Total skin electron therapy in the lying‐on‐the‐floor position using a customized flattening filter to accommodate frail patients

A total skin electron (TSE) floor technique is presented for treating patients who are unable to safely stand for extended durations. A customized flattening filter is used to eliminate the need for field junctioning, improve field uniformity, and reduce setup time. The flattening filter is constructed from copper and polycarbonate, fits into the linac's accessory slot, and is optimized to extend the useful height and width of the beam such that no field junctions are needed during treatment. A TSE floor with flattening filter (TSE FF) treatment course consisted of six patient positions: three supine and three prone. For all treatment fields, electron beam energy was 6 MeV; collimator settings were an x of 30 cm, y of 40 cm, and θcoll of 0°; and a 0.4 cm thick polycarbonate spoiler was positioned in front of the patient. Percent depth dose (PDD) and photon contamination for the TSE FF technique were compared with our standard technique, which is similar to the Stanford technique. Beam profiles were measured using radiochromic film, and dose uniformity was verified using an anthropomorphic radiological phantom. The TSE FF technique met field uniformity requirements specified by the American Association of Physicists in Medicine Task Group 30. TSE FF R80 ranges from 4 to 4.8 mm. TSE FF photon contamination was ~ 3%. Anthropomorphic radiological phantom verification demonstrated that dose to the entire skin surface was expected to be within about ±15% of the prescription dose, except for the perineum, scalp vertex, top of shoulder, and soles of the feet. The TSE floor technique presented herein eliminates field junctioning, is suitable for patients who cannot safely stand during treatment, and provides comparable quality and uniformity to the Stanford technique.