Wedges

The wedge technique is most commonly utilized to alter the dose distribution and achieve an
even/homogenous dose distribution across PTV

Why wouldn’t the distribution be even?

1. beam arrangement
2. beam weightings
3. density variations
4. a change in contour

Wedges try to optimise the plan by adjusting or compensating for these factors

In the past, a physical metal wedge was mounted on the linear accelerator (LINAC), but
modern LINACs have an enhanced dynamic wedge (EDW) by the use of the collimator jaws
to mimic the alteration of the dose distribution obtained from a physical wedge. In using an
EDW, one collimator jaw will close to the other collimator jaw and nearly make contact with
the other jaw. When the beam turns on, the collimator jaw will then move back out to open
the field size which will “spill” photons into the open field. The speed at which the collimator
jaw opens will reflect the thickness of the wedge, and the area under the field which is
blocked for a longer time period will reflect the direction of the thick end of the wedge.

1. Right click on a field and select on properties.

2. Go to the accessories tab and select a wedge ID. Depending on the orientation of the
wedge, a collimator rotation may be required to have the wedge face in your intended
direction. Wedges are most commonly used at collimator rotations of 0° and 90°.

3. Use the different planes to verify that the wedge is orientated in the correct direction
and proceed to calculate. With every modification to the wedge, a re-calculation will
be required.
Field in Field

The field-in-field technique is a method improving dose homogeneity by decreasing regions

of high dose by utilizing field-in-fields. A field-in-field or a subfield is a copy of the primary
field (e.g. 01 RT MED -> 01 RT MED.0) which can be created by right clicking on a field and
selecting “new field in field”. The MLC leaves of the field-in-field can be moved to block
regions of high dose, and by transferring monitor units (MU) from the primary field onto the
field-in-field via field weighting, dose deposition in these blocked regions will reduce. As long
as all the field sizes remain identical and the MLC leaves of the field-in-field do not extend
beyond their physical limitation, both can eventually merge to form a sliding window. Doing
so will allow a radiation therapist to treat the primary field and its respective field-in-fields in
one go allowing for a reduction in treatment time. There are different variations as to how
planners may utilize the field-in-field technique, but the following instructions are only a basic
overview:

1. Open the isodose levels tab, and check 3D for the highest isodose line. Change the
highest isodose line to a value that is 3%-5% lesser than the current maximum
hotspot and on the Beam’s Eye View (BEV) of any field, the select isodose line
should appear as a 3D cloud of dose. For example, if the maximum hotspot is 121%,
change the highest isodose line to 116%-118%. Changing the maximum hotspot by
3%-5% at a time is a recommendation because blocking a larger surface area can
result in creating dips and holes in your dose distribution.

2. Create a field-in-field from the primary field by using the function “new field in field”.

3. On the BEV of the field-in-field, bring in the MLC leaves to cover the 3D isodose line.

4. Calculate the plan after finalizing your changes. With any change in the MLC leaf
position, the plan must re-calculated for.

5. Open the field weighting tab, and transfer weighting from the primary field onto the
field-in-field. If there is other field-in-fields present, only perform weighting between
the involved fields.

6. Repeat this procedure for each subfield until the maximum hotspot is satisfactory.

It is recommended that every field-in-field comes close to meeting the following criteria:

1. Field-in-field gives more than 5 MU.

2. Field-in-field gives no more than 10-12 MUS.

3. Maximum of 3 field-in-fields per primary field.

Basic Checklist
1. Transfer the CT images to the treatment planning system (TPS) and verify that the
patient information and the number of slices are accurate.

2. Rename the CT and structure set appropriately.

 The CT and structure set should be named based on the site of treatment and
the date that the treatment CT took place; e.g. RT BREAST 11_20_17.

3. Set the user origin to the coincident location where the AP and lateral BBs intersect
unless the user origin was manually set by the physician at the CT simulation. This is
the point at which the therapists will align the patient to prior to making isocentre
shifts as used in the plan.

4. Import the appropriate plan template according to the treatment machine and
technique to be used for the treatment. Using the template will automatically insert
fields and setup fields with the correct specifications (Verify room geometry).

 Rename the plan based on the treatment site; e.g. RT BREAST.

5. Fuse any ancillary images (PET/MRI/previous CT) to the current treatment CT scan
that is requested by the physician.

6. Import the appropriate structure set template for the treatment site, and delete
structures that will be unused for the plan.

7. Create two reference points that are attached to the treatment volume structure:

 e.g. RT BREAST – delete this reference point from the image only, and, in the
prescription tab, set it to be the primary reference point, which will tracks how
much dose the patient has received from daily treatment.

 e.g. RC_RT BREAST – the Radcalc point to be used to calculate the plan. In
a 3D plan, it can be used to be a point to prescribe dose to in Plan
Normalization. In IMRT/VMAT plans, this reference point is strictly for Radcalc
use.

8. Create all the fields that will be used in this treatment.

 Try to use gantry, couch, and collimator rotations of whole numbers, ideally in
increments of 5.

 Avoid X/Y/Z shifts if doing so offers no significant dosimetric advantage. If

shifts are used, round to a whole number or to the tenths decimal place
unless extreme precision is required; e.g. SRS.

9. Apply and/or verify the appropriate beam parameters (e.g. name, energy, dose rate,
beam tolerance), geometry, and room geometry.

 The ID and Name will be identical and are written based on the total number
of beams in all courses, the gantry angle, the orientation, and/or the direction
of arc:

 3D Plan: 01 RT LAT, 02 RT MED, 03 RAO, 04 LAO, 05 AP, 06 PA.

 Static Field: 01 G60, 02 G120, 03 G150.

  VMAT Arcs: 01 RA CCW, 02 RA CW, 03 RA CCW.

 Arrange the fields in CCW order to minimize patient time on the table.

 Dose Rate should be 400 MU/min for 3D plans, 600 MU/min for most static
IMRT plans, 600 MU/min for VMAT, 1400 MU/min for 6X FFF, and 2400
MU/min for 10X FFF.

 Tolerance should be CL21EX for photons, 21EX ELC for electrons, or

SRS_SRT_SBRT for SRS/SRT/SBRT.

 Set the Room Geometry to the following specifications: Couch Vrt at 0, Couch
Lng at +100, Couch Lat at 0, Imager Vrt at +50, Imager Lng at 0, and Imager
Lat at 0.

 For an electron plan, the SSD of the field should be 100 CM or greater in
increments of 5 CM (105 CM, 110 CM, etc.):

 Set block properties to “eTray” and “Aperture”.

 Remember to print the block out in the BEV at 95 CM.

 Check for any possible collision issues for all fields.

10. Create setup fields based on what is necessary for the treatment machine. Though a
3D plan template on the SIL calls for 9 setup fields (CBCT, kV AP/LATs/PA, MV
AP/LATs/PA), a prone breast plan will require you to add only one kV PA setup field.

 MV setup fields will have a tolerance of CL21EX.

 kV and CBCT setup fields will have a tolerance of OBI.

11. Attach a digitally reconstructed image (DRR) to every field according to the treatment
area.

12. Input the correct dose prescription (verify that the dose/fraction and fractions are not
mixed up).

13. If field-in-field technique is utilized, merge the subfields into a new plan. Name the
new plan to be the treatment area, and rename the old plan to “subfields”.

 Re-add DRRs to all the fields of the new plan.

 Re-normalize the new plan to the original intended normalization (now

renamed to “subfields”).

14. Export the plan to RadCalc.

 3D plan: Do not include setup fields or structure set.

 Verify beam specifications (SSD/bolus/RC point/etc.)

 Adjust the equivalent path and SSD under the “Points & Off Axis
Assistance” tab. These values are found in the plan by going to Print
-> Report -> Stony Brook Short Summary> Preview.
  Dose difference must be within 3% for 3D plans, or 5% for field-in-field
& EDW & electron technique plans, or 1% of the fractional dose for
either type of plan.

 IMRT/VMAT plan: Include the structure set but not the setup fields.

 Verify beam specifications (SSD/bolus/RC point/etc).

 Calculate.

 Dose difference must be within 5% or 1% of the fractional dose

difference for all fields.

 Go to the “MLC Data” tab -> Volume Average Dose -> Select the
number closest to 0%.