TECHNIQUE AND DOSIMETRY

TOTAL SKIN ELECTRON

THERAPY
INTRODUCTION
INTRODUCTION

OVERVIEW
▸ Total Skin Electron Therapy (TSET) is a method using electrons to treat
entire surface of patient’s skin

▸ Most commonly used to treat a T-Cell Lymphoma called Mycosis

Fungoides, which affects the skin

▸ Patient stands naked in front of LINAC which is meters away, commonly

doing specific poses or standing on a rotary platform

▸ TSET treatments are commonly given in 36 Gy given in 36 fractions at

four a week for nine weeks

▸ Entire body may be treated each fraction, or treatments may be split

between upper and lower body
INTRODUCTION

OVERVIEW
▸ Some areas may need boosts, such as palms of hands and soles of
feet, anal area

▸ Eyes, nails, and scalp may need extra shielding

▸ Extended SSD usually can’t cover entire patient, so upper and

lower fields given

▸ Plexiglass degrader used to scatter electrons (and lower energy)

to be a uniform field (within 8% vertical and 4% horizontal
unformities)

▸ Uses in vivo dosimetry, computer dosimetry not practical

INTRODUCTION

SIDE-EFFECTS

▸ Skin - red and irritated, feeling and looking like a sunburn

▸ Hair - all hair on the body will be lost

▸ Nails - fingernails and toenails will fall off if treated

▸ Sweat glands - may not work as well, at risk for

overheating

▸ Other - standard radiotherapy symptoms including poor

appetite, fatigue, swelling
IRRADIATION
REQUIREMENTS
IRRADIATION REQUIREMENTS

TREATMENT GOAL

▸ To uniformly treat the the patients skin to a shallow depth

▸ Uniformity Achievability: 8% vertical, 4% horizontal over

centra 160 x 60 cm2 of field

▸ Field Size: Large enough to encompass patient

▸ Treatment depth: 50% isodose line to be 0.5 - 1.5 cm deep

▸ Dose Rate 0.25 Gy/min 3 meter from treatment head

IRRADIATION REQUIREMENTS

ELECTRON BEAM
▸ Since many electrons enter patient obliquely, energy must be higher than
using 2 MeV / (g / cm2) approximation.

▸ As electron beam travels towards patient, energy decreases and energy

spread increases

▸ Most probable energy ( Ep,0) is 1.95 Rp + 0.48

▸ Mean energy (E0) = 2.33 R50

▸ about 3-7 MeV at patient

▸ Accelerator energies (Ea) 4 to 10 MeV

▸ Mean entrance energy (Ez) is Eo(1-z/Rp)

IRRADIATION REQUIREMENTS

X-RAY BACKGROUND

▸ An electron contamination of 1% or less (by contributing

dose) is desired. Though, it varies form 1 to 4% depending
on electron energy. 4% is considered unacceptable by
many practitioners.

▸ Can be reduced by angling beam so peaks of x-rays lie

outside body
IRRADIATION REQUIREMENTS

DOSE RATE

▸ High dose rate preferred

▸ This is due to having elderly and weak patients in

difficult to hold positions

▸ Dose rate varies from 0.25 to several Gy per minute

IRRADIATION REQUIREMENTS

SHIELDING AND SAFETY

▸ Treatment Rooms must have enough space between the

patient and the accelerator head to treat, somewhere from
2 to 7 meters.

▸ Significant ozone production, so frequent change of air in

room is essential

▸ Electron range is 4 meters per MeV in air

IRRADIATION
TECHNIQUES
IRRADIATION TECHNIQUES

OVERVIEW

▸ Rotary technique considered best

▸ Eight field technique gives almost-as-good results as

rotary technique, but difficult to carry out so another
almost-as-good six field technique is commonly used

▸ Lucite energy degrader commonly placed 20 cm in front

of patient to scatter electrons and improve dose
uniformity. It is important to place the scatterer near the
patient so there is a high amount of lateral spread.
IRRADIATION TECHNIQUES

HISTORICAL TECHNIQUES
▸ Van de Graff narrow (1cm x 45 cm)
beams

▸ Scattered single beam

▸ Parallel beam pair

▸ Angled beam pair

▸ Pendulum-Arc

▸
IRRADIATION TECHNIQUES

STRONTIUM-YTTRIUM 90
▸ Wide spatial divergence

▸ Wide range of energies (1.12 MeV average, 2.18 MeV max)

▸ Long treatments (~15 minutes per field vs. 4 minutes per field for
LINAC)

▸ Poorer uniformity when compared to accelerators

IRRADIATION TECHNIQUES

NARROW RECTANGULAR BEAMS

▸ Fixed position Van de Graff

▸ 1.5 to 4.5 MeV at accelerator

▸ Patient moved translationally in four or more positions

▸ Electron travels through collimator 1cm x 45 cm just above

patient, right angle compared to couch
IRRADIATION TECHNIQUES

SCATTERED SINGLE BEAM

▸ LINAC Based

▸ Energy about 6.5 MeV at accelerator window

▸ Polystyrene flattening filter mounted to treatment head

▸ Long treatment distance (7 meters

▸ 8% uniformity for 1 meter radius circle

▸ Polystyrene scatterer and flattening filter attached to

treatment head
IRRADIATION TECHNIQUES

PAIR OF PARALLEL BEAMS

▸ Short treatment distance (2 meters)

▸ Energy is 8 MeV at accelerator

▸ 150 cm vertical separation between beams

▸ 5% uniformity, 200 cm treatment height

IRRADIATION TECHNIQUES

PAIRS OF ANGLED BEAMS

▸ Basis for six dual fields (described in depth later)

▸ Fields overlap joining at 50% isodose level

▸ 20 degree beam angles

▸ Treatment plane 3 meters from scatterer

▸ 0.7% x-ray background

▸ External scatterer several meters from patient

IRRADIATION TECHNIQUES

PENDULUM ARC

▸ Uses 50 degree arc

▸ Energy 8 MeV at accelerator window

▸ Plexiglass scatterer 5 cm from patient

▸ High x-ray contamination, > 4%

IRRADIATION TECHNIQUES

PATIENT ROTATION
▸ Patient on rotary platform

▸ Two scatterers, one outside of treatment window and one 20 cm

from patient

▸ Many methods, some are able to have dose calculated and be in

good agreement with measured, but may have higher x-ray
contamination

▸ Simplifies setup and treatment times and compensate for patient

motion

▸ Can be combined with other techniques

SIX DUAL-FIELD
IRRADIATION TECHNIQUE
SIX DUAL-FIELD IRRADIATION TECHNIQUE

OVERVIEW

▸ Technique described in-use at Stanford in 1987

▸ Isocentric LINAC

▸ Six dual fields in alternating sets of three (AP/PA and

Obliques)

▸ Complex, but can be done in moderate sized treatment

room

▸ Can be delivered in multiple beams, a single beam, or full

array of six dual-field beams
SIX DUAL-FIELD IRRADIATION TECHNIQUE

SINGLE HORIZONTAL BEAM

▸ Scatterer is a mix of aluminum and
presswood

▸ Max dose at 0.4 g/cm^2 and 0 at

2.4 g/cm^2

▸ 2% x-ray background

▸ 4.2 MeV at treatment plane and 8

MeV at accelerator

▸ Long distances need to be used to

cover patient height
SIX DUAL-FIELD IRRADIATION TECHNIQUE

SINGLE HORIZONTAL BEAM

▸ Scatterer is a mix of aluminum and
presswood

▸ Max dose at 0.4 g/cm^2 and 0 at

2.4 g/cm^2

▸ 2% x-ray background

▸ 4.2 MeV at treatment plane and 8

MeV at accelerator

▸ Long distances need to be used to

cover patient height
SIX DUAL-FIELD IRRADIATION TECHNIQUE

DUAL-FIELD BEAMS
▸ Most probable energy at phantom surface is
3.8 MeV, calculated from from Rp of 1.7 cm

▸ Mean energy at phantom surface is 2.6 MeV,

calculated from R50 of 1.1 cm

▸ 0.7% average contamination of a single field

and 1.5% contamination for a full set of six
fields (at any point three fields contribute
electron dose and all six fields are
contributing photon dose

▸ Dose uniformity is 4% all over the body

▸ Specific angle of 20 degrees was chosen to

maximize vertical dose uniformity
SIX DUAL-FIELD IRRADIATION TECHNIQUE

DUAL-FIELD BEAMS
▸ Most probable energy at phantom surface is
3.8 MeV, calculated from from Rp of 1.7 cm

▸ Mean energy at phantom surface is 2.6 MeV,

calculated from R50 of 1.1 cm

▸ 0.7% average contamination of a single field

and 1.5% contamination for a full set of six
fields (at any point three fields contribute
electron dose and all six fields are
contributing photon dose

▸ Dose uniformity is 4% all over the body

▸ Specific angle of 20 degrees was chosen to

maximize vertical dose uniformity
SIX DUAL-FIELD IRRADIATION TECHNIQUE

SIX DUAL-FIELD BEAMS

▸ Up to 10% dose variation at
patient surface, or 5% at 3 mm

▸ Very rapid dose fall-off

LINAC OPERATING
CONDITIONS
LINAC OPERATING CONDITIONS

LINAC OPERATING CONDITIONS

▸ Beam current may need to be 100x higher than traditional

electron therapy for some setups

▸ Flattening filter for x-rays may absorb up to 90% of CAX

intensity
LINAC OPERATING CONDITIONS

BEAM SCATTERERS AND ENERGY DEGRADERS

▸ Energy degraders are thick materials

▸ Beam scatterers are thin materials

▸ Should be interlocked

▸ All degraders create some scatter, and all scatterers rate

some beam degradation
LINAC OPERATING CONDITIONS

BEAM MONITORING
▸ Absorbed dose or fluency should be monitored

▸ This may be monitored through ion chamber in treatment head

▸ Due to high fluence rates in TSET, ion chamber recombination affect

may be significant

▸ Three chamber position options

▸ Transmission chamber in treatment head

▸ External chamber near front of treatment head

▸ External chamber near patient

DOSIMETRY AND
INSTRUMENTATION
DOSIMETRY AND INSTRUMENTATION

DOSIMETRY METHODS
▸ Suitable detectors include ionization chambers, film, TLDs, Fricke
dosimeters, electron collectors, and Faraday cups

▸ Water phantom scanning needs small thimble chambers. Parallel

plate chambers with a thin window are beneficial for depth dose
curves

▸ Diodes for good when high spatial resolution is needed.

▸ Film can be used in water but it is difficult to minimize air gaps

▸ TLD chips are are valuable but need to be compared to an ion

chamber. TLD powder in a capsule could be too bulky
DOSIMETRY AND INSTRUMENTATION

DOSIMETRY PHANTOMS

▸ No phantom perfectly mimics tissue

▸ Water is commonly used as a phantom

▸ For a dry phantom, polystyrene is commonly used due to

it’s electron density being close to that of tissue
DOSIMETRY AND INSTRUMENTATION

DOSIMETRY MEASUREMENTS

▸ Uncertainty arise due to geometric complexity of the body

▸ PDD can be obtained through a PPC in polystyrene

▸ Electron fluence can be found with a Faraday Cup

▸ 1 Gy on the skin is 0.5 nC/cm2

▸ Plane can be taken with a scanning water phantom in air,

moving the phantom to overcome field size limitations
DOSIMETRY AND INSTRUMENTATION

MULTIPLE FIELD MEASUREMENTS

▸ Because electrons enter patient at an angle the dose is

moved towards the skin surface. Consequently, the
patient’s dose distribution varies wildly and is determined
by angle between entering beam and patient’s curvature.

▸ More fields produces a more uniform dose

▸
DOSIMETRY AND INSTRUMENTATION

CALIBRATION POINT DOSE MEASUREMENTS

▸ Dose is at calibration point (0,0,0) as shown in figure.

▸ Procedure based on TG-21, with E0 found as discussed in

report.

▸ A parallel plate chamber in a polystyrene phantom is used

▸ Air volume of chamber surrounded by polystyrene to at

least 1 cm in rear and 5 cm radially. Single dual field
exposure will be employed
DOSIMETRY AND INSTRUMENTATION

TREATMENT SKIN DOSE MEASUREMENTS

▸ Calibration dose related to skin dose by a multiplicative

factor, B.

▸ Typically 2.5 to 3.1

▸ Uncertainty in this factor and skin dose should be

stressed with physician
DOSIMETRY AND INSTRUMENTATION

PRECAUTIONS AND ROUTINE CHECKS

▸ There should be a written procedure for how to change

treatment setup form conventional to TSET

▸ Redundancy to dose monitoring should be added

▸ Some centers color code treatment forms so modality is

easily recognizable
PATIENT
CONSIDERATIONS
PATIENT CONSIDERATIONS

PATIENT POSITIONING
▸ Goal: Avoid patient self-shielding

▸ Method: Rotary platform and

different poses for patient

▸ Knees should not be locked, patient

should be encouraged to move
slightly for comfort

▸ Patient monitor necessary to see if

patient has fallen

▸ Expect 25 minute treatment slot time

PATIENT CONSIDERATIONS

PATIENT SUPPORT DEVICES

▸ Consider possibility of patient fatigue

▸ Thin and wide patient belt attached to wall/framework for

auxiliary support

▸ If patient can not stand, they can lie on the floor

▸ Patient should not be exposed to any sharp objects

▸ Overhand straps can be used for support

▸ Styrofoam templates can be used for positioning, such as for

feet
PATIENT CONSIDERATIONS

PATIENT SHIELDING

▸ Lens of eyes will be shielded.

▸ If eyelids are treated, shields are internal

▸ 2mm lead common thickness with 15-25% transmission

▸ Up to 50% backscatter dose can be created

▸ Fingernails and toenails shielded by shaped lead

▸ Therapist can shield parts of patients where erythema or

swelling occurs
PATIENT CONSIDERATIONS

LOCAL BOOST FIELDS

▸ In-Vivo measurements identify areas needing boosts with

electrons or low energy photons

▸ Areas needing boosts

▸ Soles of feet, perineal, dorsal surface of penis, peri-anal

region, inframammary region if breasts large, top of
head, ear canal, skin folds

▸ This bra may eliminate need for inframammary booss

PATIENT CONSIDERATIONS

IN-VIVO DOSE MEASUREMENTS

▸ Used for determination of dose distribution and prescribed dose

▸ Small ion chambers, diodes, film, and TLD may be used for measurement

▸ At least 40 areas need to be measured during implementing a new technique, making ion chambers
and diodes impractical

▸ Large amounts of film is used in this and there may be air gaps, so its use is questionable

▸ Therefore TLD is logical choice

▸ TLD calibration can differ by 10% from Co-60 to 4 MeV electron calibration, so make sure to use electron
beam that is used clinically for TSET

▸ Dose % varies across body, most parts of the foot receive 10-25% more dose than the body, and many
areas receive 20% less dose than the reference point such as the forehead, scalp, wrist, palm, axilla, and
medial thigh.

▸ These variations are technique independent

▸ Dose must be modified to response and recurrence of the disease