H, from Ampere's law, has
Epsilon Ernittance dimensions of current in amperes divided by length in meters.
300 APPENDIX C. MISCELLANEOUS
The magnetic flux density, B, is defined in webers, such that a
rate of change in magnetic flux of one weber per second will
generate an electromotive force of one volt. One weber is 108
maxwells or "lines" and one weber per square meter is 104
gauss. The permeability, p = B I H is IT X 10-7 henrylmeter.
The henry is the unit of inductance, having units of volts
induced by a rate of change of current in amperes per second.
In some portions of this book, which are more related to
physics, a rational system of centimeter-gram-second (cgs)
practical units is used. Electromagnetic quantities are in volts,
amperes, coulombs, ohms, and watts as in the meter-kilogram-
second (rnks) system, but length and mass are in centimeters
and grams, hence involving conversion factors of 10-2 and
10-3 to convert to mks units.
C-5 TERMINOLOGY
Absorbed dose: Mean energy imparted by ionizing radiation
to matter. The special name of the unit of absorbed dose is
the gray (Gy). It equals one on joule per kilogram (J. kg- I).
Accelerator: Device for producing beams of high-energy elec-
trons. The electron gun in a television tube is a type
accelerator.
Ampere: Aunit of electriccurrent. Since 1950,by international
agreement, the ampere is defined in terms of the attractive
force that occurs between two conductors carrying this
current. The attractive force can be interpreted on the basis
of magnetic forces--one conductor carrying a current
generates a magnetic field at the other conductor, and the
current flowing in this second conductor is then influenced
by this magnetic field. The current flowing through a
100-watt bulb in an ordinary 110-volt house circuit is
about 1 ampere.
Attenuation: Reduction of a radiation quantity upon passage
of the radiation through matter resulting from all types of
interaction with this matter. The radiation quantity may be,
for example, the particle flux density or the energy flux
density. Note: Attenuation does not include the geometric
reduction of the radiation quantity with distance from the
radiation source.
Bandwidth: 1. (continuous frequency band) The difference
between the limiting frequencies. 2. (device) The range of
frequencies within which performance, with respect to
some characteristic, falls within specific limits. See: radio
receiver. 3. (wave) The least frequency interval outside of
which the power spectrum of a time-varying quantity is
everywhere less than some specified fraction of its value
at a reference frequency. Warning: This definition permits
the spectrum to be less than the specified fraction within
the interval. Note: Unless otherwise stated, the reference
frequency is that at which the spectrum has its maximum
value.
Beam dynamics: That branch of mechanics that deals with the
motion or response of an electron beam under the influ-
ence of forces.
Beam loading: The reduction of accelerated beam energy due
to extraction of power from the accelerating electromag-
netic field by the accelerated electron beam.
Beta particle: An electron, either positively or negatively
charged, emitted from a radioactive nucleus.
Betatron: Electron accelerator in which an increasing mag-
netic field maintains a stable orbit and electrons are accel-
erated by an electric field produced by the increasing
magnetic flux within the orbit.
Build-up: In a material irradiated by a beam of x- or gamma-
rays the increase in absorbed dose with depth below the
surface is called the build-up. This is due to (a) the forward
moving nature of the secondary electrons produced in the
material, as well as (b) a build-up of scattered photons due
to multiple scattering in broad beams of radiation. For
high-energy beams process (a) is the more important.
Capacitance (capacity): The property of a system of conduc-
tors and dielectrics that permits the storage of electrically
separated charges when potential differences exist be-
tween the conductors.
Centigray: 0.01 gray. 1 cGy equals one rad. (see gray)
Choke joint : A connection designed for essentially complete
transfer of power between two waveguides without metal-
lic contact between the inner walls of the waveguides. It
typically consists of one cover flange and one choke
flange.
Complex permeability: The complex (phasor) ratio of induc-
tion to magnetizing force. Notes: (1) This is related to a
phenomenon wherein the induction is not in phase with the
total magnetizing force. (2) In anisotropic media, complex
permeability becomes a matrix.
Conduction current: Through any surface, the integral of the
normal component of the conduction current density over
that surface. Note: (1) Conduction current is a scalar and
hence has no direction.
Coulomb: A unit of electrical charge. One coulomb of charge
passing a section in a conductor every second is equivalent
to a current of 1 ampere.
Coupling: The circuit element or elements, or the network, that
may be considered common to the input mesh and the
output mesh and through which energy may be transferred
from one to the other.
Coupling aperture (coupling hole, coupling slot): An aper-
ture in the bounding surface of a cavity resonator, wavegu-
ide, transmission line, or waveguide component which
permits the flow of energy to or from an external circuit.
Coupling capacitance: The association of two or more circuits
with one another by means of capacitance mutual to the
circuits.
 C-3 UNITS
Coupling coefficient (coefficient of coupling): The ratio of
impedance of the coupling to the square root of the product
of the total impedances of similar elements in the two
meshes. Notes: (1) Used only in the case of resistance,
capacitance, self-inductance, and inductance coupling. (2)
Unless otherwise specified, coefficient of coupling refers
to inductance coupling, in which case it is equal to
M/(LIL2)1/2, where M is the mutual inductance LI the
total inductance of one mesh, and L2 the total inductance
of the other.
Coupling, inductance (interference terminology): The type
of coupling in which the mechanism is mutual inductance
between the interference induced in the signal system by
a magnetic field produced by the interference source.
Curie (Ci): The previously used special unit of activity equal
to 2.7 X 1OlOdisintegrationsper second. 1 Ci = 3.7 X 1010
Bq.
Delineator: Ameans for defining the border which outlines the
simulated radiotherapy radiation field.
Depth dose: Absorbed dose at a specified depth beneath the
entrance surface of the irradiated object, usually on the
radiation beam axis.
Diaphragm: Beam limiting device with either a fixed or an
adjustable aperture in practically one plane.
Diode: A two-electrode electron tube containing an anode and
a cathode.
Dispersion (fiber optics): A term used to describe the chro-
matic or wavelength dependence of a parameter as op-
posed to the temporal dependence which is referred to as
distortion. The term is used, for example, to describe the
process by which an electromagnetic signal
- - is distorted
- -
because the various wavelength comvonents of that signal
have different propagation characteristics.The term is also
used to describe the relationship between refractive index
and wavelength.
Displacement current (any surface): The integral of the
normal component of the displacement current density
over that surface. Note: Displacement current is a scalar
and hence has no direction.
Displacement current density (any point in an electric
field): The time rate of change in SI units (International
System of Electrical Units) of the electric flux density
vector at that point.
Dispersion relation (radio wave propagation): In a source-
free region, the functional relation between angular fre-
quency w and wave vector k for plane waves with the
exponential factor explj(wt-k-r)].
Dose monitor unit: In a dose monitoring system, arbitrary unit
in which a quantity is displayed and from which absorbed
dose can be calculated.
Electric field (radio wave propagation):A state of the region
in which stationary charged bodies are subject to forces by
virtue of their charges.
301
Electric field: A vector field of electric field strength or of
electric flux density.
Electric flux density (electric displacement density) (elec-
tric induction): A quantity related to the charge displaced
within the dielectric by application of an electric field.
Notes: (1) Electric flux density at any point in an isotropic
dielectric is a vector that has the same direction as the
electric field strength and a magnitude equal to the product
of the electric field strength and the absolute capacitivity.
The electric flux density is that vector point function
whose divergence is the charge density, and that is propor-
tional to the electric field in region free of polarized matter.
The electric flux density is given by
where D is the electric flux density, q , ~is the absolute
capacitivity, and E is the electric field strength. (2) In a
nonisotropic medium, E becomes a tensor represented by
a matrix and D is not necessarily parallel to E.
Electric focusing (microwave tubes): The combination of
electric fields that acts upon the electron beam in addition
to the forces derived from momentum and space charge.
Electromagnetic waves: A wave characterized by variations
of electric and magnetic fields. Note: Electromagnetic
waves are known as radio waves, heat rays, light rays,
etcetera, depending on the frequency. A disturbance that
propagates outward from any electric charge that oscillates
or is accelerated; far from the charge it consists of vibrating
electric and magnetic fields that move at the speed of light
and are at right angles to each other and to the direction of
motion.
Electron: 1. (noun) An elementary particle containing the
smallest negative electric charge of 21.60219 X 10-19 C.
Note: The mass of the electron 9.10956 X 10-31 kg is
approximately equal to 111837 of the mass of the hydrogen
atom. 2. (adjective) Operated by, containing, or producing
electrons. Examples: Electron tube, electron emission, and
electron gun.
Electron accelerator, linear: See: linear electron accelerator.
Electron charge: Charge is atomic in character; that is, there
is a smallest amount below which charge may not be
divided. The smallest charge e,; when negative, resides on
certain elementary particles like the electron and antipro-
ton, and when positive, resides on such particles as the
positive electron (positron) and the proton. e = 1.6 X
10-20 coulomb.
Electron emission: The liberation of electrons from an elec-
trode into the surrounding space. Note: Quantitatively, it
is the rate at which electrons are emitted from an electrode.
Electron gun (electron tubes): An electrode structure that
produces and may control, focus, deflect, and converge
one or more electron beams.
302 APPENDIX C. MISCELLANEOUS
Emittance: A quantitative measurement of the nonparallelism
of a beam (that is, low emittance signifies high parallel-
ism).
Energy: The capacity to do useful work. It may be kinetic
energy, which is energy of motion, or potential energy,
which is some potential form, such as gravitational,chem-
ical, electrical, or atomic. As discussed in conservation of
energy, mass is also convertible into energy.
Fluorescence: Luminescence that occurs essentially only dur-
ing excitation.
Focal spot to skin distance: In radiotherapy, distance from the
reference plane of an effective focal spot to the point at
which the reference axis intersects with the entrance sur-
face.
Frequency (periodic function) (whereintime is the indepen-
dent variable): The number of periods per unit time.
Frequencyband: Acontinuous range of frequenciesextending
between two limiting frequencies. Note: The term fre-
quency band or band is also used in the sense of the term
bandwidth.
Full width at half maximum: For a bell shaped curve, distance
parallel to the abscissa axis between the points where the
ordinate has half of its maximum value.
Full width at tenth maximum: For a bell shaped curve,
distance parallel to the abscissa axis between the points
where the ordinate has one tenth of its maximum value.
Gantry: In equipment for radiotherapy, part of the equipment
supporting and allowing possible movement of the radia-
tion head.
Geometric unsharpness: Unsharpness of the recorded image
due to the combined optical effect of finite size of the
radiation source and geometric separation of the anatomic
area of interest.
Gradient: The maximum rate of change of a parameter or
characteristic in a given direction.
Gray (Gy): International System (SI) unit for absorbed dose.
One gray is equal to the energy imparted by ionizing
radiation to a mass of material corresponding to one joule
per kilogram; it is equal to 100 rad.
Group velocity: 1. (radio wave propagation) Of a traveling
wave, the velocity of propagation of the envelope, pro-
vided that this moves without significant change of shape.
The magnitude of the group velocity is equal to the recip
rocal of the rate of change of phase constant with angular
frequency. Note: Group velocity differs in magnitude from
phase velocity if the phase velocity varies with frequency,
and differs in direction from phase velocity if the phase
velocity varies with direction. 2. (traveling wave) The
velocity of propagation of the envelope, provided that this
moves without significant change of shape. Notes: (1) The
magnitude of the group velocity is equal to the reciprocal
of the change of phase constant with angular frequency.
(2) Group velocity differs in magnitude from phase veloc-
ity if the phase velocity varies with frequency and differs
in direction from phase velocity if the phase velocity varies
with direction. 3. (waveguide) Of a traveling wave at a
single frequency, and for a given mode, the velocity at
which the energy is transported in the direction of propa-
gation.
Harmonic components (harmonics): The harmonic compo-
+
nents of a Fourier Series are the terms C, sin (nx 0,).
Note: For example, the component that has a frequency
twice that of the fundamental (n, 2) is called the second
harmonic.
Image intensifier: An x-ray image receptor which increases
the brightness of a fluoroscopic image by electronic am-
plification and image minification.
Impedance: The total opposition that a circuit presents to an
alternating current, equal to the ratio of the voltage to the
current in complex notation. Note: The ratio Z is com-
monly expressed in terms of its orthogonal components,
thus:
where Z, R, and X are respectively termed the impedance,
resistance, and reactance, all being measured in ohms. In
a simple circuit consisting of R, L, and C all in series, Z
becomes
Z =R + j(oL - l/oC),
where o = 27rf and f is the frequency.
Incident wave: 1. (radio wave propagation) In a medium of
certain propagation characteristics, a wave which im-
pinges on a discontinuity or a medium of different propa-
gation characteristics. 2. (forward wave) (uniform
guiding systems) A wave traveling along a waveguide or
transmission line in a specified direction toward a discon-
tinuity, terminal plane, or reference plane. See: reflected
wave; waveguide.
Inductive coupling (communication circuits): The associa-
tion of two or more circuits with one another by means of
inductance mutual to the circuits or the mutual inductance
that associates the circuits.
Insertion loss: (data transmission)Resulting from the insertion
of a transducer in a transmission system, the ratio of (1)
the power delivered to that part of the system following
the transducer, to (2) the power delivered to that same part
of the system after insertion of the transducer.
Interlock: A device used to assure proper and safe use of a
radiation installation by monitoring (usually by electrical
devices) the status, presence or position of various associ-
ated devices such as source position, collimator opening,
beam direction, door closure, filter presence and prevent-
ing the production or emission of radiation if the potential
for an unsafe condition is detected.
Interruption of irradiation: Stopping of irradiation and
 C-3 UNITS
movements with the possibility of continuing without
reselecting operating conditions, (that means return to the
ready state).
Ion: In a gas, a charged particle is often referred to as an ion
(from the Greek word meaning wanderer) because it can
move under the influence of an electric field. A negative
ion may be an electron that has been freed from an atom
or molecule in the gas; it may also be an electron that has
become attached to a neutral atom or molecule. A positive
ion is an atom or molecule that has lost one or more
electrons.
Ionization: Any process by which a neutral atom or molecule
loses or gains electrons, thereby acquiring a net charge and
becoming an ion.
Ionization chamber: Ionization detector consisting of a charn-
ber filled with a suitable gas, in which an electric field,
insufficient to induce gas multiplication, is provided for
the collection at the electrodes of charges associated with
ions and the electrons produced in the sensitive volume of
the detector by ionizing radiation.
Iris: (waveguide technique) A metallic plate, usually of small
thickness compared with the wavelength, perpendicular to
the axis of a waveguide and partially blocking it. Notes:
(1) An iris acts like a shunt element in a transmission line:
it may be inductive, capacitive, or resonant. (2) When only
a single mode can be supported an iris acts substantially as
a shunt admittance.
Isocentre: In radiological equipment with several modes of
movement of the reference axis around a common centre,
centre of the smallest sphere through which the radiation
beam axis passes.
Isodose curve: A line, usually in a plane, along which the
absorbed dose is constant.
Joule (J): The absolute meter-kilogram-second unit of work or
energy equal to 107 ergs or approximately 0.7375 foot-
pounds. One kilowatt-hour, which is the unit of electricity
used by power companies, is equal to 3,600,000joules. A
mass of 1 kilogram moving with a velocity of 1 meter per
second has a kinetic energy of precisely .5 joule.
Kinetic energy: The energy that a body possesses because of
its motion; in classical mechanics, equal to one-half of the
body's mass times the square of its speed.
Klystron: An evacuated electron-beam tube in which an initial
velocity modulation imparted to electrons in the beam
results subsequently in density modulation of the beam;
used as an amplifier in the microwave region or as an
oscillator.
Line spread function: In an imaging system, distribution of
the intensity from a line source along a straight line in a
specified image plane where the straight line is normal to
the image of the line source.
Loss: 1. (power) (A) Power expended without accomplishing
useful work. Such loss is usually expressed in watts. (B)
303
(communications).The ratio of the signal power that could
be delivered to the load under specified reference condi-
tions to the signal power delivered to the load under actual
operating conditions. Such loss is usually expressed in
decibels. 2. (waveguide) The power reduction in a trans-
mission path in the mode or modes under consideration. It
is usually expressed as a positive ratio, in decibels.
Loss tangent: The ratio of the imaginary part of the complex
dielectric constant of a material to its real part.
Maximum dose depth: In a phantom whose surface is at a
specified distance from the radiation source, depth on the
beam axis at which the absorbed dose attains a maximum
value with the specified irradiated field dimensions and
beam energy.
Modulation transfer function (MTF): A mathematical entity
that expresses the relative response of an imaging system
or system component to sinusoidal inputs as a function of
varying spatial frequency, which is often expressed in line
pairs per millimeter (lplmm). The reference value most
commonly used is that for zero frequency. The MTF can
be thought of as a measure of spatial resolution of the
detector system. Fourier transform of the line spread func-
tion. For a symmetrical line spread function, the modula-
tion transfer function is the normalized fourier transform
using the equation:
L(x) cos 2wx&
M(v) =
--L(xk&
j+-
where v is the spatial frequency, L is the line spread
function, and x is the abscissa.
Negative electricity: The sign of the electric charge may be
either positive or negative (terms introduced by Benjamin
Franklin) When glass is rubbed with silk, the charge re-
tained on the glass is positive and on the silk is negative.
Nominal energy: As a characteristic of medical electron accel-
erators, radiation energy describing: for x-radiation the
energy of electrons in a monoenergetic beam equivalent to
the actual energies of the energy spectrum of electrons in
the radiation beam striking the target; for electron radiation
the energy of electrons in a monoenergetic beam equiva-
lent to the actual energies of the energy spectrum of
electrons in the radiation beam at the phantom surface at
the normal treatment distance.
Oscillator: An electronic circuit or an enclosed metallic struc-
ture in which electric and magnetic fields vary periodically
at a specific frequency.
Particle accelerator: Equipment for accelerating charged
particles such as electrons, proton, deuterons and alpha
particles to kinetic energies higher than corresponding to
the voltage applied. Thus-Electron accelerator. Linear
304 APPENDIX C. M
accelerator-particle accelerator in which charged
particles are accelerated along a straight path.
Particle fluence: At a given point of space, the number of dN
particles incident during a given time interval of a suitably
small sphere centered at that point divided by the cross-
+
sectional area of da of the sphere = -
dN
da
Peak pulse power, carrier-frequency: The power averaged
over that carrier-frequency cycle that occurs at the maxi-
mum of the pulse of power (usually one half the maximum
instantaneous power).
Penumbra: In radiology, spatial region around the radiation
beam where the value of radiation flux is between two
specified or specific fractions of the value that is measured
on the radiation beam axis, these two values being mea-
sured in a same cross-section. Note: The existence of such
spatial regions can be due to one or more of the following
phenomena: -extra-focal radiation, -scattered radiation,
-absence of lateral electron equilibrium, -pair production,
-geometry of the radiation source and of the beam limiting
system.
Percentage depth dose: The percentage depth dose in an
irradiated body is the ratio (expressed as a percentage) of
the absorbed dose, D,, at any depth x to the absorbed dose,
Do,at a fixed reference point on the central ray. Percentage
0.x
depth dose = 100 X-. For x-radiation produced at up to
Do
400 kV the reference point is at the surface. For x-radiation
above 400 kV and gamma teletherapy the reference point
is at the position of the peak absorbed dose. For moving-
field therapy it is often convenient to take the centre of
rotation as the reference point.
Periodic electromagnetic wave (radio wave propagation):
A wave in which the electric field vector is repeated in
detail in either of two ways: (1) at a fixed point, after the
lapse of a time known as the period, or (2) at a fixed time,
after the addition of a distance known as the wavelength.
Periodic function: Afunction that satisfiesf(x) =Ax + nk) for
all x and for all integers n, k being a constant. For example,
sin (x + a) = sin (x + a + 2n1~).
Phantom: An object used to simulate the absorption and scatter
characteristics of the patient's body for radiation measure-
ment purposes.
Phasing: Timing of a particle or a pulse with reference to either
an oscillation or a circulation.
Phase constant (waveguide): Of a traveling wave, the space
rate of change of phase of a field component (or of the
voltage or current) in the direction of propagation, in
radians per unit length.
Phase modulation (PM) (data transmission) (information
theory): Angle modulation in which the angle of a carrier
is caused to depart from its reference value by an amount
proportional to the instantaneous value of the modulating
function. Notes: (1) A wave phase modulated by a given
function can be regarded as a wave frequency modulated
by the time derivative of that function. (2) Combinations
of phase and frequency modulation are commonly referred
to as frequency modulation.
Phase velocity: 1. (fiber optics) For a particular mode, the ratio
of the angular frequency to the phase constant. See: axial
propagation constant; coherence time; group velocity. 2.
(of a traveling plane wave at a single frequency) The
velocity of an equiphase surface along the wave normal.
See: radio wave propagation; waveguide. 3. (radio wave
propagation) Of a traveling wave at a single frequency, the
velocity of an equiphase surface along the wave normal.
4. (waveguide) Of a traveling wave at a given frequency,
and for a given mode, the velocity of an equiphase surface
in the direction of propagation.
Photon: A massless particle; a "quantum" of electromagnetic
energy. Synonymous with x-ray and gamma.
Pixel: A two-dimensional picture element in the presented
image.
Polarity: The orientation of voltage between electrodes that
determines the direction of current flow.
Positron: A positively charged electron (see also electron
charge).
Potential energy (of a body or of a system of bodies, in a
given configuration with respect to an arbitrarily cho-
sen reference configuration): The work required to bring
this system from an arbitrarily chosen reference configu-
ration to the given configuration without change in other
energy of the system.
Potential gradient: A vector of which the direction is normal
to the equipotential surface, in the direction of decreasing
potential, and of which the magnitude gives the rate of
variation of the potential.
Practical range: For an electron beam, depth in a phantom at
which the tangent to the steepest point, on the almost
straight portion, of the depth versus absorbed dose curve,
intersects the extrapolated tail of the curve.
Preparatory state: State of equipment for setting essential
operating conditions, if in the standby state the setting of
these conditions is not possible.
Proton: Stable elementary particle having a positive charge of
1.60219 X 10-19 and a rest mass of 1.67261 X 10-27 kg.
Quantum mottle: The variation in optical density, brightness,
CT number, or other appropriate parameter in an image
which results from the random spatial distribution of the
x-ray or light quanta absorbed at the stage of the imaging
chain containing the minimum information content. This
state is known as the quantum sink.
Rad: A superseded term that is an acronym for radiation
absorbed dose. One rad is equal to 0.01 joules per kilo-
gram, or 0.01 gray.
 C-3 UNITS
Radiation (ionizing): Any electromagnetic or particulate radi-
ation capable of producing ions, directly or indirectly, by
interaction with matter. Leakage radiation-All radiation
coming from within the source assembly except for the
useful beam. (Note: Leakage radiation includes the portion
of the radiation coming directly from the source and not
absorbed by the source assembly, as well as the scattered
radiation produced within the source assembly). Scattered
radiation-Radiation that, during passage through matter
is changed in direction. (It is usually accompanied by a
decrease in energy.) Stray Radiation-The sum of leakage
and scattered radiation. Useful beam,-The radiation
which passes through the opening in the beam limiting
device and which is used for imaging or treatment.
Radiotherapy simulator: A device which uses x-ray equip-
ment to physically simulate a therapeutic radiation beam
so that the treatment volume to be irradiated during radio-
therapy can be localized and the position and size of the
therapeutic radiation field can be confirmed.
Ready state: State of equipment, in which all conditions, such
as carrying out of confirming operations and any other
satisfaction of interlocks are prevailing so that the intended
operation of such equipment can be initiated by a single
action.
Resolution: In the context of an image system, the output of
which is finally viewed by the eye, it refers to the smallest
size or highest spatial frequency of an object of given
contrast that is just perceptible. The intrinsic resolution, or
resolving power, of an imaging system is measured in line
pairs per millimeter (lplmm), ordinarily using a resolving
power target. The resolution actually achieved when im-
aging lower contrast objects is normally much less.
Reflected wave: 1. (data transmission) When a wave in one
medium is incident upon a discontinuity or a different
medium, the reflected wave is the wave component that
results in the first medium in addition to the incident wave.
Note: The reflected wave includes both the reflected rays
of geometrical optics and the diffracted wave. 2. (wavegu-
ide) At a transverse plane in a transmission line or wavegu-
ide, a wave returned from a reflecting discontinuity in a
direction opposite to the incident wave.
Reflection coefficient (waveguide): At a given frequency, at
a given point, and for a given mode of propagation, the
ratio of some quantity associated with the reflected wave
to the corresponding quantity in the incident wave. Note:
The reflection coefficient may be different for different
associated quantities, and the chosen quantity must be
specified. The voltage reflection coefficient is most com-
monly used and is defined as the ratio of the complex
electrical field strength (or voltage) of the reflected wave
to that of the incident wave. Examples of other quantities
are power or current.
Repetition rate: Repetition rate signifies broadly the number
of repetitions per unit time.
305
Resonance charging (charging inductors) direct current:
The charging of the capacitance (of a pulse-forming net-
work) to the initial peak value of a voltage in an oscillatory
series resistance- inductance-capacitance (RLC) circuit,
when supplied by a direct voltage.
Resonance frequency (resonant frequency): 1. (network).
Any frequency at which resonance occurs. Note: For a
given network, resonance frequencies may differ for dif-
ferent quantities, and almost always differ from a natural
frequencies. For example, in a simple series resistance-in-
ductance-capacitance circuit there is a resonance fre-
quency for current, a different resonance frequency for
capacitor voltage, and a natural frequency differing from
each of these. See: network analysis. 2. (crystal unit) The
frequency of a particular mode of vibration to which,
discounting dissipation, the effective impedance the crys-
tal unit is zero. See: crystal.
Resonance frequency of charging (charging inductors): The
frequency at which resonance occurs in the charging cir-
cuit of a pulse-forming network. Note: In this document,
it will be assumed to be the frequency determined as
follows:
where
fo = resonance frequency of charging
Co = capacitance of pulse-forming network
L = charging inductance.
Resonance mode (laser-maser): A natural oscillation in a
resonator characterized by a distribution of fields which
have the same harmonic time dependence throughout the
resonator.
Resonant mode: 1. (general) A component of the response of
a linear device that is characterized by a certain field
pattern, and that when not coupled to other modes is
representable as a single-tuned circuit. Note: When modes
are coupled together, the combined behavior is similar to
that of the corresponding single-tuned circuits correspond-
ingly coupled. See: waveguide. 2. (cylindrical cavities)
When a metal cylinder is closed by two metal surfaces
perpendicular to its axis a cylindrical cavity is formed. The
resonant modes in this cavity are designated by adding a
third subscript to indicate the number of half-waves along
the axis of the cavity. When the cavity is a rectangular
parallelepiped the axis of the cylinder from which the
cavity is assumed to be made should be desjgnated since
there are three possible cylinders out of which the
parallele-piped may be made.
Resonant wavelengths (cylindrical cavities): Those given by
A, = l[(l/Xc)2 + (1/2c)2]1/2 where Xc is the cutoff wave-
length for the transmission mode along the axis, I is the
306 APPENDIX C. MISCELLANEOUS
number of half-period variations of the field along the axis,
and c is the axial length of the cavity.
Resonator, waveguide (waveguide components): A wavegu-
ide or transmission line structure which can store oscillat-
ing electromagnetic energy for time periods that are long
compared with the period of the resonant frequency, at or
near the resonant frequency.
Rise time (industrial control): The time required for the
output of a system (other than first-order) to make the
change from a small specified percentage (often 5 or 10)
of the steady-state increment to a large specified percent-
age (often 90 or 95), either before overshoot or in the
absence of overshoot. Note: If the term is unqualified,
response to a step change is understood: otherwise the
pattern and magnitude of the stimulus should be specified.
Root mean square value (high voltage testing): The root
mean square value of an alternating voltage is the square
root of the mean value of the square of the voltage values
during a complete cycle.
Root-mean-square value (periodic function) (effective
value*): The square root of the average of the square of
the value of the function taken throughout one period.
Thus, if y is a periodic function o f t
where Y, is the root-mean-square value of y, a is any
value of time, and T is the period. If a periodic function is
represented by a Fourier series, then:
Root-sum-square: The square root of the sum of the squares.
Note: Commonly used to express the total harmonic dis-
tortion.
Scintillation: In radiology, luminescence of short duration (of
the order of a few microseconds or less) caused by a
directly or indirectly ionizing particle.
Shunt: A device having appreciable resistance or impedance
connected in parallel across other devices or apparatus,
and diverting some (but not all) of the current from it.
Appreciable voltage exists across the shunted device or
apparatus and an appreciable current may exist in it.
Shunting or discharge switch: A switch that serves to open or
to close a shunting circuit around any piece of apparatus
(except a resistor), such as a machine field, a machine
armature, a capacitor, or a reactor.
Sievert (Sv): The special name for the SI unit of dose equiva-
lent. One sievert equals one joule per kilogram. The pre-
viously used unit, rem, is being replaced by the sievert.
One sievert is equal to 100 rem.
Signal-to-noise ratio: For video cameras, the ratio of input
signal to background interference. The greater the ratio,
the clearer the image.
Skin effect: Concentration of currents on the surface of con-
ductors nearest to the electromagneticfield source produc-
ing them.
Spectrum: 1. (data transmission) The distribution of the am-
plitude (and sometimes phase) of the components of a
wave as a function of frequency. Spectrum is also used to
signify a continuous range of frequencies, usually wide in
extent, within which waves have some specified common
characteristic. 2. (radiation) A distribution of the intensity
of radiation as a function of energy or its equivalent
electric analog (such as charge or voltage) at the output of
a radiation detector.
Stand-by state: State of an equipment which can be main-
tained for long periods and from which it is possible to
move into rapid operation. For medical electron accelera-
tors, state in which working levels of vacuum, temperature
and other parameters are maintained but without the pos-
sibility of selecting the essential operating conditions.
Standing wave linear accelerator: Linear accelerator in
which radiofrequency energy is reflected at both ends of a
tube in such a way that the particles are accelerated in a
standing-wave electromagnetic field.
Target volume: In radiotherapy, region of the patient contain-
ing those tissues which are to be irradiated with a specified
absorbed dose according to a specified time-dose pattern.
Termination of irradiation: Stopping of irradiation without
the possibility of restarting without reselection of all o p
erating conditions, (that means return to the preparatory
state): when the preselected value of dose monitor units is
reached, or when the preselected value of elapsed time is
reached; or by deliberate manual actions; or by the opera-
tion of an interlock; or by preselected value of gantry
angular position in moving beam radiotherapy.
Thermionic cathode: A cathode in which electron emission is
produced by heat. Pertaining to the emission of electrons
as a result of heat.
Transverse electric (TE,,,,,J resonant mode (cylindrical
cavity): In a hollow metal cylinder closed by two plane
metal surfaces perpendicular to its axis, the resonant mode
whose transverse field pattern is similar to the TE,, wave
in the corresponding cylindrical waveguide and for which
p is the number of half-period field variations along the
axis. Note: When the cavity is a rectangular parallelepiped,
the axis of the cylinder from which the cavity is assumed
to be made should be designated since there are three such
axes possible. See: waveguide.
 C-3 UNITS
Transverse-electric wave: 1. (radio wave propagation) An
electromagnetic wave in which the electric field vector
is everywhere perpendicular to the wave normal. 2. (TE
wave) (general) In a homogeneous isotropic medium,
an electromagnetic wave in which the electric field vector
is everywhere perpendicular to the direction of propa-
gation. See: waveguide. 3. (TE,, wave) (rectangular
waveguide) (hollow rectangular metal cylinder) The trans-
verse electric wave for which m is the number of
half-period variations of the field along the x coordinate,
which is assumed to coincide with the larger transverse
dimension, and n is the number of half-period variations
of the field along the y coordinate, which is assumed
to coincide with the smaller transverse dimension. Note:
The dominant wave in a rectangular waveguide is TE,,,:
its electric lines are parallel to the shorter side. See:
guided waves; waveguide. 4. (TE,, wave)(circular
waveguide)(hollow circular metal cylinder) The trans-
verse electric wave for which m is the number of axial
planes along which the normal component of the electric
vector vanishes, and n is the number of coaxial cylinders
(including the boundary of the waveguide) along which
the tangential component of the electric vector vanishes.
Notes: (1) m,, waves are circular electric waves of
order n. The m,, wave is the circular electric wave
with the lowest cutoff frequency. (2) The TE,,, wave is
the dominant wave. Its lines of electric force are ap-
proximately parallel to a diameter.
Transverse electromagnetic (TEM) mode: 1. (fiber optics) A
mode whose electric and magnetic field vectors are both
normal to the direction of propagation. 2. (waveguide) A
mode in which the lon~itudinalcomDonents of the electric
w
and magnetic fields are everywhere zero.
Transverse magnetic (TM) mode: A mode whose magnetic
field vector is normal to the direction of propagation.Note:
In a planar dielectric waveguide (as within an injection
laser diode), the field direction is parallel to the core-clad-
ding interface. In an optical waveguide, transverse electric
(TE) and TM modes cornspond to meridional rays.
Transverse magnetic (TM,,,,nd resonant mode (cylindrical
cavity). In a hollow metal cylinder closed by two plane
metal surfaces perpendicular to its axis, the resonant mode
whose transverse field pattern is similar to the TM,, wave
in the corresponding cylindrical waveguide and for which
p is the number of half-period field variations along the
axis. Note: When the cavity is arectangular parallelepiped,
the axis of the cylinder from which the cavity is assumed
to be made should be designated since there are three such
axes possible. See: waveguide.
Transverse-magnetic hybrid wave (radio wave propaga-
tion): An electromagnetic wave in which the magnetic
field vector is linearly polarized normal to the plane of
propagation and the electric field vector is elliptically
polarized in this plane.
307
Transverse-magnetic wave: 1. (radio wave propagation) An
electromagnetic wave in which the magnetic field vector
is everywhere perpendicular to the wave normal. 2. (TM
wave) (general) In a homogeneous isotropic medium, an
electromagnetic wave in which the magnetic field vector
is everywhere perpendicular to the direction of propaga-
tion. See: waveguide. 3. (TM,, wave)(circular wavegu-
ide)(hollow circular metal cylinder) The transverse
magnetic wave for which m is the number of axial planes
along which the normal component of the magnetic vector
vanishes, and n is the number of coaxial cylinders to which
the electric vector is normal. Note: TMo,, waves are
circular magnetic waves of order n. The wave is the
circular magnetic wave with the lowest cutoff frequency.
See: guided wave; circular magnetic wave; waveguide. 4.
(TM,, wave) (rectangular waveguide)(hollow rec-
tangular metal cylinder). The transverse magnetic wave
for which m is the number of half-period variations of the
magnetic field along the longer transverse dimension, and
n is the number of half-period variations of the magnetic
field along the shorter transverse dimension. See: wave-
guide.
Traveling wave: The resulting wave when the electric varia-
tion in a circuit takes the form of translation of energy
along a conductor, such energy being always equally di-
vided between current and potential forms.
Traveling wave linear accelerator: Linear accelerator in
which radio-frequency energy is applied at one end of a
tube and is absorbed (or recirculated) at the other end in
such a way that particles are accelerated in a traveling
electromagnetic field.
Treatment session: Fractionation: A session is a treatment or
group of treatments delivered in one visit. Fractionation is
the splitting of a dose into a number of short sessions given
over a longer period than would be required if the dose
were given continuously in one session at the same dose
rate. A fraction is a single session in a fractionated treat-
ment. Overall time is the total time elapsing from the
beginning to the end of a session or a series of sessions if
the treatment is fractionated.
Treatment volume: In radiotherapy, region in the patient, to
which the prescribed absorbed dose is delivered.
Triode: A three-electrode electron tube containing an anode,
cathode, and a control electrode.
Volt (V): The unit of potential difference or electromotive
force in the meter-kilogram-second system, equal to the
potential difference between two points for which 1
coulomb of electricity will do 1 joule of work in going
from one point to the other. A battery of cells develops
an electric-potential difference across its terminals by
means of chemical-potential energy. The potential dif-
ference of an ordinary flashlight cell is approximately
1.6 volts.
308 APPENDIX C. MISCELLANEOUS
Waveguide: A system of material boundaries or structures for
guiding electromagnetic waves. Usually such a system is
used for guiding waves in other than TEM modes. Often,
and originally, a hollow metal pipe for guiding electromag-
netic waves.
Wavelength: The distance, for example, between two succes-
sive crests of a wave. Many illustrations of waves are
available, such as: mechanical waves on the surface of
water, along strings, and in air, electromagnetic waves as
in light and x-ray; and so-called matter waves of nuclear
and atomic particles. Matter waves were predicted by de
Broglie in 1923, and the matter waves of electrons were
discovered by Davisson and by G.P. Thomson in 1925.
These developments culminated in the theory of wave
mechanics.
Wedge angle: Angle between the perpendicular to the radia-
tion beam axis and the straight line passing through two
points equidistant from the radiation beam axis located on
the isodose curve, at the measurement depth specified in
a phantom, and separated by a distance equal to half the
irradiation field, for a given irradiation field dimension and
beam energy.
Wedge factor: For a given beam energy and irradiation field,
ratio of the absorbed dose rate in a phantom on the radia-
tion beam axis at the standard measurement depth with the
wedge filter in place to the absorbed dose rate without the
wedge filter.
Wedge filter: Filter which effects stepless change in transmis-
sion over all or a part of the radiation field.

Abbreviations, 297-298
Aberrations, second order, 131
Accelerator cavities, design of, 86-87
Accelerator control, 169- 188
computer control, 170
computer integration of radiotherapy, 181- 187
control console, 169, 177- 178
extreme dose, protection against, 176-177
interlock system, 169- 170,173- 176,256-257
miniaturization and, 170- 171
motion control system, 178- 180
operational states, 173
patient record keeping, 181
record and verify system, 180- 181
semiconductor devices, 171- 173
Accelerator facilities, 24 1-259
human engineering aspects, 257-258
megavoltage therapy accelerator facilities, 244-252
entry doors/mazes, 25 1
multimodality therapy installation, 244-247
patient obse~ation/communication,25 1-252
radioactivation of patient, 252
radioactive and toxic gas production, 252
shielding barrier design, 247-25 1
treatment room design, 247
planningloperational resources, 24 1-244
safety, 256-257
See also Accelerator maintenance
Accelerator guide, multi-x-ray energy accelerators, 191- 193
Accelerator maintenance, 252-256
conventional maintenance, 252-253
downtime experience, 256
expert systems, 254
functional performance, periodic tests of, 255-256
test equipment/instrumentation, 254-255
usageldowntime, 256
Accelerator operational states, 170
Accelerator structures, 49,67-87
accelerator cavities, design of, 86-87
electron interaction with microwave field, 68-70
Index
standing-wave accelerators, 76-82
traveling-wave accelerators, 70-76
standing-wave accelerators compared to, 82-86
Acceptance, beam transport, 115
Accessories, S d r e a t m e n t accessories, simulation
accessories
Achromatic bend magnet systems, 129-134
asymmetric 112 112-degreethree-sector uniform pole gap,
133
symmetrical 180" four-sector uniform pole gap
(isochronous), 133- 134
symmetrical 270" single-sector hyperbolic pole gap, 129
symmetrical 270" single-sector locally tilted pole gap, 129
symmetrical 270" single-sector stepped pole gap, 129- 130
symmetrical 270" three-sector uniform pole gap:
one Cx cross-over, 131- 133
two Cx cross-overs, 130- 131
Achromatic, singly, doubly, 129
Anatomical landmarks, 224
Applicator, See Treatment accessories
Arc therapy, 41
Arteriovenous malformation (AVM), See Sterotactic
surgery
Automatic frequency control (AFC), 19,27, 102- 104
high-energy (klystron), 103- 104
low-energy (magnetron), 102- 103
Automatic wedge, 228
Auxiliary systems:
gas dielectric system, 111- 113
pneumatic system, 113
vacuum systems, 107- 110
water cooling system, 110- 111
Beam collimators, 141, See also Collimation
symmetric vs. asymmetric, 141
Beam emittance, 115
Beam loading:
multi-x-ray energy accelerators, 197
standing-wave accelerators, 80-82
310 INDEX

traveling-wave accelerators, 75-76 Control console, 177- 178

Beam mode, user preferences for, 3-4 Cosine-like rays, 129
electrons, 4 Coupling, 59-62
X-ray energies, 3-4 directional couplers, 98
Beam optics of magnet systems, 115-136 Curative intent, 1, 15, 20
achromatic bend magnet systems, 129-134
beam emittance, 122- 124
bent beam linacs, 115 Defocusing, of electron rays, 119
electron motion in magnetic fields, 116- 122 Depth dose, 3
isocenter height, effect of system choice on, 115-16 Distribution, 25
linac beam characteristics, effect on, 115 Stability, 25
nonachromatic bend magnet systems, 125-129 Digital spatial filtering, 231
straight-ahead linacs, 115 Diode guns, 191
Beam stabilization, See Treatment beam stabilization Dipole magnetic field, electron motion in, 116- 117
Beam steering, 157-159, See also Field uniformity control Direct accelerators, 6
coils, 122 Directional couplers, 98
Beam transport, 122 Dispersion, 62-63
system terminology, 123 Displacement, of electron ray, 115
Beams eye view (BEV), 43,222-223 Divergence, of electron ray, 115
Beamstopper, 140 Dose buildup, 3,23
Beam waist, 124 Dose, depth, 33,37, See also Isodose, skin dose
Bent beam linacs: Dose monitoring, 157-168
beam design, 115 electromagnetic interference and, 166- 167
standing-wave, 12- 13 field uniformity control, 161- 162
vs. straight thru, 139 integrated dose/dose rate, 160- 161
Bend magnet, 18 ionization chamber, 157- 160, See also Electromagnetic
Betatron, 6-7,271-273 interference
Blocking, See Treatment accessories, field shaping systems multimodality treatment units, control of, 162-164
Bremsstrahlung (braking radiation), 275 safety, 160-164
system, 157-162
treatment beam stabilization, 164- 166
Cancer incidence, 1 Dual x-ray energy standing-wave linacs, 13
Cell repair, regeneration, redistribution, reoxygenation, 3 Dynamic therapy, multileaf collimators and, 41-43
Chromaticity, 122
Circular microtron, 14,26 1-263
beam current/focusing, 263 Electromagnetic interference (EMI), 166- 167, 171- 173
cavity power requirements, 261-262 with ionization chamber, MRI, pacemaker
gantry, 263 semiconductor devices and, 171- 173
injection methods for increased energy per orbit, 262 Electron accelerators:
machines for radiotherapy, 263 history of, 6-13
magnet size, 262 betatrons, 6-7,271-273
phase stability, 262-263 direct accelerators, 6,267
Circulators, 95-97 microwave electron linear accelerators (linacs), 7- 13
Collimation, collimators, 41, 141, See also Multileaf recirculating electron accelerator, 13-15,267-268
collimators resonant transformer, 270
Compensators, See Tissue compensators synchrotron, 273
Compton interaction, 279 transformer-rectifier,268-270
Computer control, of accelerator, 170 Van de Graaff, 270-27 1
of treatment, 41-46 Electron beam generation, 278-279. See also Electron therapy
Computer integration of radiotherapy, 181- 187 scattering foils, 143- 144,279
Conformal therapy, multileaf collimators and, 26,28-29, spurious sources, 278-279
4 1-43 Electron boast fields, 189
Contamination of radiation beam, 150 Electron-positron pair production, 279
Contour systems, 207 Electron guns:
Contrast sensitivity, 225 cathode, 67-68,191
 design of, 68 Fluorescent screen, 225
diode, 191 Focusing, of electron rays, 119
multi-x-ray energy accelerators, 191 Fractionation, of treatment course, 2
triode, 191 Frequency instabilities, 26
Electronic portal imaging, 227-238 Fringe field at dipole magnet edge, electron motion in,
lens to TV camera, 233-234 117-119
mechanically rotated multichannel ionization chamber, Functional performance, periodic tests of, 255-256
232
mounting detector on linac, 235
multiwire sequentially pulsed liquid ionization chamber, Gas dielectric system, 111- 113
230-232 Geometric image unsharpness, 225
one-dimensional vs. two-dimensional detectors, 228-230 Greek symbols, 299
silicon detectors, two-dimensional array of, 234 Group velocity, 59
silicon diode linear array, 230 Guide, See Accelerator structures, waveguide
tapered fiber optics to TV camera, 232-233 structure, 11,71, 191-193
two-dimensional amorphous silicon array, 234-235 Guns, See Electron guns
value of, 227-228
Electrons, 4
interaction with microwave field, 68-70 Half-value-layer, 34
motion of electrons, 68-70 Head leakage radiation, See Radiation shielding
motion in magnetic fields, 116- 122 Hemibody x-ray therapy, See Total-body/hemibody x-ray
beam steering coils, 122 therapy
beam transport, 122 High-energy (klystron) automatic frequency control, 103-104
in dipole magnetic field, 116- 117 H-plane tee, 98-99
electron momentum, 116 Hybrid tees, 98-99
in fringe field at dipole magnet edge, 117- 119
in quadruple magnetic field, 119- 120
in solenoid magnetic field, 120- 122 Illuminance (foot-candles), 233
space harmonics, 70 Image plane, 122
Electron synchrotron, betatron and, 27 1-273 Imaging smoothing, 23 1
Electron therapy, 142- 145 Immobilization devices, 208
beam current requirements, 163 Impedance matching, 54-55
electron scanning system, 144- 145 voltage standing-wave ratio and, 55
electron scattering system, 144 Initial seconds of each portal treatment, 26, 190
megavoltage, 37-38 In-line standing wave linacs, 11- 12
microtrons vs. linacs for, 145 Integrated dose/dose rate, monitoring, 160- 161
total skin, 38-39 Interlocks, 169-170, 173-176,256-257
Elementary linac, 50 Interrupting radiation, 169- 170
Emittance, beam, 115 Intraoperative radiation therapy, 39-40
Energy, electron, specification and measurement, 143 Ionization chamber, See also Electromagnetic interference
Energy slit, 125, 190 dose monitoring, 157- 160
Expert systems, accelerator maintenance and, 254 mechanically rotated multichannel ionization chamber,
Extreme dose, protection against, 176-177 232
multiwire sequentially pulsed liquid ionization chamber,
230-232
Facilities, See Accelerator facilities Isocenter height, effect of magnet system choice on, 115- 116
Field clamps, 119 Isocentric linac, 10
Field light and rangefinder, 142 Isochronous, 133
Field shaping systems, 204-205, See also Collimation, Isodose, 33-34,37
Multileaf collimator
Field uniformity control, 161-162, See also Beam steering
Filling time, 20 Klystrons, 8,91-92
Filter, flattening, 141, 147- 148 automatic frequency control, 103- 104
Flattening filter, 18 magnetrons vs., 191
Flexible waveguides, 97-98 multimegawatt klystron, 9
312
Leakage radiation, See Radiation shielding
L i c generated EMI, 171- 172
Local area network, 182
Localization radiograph, 224
Low-energy (magnetron) automatic frequency control,
102-103
Machine interlocks, 169,257
Machine performance requirements, treatment course
fractionation and, 2-3
Magna-field therapy, See Total-body/hemibody x-ray therapy
Magnetic resonance imaging, See MRI
Magnetrons, 8,89-91
automatic frequency control, 102-103
klystrons vs., 191
Magnet systems:
beam optics of, 115-136
isocenter height, effect of system choice on, 115- 116
Magnetic forces, 115
Magnetic minor, 129
Magnification, 119
Maintenance, See Accelerator maintenance
Mean time between failures, 26
Mechanically rotated multichannel
ionization chamber, 232
Mechanical pointers, 208
Medical electron accelerators:
accelerator control, 169- 188
accelerator facilities, 241-259
beam mode, user preferences for, 3-4
betatron, 6-7,271-273
clinical requirements, 22-23,142
precise delivered dose at depth, 22
precise position/orientation/sizeof treatment fields,
22-23
wide variety of radiation modalities, 23
design challenges, 24-26
compactness, 24
dose precision, 24
energy stability, 25
high-dose rate with large fields, 24
initial seconds, 26
treatment beam stability, 24-25
uniform electron treatment beams, 25
uniform x-ray treatment beams, 25
design criteria, 20-2 1
electron accelerators, history of, 6-15,267
electron synchrotron, 27 1-273
energy conversion, summary of steps in, 20
equipment development, future direction of, 27-29
machine performance requirements, treatment course
fractionation and, 2-3
major subsystems/components, 18-20,26-27
modulator/high-voltagepulse transformer, 18- 19
INDEX
radio frequency power sourcelradio frequency power
control, 19-20
microwave acceleration, principle of, 16- 18
need for, 1
reflexotron, 15,267-268
resonant transformer, 270
safety interlocking, 169- 188, See also Interlocking, Safety
interlocking
technology changes, 26
transformer-rectifierunits, 268-270
Van de Graaff generator, 270-271
Medical linacs, elementary description of, 15-16
example, 36-38
Medical microtron accelerators, 261-266
circular microtron, 26 1-263
beam current/focusing, 263
cavity power requirements, 261-262
gantry, 263
injection methods for increased energy per orbit, 262
machines for radiotherapy, 263
magnet size, 262
phase stability, 262-263
racetrack microtron, 263-266
accelerator structure power, 264
alignment precision, 265
configuration, 263-264
extraction, 265
injection, 264
machine for radiotherapy, 266
Megavoltage electron therapy, 37-38
beam current requirements, 163
Megavoltage therapy accelerator facilities, 244-252
entry doorslmazes, 25 1
multimodality therapy installation, 244-247
patient observation/communication, 25 1-252
radioactivation of patient, 252
radioactive and toxic gas production, 252
shielding barrier design, 247-25 1
treatment room design, 247
Megavoltage x-ray therapy, 34-35
beam current requirements, 163
Microtrons, See Medical microtron accelerators
Microwave acceleration, principle of, 16- 18
Microwave cavities, 7-8
Microwave electron linear accelerators (linacs), 7-13,267
accelerator structures, 67-87
beam characteristics, 115
bent beam standing-wave linacs, 12-13
contemporary radiotherapy accelerators, 287-296
dual x-ray energy standing-wave linacs, 13,293-294
first orientable linacs for radiotherapy, 9- 11
first stationary linac for radiotherapy, 9
in-line standing wave linacs for radiotherapy, 11- 12
klystron invention, 8
magnetron invention, 8
 INDEX 313

manufacturers' types, 287-296 standing-wave guide, switching from high to low x-ray
microwave cavities, 7-8 energy in, 193-196
microwave linac invention, 8-9 system feedback control philosophy, 199
microwave principles for, 49-66 traveling-wave guide, switching from high to low energy
multimegawatt klystron invention, 9 in, 193
operating parameters, 38, 163
pioneers, 13
standiig-wave accelerator guide, 11 Neutron activation and leakage, 150- 151
Microwave energy switch, 192, 194 Nonachromatic bend magnet systems, 125-129
Microwave linac, 8-9 Non-contact-type side cavity energy switch, 197
Microwave power sources/systems, 89- 104
automatic frequency control, 102- 104
circulators, 95-97 Object plane, 122
directional couplers, 98 Off-axis portal x-ray tube, 236
flexible waveguides, 97-98 On-axis portal x-ray tube, 236-237
klystrons, 9 1-92 Operational states, accelerator, 170
magnetrons, 89-91 Optical pointers, 208
radio frequency drivers, 92-95 Orientable linacs, 9- 11
rotary joints, 99 Orthovoltage x-ray therapy, 33-34
shuntJserieslhybrid tees, 98-99
water loads, 101- 102
waveguide bends and twists, 97-98 Pacemaker, interference with, 166- 167
waveguide windows, 100- 101 Palliation, 1
Microwaves, 50-5 1 Patient:
Miniaturization, accelerator control and, 170- 171 contour systems, 207
Modes, microwave resonator, 62-63 immobilization devices, 208
Modulation transfer function (MTF), 225,228-229 motion unsharpness, 226
Modulator, high voltage, 16 observation/communication, 25 1-252
Momentum trajectories, 131 position/motion detection, 208-209
Momentum, electron, 116 radiation interactions in, 279-281
Motion control system accelerator, 178- 180 radioactivation of, 252
MRI (magnetic resonance imaging) EM1 interference with, record keeping, 181
166 Patient support assembly, 201-204
Multileaf collimator (MLC), 28,227-228 table support types, 201-203
Multileaf collimators, dynamic and conformal therapy and, table top, 203
41-43 treatment chair, 201,203-204
Multimegawatt klystron, 9 See also Treatment accessories
Multimodality treatment units: Penumbra, 3
control of, 162- 164 Periodic structures, microwave, 59-62
installation, 244-247 Personnel interlocks, 169
Multiwire sequentially pulsed liquid ionization chamber, Phase space admittance, 264
230-232 Phase stability principle, 261
Multi-x-ray energy accelerators, 189- 199 Phase space volume, 123
design alternatives, 191- 199 Phase velocity, microwave, 59
accelerator guide, 191- 193 Photoelectric effect, 279
beam loading, 197 Photon intensity, angular distribution of, 275-276
electron gun, 191 Photon spectrum in portal imaging, 235-237
klystron vs. magnetron, 191 image contrast, dependence on x-ray energy, 236
design challenges, 189- 191 Picture archival and communication system (PACS), 182
clinical need, 189 Pneumatic system, 113
dose distribution/calibration in initial seconds, 190-191 Portal imaging:
electron beam during acceleration, 190 electronic, 227-238
energy stability, 190 off-axis portal x-ray tube, 236
performance requirements, 189- 190 on-axis portal x-ray tube, 236-237
non-contact-type side cavity energy switch, 197 photon spectrum in, 235-237
Portal imaging (cont.):
radiographic (film), 224-227
PositionJmotion detection, 208-209
Pulse-forming network (PFN), 19
Pulse modulators, 105- 107
pulse-forming network (PFW), 105, 106
Quadruple magnetic field, electron motion in, 119-120
Quadruple vs. four pole magnet, 145
Quality of life, 1
Quantum detection efficiency (QDE), 225
Racetrack microtron, 14- 15,263-266
accelerator structure power, 264
alignment precision, 265
configuration, 263-264
extraction, 265
injection, 264
machine for radiotherapy, 266
Radiation beam:
contamination of, 150
energy designation, 33
generation, See Treatment beam generation
penetration, See Dose, depth
types of, 33
Radiation head, geometric restrictions of, 138- 139
accessibility for service, 138
Radiation length, 276
Radiation shielding, 140- 141
materials, 140
neutron, 140
Radioactivation, 150- 151
of patient, 252
Radioactive and toxic gas production, 252
Radio frequency drivers, 92-95
Radiographic (film) portal imaging, 224-227
enhancement techniques, 226-227
physics of, 224-226
Radiosurgery, See Stereotactic radiosurgery
Radiotherapy:
computer integration of, 181- 185
goals of, 1-2
modalities, 33-48
arc therapy, 4 1
conformal therapy, 41-43
dynamic therapy, 41-43
intraoperative radiation therapy, 39-40
megavoltage electron therapy, 37-38
megavoltage x-ray therapy, 34-35
orthovoltage x-ray therapy, 33-34
rotational therapy, See Arc therapy
stereotactic radiosurgery, 43-45
total-body and hemibody x-ray therapy, 35-37
total skin electron therapy, 38-39
organization, procedures, staffing, 2 18,221
Radiotherapy accelerator facilities, See Accelerator facilities
Radius of curvature, 116
Recirculating electron accelerators, 13- 15
circular orbit microtron, 14
racetrack microtron, 14- 15
Reflexotron, 15,267-268
Record and verify system, 180- 181
Record keeping, patient, 181
Reflexotron, 15,267-268
Resonance/resonant cavities, 55-59
Resonant transformer, 270
Rotary joints, microwave, 99
Safety, accelerator facilities, 256-257
collision avoidance, 137
dose monitoring, 160- 164
electromagnetic interference, 166- 167
extreme dose, protection against, 176
interlocking, See Interlocks
Scanned beam dosimetry, 150
x-ray therapy, 150
Scanning system:
electrons, 42-43, 144- 145
x-ray, 42-43, 148-150
Scattering foils, electron, 279
Scattering system, electrons, 144
Series tees, 98-99
Shadow blocking, 224, See also Treatment accessories, field
shaping systems
Shielding barrier design, megavoltage therapy accelerator
facilities, 247-251, See also 140- 141
Shunt impedance, 64-66
Shunt tees, 98-99
Side coupled SW accelerator structure, 7, 11
Signal to noise ratio, 231
Simulators, treatment, See Treatment simulators
Simulator verification, treatment planning and, 221
Sine-like rays, 129
Skin dose, 34
Solenoid magnetic field, electron motion in, 120-122
Space harmonics, electrons, 70
Spatial resolution (line spread function), 231
Standing-wave accelerator guide, 11
Standing-wave accelerators, 76-82
beam loading and load line, 80-82
electron injection and bunching, 79-80
operation, theory of, 76-78
structures, 78-79
traveling-wave accelerators compared to, 82-86
See also Traveling-wave accelerators
Stationary linac, 9
Stereotactic radiosurgery, 43-45
 INDEX 315

Straight-ahead linacs, beam design, 115, See also Bent-beam neutron leakagelradioactivation,150- 151
linacs radiation beam, contamination of, 150
Support assembly, See Patient support assembly radiation head, geometric restrictions of, 138-139
Symbols, 298-299 bent-beam vs. straight-thru design, 139
Symmetrical instabilities in field flatness, 24 scanned beam dosimetry, 150
Synchronous phase, 262 treatment head, See radiation head
x-ray therapy, 146- 150
beam characteristics and subsystem, 146
Target volume, 22 x-ray scanning system, 43, 148-150
Tees, microwave, 98-99 x-ray target and flattening filter, 147- 148
Terminating radiation, 169 Treatment beam stabilization, 164-166, See also Dose
Terminology, 300-308 monitoring requirements, 164
Test equipment/instrumentation,maintenance of, Treatment chair, 201,203-204
254-255 Treatment course fractionation, machine performance
Tissue compensators, 205-207 requirements and, 2-3
Total-bodyfiemibody x-ray therapy, 35-37 Treatment field symmetry, 12
Total skin electron therapy, 38-39 Treatment modalities, See Radiotherapy modalities
Transformer-rectifier units, 268-270 Treatment planning, 220-224
Transit time, 64-66 computer and, 222
Transmission lines, 5 1-53 definition of, 220
types of, 52,53 dose contributions, computation of, 220-221
Traveling electromagnetic wave, 9 resources, 222-224
Traveling-wave accelerators, 70-76 simulator verification and, 221
beam loading and load line, 75-76 Treatment prescription, 157,221-222
electron injection and bunching, 72-75 Treatment room design, megavoltage therapy accelerator
operation, theory of, 70-7 1 facilities, 247
standing-wave accelerators compared to, 82-86 Treatment simulation, 10
structures, 7 1 Treatment simulators, 213-220,257
Treatment, radiotherapy modalities, 33-48 contemporary developments, 219-220
Treatment accessories, 204-209 mechanical features, 2 14-2 16
applicator, electron, 37,40, 143- 144 operational organization, 2 17
field shaping systems, 204-205 radiography/fluoroscopy, 216
mechanical/optical pointers, 208 regulatory requirements, 2 17-2 19
patient contour systems, 207 simulation accessories, 2 17
patient immobilization devices, 208 use of, 2 19
patient positionlmotion detection, 208-209 Treatment tablelcouch:
wedge filtersltissue compensators, 138,205-207 top, 203
Treatment beam generation, 4-6, See also Treatment beam types of, 201-203
production Triode guns, 191
electron beams, 2,778-279 Tumor localization, 10
radiation interactions in patient, 279-281 Tumor volume, 22
x-ray beams, 275-278
Treatment beam production, 137- 156, See also Treatment
beam generation Units, 299-300
ancillary components, 139- 142
beam collimators, 141, See also Collimation, collimator,
multileaf collimator Vacuum systems, 107- 110
field light and rangefinder, 142 Van de Graaff generator, 270-271
radiation shielding, 140- 141 Verification radiograph, 224
electron therapy, 142- 145 Voltage breakdown, 269,271
beam current requirements, 163 Voltage standing-wave ratio, 55
beam requirements and subsystem, 142- 143
electron scanning system, 43, 144- 145
electron scattering system, 144 Water cooling system, 110- 111
microtrons vs. linacs for, 145 Water loads, microwave, 101- 102
316 INDEX

Waveguides: choice of, 276-278

bends and twists, 97-98 x-ray scattering, 278
flexible, 97-98 X-ray energy, 3-4
See also Accelerator structures specification, 140, 146
Waveguide windows, 100- 101 X-ray therapy, 146- 150
Wedge filtersltissue compensators, 138,205-207 beam current requirements in, 18, 163
megavoltage, 34-35
orthovoltage, 33-34
X-ray beam generation, 275-278, See also 146-150 scanned beam dosimetry, 150
angular distribution of photon intensity, 275-276 scanning system, 148- 150
photon spectra on axis of unflattened lobe, 275 total-body/hemibody, 35-37
target material/thickness: x-ray target and flattening filter, 147-148