Hofstra AAPM TG 51 Calibration Protocol Specify Beam Quality Discussion

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Reports: Write a one page summary on how AAPM TG-51 Calibration Protocol (Section VIII.B and VIII.C) and IAEA TRS-398 Calibration Protocols (Section 6.3 and 7.3) specify beam quality for high-energy photon and electron beams.

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IAEA TRS-398 Absorbed Dose Determination in External Beam Radiotherapy: An International Code of Practice for Dosimetry based on Standards of Absorbed Dose to Water Pedro Andreo, Dosimetry and Medical Radiation Physics Section, IAEA David T Burns, Bureau International des Poids et Measures (BIPM) Klaus Hohlfeld, Physikalisch-Technische Bundesanstalt (PTB), Braunschweig, Germany M Saiful Huq, Thomas Jefferson University, Philadelphia, USA Tatsuaki Kanai, National Institute of Radiological Sciences (NIRS), Chiba, Japan Fedele Laitano, Ente per le Nuove Tecnologie L’Energia e L’Ambiente (ENEA), Rome, Italy Vere Smyth, National Radiation Laboratory (NRL), Christchurch, New Zealand Stefaan Vynckier, Catholic University of Louvain (UCL), Brussels, Belgium PUBLISHED BY THE IAEA ON BEHALF OF IAEA, WHO, PAHO, AND ESTRO INTERNATIONAL ATOMIC ENERGY AGENCY IAEA 05 June 2006 (V.12) The originating Section of this publication in the IAEA was: Dosimetry and Medical Radiation Physics Section International Atomic Energy Agency Wagramer Strasse 5 P.O. Box 100 A-1400 Vienna, Austria ABSORBED DOSE DETERMINATION IN EXTERNAL BEAM RADIOTHERAPY: AN INTERNATIONAL CODE OF PRACTICE FOR DOSIMETRY BASED ON STANDARDS OF ABSORBED DOSE TO WATER IAEA, VIENNA, 2000 ISSN 1011–4289 © IAEA, 2000 Printed by the IAEA in Austria 2000 II FOREWORD The International Atomic Energy Agency published in 1987 an International Code of Practice entitled Absorbed Dose Determination in Photon and Electron Beams (IAEA Technical Reports Series No. 277), recommending procedures to obtain the absorbed dose in water from measurements made with an ionization chamber in external beam radiotherapy. A second edition of TRS-277 was published in 1997 updating the dosimetry of photon beams, mainly kilovoltage x-rays. Another International Code of Practice for radiotherapy dosimetry entitled The Use of Plane-Parallel Ionization Chambers in High-Energy Electron and Photon Beams (IAEA Technical Reports Series No. 381) was published in 1997 to further update TRS-277 and complement it with respect to the area of parallel-plate ionization chambers. Both codes have proven extremely valuable for users involved in the dosimetry of the radiation beams used in radiotherapy. In TRS-277 the calibration of the ionization chambers was based on primary standards of air kerma; this procedure was also used in TRS-381, but the new trend of calibrating ionization chambers directly in a water phantom in terms of absorbed dose to water was introduced. The development of primary standards of absorbed dose to water for high-energy photon and electron beams, and improvements in radiation dosimetry concepts, offer the possibility of reducing the uncertainty in the dosimetry of radiotherapy beams. The dosimetry of kilovoltage x-rays, as well as that of proton and heavy-ion beams whose interest has grown considerably in recent years, can also be based on these standards. Thus a coherent dosimetry system based on standards of absorbed dose to water is possible for practically all radiotherapy beams. Many Primary Standard Dosimetry Laboratories (PSDLs) already provide calibrations in terms of absorbed dose to water at the radiation quality of 60Co gamma-rays. Some laboratories have extended calibrations to high-energy photon and electron beams or are in the stage of developing the necessary techniques for these modalities. Following the recommendations in 1996 of the IAEA Standing Advisory Group “Scientific Committee of the IAEA/WHO SSDL Network”, a Co-ordinated Research Project was undertaken during 1997-1999 with the task of producing a new International Code of Practice based on standards of absorbed dose to water. The group of authors were P Andreo (IAEA), D T Burns (BIPM), K Hohlfeld (Germany), M S Huq (USA), T Kanai (Japan), F Laitano (Italy), V G Smyth (New Zealand) and S Vynckier (Belgium). The Code of Practice is also endorsed by the World Health Organization (WHO), by the Pan American Health Organization (PAHO), and by the European Society of Therapeutic Radiology and Oncology (ESTRO). The final draft was reviewed by representatives of the organizations endorsing the Code of Practice and by a large number of scientists whose names are given in the list of contributors. The present Code of Practice fulfils the need for a systematic and internationally unified approach to the calibration of ionization chambers in terms of absorbed dose to water and to the use of these detectors in determining the absorbed dose to water for the radiation beams used in radiotherapy. The Code of Practice provides a methodology for the determination of absorbed dose to water in the low-, medium- and high-energy photon beams, electron beams, proton beams and heavy-ion beams used for external radiation therapy. The structure of this Code of Practice differs from TRS-277 and more closely resembles TRS-381 in that the practical recommendations and data for each radiation type have been placed in an individual section devoted to that radiation type. Each essentially forms a different Code of Practice including detailed procedures and worksheets. The Code of Practice is addressed to users provided with calibrations in terms of absorbed dose to water traceable to a PSDL. This category of users is likely to become the large majority since most standard laboratories are prepared or are planning to supply calibrations in terms of absorbed dose to water at the reference radiation qualities recommended in this Code of Practice. Users who are not yet provided with calibrations in terms of absorbed dose to water, may still refer to the current air-kerma based Codes of Practice, such as TRS-277 (2nd edition, 1997) and TRS-381, or adopt the present document using a calibration factor in terms of absorbed dose to water derived from an air kerma calibration as described in the text. Whatever procedure be used, the user is strongly advised to verify III exactly what physical quantity has been used for the calibration of the reference dosimeter in order to apply the correct formalism. Every user is invited to test critically the present edition of the International Code of Practice and submit comments to: Head, Dosimetry and Medical Radiation Physics Section Division of Human Health International Atomic Energy Agency, P.O. Box 100, A-1400 Vienna, Austria e-mail: dosimetry@iaea.org fax: +43 1 26007 EDITORIAL NOTE In preparing this publication for press, staff of the IAEA have made up the pages from the original manuscript(s). The views expressed do not necessarily reflect those of the IAEA, the governments of the nominating Member States or the nominating organizations. Throughout the text names of Member States are retained as they were when the text was compiled. The use of particular designations of countries or territories does not imply any judgement by the publisher, the IAEA, as to the legal status of such countries or territories, of their authorities and institutions or of the delimitation of their boundaries. The mention of names of specific companies or products (whether or not indicated as registered) does not imply any intention to infringe proprietary rights, nor should it be construed as an endorsement or recommendation on the part of the IAEA. IV AUTHORS P. Andreo International Atomic Energy Agency (IAEA) D. T. Burns Bureau International des Poids et Measures (BIPM) K. Hohlfeld Physikalisch-Technische Bundesanstalt (PTB), Braunschweig, Germany M. S. Huq Thomas Jefferson University, Kimmel Cancer Center of Jefferson Medical College Philadelphia, PA, USA T. Kanai National Institute of Radiological Sciences (NIRS), Chiba, Japan F. Laitano Ente per le Nuove Tecnologie L’Energia e L’Ambiente (ENEA), Instituto Nazionale di Metrologia delle Radiazioni Ionizzanti, Rome, Italy V. G. Smyth National Radiation Laboratory (NRL), Christchurch, New Zealand S. Vynckier Catholic University of Louvain (UCL), Cliniques Universitaires St-Luc Brussels, Belgium The organizations endorsing this International Code of Practice (IAEA, WHO, PAHO and ESTRO) wish to acknowledge valuable suggestions and criticism from P Allisy-Roberts (BIPM) J F Boas (AUS) M Bucciolini (ITA) F Delaunay (FRA) A DuSautoy (GBR) J E Grindborg (SWE) R B Huntley (AUS) L H Kotler (AUS) C Ma (USA) M McEwen (GBR) B Mijnheer (NLD, for ESTRO) B Nilsson (SWE) A Palm (SWE) K Rosser (GBR) G Sernbo (SWE) G Stucki (CHE) D V Webb (AUS) S Belletti (ITA) A Bridier (FRA) J E Burns (GBR) L A DeWerd (USA) I Ferreira (FRA) A Guerra (ITA) H Järvinen (FIN) S Lassen (DNK) G Marinello (FRA) J Medin (SWE) R M Millar (AUS) H Nyström (DNK) M Pimpinella (ITA) R Sabattier (FRA) J Seuntjens (CAN) H Svensson (SWE, for ESTRO) H Bjerke (NOR) A Brosed (ESP) J Chavaudra (FRA) S Duane (GBR) C Ginestet (FRA) G Hartmann (DEU) K-A Johansson (SWE) L Lindborg (SWE) O Mattsson (SWE) C Moretti (GBR) P S Negi (IND) H Palmans (BEL) M M Rehani (IND, for WHO) R J Schulz (USA, for PAHO) K Shortt (CAN) J Van Dam (BEL) V CONTENTS 1. INTRODUCTION........................................................................................................................13 1.1. 1.2. 1.3. 1.4. 1.5. 1.6. 1.7. 2. FRAMEWORK............................................................................................................................23 2.1. 2.2. 3. 3.1. 3.3. Formalism ..........................................................................................................................27 3.1.1. Reference conditions ...............................................................................................27 3.1.2. Influence quantities .................................................................................................27 Correction for the radiation quality of the beam, kQ,Qo ......................................................28 3.2.1. A modified kQ,Qo for electron-beam cross calibrations............................................29 Relation to NK-based Codes of Practice ............................................................................30 IMPLEMENTATION ..................................................................................................................33 4.1. 4.2. 4.3. 4.4. 5. The International Measurement System ............................................................................23 2.1.1. The IAEA/WHO network of SSDLs.......................................................................23 Standards of absorbed dose to water .................................................................................24 ND,w-BASED FORMALISM........................................................................................................27 3.2. 4. Background........................................................................................................................13 Advantages of a Code of Practice based on standards of absorbed dose to water ............15 1.2.1. Reduced uncertainty ................................................................................................15 1.2.2. A more robust system of primary standards............................................................16 1.2.3. Use of a simple formalism.......................................................................................17 Types of radiation and range of beam qualities.................................................................17 Practical use of the Code of Practice.................................................................................17 Expression of uncertainties................................................................................................18 Quantities and symbols......................................................................................................18 List of acronyms ................................................................................................................22 General...............................................................................................................................33 Equipment..........................................................................................................................35 4.2.1. Ionization chambers.................................................................................................35 4.2.2. Measuring assembly ................................................................................................41 4.2.3. Phantoms .................................................................................................................41 4.2.4. Waterproof sleeve for the chamber .........................................................................42 4.2.5. Positioning of ionization chambers at the reference depth .....................................43 Calibration of ionization chambers ...................................................................................44 4.3.1. Calibration in a 60Co beam ......................................................................................45 4.3.2. Calibration in kilovoltage x-rays.............................................................................45 4.3.3. Calibration at other qualities ...................................................................................46 Reference dosimetry in the user beam...............................................................................47 4.4.1. Determination of the absorbed dose to water..........................................................47 4.4.2. Practical considerations for measurements in the user beam..................................48 4.4.3. Correction for influence quantities..........................................................................48 CODE OF PRACTICE FOR COBALT-60 GAMMA RAY BEAMS.........................................55 5.1. 5.2. 5.3. 5.4. General...............................................................................................................................55 Dosimetry equipment.........................................................................................................55 5.2.1. Ionization chambers.................................................................................................55 5.2.2. Phantoms and chamber sleeves ...............................................................................55 Beam quality specification ................................................................................................56 Determination of absorbed dose to water..........................................................................56 VII 5.5. 5.6. 5.7. 5.8. 6. CODE OF PRACTICE FOR HIGH-ENERGY PHOTON BEAMS............................................61 6.1. 6.2. 6.3. 6.4. 6.5. 6.6. 6.7. 6.8. 6.9. 7. 5.4.1. Reference conditions ...............................................................................................56 5.4.2. Determination of absorbed dose under reference conditions..................................56 5.4.3. Absorbed dose at zmax ..............................................................................................57 Cross-calibration of field ionization chambers..................................................................57 Measurements under non-reference conditions.................................................................57 5.6.1. Central-axis depth-dose distributions......................................................................57 5.6.2. Output factors..........................................................................................................58 Estimated uncertainty in the determination of absorbed dose to water under reference conditions...........................................................................................................................58 Worksheet..........................................................................................................................59 General...............................................................................................................................61 Dosimetry equipment.........................................................................................................61 6.2.1. Ionization chambers.................................................................................................61 6.2.2. Phantoms and chamber sleeves ...............................................................................61 Beam quality specification ................................................................................................62 6.3.1. Choice of beam quality index..................................................................................62 6.3.2. Measurement of beam quality .................................................................................63 Determination of absorbed dose to water..........................................................................64 6.4.1. Reference conditions ...............................................................................................64 6.4.2. Determination of absorbed dose under reference conditions..................................64 6.4.3. Absorbed dose at zmax ..............................................................................................64 Values for kQ,Qo ..................................................................................................................65 6.5.1. Chamber calibrated in 60Co .....................................................................................65 6.5.2. Chamber calibrated in a series of photon beam qualities........................................68 6.5.3. Chamber calibrated at Qo with generic experimental kQ,Qo values..........................68 Cross-calibration of field ionization chambers..................................................................68 Measurements under non-reference conditions.................................................................69 6.7.1. Central-axis depth-dose distributions......................................................................69 6.7.2. Output factors..........................................................................................................69 Estimated uncertainty in the determination of absorbed dose to water under reference conditions...........................................................................................................................70 Worksheet..........................................................................................................................72 CODE OF PRACTICE FOR HIGH-ENERGY ELECTRON BEAMS.......................................75 7.1. 7.2. 7.3. 7.4. 7.5. 7.6. General...............................................................................................................................75 Dosimetry equipment.........................................................................................................75 7.2.1. Ionization chambers.................................................................................................75 7.2.2. Phantoms and chamber sleeves ...............................................................................75 Beam quality specification ................................................................................................76 7.3.1. Choice of beam quality index..................................................................................76 7.3.2. Measurement of beam quality .................................................................................76 Determination of absorbed dose to water..........................................................................77 7.4.1. Reference conditions ...............................................................................................77 7.4.2. Determination of absorbed dose under reference conditions..................................78 7.4.3. Absorbed dose at zmax ..............................................................................................78 Values for kQ,Qo ..................................................................................................................78 7.5.1. Chamber calibrated in 60Co .....................................................................................78 7.5.2. Chamber calibrated at a series of electron beam qualities ......................................80 Cross-calibration of ionization chambers ..........................................................................80 7.6.1. Cross-calibration procedure ....................................................................................80 7.6.2. Subsequent use of a cross-calibrated chamber........................................................81 VIII 7.7. Measurements under non-reference conditions.................................................................85 7.7.1. Central-axis depth-dose distributions......................................................................85 7.7.2. Output factors..........................................................................................................85 7.8. Use of plastic phantoms.....................................................................................................85 7.8.1. Scaling of depths .....................................................................................................85 7.8.2. Plastic phantoms for beam quality specification.....................................................86 7.8.3. Plastic phantoms for absorbed dose determination at zref........................................86 7.8.4. Plastic phantoms for depth-dose distributions ........................................................87 7.9. Estimated uncertainty in the determination of absorbed dose to water under reference conditions...........................................................................................................................87 7.10. Worksheet..........................................................................................................................90 8. CODE OF PRACTICE FOR LOW-ENERGY KILOVOLTAGE X-RAY BEAMS...................93 8.1. 8.2. 8.3. 8.4. 8.5. 8.6. 8.7. 8.8. 9. Measurements under non-reference conditions.................................................................98 8.6.1. Central axis depth-dose distributions ......................................................................98 8.6.2. Output factors..........................................................................................................98 Estimated uncertainty in the determination of absorbed dose to water under reference conditions...........................................................................................................................98 Worksheet........................................................................................................................100 CODE OF PRACTICE FOR MEDIUM-ENERGY KILOVOLTAGE X-RAY BEAMS .........103 9.1. 9.2. 9.3. 9.4. 9.5. 9.6. 9.7. 9.8. 10. General...............................................................................................................................93 Dosimetry equipment.........................................................................................................93 8.2.1. Ionization chambers.................................................................................................93 8.2.2. Phantoms .................................................................................................................94 Beam quality specification ................................................................................................94 8.3.1. Choice of beam quality index..................................................................................94 8.3.2. Measurement of beam quality .................................................................................95 Determination of absorbed dose to water..........................................................................96 8.4.1. Reference conditions ...............................................................................................96 8.4.2. Determination of absorbed dose under reference conditions..................................97 Values for kQ,Qo ..................................................................................................................97 General.............................................................................................................................103 Dosimetry equipment.......................................................................................................103 9.2.1. Ionization chambers...............................................................................................103 9.2.2. Phantoms and chamber sleeves .............................................................................104 Beam quality specification ..............................................................................................105 9.3.1. Choice of beam quality index................................................................................105 9.3.2. Measurement of beam quality ...............................................................................106 Determination of absorbed dose to water........................................................................106 9.4.1. Reference conditions .............................................................................................106 9.4.2. Determination of absorbed dose under reference conditions................................107 Values for kQ,Qo ................................................................................................................107 Measurements under non-reference conditions...............................................................108 9.6.1. Central axis depth-dose distributions ....................................................................108 9.6.2. Output factors........................................................................................................108 Estimated uncertainty in the determination of absorbed dose to water under reference conditions.........................................................................................................................109 Worksheet........................................................................................................................111 CODE OF PRACTICE FOR PROTON BEAMS ......................................................................113 10.1. General.............................................................................................................................113 10.2. Dosimetry equipment.......................................................................................................113 IX 10.3. 10.4. 10.5. 10.6. 10.7. 10.8. 11. 10.2.1. Ionization chambers ............................................................................................113 10.2.2. Phantoms and chamber sleeves...........................................................................115 Beam quality specification ..............................................................................................115 10.3.1. Choice of beam quality index .............................................................................115 10.3.2. Measurement of beam quality.............................................................................116 Determination of absorbed dose to water........................................................................116 10.4.1. Reference conditions ..........................................................................................116 10.4.2. Determination of absorbed dose under reference conditions .............................116 Values for kQ,Qo ................................................................................................................117 Measurements under non-reference conditions...............................................................117 10.6.1. Central-axis depth-dose distributions .................................................................117 10.6.2. Output factors .....................................................................................................118 10.6.3. Use of plastic phantoms for relative dosimetry ..................................................121 Estimated uncertainty in the determination of absorbed dose to water under reference conditions.........................................................................................................................121 Worksheet........................................................................................................................123 CODE OF PRACTICE FOR HEAVY-ION BEAMS................................................................125 11.1. General.............................................................................................................................125 11.2. Dosimetry equipment.......................................................................................................127 11.2.1. Ionization chambers ............................................................................................127 11.2.2. Phantoms and chamber sleeves...........................................................................128 11.3. Beam quality specification ..............................................................................................128 11.4. Determination of absorbed dose to water........................................................................128 11.4.1. Reference conditions ..........................................................................................128 11.4.2. Determination of absorbed dose under reference conditions .............................129 11.5. Values for kQ,Qo ................................................................................................................130 11.6. Measurements under non-reference conditions...............................................................130 11.7. Estimated uncertainty in the determination of absorbed dose to water under reference conditions.........................................................................................................................132 11.8. Worksheet........................................................................................................................134 APPENDIX A. RELATION BETWEEN NK AND ND,w BASED CODES OF PRACTICE ...............137 A.1. 60Co and high-energy photon and electron beams..............................................................137 A.1.1. A summary of notations used for calibration factors ...........................................139 A.1.2. Comparison of Dw determinations ........................................................................140 A.2. Kilovoltage x-ray beams ....................................................................................................142 APPENDIX B. CALCULATION OF kQ,Qo AND ITS UNCERTAINTY ............................................143 B.1. General ...............................................................................................................................143 B.2. 60Co gamma radiation.........................................................................................................143 B.2.1. Value for sw,air in 60Co............................................................................................143 B.2.2. Value for Wair in 60Co............................................................................................144 B.2.3. Values for pQ in 60Co.............................................................................................144 B.2.4. Summary of values and uncertainties in 60Co .......................................................145 B.3. High-energy photon beams.................................................................................................148 B.3.1. Values for sw,air in high-energy photon beams ......................................................148 B.3.2. Value for Wair in high-energy photon beams ........................................................148 B.3.3. Values for pQ in high-energy photon beams .........................................................148 B.3.4. Summary of uncertainties in high-energy photon beams......................................149 B.4. Electron beams ...................................................................................................................150 B.4.1. Values for sw,air in electron beams.........................................................................150 B.4.2. Value for Wair in electron beams...........................................................................151 X B.4.3. Values for pQ in electron beams............................................................................151 B.4.4. Summary of uncertainties in electron beams ........................................................153 B.5. Proton beams ......................................................................................................................154 B.5.1. Values for sw,air in proton beams ...........................................................................154 B.5.2. Value for Wair in proton beams .............................................................................155 B.5.3. Values for pQ in proton beams ..............................................................................155 B.5.4. Summary of uncertainties in proton beams...........................................................156 B.6. Heavy-ion beams ................................................................................................................156 B.6.1. Value for sw,air in heavy-ion beams .......................................................................156 B.6.2. Value for Wair in heavy-ion beams........................................................................157 B.6.3. Value for pQ in heavy-ion beams ..........................................................................158 B.6.4. Summary of uncertainties in heavy-ion beams .....................................................158 APPENDIX C. PHOTON BEAM QUALITY SPECIFICATION.......................................................159 C.1. Overview of common photon beam quality specifiers.......................................................159 C.2. Advantages and disadvantages of TPR20,10 .........................................................................160 C.3. Advantages and disadvantages of PDD(10)x......................................................................162 C.4. Concluding remarks ...........................................................................................................166 APPENDIX D. EXPRESSION OF UNCERTAINTIES......................................................................167 D.1 General considerations on errors and uncertainties ............................................................167 D.2 Type A standard uncertainties ............................................................................................167 D.3 Type B standard uncertainties.............................................................................................168 D.4 Combined and expanded uncertainties ...............................................................................169 REFERENCES.....................................................................................................................................171 IAEA MEETINGS RELATED TO THIS PUBLICATION ................................................................181 RECENT IAEA PUBLICATIONS ON RADIATION DOSIMETRY AND MEDICAL RADIATION PHYSICS ...................................................................................................................................183 XI 1. INTRODUCTION 1.1. Background In its Report 24 on Determination of Absorbed Dose in a Patient Irradiated by Beams of X or Gamma Rays in Radiotherapy Procedures, the ICRU [1] concluded “although it is too early to generalize, the available evidence for certain types of tumour points to the need for an accuracy of ±5% in the delivery of an absorbed dose to a target volume if the eradication of the primary tumour is sought”. ICRU continues “Some clinicians have requested even closer limits such as ±2%, but at the present time (in 1976) it is virtually impossible to achieve such a standard”. These statements were given in a context where uncertainties were estimated at the 95% confidence level, and have been interpreted as if they correspond to approximately two standard deviations. Thus the requirement for an accuracy of 5% in the delivery of absorbed dose would correspond to a combined uncertainty of 2.5% at the level of one standard deviation. Today it is considered that a goal in dose delivery to the patient based on such an accuracy requirement is too strict and the figure should be increased to about one standard deviation of 5%, but there are no definite recommendations in this respect 1. The requirement for an accuracy of ±5% could, on the other hand, be also interpreted as a tolerance for the deviation between the prescribed dose and the dose delivered to the target volume. Modern radiotherapy has confirmed, in any case, the need for high accuracy in dose delivery if new techniques, including dose escalation in 3D conformal radiotherapy, are to be applied. Emerging technologies in radiotherapy, for example modern diagnostic tools for the determination of the target volume, 3D commercial treatment planning systems and advanced accelerators for irradiation, can only be fully utilized if there is high accuracy in dose determination and delivery. The various steps between the calibration of ionization chambers in terms of the quantity air kerma, Kair, at the standardizing dosimetry laboratories and the determination of absorbed dose to water, Dw, at hospitals using dosimetry protocols based on the factor 2 ND,air (or Ngas) introduce undesirable uncertainties into the realization of Dw. Many factors are involved in the dosimetric chain that starts with a calibration factor in terms of air kerma, NK, measured in air using a 60Co beam and ends with the absorbed dose to water, Dw, measured in water in clinical beams. Uncertainties in the chain arise mainly from conversions performed by the user at the hospital, for instance the well-known km and katt factors used in most Codes of Practice and dosimetry protocols [8-19]. Uncertainties associated with the conversion of NK to ND,air (or Ngas) mean that in practice the starting point of the calibration of clinical beams already involves a considerable uncertainty [20]. The estimation of uncertainties given in previous IAEA Codes of Practice, TRS-277 and TRS-381 [17, 21] showed that the largest contribution to the uncertainty during beam calibration arises from the different physical quantities involved and the large number of steps performed, yielding standard uncertainties of up to 3 or 4%. Even if more recent uncertainty estimates [22, 23] have lowered these figures, the contribution from the first steps in the radiotherapy dosimetry chain still do not comply with the demand for a low uncertainty to minimize the final uncertainty in patient dose delivery. 1 2 Several studies have concluded that for certain types of tumors the combined standard uncertainty in dose delivery should be smaller than 3.3% or 3.5% [2-4], “even if in many cases larger values are acceptable and in some special cases even smaller values should be aimed at” [3]. It has also been stated that taking into account the uncertainties in dose calculation algorithms, a more appropriate limit for the combined standard uncertainty of the dose delivered to the target volume would be around 5% [4, 5]. The standard ISO 31-0 [6], Quantities and units, has provided guidelines with regard to the use of the term coefficient, which should be used for a multiplier possessing dimensions, and factor, which should be reserved for a dimensionless multiplier. The more recent standard IEC-60731 [7] is not consistent, however, with the ISO vocabulary and still provides a definition of the term calibration factor. Although the present Code of Practice continues using the term calibration factor, users should be aware of the possibility of a change in terminology by standards laboratories in favour of calibration coefficient. 13 Reich [24] proposed the calibration of therapy-level dosimeters in terms of absorbed dose to water, stressing the advantages of using the same quantity and experimental conditions as the user. The current status of development of primary standards of absorbed dose to water for high-energy photons and electrons, and the improvement in radiation dosimetry concepts and data available, have made it possible to reduce the uncertainty in the calibration of radiation beams. The development of standards of absorbed dose to water at Primary Standard Dosimetry Laboratories (PSDLs) has been a major goal pursued by the Comité Consultatif pour les Etalons de Mesure des Rayonnements Ionisants (Section I) [25]. Measurements of absorbed dose to graphite using graphite calorimeters were developed first and continue to be used in many laboratories. This procedure was considered as an intermediate step between air kerma and direct determination of the absorbed dose to water, since absolute calorimetric measurements in water are more problematic. Comparisons of determinations of absorbed dose to graphite were satisfactory, and consequently, the development of standards of absorbed dose to water was undertaken in some laboratories. Procedures to determine absorbed dose to water using methods to measure appropriate base or derived quantities have considerably improved at the PSDLs in the last decade. The well established procedures are the ionization method, chemical dosimetry, and water and graphite calorimetry. Although only the water calorimeter allows the direct determination of the absorbed dose to water in a water phantom, the required conversion and perturbation factors for the other procedures are now well known at many laboratories. These developments lend support to a change in the quantity used at present to calibrate ionization chambers and provide calibration factors in terms of absorbed dose to water, ND,w, for use in radiotherapy beams. Many PSDLs already provide ND,w calibrations at 60Co gamma-ray beams and some laboratories have extended these calibration procedures to high-energy photon and electron beams; others are developing the necessary techniques for such modalities. At Secondary Standard Dosimetry Laboratories (SSDLs) calibration factors from a PSDL or from the Bureau International des Poids et Mesures (BIPM) are transferred to hospital users. For 60Co gammaray beams most SSDLs can provide users with a calibration factor in terms of absorbed dose to water without much experimental effort, as all SSDLs have such beams. However, it is not possible for them, in general, to supply experimentally determined calibration factors at high-energy photon and electron beams. Numerical calculations of a beam quality correction factor, related to 60Co can, however, be performed which should be equivalent to those obtained experimentally but with a larger uncertainty. A major advance in radiotherapy over the last few years has been the increasing use of proton and heavy-ion irradiation facilities for radiation therapy. Practical dosimetry in these fields is also based on the use of ionization chambers that may be provided with calibrations both in terms of air kerma and in terms of absorbed dose to water. Therefore the dosimetry procedures developed for highenergy photons and electrons can also be applicable to protons and heavy ions. At the other extreme of the range of available teletherapy beams lie kilovoltage x-ray beams and for these the use of standards of absorbed dose to water was introduced in TRS-277 [17]. However, for kilovoltage x-rays there are, at present, very few laboratories providing ND,w calibrations because most PSDLs have not yet established primary standards of absorbed dose to water for such radiation qualities. Nevertheless ND,w calibrations in kilovoltage x-ray beams may be provided by PSDLs and SSDLs based on their standards of air kerma and one of the current dosimetry protocols for x-ray beams. Thus a coherent dosimetry system based on standards of absorbed dose to water is now possible for practically all radiotherapy beams 3, see Fig. 1.1. 3 For neutron therapy beams, the reference material to which the absorbed dose relates is ICRU soft tissue [26]. The present Code of Practice is based on the quantity absorbed dose to water. Due to the strong dependence of neutron interaction coefficients on neutron energy and material composition, there is no straightforward procedure to derive absorbed dose to soft tissue from absorbed dose to water. Moreover, neutron dosimetry is traditionally performed with tissue-equivalent ionization chambers, flushed with a tissue-equivalent gas in order to determine the absorbed dose in an homogeneous medium. Although it is possible to express the resulting formalism [26] in terms of kQ,Q , for most ionization chamber o types there is a lack of data on the physical parameters which apply to the measurement of absorbed dose to water in a neutron beam. Therefore, the dosimetry of the radiotherapy neutron beams is not dealt with in this Code of Practice. 14 Fig 1.1. Coherent dosimetry system based on standards of absorbed dose to water. Primary standards based on water calorimetry, graphite calorimetry, chemical dosimetry, and ionometry allow the calibration of ionization chambers in terms of absorbed dose to water, ND,w. A single Code of Practice provides the methodology for the determination of absorbed dose to water in the low, medium, 60Co and high-energy photon beams, electron beams, proton beams and heavy-ion beams used for external radiation therapy. This new international Code of Practice for the determination of absorbed dose to water in external beam radiotherapy, using an ionization chamber or a dosimeter having an ND,w calibration factor, will be applicable in all hospitals and facilities providing radiation treatment of cancer patients. Even though the nature of these institutions may be widely different, this Code of Practice will serve as a useful document to the medical physics and radiotherapy community and help achieve uniformity and consistency in radiation dose delivery throughout the world. The Code of Practice should also be of great value to the IAEA/WHO network of SSDLs in improving the accuracy and consistency of their dose determination and thereby the standardization of radiation dosimetry in the many countries which they serve. 1.2. Advantages of a Code of Practice based on standards of absorbed dose to water Absorbed dose to water is the quantity of main interest in radiation therapy, since this quantity relates closely to the biological effects of radiation. The advantages of calibrations in terms of absorbed dose to water and dosimetry procedures using these calibration factors have been presented by several authors [20, 27, 28] and are described in detail in the ICRU Report on photon dosimetry [29]. A summary of the most relevant aspects is given below. 1.2.1. Reduced uncertainty The drive towards an improved basis for dosimetry in radiotherapy has caused the PSDLs to devote much effort in the last two decades towards developing primary standards of absorbed dose to water. The rationale for changing the basis of calibrations from air kerma to absorbed dose to water was the expectation that the calibration of ionization chambers in terms of absorbed dose to water would reduce considerably the uncertainty in determining the absorbed dose to water in radiotherapy beams. Measurements based on calibration in air in terms of air kerma require chamber-dependent conversion factors to determine absorbed dose to water. These conversion factors do not account for differences between individual chambers of a particular type. In contrast, calibrations in terms of absorbed dose 15 to water can be performed under similar conditions to subsequent measurements in the user beam, so that the response of each individual chamber is taken into account. Fig. 1.2 shows chamber-tochamber variations, demonstrated for a given chamber type by the lack of constancy in the ND,w/NK ratio at 60Co, for a large number of cylindrical ionization chambers commonly used in radiotherapy dosimetry. For a given chamber type, chamber-to-chamber differences of up to 0.8% have also been reported by the BIPM [30]. The elimination of the uncertainty component caused by the assumption that all chambers of a given type are identical is a justification for favouring direct calibration of ionization chambers in terms of absorbed dose to water. 1.12 PTW30002 PTW30004 PTW30006 PTW23333 1.11 ND,w / NK NE2581 1.10 NE2561 and NE2611 NE2571 PTW30001 1.09 1.08 1.07 Fig 1.2. The ratio of 60Co calibration factors ND,w/NK is a useful indicator of the uniformity within a given type of chamber [30]. Chamber-to-chamber variations, demonstrated by differences in the ratio ND,w/NK for chambers of a given type, are shown for a large number of cylindrical ionization chambers commonly used in radiotherapy dosimetry (see Table 4.I for a description of each chamber type). The large variation for NE 2581 chambers is considered to be caused by the hygroscopic properties of the A-150 plastic walls. Data measured in the IAEA Dosimetry Laboratory. In principle, primary standards of absorbed dose to water can operate in both 60Co beams and accelerator beams. Thus, for high-energy photon and electron radiation an experimental determination of the energy dependence of ionization chambers becomes available, resulting in a reduced uncertainty due to the effect of beam quality. Similar conclusions can be drawn for therapeutic proton and heavy ions beams, although primary standards of absorbed dose to water are not yet available at these radiation qualities. 1.2.2. A more robust system of primary standards Despite the fact that the quantity of interest in radiation dosimetry is absorbed dose to water, most national, regional and international dosimetry recommendations are based on the use of an air-kerma calibration factor for an ionization chamber, traceable to a national or international primary standard of air kerma for 60Co gamma radiation. Although international comparisons of these standards have exhibited very good agreement, a substantial weakness prevails in that all such standards are based on ionization chambers and are therefore subject to common errors. In addition, depending on the method of evaluation, a factor related to the attenuation in the chamber wall entering into the determination of the quantity air kerma has been found to differ by up to 0.7% for some primary standards [31]. In contrast, primary standards of absorbed dose to water are based on a number of different physical 16 principles. There are no assumptions or estimated correction factors common to all of them. Therefore good agreement among these standards (see Section 2.2) gives much greater confidence in their accuracy. 1.2.3. Use of a simple formalism The formalism given in TRS-277 [17] and in most national and international dosimetry protocols for the determination of absorbed dose to water in radiotherapy beams is based on the application of several coefficients, perturbation and other correction factors. This is because of the practical difficulty in making the conversion from the free-air quantity air kerma to the in-phantom quantity absorbed dose to water. This complexity is best demonstrated by considering the equations needed, and the procedures for selecting the appropriate data. Reliable information about certain physical characteristics of the ionization chamber used is also required. Many of these data, such as displacement correction factors and stopping-power ratios, are derived from complex measurements or calculations based on theoretical models. A simplified procedure starting from a calibration factor in terms of absorbed dose to water, and applying correction factors for all influence quantities, reduces the possibility of errors in the determination of absorbed dose to water in the radiation beam. The simplicity of the formalism in terms of absorbed dose to water becomes obvious when the general equation for the determination of absorbed dose to water is considered (see Section 3). 1.3. Types of radiation and range of beam qualities The present Code of Practice provides a methodology for the determination of absorbed dose to water in the low-, medium- and high-energy photon beams, electron beams, proton beams and heavy-ion beams used for external radiation therapy. The ranges of radiation qualities covered in this document are given below (for a description of the beam quality index see the corresponding Sections): (a) (b) (c) (d) (e) (f) (g) low-energy x-rays with generating potentials up to 100 kV and HVL of 3 mm Al (the lower limit is determined by the availability of standards) 4 medium-energy x-rays with generating potentials above 80 kV and HVL of 2 mm Al 4 60 Co gamma-radiation high-energy photons generated by electrons with energies in the interval 1 MeV to 50 MeV, with TPR20,10 values between 0.50 and 0.84 electrons in the energy interval 3 MeV to 50 MeV, with a half-value depth, R50, between 1 g cm-2 and 20 g cm-2 protons in the energy interval 50 MeV to 250 MeV, with a practical range, Rp, between 0.25 g cm-2 and 25 g cm-2 heavy ions with Z between 2 (He) and 18 (Ar) having a practical range in water, Rp, of 2 g cm-2 to 30 g cm-2 (for carbon ions this corresponds to an energy range of 100 MeV/u to 450 MeV/u, where u is the atomic mass unit). 1.4. Practical use of the Code of Practice Emphasis has been given to making the practical use of this document as simple as possible. The structure of this Code of Practice differs from TRS-277 [17] and more closely resembles TRS-381 [21] in that the practical recommendations and data for each radiation type have been placed in an individual section devoted to that radiation type. Each essentially forms a different Code of Practice including detailed procedures and worksheets. The reader can perform a dose determination for a given beam by working through the appropriate Section; the search for procedures or tables contained in other parts of the document has been reduced to a minimum. Making the various Codes of Practice independent and self-contained has required an unavoidable repetition of some portions of text, but 4 The boundary between the two ranges for kilovoltage x-rays is not strict and has an overlap between 80 kV, 2 mm Al and 100 kV, 3 mm Al. In this overlap region the methods for absorbed dose determination of either Section 8 or 9 are equally satisfactory and whichever is more convenient should be used. 17 this is expected to result in a document which is simpler and easier to use, especially for users having access to a limited number of radiation types. The first four Sections contain general concepts that apply to all radiation types. Appendices provide a complement to the information supplied in the various Sections. Compared with previous Codes of Practice or dosimetry protocols based on standards of air kerma (c.f. TRS-277 [17] and TRS-381 [21]), the adoption of the new Code of Practice will introduce small differences in the value of the absorbed dose to water determined in clinical beams. Detailed comparisons will be published in the open literature, and the results are expected to depend on the type and quality of the beam and on the type of ionization chamber. Where differences arise, it is important to notice that they might be due to two contributions: i) inaccuracies in the numerical factors and expressions (for example km, pwall, etc.) in the NK-based method and, to a lesser extent, in the present Code of Practice, and ii) the primary standards to which the calibrations in terms of air kerma and absorbed dose to water are traceable. Even for 60Co gamma radiation, which is generally better characterized than other modalities, beam calibrations based on the two different standards, Kair and Dw, differ by typically 1% (see Appendix A); the value derived using the present Code of Practice is considered to be the better estimate. Any conclusions drawn from comparisons between protocols based on standards of air kerma and absorbed dose to water must take account of the differences between primary standards. 1.5. Expression of uncertainties The evaluation of uncertainties in this Code of Practice follows the guidance given by ISO [32]. Uncertainties of measurements are expressed as relative standard uncertainties and the evaluation of standard uncertainties is classified into type A and type B. The method of evaluation of type A standard uncertainty is by statistical analysis of a series of observations, whereas the method of evaluation of type B standard uncertainty is based on means other than statistical analysis of a series of observations. A practical implementation of the ISO recommendations, based on the summaries provided in IAEA TRS-374 [33] and IAEA TRS-277 [17], is given for completeness in Appendix D of this Code of Practice. Estimates of the uncertainty in dose determination for the different radiation types are given in the appropriate Sections. Compared with estimates in previous Codes of Practice, the present values are generally smaller. This arises from the greater confidence in determinations of absorbed dose to water based on Dw standards and, in some cases, from a more rigorous analysis of uncertainties in accordance with the ISO guidelines. 1.6. Quantities and symbols Most of the symbols used in this Code of Practice are identical to those used in TRS-277 [17] and TRS-381 [21], and only a few are new in the context of standards of absorbed dose to water. For completeness a summary is provided here for all quantities of relevance to the different methods used in the present Code of Practice. cpl Material-dependent scaling factor to convert ranges and depths measured in plastic phantoms into the equivalent values in water. This applies to electron, proton and heavy-ion beams. Note that in the present Code of Practice the depths and ranges are defined in units of g cm-2, in contrast to their definition in cm in TRS-381 [21] for electron beams. As a result, the values given for cpl in the present Code of Practice for electrons differ from those for Cpl given in TRS-381. The use of lowercase for cpl denotes this change. csda Continuous slowing-down approximation. 18 Dw,Q Absorbed dose to water at the reference depth, zref, in a water phantom irradiated by a beam of quality Q. The subscript Q is omitted when the reference beam quality is 60Co. Unit: gray, Gy Eo , E z Mean energy of an electron beam at the phantom surface and at depth z, respectively. Unit: MeV. hpl Material-dependent fluence scaling factor to correct for the difference in electron fluence in plastic compared with that in water at an equivalent depth. HVL Half-value layer, used as a beam quality index for low- and medium-energy x-ray beams. ki General correction factor used in the formalism to correct for the effect of the difference in the value of an influence quantity between the calibration of a dosimeter under reference conditions in the standards laboratory and the use of the dosimeter in the user facility under different conditions. kelec Calibration factor of an electrometer. kh Factor to correct the response of an ionization chamber for the effect of humidity if the chamber calibration factor is referred to dry air. kpol Factor to correct the response of an ionization chamber for the effect of a change in polarity of the polarizing voltage applied to the chamber. kQ,Qo Factor to correct for the difference between the response of an ionization chamber in the reference beam quality Qo used for calibrating the chamber and in the actual user beam quality, Q. The subscript Qo is omitted when the reference quality is 60Co gamma radiation (i.e., the reduced notation kQ always corresponds to the reference quality 60Co). ks Factor to correct the response of an ionization chamber for the lack of complete charge collection (due to ion recombination). kTP Factor to correct the response of an ionization chamber for the effect of the difference that may exist between the standard reference temperature and pressure specified by the standards laboratory and the temperature and pressure of the chamber in the user facility under different environmental conditions. MQ Reading of a dosimeter at the quality Q, corrected for influence quantities other than beam quality. Unit: C or rdg. Mem Reading of a dosimeter used as external monitor. Unit: C or rdg. (µen/ρ)m1,m2 ratio of the mean mass energy-absorption coefficients of materials m1 and m2, averaged over a photon spectrum ND,air Absorbed dose to air chamber factor of an ionization chamber used in air-kerma based dosimetry protocols (c.f. IAEA TRS-277 [17] and TRS-381 [17, 21]). This is the Ngas of AAPM TG-21 [9]. The factor ND,air was called ND in ICRU Report 35 [11] and in TRS-277 [17], but the subscript “air” was included in TRS-381 [21] to specify without ambiguity that it refers to the absorbed dose to the air of the chamber cavity. Care should be paid by the user to avoid confusing ND,air, or the former ND, with the calibration factor in terms of absorbed dose to water ND,w described below (see Appendix A). Unit: Gy/C or Gy/rdg. 19 ND,w,Qo Calibration factor in terms of absorbed dose to water for a dosimeter at a reference beam quality Qo. The product MQo ND,w,Qo yields the absorbed dose to water, Dw,Qo, at the reference depth zref and in the absence of the chamber. The subscript Qo is omitted when the reference quality is a beam of 60Co gamma rays (i.e., ND,w always corresponds to the calibration factor in terms of absorbed dose to water in a 60Co beam). The factor ND,w was called ND in AAPM TG-21 [9], where a relationship between Ngas and ND was given similar to that described in Section 3.3 and Appendix A. The symbol ND is also used in calibration certificates issued by some standards laboratories and manufacturers instead of ND,w. Users are strongly recommended to ascertain the physical quantity used for the calibration of their detectors in order to avoid severe mistakes 5. Unit: Gy/C or Gy/rdg. NK,Qo Calibration factor in terms of air kerma for a dosimeter at a reference beam quality Qo. Unit: Gy/C or Gy/rdg. pcav Factor that corrects the response of an ionization chamber for effects related to the air cavity, predominantly the in-scattering of electrons that makes the electron fluence inside a cavity different from that in the medium in the absence of the cavity. pcel Factor that corrects the response of an ionization chamber for the effect of the central electrode during in-phantom measurements in high-energy photon (including 60Co), electron and proton beams. Note that this factor is not the same as in TRS-277 [17], where the correction took into account the global effect of the central electrode both during the calibration of the chamber in air in a 60Co beam, and during subsequent measurements in photon and electron beams in a phantom. To avoid ambiguities TRS-381 [21] called the correction factor used in TRS-277 pcel-gbl, keeping the symbol pcel exclusively for in-phantom measurements (see Appendix A). PDD Percentage depth-dose. pdis Factor that accounts for the effect of replacing a volume of water with the detector cavity when the reference point of the chamber 6 is taken to be at the chamber centre. It is the alternative to the use of an effective point of measurement of the chamber, Peff. For planeparallel ionization chambers pdis is not required. Peff The effective point of measurement of an ionization chamber. For the standard calibration geometry, i. e. a radiation beam incident from one direction, Peff is shifted from the position of the centre towards the source by a distance which depends on the type of beam and chamber. For plane-parallel ionization chambers Peff is usually assumed to be situated in the centre of the front surface of the air cavity 7. The concept of the effective point of measurement of a cylindrical ionization chamber was used for all radiation types in TRS277 [17] but in the present Code of Practice it is only used for electron and heavy-ion beams. For other beams, reference dosimetry is based on positioning the reference point of the chamber at the reference depth, zref, where the dose is determined. The reference point of an ionization chamber is specified for each radiation type in the corresponding Section. 5 6 7 The difference between ND,air and ND,w is close to the value of the stopping-power ratio, water to air, in 60Co gamma rays. A confusion in the meaning of the factors could therefore result in an error in the dose delivered to patients of approximately 13% (see Appendix A). The reference point of a chamber is specified in this Code of Practice in each Section for each type of chamber. It usually refers to the point of the chamber specified by a calibration document to be that at which the calibration factor applies [33]. This assumption might fail if the chamber design does not follow certain requirements regarding the ratio of cavity diameter to cavity height as well as that of guard-ring width to cavity height (see TRS-381 [21]). 20 pQ Overall perturbation factor for an ionization chamber for in-phantom measurements at a beam quality Q. It is equal to the product of various factors correcting for different effects, each correcting for small perturbations; in practice these are pcav, pcel, pdis and pwall. pwall Factor that corrects the response of an ionization chamber for the non-medium equivalence of the chamber wall and any waterproofing material. Q General symbol to indicate the quality of a radiation beam. A subscript “o”, i.e. Qo, indicates the reference quality used for the calibration of an ionization chamber or a dosimeter. rdg value, in arbitrary units, used for the reading of a dosimeter. R50 Half-value depth in water (in g cm-2), used as the beam quality index for electron beams. Rp Practical range (in g cm-2) for electron, proton and heavy-ion beams. Rres Residual range (in g cm-2) for proton beams. rcyl Cavity radius of a cylindrical ionization chamber. SAD Source-axis distance. SCD Source-chamber distance. SOBP Spread-out Bragg peak. SSD Source-surface distance. sm,air Stopping-power ratio medium to air, defined as the ratio of the mean restricted mass stopping powers of materials m and air, averaged over an electron spectrum. For all highenergy radiotherapy beams in this Code of Practice, except for heavy-ion beams, stoppingpower ratios are of the Spencer-Attix type with a cut-off energy ∆=10 keV (see ICRU Report 35 [11]). TMR Tissue-maximum ratio. TPR20,10 Tissue-phantom ratio in water at depths of 20 and 10 g/cm-2, for a field size of 10 cm x 10 cm and a SCD of 100 cm, used as the beam quality index for high-energy photon radiation. uc Combined standard uncertainty of a quantity. Wair The mean energy expended in air per ion pair formed. zmax Depth of maximum dose (in g cm-2) zref Reference depth (in g cm-2) for in-phantom measurements. When specified at zref, the absorbed dose to water refers to Dw,Q at the intersection of the beam central axis with the plane defined by zref. 21 1.7. List of acronyms The following acronyms are used throughout this document to refer to different organizations relevant to the field of radiation dosimetry: ARPANSA Australian Radiation Protection and Nuclear Safety Agency, Australia BIPM Bureau International des Poids et Mesures BEV CCEMRI(I) CCRI(I) CIPM ENEA-INMRI Bundesamt für das Eich- und Vermessungswesen, Austria Comité Consultatif pour les Etalons de Mesure des Rayonnements Ionisants (Section I) (Consultative Committee for Standards of Ionizing Radiation) Since September 1997 the CCEMRI and its Sections has been renamed the CCRI. Comité Consultatif des Rayonnements Ionisants (Section I) (Consultative Committee for Ionizing Radiation) Comité International des Poids et Mesures Ente per le Nuove Tecnologie, l´Energia e l´Ambiente, Instituto Nazionale di Metrologia delle Radiazioni Ionizzanti, Italy IAEA International Atomic Energy Agency IEC International Electrotechnical Commission ICRU IMS ISO International Commission on Radiation Units and Measurements International Measurement System International Organization for Standardization LPRI Laboratoire Primaire de Métrologie des Rayonnements Ionisants, France NPL National Physical Laboratory, Great Britain NIST National Institute of Standards and Technology, USA NRC National Research Council, Canada OIML Organisation International de Métrologie Légale PTB Physikalisch-Technische Bundesanstalt, Germany NRL PSDL SSDL National Radiation Laboratory, New Zealand Primary Standard Dosimetry Laboratory Secondary Standard Dosimetry Laboratory 22 2. FRAMEWORK 2.1. The International Measurement System The International Measurement System (IMS) for radiation metrology provides the framework for consistency in radiation dosimetry by disseminating to users calibrated radiation instruments which are traceable to primary standards (see Fig 2.1). PSDLs BIPM PSDLs SSDLs IAEA SSDLs SSDLs Users Users Users Users Users Fig 2.1. The International Measurement System (IMS) for radiation metrology, where the traceability of user reference instruments to Primary Standards is achieved either by direct calibration in a Primary Standard Dosimetry Laboratory (PSDL) or, more commonly, in a Secondary Standard Dosimetry Laboratory (SSDL) with direct link to the BIPM, a PSDL or to the IAEA/WHO network of SSDLs. Most SSDLs from countries not members of the Metre Convention achieve the traceability of their standards through the IAEA. The dashed lines indicate intercomparisons of primary and secondary standards. The BIPM was set up by the Metre Convention (originally signed in 1875, with 48 Member States as of 31 December 1997 [34]) as the international centre for metrology, with its laboratory and offices in Sèvres (France), in order to ensure world-wide uniformity on matters relating to metrology. In radiation dosimetry, the PSDLs of many Member States of the Metre Convention have developed primary standards for radiation measurements (see Table 2.I) that are compared with those of the BIPM and other PSDLs. However, world-wide there are only some twenty countries with PSDLs involved in radiation dosimetry and they cannot calibrate the very large number of radiation dosimeters that are in use all over the world. Those national laboratories that maintain primary standards calibrate the secondary standards of SSDLs (see Table 2.I), which in turn calibrate the reference instruments of users (some PSDLs also calibrate the reference instruments of users). 2.1.1. The IAEA/WHO network of SSDLs The main role of SSDLs is to bridge the gap between the PSDLs and the users of ionizing radiation by enabling the transfer of dosimeter calibrations from the primary standard to the user instrument [35]. In 1976 a network of SSDLs was established as a joint effort by the IAEA and the WHO in order to disseminate calibrations to users by providing the link between users and primary standards, mainly for countries that are not members of the Metre Convention. By 1998 the network included 70 laboratories and 6 SSDL national organizations in 58 IAEA Member States, of which over half are in developing countries. The SSDL network also includes 16 affiliated members, among them the BIPM, 23 several national PSDLs, the ICRU and other international organizations that provide support to the network [36]. TABLE 2.I. CLASSIFICATION OF INSTRUMENTS AND STANDARDS LABORATORIES (Adapted from IAEA TRS-374 [33]) Classification of instruments Standards laboratories Primary standard An instrument of the highest metrological quality that permits determination of the unit of a quantity from its definition, the accuracy of which has been verified by comparison with the comparable standards of other institutions at the same level. Primary Standard Dosimetry Laboratory (PSDL) A national standardizing laboratory designated by the government for the purpose of developing, maintaining and improving primary standards in radiation dosimetry. Secondary standard An instrument calibrated by comparison with a primary standard. National standard A standard recognized by an official national decision as the basis for fixing the value in a country of all other standards of the given quantity. Secondary Standard Dosimetry Laboratory (SSDL) A dosimetry laboratory designated by the competent authorities to provide calibration services, and which is equipped with at least one secondary standard that has been calibrated against a primary standard. Reference instrument An instrument of the highest metrological quality available at a given location, from which measurements at that location are derived. Field instrument A measuring instrument used for routine measurements whose calibration is related to the reference instrument. As the organizer of the network, the IAEA has the responsibility to verify that the services provided by the SSDL member laboratories follow internationally accepted metrological standards (including the traceability for radiation protection instruments). The first step in this process is the dissemination of dosimeter calibrations from the BIPM or PSDLs through the IAEA to the SSDLs. In the next step, follow-up programmes and dose quality audits are implemented by the IAEA for the SSDLs to guarantee that the standards disseminated to users are kept within the levels of accuracy required by the IMS [36]. One of the principal goals of the SSDL network in the field of radiotherapy dosimetry is to guarantee that the dose delivered to patients undergoing radiotherapy treatment is within internationally accepted levels of accuracy. This is accomplished by ensuring that the calibrations of instruments provided by the SSDLs are correct, emphasizing the participation of the SSDLs in quality assurance programmes for radiotherapy, promoting the contribution of the SSDLs to support dosimetry quality audits in therapy centres, and assisting if needed in performing the calibration of radiotherapy equipment in hospitals. 2.2. Standards of absorbed dose to water There are three basic methods currently used for the absolute determination of absorbed dose to water: calorimetry, chemical dosimetry and ionization dosimetry. At present, these are the only methods that are sufficiently accurate to form the basis of primary standards for measurements of absorbed dose to water [29]. The PSDLs have developed various experimental approaches to establish standards of absorbed dose to water. These standards are described briefly and results of international comparisons of absorbed dose to water are presented below. 24 In most PSDLs the primary standards of absorbed dose to water operate in a 60Co gamma-ray beam and in some PSDLs the standards of absorbed dose to water operate also at other radiation qualities such as high-energy photons, electrons and kilovoltage x-rays. Primary standards operating in 60Co gamma-ray beams or in photon and electron beams produced by accelerators are based on one of the following methods: I. The ionization chamber primary standard consists of a graphite cavity chamber with accurately known chamber volume, designed to fulfil as far as possible the requirements of a Bragg-Gray detector. The chamber is placed in a water phantom and the absorbed dose to water at the reference point derived from the mean specific energy imparted to the air of the cavity [37]. II. The graphite calorimeter developed by Domen and Lamperti [38] is used with slight modifications by several PSDLs to determine the absorbed dose to graphite in a graphite phantom. The conversion to absorbed dose to water at the reference point in a water phantom may be performed in different ways, e.g. by application of the photon fluence scaling theorem or by measurements based on cavity ionization theory [39, 40]. III. The water calorimeter offers a more direct determination of the absorbed dose to water at the reference point in a water phantom. The sealed water system [41, 42] consists of a small glass vessel containing high-purity water and a thermistor detector unit. Water purity is important because the heat defect of water is strongly influenced by impurities. With the sealed water arrangement high-purity water can be saturated with various gases to create a mixture for which the heat defect has a well-defined and stable value. IV. The water calorimeter with Fricke transfer dosimeter [43] is based on the measurement of the average temperature increase induced by the absorption of high-energy photons. The water is stirred continuously and the absorbed dose to water averaged over the volume of the vessel is determined. Fricke solution is calibrated by irradiation under the same conditions and the absorbed dose to water at the reference point in a water phantom is obtained using the Fricke dosimeter as the transfer standard. V. The Fricke standard of absorbed dose to water determines the response of Fricke solution using the total absorption of an electron beam in the solution [44]. Knowing the electron energy, the beam current and the absorbing mass accurately, the total absorbed energy can be determined and related to the change in absorbance of the Fricke solution as measured spectrophotometrically. The absorbed dose to water at the reference point in a water phantom is obtained using the Fricke dosimeter as the transfer standard. The methods outlined above are not applied at PSDLs to primary standards for use in kilovoltage xray beams. Absolute measurements for the determination of absorbed dose to water in kilovoltage xray beams have been based so far almost exclusively on the use of extrapolation ionization chambers [45]. Comparisons of primary standards of absorbed dose to water have been carried out over the past decade [29, 46, 47], whereas comparisons of air-kerma primary standards have a much longer history. Results of comparisons at the BIPM in terms of absorbed dose to water for 60Co gamma radiation are given in Ref. [48], see Fig. 2.2a. The agreement is well within the relative standard uncertainties estimated by each PSDL. Comparisons of air-kerma primary standards for 60Co gamma radiation exhibit a similar standard deviation, see Fig. 2.2b. However, the air-kerma primary standards of all PSDLs are graphite cavity ionization chambers and the conversion and correction factors used are strongly correlated. As can be seen from Table 2.II the PSDLs involved in the comparisons of absorbed dose to water use different methods to determine absorbed dose to water which have uncorrelated, or very weakly correlated, uncertainties and constitute a system which is more robust than the primary standards based on air kerma and less susceptible to unknown systematic influences. 25 TABLE 2.II. PRIMARY STANDARDS USED IN THE COMPARISONS OF ABSORBED DOSE TO WATER AT THE BIPM PSDL Primary Standard BIPM PSDL ionization chamber Primary Standard NIST (USA) sealed water calorimeter NRC (Canada) sealed water calorimeter ARPANSA (Australia) graphite calorimeter NPL (Great Britain) ENEA (Italy) graphite calorimeter PTB (Germany) BEV (Austria) LPRI (France) graphite calorimeter graphite calorimeter graphite calorimeter Fricke dosimeter Dw(PSDL) / Dw(BIPM) 1.02 1.01 1.00 0.99 0.98 ARPANSA AUS BEV AUT BIPM ENEA ITA LPRI FRA NIST USA NPL GBR NRC CAN PTB DEU Fig 2.2a. Results of comparisons of standards of absorbed dose to water at the BIPM in the 60Co beam [48]. The results are relative to the BIPM determination and are those for the most recent comparison for each national metrology institute, the oldest dating from 1989. The uncertainty bars represent the relative standard uncertainty of the determination of absorbed dose to water at each institute. Information on the primary standards used by the PSDLs is given in Table 2.II. Kair(PSDL) / Kair(BIPM) 1.02 1.01 1.00 0.99 0.98 ARPANSA BARC BEV BIPM ENEA GUM LNMRI LPRI AUS IND AUT ITA POL BRA FRA NIST NMi USA NLD NPL NRC OMH PTB GBR CAN HUN DEU CMI CZE NIIM RUS Fig 2.2b. Results of comparisons of standards of air kerma at the BIPM in the 60Co beam [48]. The results are relative to the BIPM determination and are those for the most recent comparison for each national metrology institute. The uncertainty bars represent the relative standard uncertainty of the air-kerma determination at each institute. 26 3. ND,w-BASED FORMALISM The formalism for the determination of absorbed dose to water in high-energy photon and electron beams using an ionization chamber or a dosimeter calibrated in terms of absorbed dose to water in a 60 Co beam has been given in detail by Hohlfeld [27]. Complementary work on this topic and extensions of the formalism have been developed by Andreo [20] and Rogers [28]. The procedure for the determination of absorbed dose to water based on standards of absorbed dose to water has been implemented in the national dosimetry recommendations by the IPSM [49], DIN 6800-2 [50], and AAPM TG-51 [51]. It was also included in the IAEA Code of Practice for plane-parallel ionization chambers, TRS-381 [21]. 3.1. Formalism The absorbed dose to water at the reference depth zref in water for a reference beam of quality Q0 and in the absence of the chamber is given by Dw,Q O = M QO N D , w,QO (3.1) where MQo is the reading of the dosimeter under the reference conditions used in the standards laboratory and ND,w,Qo is the calibration factor in terms of absorbed dose to water of the dosimeter obtained from a standards laboratory. In most clinical situations the measurement conditions do not match the reference conditions used in the standards laboratory. This may affect the response of the dosimeter and it is then necessary to differentiate between the reference conditions used in the standards laboratory and the clinical measurement conditions. 3.1.1. Reference conditions The calibration factor for an ionization chamber irradiated under reference conditions is the ratio of the conventional true value of the quantity to be measured to the indicated value 8. Reference conditions are described by a set of values of influence quantities for which the calibration factor is valid without further correction factors. The reference conditions for calibrations in terms of absorbed dose to water are, for example, the geometrical arrangement (distance and depth), the field size, the material and dimensions of the irradiated phantom, and the ambient temperature, pressure and relative humidity. 3.1.2. Influence quantities Influence quantities are defined as quantities not being the subject of the measurement, but yet influencing the quantity under measurement. They may be of different nature as, for example, pressure, temperature and polarization voltage; they may arise from the dosimeter (e.g. ageing, zero drift, warm-up), or may be quantities related to the radiation field (e.g. beam quality, dose rate, field size, depth in a phantom). In calibrating an ionization chamber or a dosimeter as many influence quantities as practicable are kept under control. However, many influence quantities cannot be controlled, for example air pressure and humidity, and dose rate in 60Co gamma radiation. It is possible to correct for the effect of these 8 The conventional true value of a quantity is the value attributed to a particular quantity and accepted, sometimes by convention, as having an uncertainty appropriate for a given purpose. The conventional true value is sometimes called assigned value, best estimate of the value, conventional value or reference value [52]. At a given laboratory or hospital, the value realized by a reference standard may be taken as a conventional true value and, frequently, the mean of a number of results of measurements of a quantity is used to establish a conventional true value. 27 influence quantities by applying appropriate factors. Assuming that influence quantities act independently from each other, a product of correction factors can be applied, ∏ k i , where each correction factor ki is related to one influence quantity only. The independence of the ki holds for the common corrections for pressure and temperature, polarity, collection efficiency, etc. which are dealt with in Section 4. A departure from the reference beam quality Qo used to calibrate an ionization chamber can also be treated as an influence quantity. Measurements at radiation qualities other than the reference quality Qo therefore require a correction factor. In this Code of Practice this is treated explicitly by the factor kQ,Qo which is not included in the ki above; the correction for the radiation beam quality is described in detail below. 3.2. Correction for the radiation quality of the beam, kQ,Qo When a dosimeter is used in a beam of quality Q different from that used in its calibration, Qo, the absorbed dose to water is given by (3.2) Dw,Q = M Q N D, w,Q kQ ,Qo o where the factor kQ,Qo corrects for the effects of the difference between the reference beam quality Qo and the actual user quality Q, and the dosimeter reading MQ has been corrected to the reference values of influence quantities, other than beam quality, for which the calibration factor is valid. The beam quality correction factor kQ,Qo is defined as the ratio, at the qualities Q and Qo, of the calibration factors in terms of absorbed dose to water of the ionization chamber k Q ,Qo = N D , w,Q = N D , w,Qo D w,Q / M Q D w,Qo / M Q o (3.3) The most common reference quality Qo used for the calibration of ionization chambers is 60Co gamma radiation, in which case the symbol kQ is used in this Code of Practice for the beam quality correction factor. In some PSDLs high-energy photon and electron beams are directly used for calibration purposes and the symbol kQ,Qo is used in those cases. Ideally, the beam quality correction factor should be measured directly for each chamber at the same quality as the user beam. However, this is not achievable in most standards laboratories. Such measurements can be performed only in laboratories having access to the appropriate beam qualities. For this reason the technique is at present restricted to a few PSDLs in the world. The procedure requires the availability of an energy-independent dosimetry system, such as a calorimeter, operating at these qualities. A related problem is the difficulty in reproducing in a standards laboratory beam qualities identical to those produced by clinical accelerators [53]. When no experimental data are available, or it is difficult to measure kQ,Qo directly for realistic clinical beams, in many cases the correction factors can be calculated theoretically. Where Bragg-Gray theory can be applied, an expression for kQ,Qo can be derived comparing Eq. (3.2) with the ND,air formalism used in the IAEA Codes of Practice TRS-277 [17] and TRS-381 [21] and other dosimetry protocols. A general expression for kQ,Qo has been given in Refs. [20, 54] k Q ,Qo = (s w,air )Q (Wair )Q (s w,air )Q (Wair )Qo o pQ pQ o (3.4) 28 which is valid for all types of high-energy beams and includes ratios, at the qualities Q and Qo, of Spencer-Attix water/air stopping-power ratios, sw,air, of the mean energy expended in air per ion pair formed, Wair 9, and of the perturbation factors pQ. The overall perturbation factors pQ and pQo include all departures from the ideal Bragg-Gray detector conditions, i.e., pwall, pcav, pcel and pdis. These perturbation factors have been defined in Section 1.6. In therapeutic electron and photon beams the general assumption of (Wair)Q=(Wair)Qo simpler equation for kQ,Qo [27] kQ ,Qo ≈ ( sw,air )Q ( sw,air )Q o pQ pQ o 10 yields the (3.5) which depends only on quotients of water to air stopping-power ratios and perturbation factors at the beam qualities Q and Qo. The only chamber specific factors involved are the perturbation correction factors pQ and pQo. It should be emphasized, however, that when comparing experimental and theoretical determinations of kQ,Qo it is the full Eq. (3.4) that is relevant, rather than the approximate Eq. (3.5). The possible energy variation of Wair, as suggested by some experimental evidence (c.f. Ref. [55]), makes it necessary to use the approximate symbol (≈) in the latter expression. When the reference quality Qo is 60Co gamma radiation, values of the product (sw,air)Qo pQo in the denominator of Eq. (3.4) are given in Appendix B for cylindrical ionization chambers listed in this Code of Practice. These values have been used in the calculation of all kQ,Qo factors given in the different Sections of this Code of Practice when they are normalized to 60Co; the symbol kQ is used in those cases. In the case of low- and medium-energy x-ray beams Bragg-Gray conditions do not apply and therefore Eq. (3.4) cannot be used. In addition, the chamber to chamber variation in response is usually rather large (see Sections 8 and 9). For these radiation qualities the formalism is based exclusively on the use of directly measured ND,w,Q or kQ,Qo factors for individual user chambers. 3.2.1. A modified kQ,Qo for electron-beam cross calibrations For dosimeters that are used in electron beams, when the calibration quality Qo is 60Co, the situation is the same as discussed previously. For a user electron beam quality Q, the beam quality correction factor kQ is given by Eq. (3.4). An alternative to this is the direct calibration of chambers in electron beams, although this option has little application at present because of the limited availability of such calibrations. However, the ongoing development of electron-beam primary standards will enable calibration at a series of electron beam qualities. From these calibration factors, a series of measured kQ,Qo factors may be derived following the procedure given in Section 7.5.2 (the same procedure is used for chambers calibrated directly in high-energy photons and in low- and medium-energy x-rays). A third possibility, which in the absence of direct calibration in electron beams is the preferred choice, is the cross calibration of a plane-parallel chamber against a calibrated cylindrical chamber in a high-energy electron beam of quality Qcross. The factors kQ,Qcross, which allow the subsequent use of 9 It should be noticed that Wair, as well as sw,air, should be averaged over the complete spectra of particles present. This is an important limitation in the case of heavy charged particles, where the determination of all possible particle spectra is a considerable undertaking. 10 Note that this is the same assumption as for the non-dependence of ND,air on the quality of the beam (see TRS-277 [17]). 29 this chamber in an electron beam of quality Q, are non-trivial because the cross-calibration quality Qcross is not unique and so for each chamber type a two dimensional table of kQ,Qcross factors is required. However, it is possible to present the required data in a single table by introducing an arbitrary electron beam quality Qint which acts as an intermediate between the cross calibration quality Qcross and the user quality Q (no measurements are made at Qint, it is a tool to simplify the presentation of the data). The required kQ,Qcross factor is evaluated as the ratio of the factors kQ,Qint and kQcross,Qint: kQ ,Qcross = kQ ,Qint (3.6) kQcross ,Qint -1 The factor (kQcross,Qint) corrects the actual chamber calibration factor ND,w,Qcross into a calibration factor which applies at the intermediate quality Qint. The factor kQ,Qint corrects this latter calibration factor into one which applies at Q so that the general Eq. (3.2) for Dw,Q can be applied. The expressions for kQ,Qint and kQcross,Qint follow from Eq. (3.5), from which it is clear that the stoppingpower ratios and perturbation factors at Qint will cancel in Eq. (3.6). Thus the value chosen for Qint is arbitrary and in the present Code of Practice is chosen as R50 = 7.5 g cm-2, where R50 is the beam quality index in electron beams (see Section 7). Values for kQ,Qint and kQcross,Qint calculated on this basis are given in Table 7.IV for a series of chamber types. The data of Table 7.IV highlight another advantage of this approach. For a given Q and Qcross, the value for kQ,Qcross is the same for all well-guarded plane-parallel chamber types. For cylindrical chamber types it depends only on the chamber radius rcyl. The chosen value for Qint minimizes the differences for cylindrical chambers of different rcyl over the range of beam qualities for which cylindrical chambers are used. This value for Qint (R50 = 7.5 g cm-2) is also consistent with AAPM TG51 [51] so that the same measured or calculated values for kQ,Qint and kQcross,Qint may be used in Eq. (3.6). Note that the above method may also be used for plane-parallel or cylindrical chambers calibrated at a standards laboratory at a single electron beam quality Qo. 3.3. Relation to NK-based Codes of Practice The connection between the NK - ND,air formalism (used for example in TRS-277 [17] and TRS-381 [21]) and the present ND,w formalism is established for high-energy beams by the relationship N D ,w,Qo = N D ,air ( s w,air ) Qo pQo (3.7) where Qo is the reference quality (60Co gamma rays in previous Codes of Practice) and pQo the overall perturbation factor given by pQo = [ p dis p wall p cav p cel ]Q o (3.8) The meaning of the different perturbation factors has been described in Section 1.6, where it was emphasized that pcel refers exclusively to in-phantom measurements and should not be confused with the symbol used in TRS-277 to account for the combined effect of the central electrode in air and in phantom measurements. A similar relationship can be established for low- and medium-energy x-rays. Details on the comparison between the two formalisms are given in Appendix A. 30 Although the use of a calculated ND,w,Qo calibration factor is not recommended, this option could be used during an interim period aiming at the practical implementation of this Code of Practice using existing air-kerma calibrations. This will be the most common procedure for kilovoltage x-rays until standards of absorbed dose to water become more widely disseminated. It is emphasized, however, that calculated ND,w,Qo calibration factors are not traceable to primary standards of absorbed dose to water. A calculated ND,w,Qo can also be used to verify that therapy beam calibrations based on the two formalisms, ND,w and NK, yield approximately the same absorbed dose to water under reference conditions (see Appendix A for details). Should this not be the case, the reasons for the discrepancy should be carefully investigated before switching to the ND,w method. 31 4. IMPLEMENTATION 4.1. General Efforts in PSDLs have concentrated on providing calibrations in terms of absorbed dose to water of ionization chambers in 60Co gamma-ray beams, and to a lesser extent in high-energy photon and electron beams [46, 56-59]. Depending on the standards laboratory, users may be provided with ND,w,Qo calibrations according to different options. These options are clarified here in order to avoid the incorrect use of this Code of Practice: (a) The first approach is to provide users with a calibration factor at a reference beam quality Qo, usually 60Co. For additional qualities the calibration at the reference quality is supplied together with directly measured beam quality correction factors kQ,Qo for that particular chamber at specific beam qualities Q. Only laboratories having radiation sources and standards operating at different beam qualities can provide directly measured values of kQ,Qo for these qualities. The main advantage of this approach is that the individual chamber response in a water phantom irradiated by various beam types and qualities is intrinsically taken into account. A possible limitation, common to option (b) below, resides in the difference between the beam qualities used at the standards laboratory and at the user facility, which is of special relevance for highenergy beams (c.f. Ref. [53]) and whose influence is still the subject of studies at some PSDLs. (b) An alternative approach, in practical terms identical to the one described above and differing only in the presentation of the data, is to provide a series of ND,w,Q calibrations of the user ionization chamber at beam qualities Q. There is, however, an advantage in presenting the data by normalizing all calibration factors to a single calibration factor ND,w,Qo together with directly measured values of kQ,Qo. Once directly measured values of kQ,Qo for a particular chamber have been obtained, it may not be necessary for the user to re-calibrate the chamber at all qualities Q, but only at the single reference quality Qo. The quality dependence of that chamber can be verified less often by calibration at all qualities 11. Furthermore, this single reference quality calibration does not need to be performed at the same laboratory where the kQ,Qo values were measured (usually a PSDL). (c) In the third approach users can be provided with a ND,w,Qo calibration factor for the ionization chamber, most commonly at the reference quality 60Co, and theoretically derived beam quality correction factors kQ,Qo for that chamber type which must be applied for other beam qualities. This method ignores chamber-to-chamber variations in response with energy of a given chamber type, and calculations rely on chamber specifications provided by manufacturers. (d) A fourth approach, offered by some standards laboratories, is to provide a single measured ND,w,Qo for a given chamber, obtained at a selected reference quality, together with generic 12 experimental values of kQ,Qo for that ionization chamber type. This option does not take into account possible chamber-to-chamber variations within a given chamber type. Furthermore, there are currently only limited experimental data on kQ,Qo for most commercial chambers. This approach has much in common with option (c) above and, if for a given chamber type, the 11 12 See Section 4.3 for recommendations on the frequency of dosimeter calibrations. In the present context, generic stands for factors common to a specific ionization chamber type, supplied by a given manufacturer. 33 theoretical values of kQ,Qo are verified experimentally in a standards laboratory for a large sample of chambers, the theoretical values of kQ,Qo can be assumed to correspond to a mean value. Based on these descriptions, the following recommendations are given for compliance with this Code of Practice: (1) (2) (3) (4) (5) Approach (a), or its equivalent (b), are the preferred alternatives, although it is acknowledged that for beam qualities other than 60Co such possibilities are at present restricted to a few PSDLs. Approach (c) is recommended for those use...
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summary on how AAPM TG-51
Calibration Protocol:

For the purposes of reference beam dosimetry, beam quality in accelerator photon beams
is specified by %dd(10)x ,the percentage depth dose at 10 cm depth in a water phantom due to
photons only ~i.e., excluding electron contamination!.The value of %dd(10)x is defined for a
field size of 10×10 cm^2 at the phantom surface at an SSD of 100 cm. For60Co beams
%dd(10)x is not required since kQ51.000 by definition. At higher energies, the electrons from
the accelerator head may significantl...


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