Technical Reports SeriEs No.

483

Dosimetry of Small Static

Fields Used in External
Beam Radiotherapy
An International Code of Practice for
Reference and Relative Dose Determination
Sponsored by the IAEA and AAPM

1
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 DOSIMETRY OF
SMALL STATIC FIELDS USED IN
EXTERNAL BEAM RADIOTHERAPY
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 TECHNICAL REPORTS SERIES No. 483

DOSIMETRY OF
SMALL STATIC FIELDS USED IN
EXTERNAL BEAM RADIOTHERAPY
AN INTERNATIONAL CODE OF PRACTICE FOR
REFERENCE AND RELATIVE DOSE DETERMINATION

INTERNATIONAL ATOMIC ENERGY AGENCY

VIENNA, 2017
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STI/DOC/010/483

IAEA Library Cataloguing in Publication Data

Names: International Atomic Energy Agency.
Title: Dosimetry of small static fields used in external beam radiotherapy: an
IAEA-AAPM International Code of Practice for reference and relative dose
determination / International Atomic Energy Agency.
Description: Vienna : International Atomic Energy Agency, 2017. | Series: Technical
reports series (International Atomic Energy Agency), ISSN 0074–1914 ; no. 483 |
Includes bibliographical references.
Identifiers: IAEAL 17-01121 | ISBN 978–92–0–105916–1 (paperback : alk. paper)
Subjects: LCSH: Radiation dosimetry. | Radiotherapy. | Radiotherapy — Safety
measures.
Classification: UDC 615.849.5 | STI/DOC/010/483
 FOREWORD

In radiotherapy it is essential that the dose delivered to the patient be known

accurately so that patients receive the correct amount of radiation to kill the
cancer cells while at the same time sparing healthy tissue. Consistent reference
dosimetry traceable to metrological primary standards is key to the radiotherapy
process and enables common procedures to be followed within a country. For
conventional radiotherapy this has been achieved by universally adopted codes
of practice such as the IAEA publication titled Absorbed Dose Determination in
External Beam Radiotherapy: An International Code of Practice for Dosimetry
Based on Standards of Absorbed Dose to Water (Technical Reports Series
No. 398) and the American Association of Physicists in Medicine (AAPM)
publication titled AAPM’s TG-51 Protocol for Clinical Reference Dosimetry
of High-Energy Photon and Electron Beams. However, recent developments in
radiotherapy have resulted in an upsurge in the use of small static photon beams
such as those used in various forms of stereotactic radiotherapy, stereotactic body
radiotherapy, stereotactic radiosurgery and intensity modulated radiotherapy.
These radiotherapy treatments are performed not only with specialized, dedicated
machines such as TomoTherapy®, CyberKnife® or Gamma Knife®, but also
with conventional, non-dedicated accelerators equipped with high resolution
multileaf collimators. These developments have increased the uncertainty of
clinical dosimetry and weakened its traceability to reference dosimetry based on
codes of practice for conventional radiotherapy. Accidents have occurred in some
radiotherapy centres owing to the use of methods and procedures recommended
in conventional codes of practice that are not applicable to small fields.
This publication has been written in collaboration with the AAPM. It is
the first Code of Practice dedicated to the dosimetry of small static fields used
in radiotherapy and fulfils the need for a systematic and internationally unified
approach to the dosimetry of small static fields.
This Code of Practice is addressed to clinical medical physicists using
small static photon fields with energies less than 10 MV, provided with ionization
chambers calibrated in terms of absorbed dose to water traceable to a primary
standards dosimetry laboratory.
The IAEA wishes to express its gratitude to the authors and reviewers
of this publication, in particular H. Palmans (Belgium), P. Andreo (Sweden),
M. Saiful Huq (United States of America) and J. Seuntjens (Canada).
The IAEA officers responsible for this publication were S. Vatnitsky,
A. Meghzifene and K. Christaki of the Division of Human Health.
 ACKNOWLEDGEMENTS

The IAEA and the AAPM wish to acknowledge the following people for
their valuable suggestions:
M. Aspradakis (Switzerland), H. Bouchard (Canada), G. Bruggmoser
(Germany), S. Derreumaux (France), G. Ding (United States of America),
D. Followill (United States of America), P. Francescon (Italy), F. Gomez (Spain),
D. Gonzalez-Castaño (Spain), S. Kim (United States of America), M. McEwen
(Canada), C. Reft (United States of America), F. Sanchez-Doblado (Spain),
O.A. Sauer (Germany), T. Zhu (United States of America).

EDITORIAL NOTE
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consequences which may arise from its use.
This publication does not address questions of responsibility, legal or otherwise, for acts
or omissions on the part of any person.
Guidance provided here, describing good practices, represents expert opinion but does
not constitute recommendations made on the basis of a consensus of Member States.
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.
The IAEA has no responsibility for the persistence or accuracy of URLs for external or
third party Internet web sites referred to in this publication and does not guarantee that any
content on such web sites is, or will remain, accurate or appropriate.
 CONTENTS

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.1. Definition of small field . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.1.2. Dosimetry equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.1.3. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.4. Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.1.5. Expression of uncertainties . . . . . . . . . . . . . . . . . . . . . . . 4
1.1.6. Quantities and symbols . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2. Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3. Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.4. Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2. PHYSICS OF SMALL FIELD DOSIMETRY . . . . . . . . . . . . . . . . . . 9

2.1. Parameters describing small fields and problems of

small field dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1.1. Small field conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1.2. Definition of field size . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1.3. Hardening of the energy spectrum of small fields . . . . . 15
2.1.4. Beam quality of small fields and msr fields . . . . . . . . . . 16
2.1.5. Detector response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.1.6. Energy range of interest . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.1.7. Summary of small field characterization
for dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.2. Absorbed dose to water standards for small fields . . . . . . . . . . . 24
2.3. Overview of current reference and relative dosimetry of
radiotherapy beams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.3.1. Reference dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.3.2. Relative dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

3. CONCEPTS AND FORMALISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

3.1. Concepts of small fields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

3.1.1. Definition of field size . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.1.2. The msr field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.1.3. Lateral charged particle equilibrium range . . . . . . . . . . . 36
 3.1.4. Volume averaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.1.5. Beam quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.2. Formalism for the determination of the reference absorbed
dose to water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.2.1. Approaches for the reference dosimetry of msr fields . . 40
3.2.2. Measurement in plastic water substitute phantoms . . . . 45
3.2.3. Determination of field output factors . . . . . . . . . . . . . . . 46
3.3. Reference conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

4. DETECTORS AND EQUIPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

4.1. Equipment for machine specific reference dosimetry . . . . . . . . 51

4.1.1. Ionization chambers for msr reference dosimetry . . . . . 52
4.1.2. Phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.2. Equipment for relative dosimetry in small and
non-reference fields . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
4.2.1. General characteristics of detectors for small field
dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.2.2. Phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

5. CODE OF PRACTICE FOR REFERENCE DOSIMETRY OF

MACHINE SPECIFIC REFERENCE FIELDS . . . . . . . . . . . . . . . . . 77

5.1. General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.2. Dosimetry equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.2.1. Ionization chambers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
5.2.2. Phantoms and chamber sleeves . . . . . . . . . . . . . . . . . . . 78
5.3. Determination of absorbed dose to water in the
msr field,  fmsr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.3.1. Reference conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.3.2. Machine specific determination of absorbed dose
to water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
5.3.3. Determination of the beam quality when the
conventional  fref  cannot be realized . . . . . . . . . . . . . . . . 87
5.3.4. Measurement in plastic water substitute phantoms . . . . 99
5.4. Correction for influence quantities . . . . . . . . . . . . . . . . . . . . . . . 103
5.4.1. Air density correction . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.4.2. Humidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.4.3. Electrometer calibration factor kelec . . . . . . . . . . . . . . . . 103
5.4.4. Polarity correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
5.4.5. Recombination correction . . . . . . . . . . . . . . . . . . . . . . . . 104
 5.5. Cross-calibration in the msr field . . . . . . . . . . . . . . . . . . . . . . . . 106

6. CODE OF PRACTICE FOR RELATIVE DOSIMETRY OF

SMALL FIELDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

6.1. Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

6.1.1. Detectors for relative dosimetry . . . . . . . . . . . . . . . . . . . 109
6.1.2. Phantoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
6.2. In-phantom detector set-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
6.2.1. Detector orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
6.2.2. Placement of the detector’s reference point at
the reference depth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6.2.3. Detector alignment with beam central axis . . . . . . . . . . 114
6.2.4. Set-up of SSD or SAD . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6.3. Measurement of lateral beam profiles . . . . . . . . . . . . . . . . . . . . 118
6.4. Determination of absorbed dose at zmax . . . . . . . . . . . . . . . . . . . 118
6.5. Determination of in-phantom field output factors . . . . . . . . . . . 119
6.5.1. Reference conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
6.5.2. Determination of the equivalent square small
field size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
6.5.3. Determination of field output factors . . . . . . . . . . . . . . . 121
6.5.4. Some practical considerations . . . . . . . . . . . . . . . . . . . . 122
6.6. Tables of field output correction factors . . . . . . . . . . . . . . . . . . . 123

APPENDIX I: DETERMINATION OF BEAM QUALITY

CORRECTION FACTORS FOR REFERENCE
DOSIMETRY AND THEIR UNCERTAINTY
ESTIMATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

APPENDIX II: DETERMINATION OF FIELD OUTPUT

CORRECTION FACTORS AND THEIR
UNCERTAINTY ESTIMATES . . . . . . . . . . . . . . . . . . . . . 161

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
CONTRIBUTORS TO DRAFTING AND REVIEW . . . . . . . . . . . . . . . . . . 211
 1.  INTRODUCTION

1.1. BACKGROUND

For conventional radiotherapy, dosimetry is based on widely adopted

codes of practice (COPs) such as Technical Reports Series No. 398 (Absorbed
Dose Determination in External Beam Radiotherapy: An International Code of
Practice for Dosimetry Based on Standards of Absorbed Dose to Water) [1],
the American Association of Physicists in Medicine (AAPM) publication titled
AAPM’s TG-51 Protocol for Clinical Reference Dosimetry of High-Energy
Photon and Electron Beams [2] and Refs [3–7]. These and other dosimetry
protocols are based on measurements using an ionization chamber with a
calibration coefficient in terms of absorbed dose to water, traceable to a primary
standards dosimetry laboratory (PSDL) for reference conditions, such as a
conventional field size of 10 cm × 10 cm. Departure from reference conditions,
such as the determination of absorbed dose to water in beams of different field
sizes, were considered in less detail, or not included at all.
However, in radiotherapy there has been an escalation in the use of small
static fields that has been facilitated by the generalized availability of standard
and add-on multileaf collimators (MLCs) and a variety of treatment machines
of new design. This has increased the uncertainty of clinical dosimetry and
weakened its traceability to reference dosimetry based on conventional COPs.
At the same time, dosimetric errors have become considerably larger than with
conventional beams, mostly for two reasons [8]:

(a) The reference conditions recommended by conventional COPs cannot be

realized in some machines;
(b) The measurement procedures for determination of absorbed dose to
water in small and composite fields are not standardized. In some cases
accidents have occurred owing to the use of methods and procedures that
are appropriate for large fields but not for small fields [9].

To develop standardized guidance for dosimetry procedures and detectors,

an international working group on reference dosimetry of small static fields used
in external beam radiotherapy was established by the IAEA in cooperation with
the AAPM. In 2008 this working group published a formalism for the dosimetry
of small and composite fields [8]. This formalism introduced the concept of two
new intermediate calibration fields: (i) a static machine specific reference (msr)
field for those modalities that cannot establish conventional reference conditions
and (ii) a plan class specific reference field that is closer to the patient specific

1
clinical fields and thereby facilitates standardization of composite field dosimetry.
Prior to progressing with developing a COP, the members of this IAEA/AAPM
working group requested comments from the international medical physics
community on the formalism. Since 2008 there have not been comprehensive
data available for plan class specific reference fields, so this COP was written for
static fields, with the intention of adding the second part of the Code when more
data become available. However, there have been many challenges in writing this
Code, mainly relating to providing a comprehensive set of relevant data together
with associated uncertainties.
Guidance provided here, describing good practices, represents expert
opinion but does not constitute recommendations made on the basis of a
consensus of Member States.

1.1.1. Definition of small field

In this COP, the requirements of a small field are described in detail.

To summarize, at least one of the following three physical conditions will be
fulfilled for an external photon beam to be designated small:

(i) There is a loss of lateral charged particle equilibrium (LCPE) on the beam
axis;
(ii) There is partial occlusion of the primary photon source by the collimating
devices on the beam axis;
(iii) The size of the detector is similar or large compared to the beam dimensions.

The first two characteristics are beam related, while the third one is detector
related for a given field size. All three of these conditions result in overlap
between the field penumbrae and the detector volume.

1.1.2. Dosimetry equipment

For the msr field it is advised to use an ionization chamber calibrated in

terms of absorbed dose to water. The size restriction on an ionization chamber
for msr dosimetry is that the outer boundaries of the detector are at least a lateral
charged particle distance rLCPE away from the field edges (at 50% absorbed
dose level). The preferred approach for reference dosimetry is to obtain a
calibration coefficient directly in the msr field, provided the standards laboratory
is able to supply such a calibration coefficient. There has been research into
the use of calorimeters in small fields, but to date PSDLs are not able to offer
calibrations in small fields, although it is expected that they will be available in

2
the future. In a second approach, the ionization chamber is calibrated for current
standard reference conditions and factors are used to convert to the msr field.
Ionization chambers, which have been the ‘backbone’ of radiotherapy
dosimetry, are not always suitable for both reference and relative measurements in
small fields. Volume averaging and lack of electronic equilibrium, which requires
a sufficiently large region of uniform particle fluence surrounding the detector,
complicates the use of certain ionization chambers for the dosimetry of small
photon beams. As is well known, any detector perturbs the particle fluence in the
medium, and appropriate correction factors are used to account for this effect;
however, when relatively large ionization chambers (e.g. of a Farmer type) are
used in small fields, the necessary corrections either become excessively large
and uncertain or are not known. This implies that the conversion from ionization
to absorbed dose to water based on cavity theory and using the currently
available perturbation factors used in existing dosimetry COPs or protocols such
as Refs [1, 2, 7] is not accurate. Furthermore, spectra, and therefore beam quality,
may change as the field size decreases. Hence, for small fields, other detectors
for relative dosimetry are discussed and proposed in this Code.
For some treatment units, the use of water phantoms for reference
dosimetry is possible but highly inconvenient, and therefore plastic water
substitute phantoms may be necessary. Today, plastic materials such as
polymethylmethacrylate (PMMA) (Lucite), acrylonitrile butadiene styrene
(ABS) and Solid Water® (Sun Nuclear Corp., Melbourne, FL) have well
controlled densities, well defined atomic properties, and can be machined for
accurate positioning of dosimeters. Therefore, this Code gives a methodology for
use of plastic water substitute phantoms that complements the dosimetry in the
reference conditions recommended in existing COPs.

1.1.3. Methodology

This COP builds on the established reference dosimetry for conventional

10  cm × 10  cm fields such as that given in Refs  [1,  2,  7]. It then extends the
dosimetry down to small fields by introducing an msr field and gives the required
factors as recommended by Alfonso et al. [8]. It is recommended that the msr field
have dimensions as close as possible to those of the conventional reference field
and extend at least a distance rLCPE beyond the outer boundaries of the reference
ionization chamber. In the case that only fields smaller than the 10 cm × 10 cm
reference field can be realized, the msr field will usually be the largest achievable
field.
Field size is not uniquely defined for small fields, so for the purpose of
applying the procedures in this COP, the field size is the pair of dimensions
(in case of rectangular fields) or the diameter (in case of circular fields) that

3
define(s) the area of the field at the measurement distance. Each dimension is
defined by the full width at half maximum (FWHM) of the lateral beam profile
measured at a depth sufficient to eliminate the contribution of contaminating
electrons; 10 cm is the depth recommended in this COP.
The beam quality indices given in Ref.  [1] (TPR20,10) and Refs  [2,  7]
(%dd(10)x) apply only for a conventional 10 cm × 10 cm field, so this Code gives
guidance on how to convert these indices from the msr field to a conventional
field size so that conventional dosimetry coefficients can be used. Many modern
radiotherapy machines give the option of having a beam that is flattening filter
free (FFF); therefore the Code gives details of how to perform dosimetry for
small, FFF beams.
Owing to the difficulty of measuring field output factors, this Code gives
the option to move away from reference conditions and gives a methodology and
factors to determine field output factors. The determination of field output factors
is treated as formally as reference dosimetry, and requires explicit correction
factors to be applied.

1.1.4. Data

All of the data presented in this COP are based on values published in peer
reviewed journals, determined using Monte Carlo calculations and measurements,
following the considerable amount of research undertaken on small megavoltage
photon beam dosimetry during recent years. Unfortunately, the published data
are rather scattered for certain field sizes, especially for the smallest fields,
and lack homogeneity with regard to the source-to-surface distance (SSD) or
source-to-detector distance (SDD) used, the depth of measurement or calculation,
the definition of field size at the surface or at a reference depth, etc. Further
complicating the determination of average values for the different detectors and
their subsequent statistical analysis is the fact that most of the published data
lack a proper estimation of the uncertainty in the various steps involved in the
determination of the correction factors given by the different authors. Values of
the correction for the small field of interest are limited to a maximum value of
5% in this COP.

1.1.5. Expression of uncertainties

Uncertainty estimates have been derived following as closely as possible

Ref. [10], according to a procedure adapted from Ref. [11]. A detailed analysis of
the estimated uncertainties for factors used in reference and relative dosimetry is
given in the appendices of this COP.

4
1.1.6. Quantities and symbols

Most of the symbols used in this COP are comparable to those used in
Ref.  [1], although some are new in the context of small field dosimetry. For
completeness, Table 1 contains a summary of all the quantities used in this COP.

TABLE 1.  QUANTITIES AND SYMBOLS USED IN THIS PUBLICATION

Symbol Definition

%dd(10,10) Percentage depth dose at 10 cm depth in a water phantom for a field size
of 10 cm × 10 cm at an SSD of 100 cm.

%dd(10,10)x Percentage depth dose at 10 cm depth in a water phantom due to photons
only (i.e. excluding the contribution of electron contamination) for a
field size of 10 cm × 10 cm at an SSD of 100 cm.

%dd(10,S)x Percentage depth dose at 10 cm depth in a water phantom due to photons
only (i.e. excluding the contribution of electron contamination) for an
equivalent square field size of S cm × S cm at an SSD of 100 cm.

Dw,Q Absorbed dose to water at the reference depth, zref, in a water phantom
irradiated by a beam of quality Q (unit: Gy).

fmsr Machine specific reference field.

fref Conventional reference field (i.e. 10 cm × 10 cm, at an SDD of 100 cm),

used for calibration at the standards laboratory and for reference
dosimetry, according to COPs such as Refs [1, 2, 7], at a depth of
10 g/cm2 in water.

fclin Clinical non-reference field.

f ,f
k Q1 ,Q2 Generic form of a correction factor that accounts for the differences
1 2
between the response of a detector in a field  f2 in a beam of quality Q2
and a field  f1 in a beam of quality Q1. If  f1 and f2 represent the same field
(i.e. field size, reference depth, phantom, etc.), the superscript ‘f1, f2’ is
replaced with a single ‘f1’.

k Qw,plastic Phantom dose conversion factor, for measurements performed in plastic

msr
water substitute phantoms.

MQ Reading of a dosimeter at the quality Q, corrected for influence

quantities other than beam quality (unit: C or meter reading (rdg)).

5
TABLE 1.  QUANTITIES AND SYMBOLS USED IN THIS PUBLICATION
(cont.)

Symbol Definition

M Qf Reading of a detector in a field   f  in a beam of quality Q, corrected for

influence quantities other than beam quality.

f
M plastic,Q Reading of a detector in a plastic water substitute phantom in a field  f
in a beam of quality Q, corrected for influence quantities other than
beam quality.

f
M w,Q
As M Qf , but used when a distinction has to be made between
measurements in a water phantom and in a plastic water substitute
phantom.

f
N Dref,w,Q Calibration coefficient in terms of absorbed dose to water for an
0
ionization chamber at a reference beam quality Q0 in the conventional
reference field  fref.

f
N Dmsr
,w,Q
Calibration coefficient in terms of absorbed dose to water for an
msr
ionization chamber in a machine specific reference field  fmsr at the beam
quality Qmsr.
f ,f
WQclin ,Qref Field output factor of a clinical, non-reference field  fclin with respect to
clin
the conventional 10 cm × 10 cm reference field  fref.

f ,f
WQclin ,Qmsr Field output factor of a clinical, non-reference field  fclin with respect to
clin msr
the machine specific reference field  fmsr.

OAR(x,y) Off-axis ratio, the lateral beam profile at the measurement depth
normalized to unity on the central axis.

Q General symbol to indicate the quality of a radiation beam. A subscript

“0”, i.e. Q0, indicates the reference quality used for the calibration of an
ionization chamber or a dosimeter.

Qmsr Beam quality of a machine specific reference beam.

Qclin Beam quality of a clinical, non-reference beam.

rLCPE Lateral charged particle equilibrium range.

TPR20,10(10) Tissue phantom ratio in water at the depths of 20 and 10 g/cm2,

for a field size of 10 cm × 10 cm defined at an SDD of 100 cm.

6
TABLE 1.  QUANTITIES AND SYMBOLS USED IN THIS PUBLICATION
(cont.)

Symbol Definition

TPR20,10(S) Tissue phantom ratio in water at the depths of 20 and 10 g/cm2, for an
equivalent field size of S cm × S cm defined at an SDD of 100 cm.

w(x,y) Weighting function representing the extension of the sensitive volume of

a detector along the beam axis as a function of the lateral coordinates x
and y.a

zmax Depth of maximum dose (in g/cm2).

zref Reference depth (in g/cm2) in water for in-phantom measurements.

zeq,plastic Depth in plastic water substitute phantom (in g/cm2), equivalent to the
reference depth in water, scaled according to the ratio of electron
densities.

a
See Appendix I for its definition and examples of its usage.

1.2. OBJECTIVES

This is the first international COP dedicated to reference and relative

dosimetry of small static fields used in radiotherapy. It will provide consistent
reference dosimetry traceable to metrological primary standards and enable
common procedures to be followed within a country for small field dosimetry.

1.3. SCOPE

This COP addresses the reference and relative dosimetry of small static
fields used for external beam photon radiotherapy of energies with nominal
accelerating potential up to 10  MV. It does not address other radiotherapy
modalities such as electron, proton and orthovoltage beams.
This COP consists of six sections. The first two are introductory sections
describing the rationale of the COP and the physics of small field dosimetry. The
COP is based on the concepts and formalism introduced by Alfonso et al. [8];
these are described in Section 3. The fourth section discusses the detectors and
equipment that are suitable for use in msr fields and for relative dosimetry in
small fields. The fifth section is the COP for reference dosimetry in msr fields for
both beams with flattening filter (WFF) and FFF. The sixth section is the COP for

7
relative dosimetry for small fields. Sections 5 and 6 give data required to use the
COP. Appendix I discusses the origin of the beam quality correction factors for
reference dosimetry and their associated uncertainties, and Appendix II discusses
the origin of the field output correction factors and their associated uncertainties.

1.4. STRUCTURE

In this COP, an overview of the physics of small field dosimetry is presented

first, followed by a general formalism for reference dosimetry in small fields.
Guidelines for its practical implementation using suitable detectors and methods
for the determination of field output factors are given for specific clinical
machines that use small static fields. Guidance for relative dosimetry including
detectors, procedures and data is also provided.

8
 2.  PHYSICS OF SMALL FIELD DOSIMETRY

Small fields in external radiotherapy are created by downstream collimation

of a flattened or unflattened photon beam. Different collimation types are
used, including jaws, MLCs and, in some cases, cones or adjustable tertiary
collimators. Small photon fields differ from conventional reference fields1
in their lateral dimensions, causing the penumbrae at both sides of the field to
overlap and making most of the commonly used detectors large relative to the
radiation field size. This has physical repercussions on dosimetry, which have
in general been described well in the literature. Until the publication of Institute
of Physics and Engineering in Medicine (IPEM) Report 103 [12], however,
those repercussions had not been comprehensively reviewed. This section
discusses the physics aspects that are relevant for reference dosimetry and for
the determination of field output factors in small static photon fields. It is not
meant to present a comprehensive literature overview similar to that in Ref. [12].
Rather it focuses on those small field issues that are of particular relevance to
reference dosimetry and on the determination of field output factors. There is
some overlap with Ref. [12], but a number of other aspects are introduced, such
as the measurement of beam quality when conventional reference conditions
cannot be met, equivalent square msr fields and equivalent square small fields,
the use of plastic water substitute phantoms for reference dosimetry and a formal
approach for the determination of field output factors. Additionally, this section
provides a brief overview of the current status of primary standards of absorbed
dose to water for small fields, of the current practice of performing reference
dosimetry and of the determination of field output factors.

2.1. PARAMETERS DESCRIBING SMALL FIELDS AND PROBLEMS OF

SMALL FIELD DOSIMETRY

2.1.1. Small field conditions

At least one of the following three physical conditions will be fulfilled for
an external photon beam to be designated small:

1
In this COP the term ‘conventional reference fields’ refers to the reference fields
(and conditions) for the user’s beam calibration prescribed in COPs such as those mentioned in
Section 1. In the future, new reference conditions such as those introduced by Alfonso et al. [8]
may become conventional for small field dosimetry, but they are not used that way at present.

9
(i) There is a loss of LCPE on the beam axis (Fig. 1);
(ii) There is partial occlusion of the primary photon source by the collimating
devices on the beam axis (Fig. 2);
(iii) The size of the detector is similar or large compared to the beam dimensions
(Fig. 3).

The first two characteristics are beam related, while the third one is detector
related for a given field size. All three of these conditions result in overlap
between the field penumbrae and the detector volume.

2.1.1.1. Beam related conditions

Loss of LCPE occurs in photon beams if the beam half width or radius
is smaller than the maximum range of secondary electrons that contribute
measurably to the absorbed dose. This condition has been quantified by
evaluating the minimum radius of a circular photon field for which collision
kerma in water and absorbed dose to water have reached the values determined
by broad beam transient charged particle equilibrium (TCPE) conditions (for the
definition of TCPE refer to Attix [13], chapter 2, section VII). An illustration
is shown in Fig.  1 [14]. Absence of LCPE is problematic for dosimetry using

FIG. 1.  Ratios of dose-to-water to water-collision-kerma calculated by Monte Carlo

simulation in water at 5 cm depth on the central axis of high energy photon beams. The data
are plotted as a function of the radius of clinical narrow beams defined at 100  cm SSD for
the high energy X  ray beams and 80  cm SSD for 60Co (reproduced from Ref.  [14] with the
permission of P. Papaconstadopoulos, McGill University, Canada).

10
non-water detector materials, as will be discussed in Sections 2.1.1.2 and 2.1.5.
A practical parameter that quantitatively determines when field sizes are small
is the lateral charged particle equilibrium range (rLCPE), defined as the minimum
radius of a circular photon field for which collision kerma in water and absorbed
dose to water are equal at the centre of the field (aside from a correction for the
centre of electron production in TCPE). This parameter will be discussed in more
detail in Section 3.1.3.
The second condition is illustrated in Fig. 2 and is related to the finite size
of the primary photon beam source, the extended focal spot, which is usually
determined by the FWHM of the bremsstrahlung photon fluence distribution
exiting the target. A small field created by collimation that shields part of the
finite primary photon source will produce a lower beam output on the beam axis
compared to field sizes where the source is not partially blocked. This primary
source occlusion effect becomes important when the field size is comparable
to or smaller than the size of the primary photon source. For modern linear
accelerators where the primary photon source size is not larger than 5 mm, direct
source occlusion usually occurs at field sizes smaller than those where lateral
electron disequilibrium starts [12]. Partial occlusion of the primary photon source
influences the particle spectrum and is a source of steep local absorbed dose
gradients, both of which can have a large effect on the detector response.
The loss of LCPE and the primary photon source occlusion effect are both
responsible for a sharp drop in beam output with decreasing field size. This drop

FIG. 2.  Schematic illustration of the source occlusion effect (replotted from Ref. [12] with the
permission of the Institute of Physics and Engineering in Medicine).

11
becomes more pronounced when the photon beam energy increases or the density
of the medium decreases (in both cases the electron ranges increase).

2.1.1.2. Detector related conditions

The third feature that characterizes a small field is the size of the detector
relative to the size of the radiation field. A detector produces a signal that is
proportional to the mean absorbed dose over its sensitive volume and this
signal is affected by the homogeneity of the absorbed dose over the detection
volume (volume averaging). The effect in a small field is illustrated in Fig.  3.
A deconvolution process would be required to derive the absorbed dose to water
at a point from this signal.
Besides volume averaging, the perturbation of the charged particle fluence
(and thus the deviation from Bragg–Gray cavity theory conditions) due to
the presence of a detector is an important issue and it must be noted that both
effects are always entangled. In the presence of large dose gradients and in the
absence of LCPE conditions, fluence perturbations become large and difficult

1.00 gaussian

average 5 mm
0.80
Lateral beam profile

difference with
0.60 gaussian

0.40

0.20

0.00

-0.20
-20.0 -15.0 -10.0 -5.0 0.0 5.0 10.0 15.0 20.0
Distance to central axis / mm

FIG. 3.  Schematic illustration of the volume averaging effect in one dimension. The black
curve is a Gaussian curve approximating a small field profile; the dashed black curve
represents what a detector of 5 mm length would measure. The double arrow represents the
dimension of the detector along the scanning axis. The dash-dotted line shows the difference
between the two curves as a fraction of the maximum dose (replotted from Ref. [15] with the
permission of the International Organization for Medical Physics).

12
to model. Corrections for volume averaging will also have a larger uncertainty.
The dosimetric difficulties thus caused start to show up as soon as the effects
of lateral absorbed dose gradients and charged particle disequilibrium reach the
detector volume. For these reasons, small field conditions can be assumed to
exist when the external edge of the detector volume is at a distance from the field
edge smaller than the rLCPE in the medium. To avoid this condition in central axis
measurements, the beam half width or radius has to be at least as large as rLCPE
plus half the size of the external volume of the detector.

2.1.2. Definition of field size

The International Electrotechnical Commission provides definitions for

two differently termed field sizes [16]:

—— The geometrical field size is defined as the geometrical projection of the

collimator opening by the radiation source on a plane perpendicular to the
axis of the beam;
—— The irradiation field size is defined in terms of the dimensions of an area
in a plane perpendicular to the radiation beam axis defined by specified
isodose lines.

The geometrical field size corresponds with an aligned light field which
equals the collimator setting for focused flat edged collimators. For cylindrical
collimators, the relation between geometrical field size and collimator settings
is a quadratic curve [17]. In broad beams, the FWHM of the lateral profiles,
i.e. the irradiation field size specified at the 50% relative dose level, equals the
collimator setting and is thus congruent with the geometrical field size. The field
size defined by the collimator setting thus corresponds well with the FWHM of
the lateral beam profile at the isocentre depth, and measuring the FWHM is a
common way of verifying the field size setting. In small fields, however, owing to
partial occlusion of the finite primary photon source and loss of LCPE, resulting
in a drastic reduction of beam output, this congruence breaks down as is shown in
Fig. 4(c) [12, 18]. Because the central axis maximum dose value is reduced, the
FWHM is determined by a lower position on the penumbral curve (see Fig. 4).
The FWHM of the resulting field is therefore not consistent with the geometrical
definition of the field. The irradiation field size specified at 50% relative dose
level thus becomes broader than the geometrical field size defined by the
projected collimator settings, an effect called apparent field widening. For a
given SDD, this effect is dependent on the source-to-collimator distance.

13
FIG. 4.  Effect of overlapping penumbrae on the FWHM of the lateral beam profile for small
fields illustrating the apparent field widening compared to the collimator settings (reproduced
from Ref. [18] with the permission of the American Association of Physicists in Medicine).

The absence of information on whether the size of a field has been specified
in terms of FWHM of the lateral beam profile or of the projected collimator
setting complicates the interpretation of field output factor data published in the
literature. This COP advises that publication of all small field data such as field
output factors be accompanied by unambiguous statements on how the field size
is defined. It has been shown that the detector response and perturbation depend
on the irradiation field size specified at 50% relative dose level, i.e. the FWHM,
at the measurement depth rather than on the collimator setting [19]. The analysis
of published data on detector perturbation corrections indicates that the errors
made when choosing an incorrect field size specification are substantial [20]. It is
advised that the FWHM be used for selecting detector perturbations as a function
of field size. It is thus concluded that the FWHM of the lateral beam profile is
the most representative and essential field size parameter for accurate small field
dosimetry, and field size for small field dosimetry is, in this COP, defined as the
irradiation field size or the FWHM of the field. If another field size parameter is
referred to, such as geometrical field size, then this will be explicitly mentioned.
To facilitate establishing a relationship between FWHM and collimator setting,
it is also advised that both the FWHM and the geometrical field size be recorded
when reporting small field data. The accurate measurement of profiles for small

14
fields involves careful procedures; these will be discussed in Section 6 and
measurement guidelines are provided in that section.

2.1.3. Hardening of the energy spectrum of small fields

The collimator that defines a small field not only occludes the primary
photon source but also shields photons that are scattered from different
components inside the linac head, including flattening filter and primary
collimator. Thus, the number of low energy photons scattered from the primary
collimator, flattening filter and other components in the linac head reaching the
centre of the small field is reduced. For off-axis fields, however, there may be an
increased relative contribution of photons scattered in the treatment head, and
whether this leads to softening or hardening depends on the shape and materials
of the flattening filter (if present). Additionally, the amount of phantom scatter
also decreases for a small field as compared with a broad field. For most depths,
this has a larger effect than the reduced head scatter. These two effects result in
a hardening of the photon energy spectrum at any point on the beam axis with
decreasing field size and an increase in the average photon energy in comparison
with broad beam conditions. This results in a change of the ratio of mass energy
absorption coefficients between water and the detector material (e.g. ratio of mass
energy absorption coefficients of water to silicon will increase with decreasing
field size) and a potential change of the stopping-power ratio between water and
the detector material (e.g. the water to air stopping-power ratio will decrease with
decreasing field size). An additional effect that plays a role is that when the field
is too small for achieving LCPE, there will be a deficit of low energy electrons
reaching the central axis, resulting in an increase of the mean electron energy,
which can also affect the stopping-power ratio.
Monte Carlo simulations indicate that, although the photon fluence
spectrum changes considerably as a function of field size, the charged particle
spectrum produced in water is much less affected. Thus, the influence of field
size on the water to air stopping-power ratio is found to decrease by not more than
0.5% at a depth of 10 cm in a 6 MV photon beam over a range of field sizes from
the 10 cm × 10 cm reference field down to 0.3 cm × 0.3 cm for square fields and
a 0.3 cm diameter for circular fields [21, 22]. Even over a range of depths from
the depth of dose maximum to 30 cm, the variation is not larger than 1% [21].
The increased average photon energy of the beam does affect the response of
silicon based diode detectors because of the large variation of the water to silicon
mass energy absorption coefficient ratio for photon energies below 100  keV.
Simulations show a variation of 3–4% in the response of unshielded diodes over
a range of field sizes from 10 cm × 10 cm to 0.5 cm × 0.5 cm at a measurement

15
depth of 10  cm as a result of the reduced phantom scatter [23], and this is
supported by experimental data [24].

2.1.4. Beam quality of small fields and msr fields

Conventional reference dosimetry of a high energy photon beam with

quality Q using an ionization chamber requires an absorbed dose to water
calibration coefficient in the beam quality Q or, if that is not available, an
absorbed dose to water calibration coefficient in a calibration beam quality Q0
and a beam quality and chamber dependent beam quality correction factor kQ,Q0.
The subscript Q0 is omitted when the reference quality is 60Co gamma radiation
(i.e. the reduced notation kQ always corresponds to the reference quality 60Co) [1].
The beam quality for high energy photon beams is specified in Ref.  [1] and
most other absorbed dose to water based dosimetry protocols by a single beam
quality index, the tissue phantom ratio in water at depths of 20 and 10 g/cm2 for
a field size of 10 cm × 10 cm and SDD of 100 cm, here denoted TPR20,10(10)2.
In Refs [2, 7], the beam quality specifier or index is the percentage depth dose at
10 cm depth in a water phantom due to photons only, here denoted %dd(10,10)x.
The beam quality indices in these protocols are used for the selection of the beam
quality correction factor kQ,Q0 , required when reference dosimetry is performed
with an ionization chamber in a beam with quality different from that used for
its calibration; they are also used by standards laboratories to specify the beam
quality of high energy beams used for calibration.
In Ref.  [1], the preferred approach is to use experimental kQ,Q0 values
measured for the user’s chamber at specific beam qualities Q in a PSDL or a
secondary standards dosimetry laboratory (SSDL). The difference between
beam qualities at the standards laboratory and at the user’s facility would
give preference to kQ,Q0 factors determined for a specific clinical radiotherapy
machine, a possibility that only exists if the PSDL or SSDL calibrates chambers
in the beam of the particular clinical machine or the same machine type. Some
PSDLs and SSDLs provide high energy photon beam calibrations using clinical
linacs; this option is realistic given the small differences between calibration
coefficients in different machines of the same type. Indeed, with modern
radiotherapy technology, differences between machines of the same type have
been reduced significantly and, within a certain tolerance, the beam quality
for a given photon beam energy at a given machine type is found to vary only
modestly from machine to machine. Thus, it is conceivable that a unique beam

2
Note that the symbols used differ from those used to denote the beam quality index in
Ref. [1] (TPR20, 10) and in Refs [2, 7] (%dd(10)x), because in this COP an additional parameter
in brackets is used to specify the field size.

16
quality correction factor could be used for a particular combination of ionization
chamber type and radiotherapy machine type and the dosimetry at these machines
could, in principle, be done without a need for beam quality indices. This has
to some extent been demonstrated for Gamma Knife® (Elekta AB, Stockholm),
Cyberknife® (Accuray Inc., Sunnyvale, CA) and TomoTherapy® (Accuray Inc.,
Sunnyvale, CA) machines. Likewise, for conventional radiotherapy machines with
fields collimated by jaws or MLCs, machine uniformity has improved [25–27].
It must be emphasized though that this does not remove the necessity of verifying
that the beam quality index is within the normal range for a given machine type
and that even if the determination of the beam quality index is not needed to look
up beam quality correction factors, it remains an essential part of commissioning
and quality assurance (QA) procedures. Another point is that most intensity
modulated radiotherapy (IMRT) and stereotactic treatments are delivered with
photon beams of nominal energies not exceeding 10 MV, where the sensitivity
of kQ,Q0 to the beam quality specifier is rather small [1,  2]. The multitude of
add-ons used for IMRT and stereotactic treatments, however, makes it difficult
to tabulate factors for all combinations of basic radiotherapy machines, add-ons
and chamber types. Overall, the current situation is that for a wide range of high
energy photon treatment machines, kQ,Q0 for specific machine/ionization chamber
combinations is not available. Consequently, one has to continue to rely on the
use of beam quality indices to link the calibration beam quality to individual end
user machines.
For the dosimetry of small fields, two practical questions remain to be
considered: Is the beam quality specification for the conventional 10 cm × 10 cm
reference field appropriate and sufficient for the dosimetry of smaller fields
in the same machine? If the answer to this question is yes, how can the beam
quality index be determined for radiation generators that cannot establish the
conventional reference conditions prescribed for the measurement of beam
quality?
The first question has already been partially answered in the previous
section: the very small variation of water to air stopping-power ratios with field
size suggests that for ionization chambers the beam quality index of the broad
field would be sufficient for all field sizes. The variation of stopping-power
ratios and perturbation factors with field size can then be incorporated into a field
dependent output correction factor.
Various approaches have been suggested to address the second question.
For those types of generators, Alfonso et al. [8] introduced the concept of an msr
field,  fmsr. For TomoTherapy machines, one study [28] introduced a specific beam
quality index similar in definition to %dd(10,10)x but measured under different
conditions achievable in these treatment machines. Monte Carlo calculated
kQ values as a function of this specific index were then compared with values as

17
a function of the conventional beam quality index to establish a relation between
the machine specific index and the conventional index. This approach has been
adopted by Ref. [29]. Another approach relies on the measurement of TPR20,10(S ),
the ratio of absorbed dose to water values at the depths of 20 and 10  g/cm2
in water for a square field size of S cm × S cm defined at an SDD of 100 cm.
TPR20,10(S ) values are measured for the non-conventional machine at a series of
square field sizes S and compared with the variation for a machine where the
conventional reference conditions can be established, enabling extrapolation of
the measured data [30]. A related approach used in several publications [30, 31]
is to extrapolate measurements as a function of field size using data for the same
range of field sizes from the generic set in Ref. [32]. Mainly based on these data,
a generic expression was formulated for deriving the beam quality index of the
conventional 10 cm × 10 cm reference field, TPR20,10(10), from a measurement
of TPR20,10(S ) [33].
It was demonstrated by Sauer [33] that the model works well also for
non-square (e.g. circular or rectangular) fields using the equivalent square field
method (Ref. [32]), and even for FFF beams applying a correction for the scatter
deficiency caused by their conical lateral beam profiles. It is important to be aware
of the slightly different relation between stopping-power ratios and beam quality
index between FFF beams and beams with flattening filter (WFF) [34–37].
Consistent formulas for TPR20,10(10) and %dd(10,10)x for a narrower range
of square field sizes (S between 4 cm and 12 cm, the relevant range for this COP)
have been derived [38] based on the same data from Ref. [32] and are illustrated
for TPR20,10(10) in Fig. 5. The expressions are given in Section 5.

2.1.5. Detector response

In radiotherapy dosimetry it is well known that the characteristics of a

detector may affect its response to ionizing radiation considerably. For example,
the particle fluence that is sampled by the detector differs, sometimes substantially,
from the fluence that exists in a homogeneous medium in the absence of
the detector. This is caused by the size, shape and materials in the detector,
which result in deviations from the ideal small volume concept underlying
the Bragg–Gray principle. For a real detector, the application of Bragg–Gray
cavity theory based on medium-to-detector stopping-power ratios requires a
modification using perturbation correction factors. All dosimetry protocols for
conventional reference dosimetry based on a theoretical determination of all
perturbation correction factors necessary to correct the detector response from
the calibration beam quality to the user’s beam quality explicitly or implicitly
include such perturbation correction factors [1, 2, 39, 40]. When measurements
are performed in CPE or TCPE conditions, any variation in stopping-power ratio

18
 0.75

0.73

0.71
10 MV
0.69
8 MV
0.67
TPR20,10(S)

0.65
6 MV
0.63

0.61 5 MV

0.59 4 MV
0.57

0.55
2 4 6 8 10 12
S / cm

FIG. 5.  Dependence of TPR20,10(S) on the field size S based on data from Ref. [32] (square
symbols), and according to the model of Palmans [38] (curves) for field sizes between 4 cm
and 12 cm and nominal photon beam energies between 4 MV and 10 MV (reproduced from
Ref. [38] with the permission of the American Association of Physicists in Medicine).

is evaluated independently of perturbation correction factors for wall effects,

the presence, if any, of a central electrode, electron in-scattering effects, volume
of the medium displaced by the detector, etc. [41], all assumed to be small
and independent. In recent years there has been a renewed interest in accurate
determinations of perturbation correction factors for ionization chambers. In
particular, Monte Carlo methods have analysed in detail the various types of
perturbation effects in a stepwise fashion [42–44], leading to a total perturbation
correction factor for an ionization chamber in a given beam quality.
Studies on perturbation effects of small ionization chambers in small static
beams are scarce. One of the earliest comprehensive studies pertaining to this area
is the work by Crop et al. [45]. The results of this Monte Carlo study, of which
the data at the centre of a 0.8 cm × 0.8 cm field are shown in Fig. 6, indicated that
the central electrode and wall perturbation correction factors were, even though
different from those in a broad beam, close to unity. The major perturbations
were caused by the volume averaging effect and the difference between the mass
density of the detector and that of the medium, and both corrections were rather
large and of similar size. The perturbations were considerably larger for off-axis
measurements. This shows that for small fields, perturbation effects even for small
detectors are considerably larger than for conventional ionization chambers in
broad beams. In the smallest fields of interest, some perturbations become so large

19
FIG. 6.  Contributions to the Monte Carlo calculated overall perturbation correction factor
in the centre of a 0.8 cm × 0.8 cm field in a 6 MV photon beam resulting from the non-water
equivalence of the wall (pwall ), the presence of the central electrode (pcel ), the perturbation
from replacing water with air (pa,w ) and volume averaging (pvol ) for two types of PinPoint
chambers (PP16 = PTW 31016 and PP06 = PTW 31006 with nominal volumes of 0.016 cm3
and 0.015 cm3, respectively) and two electron spot sizes (6G and 20G = 0.6 mm and 2.0 mm
FWHM, respectively). The data are not in any particular order and the dotted lines serve
only the purpose of visually connecting data points that represent the same contributing
factor. Note that, for comparison, the value of the total perturbation correction factor ptot in
a 10  cm × 10  cm field amounts to 0.99 (reproduced from Ref.  [45] with the permission of
IOP Publishing).

that the various contributions to the overall perturbation correction factors are no
longer independent. This situation, which differs from broad beam conditions,
undermines our current approach of applying Bragg–Gray cavity theory. Monte
Carlo calculations based on a ratio of absorbed dose to water and absorbed dose
to the detector material for the entire detector geometry are then preferable for
calculating an overall conversion factor. It might still be of scientific interest to
study the contributions in a stepwise fashion but not with the aim of proposing
independent values for the various factors that could be reproduced via different
routes. Decreasing the relative detector-to-beam size, misalignments, or primary
photon source size can in addition, lead to unpredictably large effects. Figure 7
illustrates the uncertainty contribution to the absorbed dose determination using
a PTW 60012 diode due to a uniformly distributed displacement error of 1 mm in
all directions perpendicular to the beam axis.

20
FIG. 7.  Uncertainty contribution to the absorbed dose determination using a PTW 60012 diode
due to a uniformly distributed displacement error of 1 mm in all directions perpendicular to
the beam axis only calculated by Monte Carlo (reproduced from Ref. [46] with the permission
of IOP Publishing).

More recently, a number of authors have studied the components of small

field perturbation factors by Monte Carlo simulations in a more systematic
way [47–50]. Scott et al. [47] defined the ratio of absorbed dose to water at the
measurement point in the water phantom and the mean absorbed dose over a
volume of water replacing the entire detector’s sensitive volume as the volume
averaging correction factor. Any other factor is then related to the non-water
equivalence of detector materials in the sensitive volume, the electrodes and the
encapsulation. It was then observed that, next to volume averaging, the main
additional contribution to small field perturbation factors is the difference in
density between the detector materials and water, especially in the variation of
perturbation factors with field size. Not only is the density of the material in the
sensitive volume of importance, but so is that of surrounding materials such as
the epoxy encapsulation of diode detectors [51, 52], thin metallic electrodes and
presence of small air gaps [53].
Differences in interaction data, while important in the overall conversion
factor, are found to make only a small contribution to the variation of the
perturbation correction factor with field size. Following up on those observations,
Monte Carlo studies have investigated the possibility of compensating for small
field perturbations by ‘mass density compensation’ [54, 55].

21
 It is emphasized that small solid state detectors may also exhibit some
level of volume averaging, which, considering their size, is shown only for the
smallest therapeutic fields, i.e. those smaller than 1  cm [47,  56–58]. For these
detectors, other perturbation effects may play a role as well (e.g. backscattering
from metallic electrodes). The energy and angular dependence of some detectors,
such as diodes, plays an important role. Owing to the fact that silicon has a higher
mass energy absorption coefficient than water, unshielded diodes over-respond in
large fields because of the significant phantom scatter component of low energy
photons. The consequence is an underestimation of field output factors when they
are normalized to a large field size (e.g. the conventional 10 cm × 10 cm reference
field). In large fields, the over-response is usually compensated by adding a
layer of high Z material around the sides and the bottom of the silicon chip that
filters out the low energy scattered photons. These high Z caps are, however,
undesirable in very small fields, as they may cause large perturbation effects
that are difficult to determine accurately even with Monte Carlo calculations, as
detector-to-detector differences are complicated to simulate [59].

2.1.6. Energy range of interest

Photon beams with nominal accelerator potentials greater than 10 MV are
often thought necessary for deep seated tumours. Compared to lower energy
beams, these create electrons with longer ranges so that full buildup occurs at
greater depths, resulting in a lower absorbed dose to water at shallow depths.
In addition to the longer forward electron range, higher energy beams also have
a longer lateral electron range that increases the penumbral width significantly.
This is particularly noticeable for small field sizes and within low density tissues
such as the lung.
In IMRT, fluence modulation is primarily determined by beam transmission
through open and closed leaf positions but is also heavily influenced by the
penumbrae of the lateral beam profiles. A simple illustrative example is shown
in Fig. 8 whereby the profiles created by alternating open and closed leaves are
compared for 18 and 6  MV beams. The peak doses are higher and the valley
doses are lower for 6 MV beams, indicating better modulation for lower energy
beams. In addition, at least part of the reason for the lower valley depth is the
lower collimator transmission for 6  MV beams. Neutron production from high
energy photons is a particular problem for IMRT because a significant number
of (γ,n) reactions occur in the high atomic number collimation components. For
example, at 18 MV the cross-section for neutron production by collimation is two
orders of magnitude greater than for 10 MV photons [60]. Not only do neutrons
produce unwanted radiation exposure to the patient, but they also cause activation
of linac components that leads to extra exposure to staff and service personnel.

22
FIG. 8.  Absorbed dose to water profiles for alternating open and closed MLC leaves. Both
measurement and Monte Carlo calculation show improved modulation for the lower energy
beam. For the higher energy beam, a larger fraction of electrons scatter from the open to
closed field region  and the MLC transmission is higher  (courtesy of Jeffrey Siebers,
Virginia Commonwealth University). 

Based on these observations, the International Commission on Radiation Units

and Measurements (ICRU) stated that the use of higher energy beams is not
justified for IMRT [61]. For these reasons, guidance in this COP is only provided
for high energy photon beams with nominal accelerating potential up to 10 MV.
The predominance of the use of these beams also provides a robust argument to
restrict the applicability of this COP to potentials below or equal to 10 MV. Data
from IAEA’s Directory of Radiotherapy Centres (DIRAC) database show that
about 80% of beams used at linacs installed after the year 2000 used for all forms
of radiotherapy have nominal energies of 10  MV or lower [62]. Furthermore,
data from the Imaging and Radiation Oncology Core (IROC) Houston QA Center
indicate that, for lung stereotactic radiotherapy, about 96.4% of the beams used
are of 6 MV and 3.2% of 10 MV, whereas for liver stereotactic radiotherapy the
figures are 80% and 15.7% respectively [63]. The availability of data for small
field dosimetry is also dominated by the 6–10 MV range.

23
2.1.7. Summary of small field characterization for dosimetry

Based on the discussion in the previous sections, a summary is given here

of the parameters that need to be determined to enable accurate dosimetry of
small fields:

—— It is advised that to allow lookup of output correction factors from tables,

the field size be specified by the FWHM of the lateral beam profile at the
measurement depth (see Section 2.1.2). The depth of measurement is such
that electron contamination originating from the materials in the beam path
is negligible (in this COP, 10 cm is recommended). The reference distance
will usually be the isocentric distance. The collimator setting, which is
the aperture size projected to a reference position (isocentre or reference
distance from the source), could be recorded as well to enable the link with
the beam data management and treatment planning systems.
—— The beam quality of a small field, representing the energy spectrum of
the beam, is characterized by the determination of a beam quality index
(TPR20,10(10) or %dd(10,10)x) for a conventional 10 cm × 10 cm reference
field at the beam. For machines that cannot establish this conventional
reference field, modified procedures exist to derive the beam quality index
from quantities measurable in smaller fields (see Section 2.1.4).
—— A distinction between small and large fields is made by introducing the
concept of the beam energy dependent rLCPE. Because detector perturbations
are influenced substantially by the absence of equilibrium conditions,
small field conditions are also assumed to exist when any point within the
outer boundaries of the detector volume is less than rLCPE away from any
field edge (at 50% absorbed dose level). Equations are provided of the
dependence of rLCPE on the beam quality index.

2.2. ABSORBED DOSE TO WATER STANDARDS FOR SMALL FIELDS

In small field radiotherapy, as in conventional radiotherapy, all dosimetric

measurements need to be traceable to primary radiation standards. Traceability
is obtained by the process of detector calibration and the entire path between
a clinical measurement and a standard is referred to as the calibration chain.
QA programmes need to be in place to ensure the quality of the calibration chain.
For broad reference fields (10 cm × 10 cm), primary standards of absorbed dose
to water exist. These instruments allow for the determination of the absorbed
dose to water according to its definition. They are normally maintained in PSDLs.
User instruments can be directly calibrated against these primary standards, but

24
more often they are calibrated against secondary standards, which themselves
are calibrated against primary standards. Secondary standards are maintained
in SSDLs or Accredited Dosimetry Calibration Laboratories (ADCLs) in
North America. The exact roles and positions of PSDLs, SSDLs, the Bureau
International des Poids et Mesures (BIPM) and the role of key comparisons are
explained by the BIPM web pages (www.bipm.org) and, particularly in terms of
how they relate to radiotherapy dosimetry, in Ref. [1].
The most common primary standard for absorbed dose to water in
conventional reference fields is calorimetry, although standards based on
other methods, such as ionization chambers and chemical dosimeters, are also
available. Water calorimetry is the most direct method for the measurement
of absorbed dose to water. Graphite calorimeters are also common given their
higher sensitivity and robustness as compared to water calorimeters. An extensive
review of calorimetric absorbed dose standards for external beams can be found
in Seuntjens and Duane [64] and McEwen and DuSautoy [65]. However, only a
few studies deal with the application of calorimetry to small field dosimetry; for
example, Krauss [66] has applied the primary standard water calorimeter of the
Physikalisch-Technische Bundesanstalt (PTB), the National Metrology Institute
of Germany, to determine absorbed dose to water and to calibrate ionization
chambers in 5  cm × 5  cm and 3  cm × 3  cm fields [67–69]. One of the main
technical complications of using a water calorimeter designed for measurements
in a 10  cm × 10  cm field in small fields is the increasing correction for heat
conduction across the lateral profile. De Prez [70] simulated heat loss corrections
for the VSL (Dutch Primary Standards Laboratory) water calorimeter and found
that these corrections were within 5% for field sizes down to 3 cm × 3 cm and
increased dramatically for smaller field sizes (up to 60% for a 1.8 cm × 1.8 cm
field). These corrections depend on the measurement time, which, in turn,
depends on the available dose rate. However, if the irradiation time could be
shortened, absorbed dose to water determination in a small field using water
calorimetry could be feasible; although a substantial increase in absorbed dose
rates would be needed for this purpose. This is possible with FFF photon beams.
While graphite calorimeters that are used as primary standards instruments
have cores that are too large for small field dosimetry, small core graphite
calorimeter probes that can be used in water or a water equivalent phantom have
been constructed [71, 72] for dosimetry in small photon fields and IMRT fields.
Following on the suggestion to derive field output factors from integrated lateral
dose or ionization profiles [73,  74], dose–area product calorimeters have been
proposed. The BIPM calorimeter [75] has this capability for a limited range of
field sizes with its core diameter of 45 mm.
For practical reasons, transfer standards are often used in standards
laboratories to calibrate individual user instruments. Also, given that in

25
most calorimeters, the phantom is part of the construction and thus there is
no flexibility on phantom shape, transfer standards are used to establish the
calibration quantity in different phantoms. Ionization chambers, ferrous sulphate
chemical dosimeters and alanine/electron spin resonance (ESR) have been used
for that purpose. Of these, alanine/ESR has also been used as a transfer standard
for dose determination in small fields. Because the density of alanine pellets is
close to the density of water, the overall correction can be determined with good
accuracy as it is dominated by volume averaging. Even for a 0.5  cm diameter
field, volume averaging corrections from 3-D dose distributions obtained by
gel dosimetry bring the alanine response into good agreement with the response
of a range of small detectors [76]. One of its disadvantages is its relatively low
sensitivity; however, a type-A standard uncertainty of 0.5% can be achieved for
absorbed dose to water values of 10 Gy [77, 78]. For high energy photon fields,
a difference of 0.3% to 0.6% in detector response has been reported as compared
to 60Co [79, 80].

2.3. OVERVIEW OF CURRENT REFERENCE AND

RELATIVE DOSIMETRY OF RADIOTHERAPY BEAMS

2.3.1. Reference dosimetry

2.3.1.1. Conventional reference beams

Guidance for the determination of absorbed dose to water in high energy

photon beams based on standards of absorbed dose to water has been provided in
various national and international COPs (including Refs [1, 2, 4, 5, 7]). These use
common reference conditions for the determination of the beam quality and for
the determination of absorbed dose to water: a field size of 10 cm × 10 cm at the
phantom surface or at the measurement depth, and an SSD or SDD of 100 cm.
These formalisms are very similar and can be described by that given in Ref. [1],
which is used as the basis for the formalism in this report and briefly summarized
here.
The absorbed dose to water at the reference depth zref in water for a user
beam quality Q and in the absence of the chamber is given by:

Dw,Q = MQ ND,w,Q (1)

where MQ is the reading of the ionization chamber at the user’s beam quality Q,
corrected to the reference values of influence quantities other than beam quality,
for which the calibration coefficient is valid, and ND,w,Q is the calibration

26
coefficient in terms of absorbed dose to water of the ionization chamber measured
at a standards laboratory for the user’s beam quality Q.
In most countries, direct calibrations in clinical beam qualities are not
available, and even when they are available, the calibration beam quality
Q0 is usually different from the user’s beam quality Q. In that case, Eq.  (1) is
replaced by:

Dw,Q = MQ ND,w,Q k Q,Q

0 0
(2)

where ND,w,Q0 is the calibration coefficient in terms of absorbed dose to water

of the ionization chamber measured at a standards laboratory for the calibration
beam quality Q0, and kQ,Q0 is the factor that corrects ND,w,Q0 for the difference
between the reference beam quality Q0 and the actual user quality Q.

2.3.1.2. Non-conventional reference beams

Several modern radiation generators that are purposely developed for

stereotactic treatments or IMRT cannot establish the reference conditions
prescribed in the COPs mentioned. Issues related to the determination of the
beam quality index for such machines have been described in Section 2.1.4. For
reference dosimetry, the common practice is to use the same formulas as for
conventional beams, but performing reference dosimetry in the field size closest
to 10 cm × 10 cm (often the largest field available) and in most cases assuming
that the beam quality correction factors are the same. Specific procedures are
often followed for a particular type of radiotherapy machine. For FFF beams it
has been determined that an additional volume averaging correction factor may
be required to correct for the non-homogeneity of the lateral profile [81, 82].
For TomoTherapy, a 5 cm × 10 cm reference field at a distance of 85 cm
from the source is recommended in Ref. [29], and for the selection of the beam
quality correction factor, a generic relation between a TomoTherapy specific
beam quality index and the conventional beam quality index from Refs [2,  7]
is given. The formalism of Alfonso et al. [8] is followed and a factor to correct
for the difference between the ionization chamber’s response in a virtual
10  cm × 10  cm reference field and the 5  cm × 10  cm TomoTherapy specific
reference field is advised. The value of this factor was based on Monte Carlo
simulations and is close to unity.
For CyberKnife, the largest fixed collimator defined field is taken as the
reference field. This field is circular and has a nominal 6 cm diameter at a distance
of 80  cm from the source. For the determination of the beam quality index,
equivalent field and interpolation methods using data from Ref. [32], similar to
those described by Sauer [33], have been used for deriving TPR20,10(10) [83] and

27
%dd(10,10)x [31] from measurements in the largest circular field. Beam quality
correction factors for ionization chambers in this field are found to be close to
those for other 6 MV machines, but for the relatively long Farmer type chambers,
a correction greater than 1% needs to be applied for volume averaging over the
projected effective area of the ionization chamber [81, 82].
The Gamma Knife is a special case because a treatment field is always
composed of a superposition of multiple small fields. Nevertheless, it is
considered a case to be categorized under static small field dosimetry rather than
composite field dosimetry. The maximum field size diameter is 1.8 cm or 1.6 cm,
depending on the machine model, and reference dosimetry for that field size is
performed in the centre of a plastic sphere using a microchamber calibrated in
60
Co without the use of a beam quality correction factor [84–86]. An air kerma
based approach has also been suggested [87].
For Brainlab add-ons, the reference SDD or SSD of 100  cm can be
established, but the field size cannot be set to exactly 10 cm × 10 cm, so the nearest
field size is used. By choosing one dimension larger than 10 cm and the other
smaller, one can achieve a field area which is almost identical to a 10 cm × 10 cm
field (e.g. 9.6  cm × 10.4  cm), in which case no special considerations for the
determination of beam quality and for reference dosimetry are required.
A formal treatment of the dosimetry of non-standard3 beams was published
by Alfonso et al. [8], and their formalism will be followed in this COP.

2.3.2. Relative dosimetry

2.3.2.1. Field output factors

A field output factor is defined as the ratio of absorbed dose to water

in any non-reference field to that in a reference field at a given depth. In
conventional broad beams, it is derived from a ratio of detector readings because
of the practical independence of dosimetric quantities on field size. In small field
dosimetry, however, such independence does not exist, notably for perturbation
factors, and a field output factor will in most cases require an output correction
factor to be applied to the measured detector reading ratio. It will thus in most
cases be incorrect to report a ratio of readings as a field output factor, a mistake
which is, unfortunately, all too often encountered in clinical practice as well as
in the scientific literature [88]. Many examples have been published showing
large discrepancies between the ratio of readings measured with different types
of detectors for a particular beam compared with the actual ratio of absorbed

3
‘Non-conventional’ in the nomenclature of this COP.

28
dose to water values [18, 24, 73]. These discrepancies are mainly field size and
detector dependent and can be unacceptably high when measured with detectors
that have a large volume compared to the size of the small field. The common
practice of reporting ratios of detector readings as field output factors is a mistake
that has led to much confusion, potentially to serious errors and, in some of the
worst cases, to real accidents. For example, the use of inappropriate detectors for
measuring field output factors without further corrections has been reported as
the main cause of an accidental overdosage of patients for beams defined by the
Brainlab m3 micro MLC [89]. A comparison of beam data measured in different
centres in France with microchambers for the 0.6 cm × 0.6 cm beam of different
Varian Clinac models, under identical measuring conditions (6  MV photons,
micro MLC type, SSD, depth, type and orientation of the detector), showed a
discrepancy of about 15% in the extreme values of the detector output ratios
as uncorrected estimates for field output factors, as shown in Fig. 9. The report
by the French Society of Medical Physics (SFPM), which was the result of a
follow-up effort after this accident, advises using at least two different detectors
for the measurement of field output factors [89].

FIG. 9.  Detector output ratios as uncorrected estimates for field output factors determined
in different centres in France for 6  MV photon beams and the Brainlab m3 micro MLC
(SSD  =  100  cm, depth  =  5.0  cm) using three different detector types. The Brainlab
WOI 10-26 data correspond to manufacturer guidance data. (Reproduced from Ref. [89] with
the permission of the Institut de radioprotection et de sûreté nucléaire.)

29
 Alfonso et al. [8] have emphasized the distinction between ratios of detector
readings and ratios of absorbed dose to water values by explicitly including an
output correction factor in the expression for the field output factor.
In large reference fields, output correction factors are required for detectors
exhibiting an energy dependent response due to low energy scattered photons
originating in the treatment head and in the phantom combined with the different
mass energy absorption coefficient for those low energy photons. This is
for example the case for silicon based devices such as unshielded diodes and
metal oxide semiconductor field-effect transistors (MOSFETs), as described
in Section 2.1.5, and it results in a more or less linear increase of the response
with increasing field size as illustrated in Fig. 10. From these observations, the
approach employed to obtain field output factors is to use an ionization chamber
for field sizes down to the one where volume averaging sets in, and use a small
detector (e.g. a diode, diamond, liquid ionization chamber or organic scintillator)
for smaller fields. The field output factors derived from the measurements with
the small detectors are renormalized at the smallest field size where the ionization
chamber is used; this is referred to as the intermediate field method in this COP.
This method has sometimes been called “daisy-chaining” [90].
For determination of field output factors in small fields, another approach
has been proposed that suggests using a large area parallel plane ionization
chamber (LAC) in combination with radiographic or radiochromic film [73, 74].
From the signal produced by the two dimensional fluence distribution over the
area of the LAC, the value of the dose–area product (DAP) can be determined.
With accurate film dosimetry at the same plane of measurement as the LAC,
the field size and a two dimensional relative absorbed dose distribution can be
determined. From this and the DAP value, the absorbed dose to water is derived
at the region of interest. While this is an interesting area of research, there is
not enough experience and information at present to provide guidance on this
method.

2.3.2.2. Lateral beam profiles

The lateral beam profile is defined as the distribution of absorbed dose

to water at the reference depth in the phantom, perpendicular to the beam axis
and parallel to the phantom surface. The difficulties of measuring lateral beam
profiles in small photon fields are associated with the dimension of the detector’s
sensitive volume, defined as the geometrical dimension of the measuring
volume in the scan direction, in relation with the beam penumbra size. Even for
conventional broad fields, when tertiary collimation is used for reduction of their
penumbra, the effect of the detector’s finite volume can lead to inaccuracies in
the determination of the penumbra width. This becomes a crucial problem in

30
FIG. 10.  Ratio of the relative readings of various detectors and the relative reading of
a PTW 31010 Semiflex ionization chamber. The relative readings of all detectors were
normalized at the value for 10 cm equivalent square field size. This figure illustrates the field
size dependence of solid detectors for large fields and the perturbation of ionization chambers
in small fields for (a) a PTW 31006 PinPoint ionization chamber, a Scanditronix Stereotactic
Field Diode (SFD) and a Scanditronix Photon Field Diode (PFD), and (b)  two Thomson
Nielsen Si-MOSFETS of the same type (Mosfet1 and Mosfet2) and a PTW 60003 diamond
detector (replotted from Ref.  [24]). The full lines are linear fits to the data points for field
sizes larger than 5  cm × 5  cm and the dashed lines extrapolations of those fits to smaller
field sizes to illustrate the field size dependence of the diode response solely due to phantom
scatter, i.e. ignoring the effect of fluence perturbations. (Reproduced from Ref. [24] with the
permission of the American Association of Physicists in Medicine.)

31
very small fields, as the penumbra represents an important portion of the field.
Because for these small fields detector perturbation factors show a very steep
dependence on field size, small errors in penumbra measurements can result in
substantial dosimetric errors.
Suitable detectors to resolve the penumbra in small photon fields are tissue
equivalent radiochromic film, diodes (stereotactic, shielded or unshielded and
oriented parallel to central axis), diamond detectors, small air filled ionization
chambers and liquid ionization chambers [12]. Even those detectors require
special measures to avoid various artefacts (e.g. the readout procedure for
radiochromic film needs to be well conducted). For scanning detectors, the
orientation needs to be considered and effects of stem and cable irradiation
taken into account. A method has been published to derive corrected penumbrae
from measurements with a series of different sized detectors [91]. A paper by
Francescon et al. [58] investigated the variation of the perturbation of various
small detectors as a function of off-axis position. This is very helpful in advising
on the type of detector to be used for profile measurements, but it is important to
be aware that owing to detector-to-detector variations combined with the extreme
sensitivity of these perturbations to detector dimensions, it is advised that
these not be regarded as providing generic output correction factors for profile
measurements.
Another approach which has been suggested is to deconvolve the lateral
beam profile from the measured profile using Monte Carlo calculated detector
specific kernels [92] or simply Gaussian kernels [93] based on the observation
that despite the lateral fluence convolution kernels for many detectors being quite
complicated, the dose convolution kernels are blurred by the lateral range of
secondary electrons and the effects of the detector construction details are lost,
making Gaussian kernels adequate.
An interesting observation was made by Underwood et al. [54], who
suggested that, while most detectors either under-respond or over-respond on
the central axis, i.e. in the measurement of field output factors, in small fields,
this is actually compensated by an opposing over-response or under-response,
respectively, in the profile tails, and that the integral dose measured for many
detectors would be accurate without any output correction factors. Figure  11
illustrates this for three types of detectors. In IMRT, the integral dose contribution
of a small field is indeed more important than the absorbed dose to water in
the centre of the field itself. This approach would of course only make sense if
the same detector is used to measure the field output factor and to measure the
profile, while in practice often a combination of a point detector for the field
output factor and radiochromic film for the profiles would be used.

32
FIG. 11.  Lateral beam profiles of a 0.5 cm × 40 cm field (along the short axis of the rectangular
field) in a 6 MV beam measured using three different detectors. These profiles are expressed in
terms of absorbed dose in cGy per monitor unit (MU) by calibration of the detectors in a large
field, denoted as “Calibrated detector reading”. This figure shows the under-response of the
larger detectors around the dose maximum, as schematically explained in Fig. 3.  The arrows
on the right hand side vertical axis indicate the ratio of the dose length product (DLP) of the
solid detectors (diamond, diode) to the DLP of the PinPoint ionization chamber, illustrating
that for the diamond detector and the IBA unshielded diode, the DLP is the same, despite
their differences on the axis of the field. (Reproduced from Ref. [54] with the permission of the
American Association of Physicists in Medicine.)

33
 3.  CONCEPTS AND FORMALISM

This section presents the formalism and concepts underlying the small field
dosimetry procedures described in this COP. A distinction will be made between
situations where data are available for specific radiation generator/detector
combinations and for other situations where procedures have to rely on the less
favourable generic approach of using beam quality characterization to look up
beam quality correction factors in tabulated data. Note that for completeness,
some concepts described in the preceding section are also reproduced here.

3.1. CONCEPTS OF SMALL FIELDS

3.1.1. Definition of field size

For the purpose of applying the procedures in this COP, the field size is the
pair of dimensions (in the case of rectangular fields) or the diameter (in the case
of a circular field) that define(s) the area of the field at the measurement distance.
Each dimension is defined by the FWHM of the lateral beam profile measured
at a depth sufficient to eliminate the contribution of contamination electrons.
‘Field size’ is thus used as synonym for ‘irradiation field size’ as defined by
the International Electrotechnical Commission [16]. A depth of 10 cm in water
with the detector’s reference point at the isocentre is advised because this is
adequate to eliminate contamination electrons and because beam flatness has
historically been defined at 10 cm depth. It is advised that the measurement be
made with a dosimeter capable of sufficient spatial resolution. There is no need
for a calibrated dosimeter for this task because many dosimeter types that have
an adequate spatial resolution can be used (for example film, diodes or diamond
detectors), none of which are reference class dosimeters.
It is advised to record, in addition, the collimator settings as a nominal
identification for practical purposes. For example, the treatment planning system,
the electronic patient record and the record and verify system all use the nominal
field setting rather than the FWHM relative to which the profile data, patient
treatment plan and radiation delivery are referenced. This guidance is analogous
to that of stating the nominal accelerating potential (MV) to refer in practice to a
beam with a certain quality index.
In this COP, output correction factors for small fields are tabulated as a
function of the equivalent square small field size. For non-square fields, a
method is provided to determine the equivalent square small field size for which

35
the output correction factors are the same. This method simply equates the areas
of the non-square and square small fields as explained in Section 6.5.2.
Note that, distinct from this, for beam quality specification in non-square
msr fields, equivalent square msr fields have to be determined. These are based
on equating the amount of phantom scatter, as explained in Section 2.1.2.

3.1.2. The msr field

In high energy photon beam generators where the conventional

10 cm × 10 cm reference field cannot be established, an msr field is introduced
which has dimensions that are as close as possible to those of the conventional
reference field and extend at least a distance rLCPE beyond the outer boundaries
of the reference ionization chamber (see Section 4). In the case that only fields
smaller than the 10  cm × 10  cm reference field can be realized, the msr field
will usually be the largest achievable field. Examples of msr fields specific for
different radiotherapy treatment machines are summarized in Section  3.3 and
presented in more detail in Section 5.3.1.

3.1.3. Lateral charged particle equilibrium range

The rLCPE is an important parameter for establishing the relation between

the field size and the minimum detector size for which LCPE conditions exist.
The rLCPE depends on the beam energy and has been quantified by Li et al. [94],
who performed Monte Carlo simulations of absorbed dose to water and water
kerma in water for photon beams of different nominal energies. The rLCPE was
derived as the minimum radius of a circular field for which the absorbed dose to
water in the centre of the field is related by a constant factor to the water kerma
in water. Updated Monte Carlo calculations [14] have been performed for this
parameter, and expressed as a function of the conventional photon beam quality
index TPR20,10(10), rLCPE (in cm) is given by:

rLCPE = 8.369´ TPR 20,10 (10) - 4.382 (3)

Its use is described in Section  5.2.1. When the beam quality index
%dd(10,10)x is used, rLCPE can be derived using an approximate relation between
%dd(10,10)x and TPR20,10(10) [95]:

rLCPE = 77.97´10 -3 ´%dd (10,10) x - 4.112 (4)

36
3.1.4. Volume averaging

The volume averaging correction factor is defined as the ratio of the

absorbed dose to water at the reference point in the water phantom in the
absence of the detector and the mean absorbed dose to water over the sensitive
volume of the detector (still in the absence of the detector). It can be derived
from an integration of the 3-D dose distribution in the water phantom over
the volume of the detector [56,  96–100]. In the case of plane-parallel detector
geometry (e.g. plane-parallel ionization chamber, diode or diamond) with the
parallel electrodes oriented perpendicular to the beam axis, this integration can
be simplified to a 2-D integration of the lateral beam profile over the sensitive
area of the detector facing the beam. In the case of a cylindrical ionization
chamber, an integration over the 2-D area of the sensitive volume projected
perpendicularly to the beam axis includes a weighting function to account for the
fraction of the sensitive volume at different lateral offsets from the beam axis,
although an unweighted integration over the projected area could be sufficient
in many cases [81]. A suitable, high resolution detector is used for lateral profile
measurements with special consideration of the detector orientation. Details are
provided in Section  6. The generic equation to calculate the volume averaging
correction factor is:

k vol =
òò A
w ( x, y)dx dy
(5)
òò A
w ( x, y)OAR ( x, y)dx dy

where x and y are the coordinates on the axes orthogonal to the beam central axis,
A is the area of the projection of the sensitive volume of the chamber on a plane
orthogonal to the beam axis, OAR(x,y) is the off-axis ratio, which is the lateral
beam profile at the measurement depth normalized to unity on the central axis,
and w(x,y) is a weighting function representing the extension of the air cavity
of the ionization chamber along the beam axis (z) as a function of the beam
lateral coordinates (x and y). For plane-parallel detector geometry, w(x,y) is unity
over the integration area. Examples of the calculation of the volume averaging
correction factor are given in Appendix I.

3.1.5. Beam quality

The option preferred in this COP for beam quality characterization, to

be discussed in Section  3.2.1, is to rely on data derived for specific radiation
generators as, currently, machine-to-machine differences for a given generator
model are rather small and, for the purpose of reference dosimetry, the beam

37
quality index can be easily verified to be within tolerance for the data to be valid.
When data are not available, the common approach of characterizing the beam
in terms of a quality index has to be used. As mentioned in Section 2.1.4, there
are currently two beam quality indices used for conventional high energy photon
beams: TPR20,10(10), used in Ref.  [1] and most other COPs, and %dd(10,10)x,
used in Refs [2, 7]. The guidance given here is restricted to these two beam quality
indices.
If a 10 cm × 10 cm reference field cannot be established, it is advised to
measure TPR20,10(S ) or %dd(10,S )x for the largest possible square field size S
(or in case of a circular or rectangular field, an equivalent square msr field size S )
and derive TPR20,10(10) or %dd(10,10)x, using the expressions of Palmans [38]
(these are given in Section  5.3.3). If the SSD is not 100  cm, an additional
correction is required to account for the inverse square law, for the difference
in electron contamination and for the different scatter conditions (also given in
Section 5.3.3).
For photon beams WFF, the determination of an equivalent square msr
field for a circular or rectangular field is based on the guidance in Ref.  [32].
The equivalent square msr field is defined as the one that produces an equal
amount of scatter on the central axis at the measurement depth as the circular or
rectangular field. For a FFF beam which exhibits a non-flat lateral beam profile,
the lateral integration of the scatter function [32] is included in the lateral fluence
distribution because the on-axis scatter is the sum of all scatter contributions
from each off-axis elemental volume. This is proportional to the lateral fluence
distribution, which is as a first order approximation given by the lateral beam
profile.
Note that the issue of equivalent field size is very different for small
fields. In the absence of head scatter and any substantial phantom scatter,
the equivalence of small fields is in this COP based on fields that exhibit the
same detector perturbation factors. It has been shown that for this purpose, the
geometric mean of the length and width of a rectangular field (provided the field
is not too elongated) is adequate to represent the equivalent square small field
size [19]. This means that the equivalent square small field has the same area
as the rectangular field, and the assumption is made that this is also valid for
deriving the square small field equivalent of a circular small field. Given that
for square field sizes below 4  cm, phantom scatter factors are independent of
collimation and linac type and only dependent on measurement depth and the
field area [19], 4  cm is taken as the borderline value between the broad beam
equivalent field size method and the small field equivalent field size method.

38
3.2. FORMALISM FOR THE DETERMINATION OF THE REFERENCE
ABSORBED DOSE TO WATER

The formalism published by Alfonso et al. [8] for the reference dosimetry
of small fields is followed in this COP with minor modifications. It is based on
the use of an ionization chamber for which a calibration coefficient in terms
of absorbed dose to water in a reference beam is available from a standards
laboratory. For the dosimetry of small photon fields, two steps are considered:
(a)  reference dosimetry following the formalism outlined in the following
sections and (b) relative dosimetry following the guidance that will be given for
the determination of field output factors. The practical procedures based on this
formalism will be presented in Sections 5 and 6.
In radiation generators where a conventional 10  cm × 10  cm reference
field can be established, reference dosimetry is performed according to the
guidance given in Refs  [1–7] or an equivalent protocol. In generators where a
conventional 10 cm × 10 cm reference field cannot be established, an msr field
is introduced which, whenever possible4, has dimensions as close as possible to
the conventional reference field and extends at least a distance rLCPE beyond the
outer boundaries of the reference ionization chamber. In other words, if the size
of the detector is d (greatest distance between two points on the outer boundary
of the detector), the FWHM of the field has to fulfil the following condition:

FWHM ³ 2rLCPE + d (6)

As an example, let us assume a photon beam with quality

TPR20,10(10) = 0.677, for which Eq. (3) yields rLCPE  = 12.8 mm. An IBA CC08
ion chamber has a cavity length l  =  4 mm, a cavity radius r  =  3 mm and
a wall thickness twall  =  0.07  g/cm2 (see Table  5 in Section  4.1.1.2); with
ρ(C-552) = 1.76 g/cm3, twall = 0.40 mm. In the longitudinal direction, the chamber
outer size will be dl = l + twall = 4.4 mm and radially dr = 2(r + twall) = 6.8 mm. As
dr  > dl, the largest detector size is d = dr and Eq. (6) yields a field size having a
FWHM = 2 × 12.8 + 6.8 = 32.5 mm at a depth of 100 mm in water. Proceeding
in this manner it can be verified that for the chambers listed in Table  5, the
FWHM varies between 29.1 mm (Exradin A16 micro) and 38.2 mm (Victoreen
Radocon II 555) for this beam, i.e. for the chambers in this table the dominant
contribution to the required FWHM is the term 2rLCPE.

4
There are some special radiation generators which offer no option for that, such as the
Gamma Knife. These will have to be considered on a case by case basis, but for the case of the
Gamma Knife, for example, the second required condition of LCPE can still be fulfilled for
sufficiently small ionization chambers.

39
3.2.1. Approaches for the reference dosimetry of msr fields

3.2.1.1. Chamber calibrated specifically for the msr field

The preferred approach for the reference dosimetry is to obtain a calibration

coefficient directly in the msr field (  fmsr), provided the standards laboratory is
able to supply such a calibration coefficient. In this case, the absorbed dose to
water at the reference depth zref in water in the absence of the ionization chamber
is given by:

f f f
Dw,msr
Q msr
= M Qmsr N Dmsr
msr ,w,Q msr
(7)

where Qmsr is the beam quality of the msr field (note that this can be different
from the beam quality of a conventional reference field owing to the influence of
the field size on the particle spectrum); MQf msr is the reading of the dosimeter in the
msr
msr field  fmsr corrected for influence quantities, such as pressure, temperature,
incomplete charge collection, polarity effects, etc.; and N Df msr
,w,Qmsr
is the calibration
coefficient in terms of absorbed dose to water of the ionization chamber measured
by the standards laboratory for the msr field fmsr of quality Qmsr.
Although it is not widely available yet, some standards laboratories provide
calibrations of ionization chambers in the hospital’s msr field. A calibration
coefficient could also be available via a cross-calibration, a procedure that will be
described in Section 5.5.

3.2.1.2. Chamber calibrated for a conventional reference field, with generic

beam quality correction factors available

In most cases, the ionization chamber calibration coefficient is measured

in a calibration beam of quality Q0 for a conventional 10 cm × 10 cm reference
field  fref. In that case, a beam quality correction factor is required for the use of
the calibration coefficient in a beam of a different quality than the one used for
the chamber calibration. The absorbed dose to water for the msr field is then
given by:

f f f f ,f
Dw,msr
Q = M Qmsr N Dref,w,Q k Qmsr ,Qref (8)
msr msr 0 msr 0

where MQf msr is the reading of the dosimeter in the msr field  fmsr corrected for
msr
influence quantities, such as pressure, temperature, incomplete charge collection,
polarity effects, etc.; N Df ref,w,Q0 is the calibration coefficient in terms of absorbed
dose to water of the ionization chamber measured at the standards laboratory for
a conventional 10 cm × 10 cm reference calibration field  fref with beam quality

40
 , f ref
Q0; and k Qf msr
msr ,Q0
is a factor to correct for the difference between the response of
the ionization chamber in a conventional reference calibration field fref with
beam quality Q0 at the standards laboratory and the response of the ionization
chamber in the msr field  fmsr with beam quality Qmsr.
, f ref
The beam quality correction factor k Qf msr msr ,Q0
is defined as the ratio of
the ionization chamber’s calibration coefficients in the machine specific and
conventional reference fields:

f f f
f ,f
N Dmsr
,w,Q Dw,msr
Q M Qmsr
k Qmsr ,Qref = f
msr
= f
msr
f
msr
(9)
msr 0
N Dref,w,Q Dw,refQ M Qref
0 0 0

In most cases Q0 will be a 60Co gamma ray beam, but it could also be a
high energy X ray beam. Ideally, the beam quality correction factor is determined
directly by calibration of the ionization chamber in the calibration reference
and msr fields. A few standards laboratories have developed the capability
of performing such calibrations for clinical machines, but such services are
not widely available. However, given the increased uniformity in physical
characteristics of series of treatment machines of the same type, generic
experimental values for the beam quality correction factors may be available. For
the same reason, generic Monte Carlo calculated beam quality correction factors
may be determined for a particular ionization chamber type in such machines as:

f f
f ,f
Dw,msr
Q Dair,
msr
Q
k Qmsr ,Qref = f
msr
f
msr
(10)
msr 0
Dw,refQ Dair,
ref
Q
0 0

where all quantities on the right hand side of the equation are calculated in the
Monte Carlo simulation, Dw is the absorbed dose to water at the measurement
point, which, in practice, is calculated as the mean absorbed dose to water over a
small volume around the measurement point (the suitable size of which depends
on the field size) and Dair is the mean absorbed dose to air in the cavity of the
ionization chamber.
Where generic experimental or Monte Carlo calculated beam quality
correction factors are available for particular treatment machine/ionization
chamber combinations, they are tabulated in Section 5. Machines for which such
data are available are Gamma Knife, CyberKnife and TomoTherapy for a limited
number of chamber types.
Note that a standards laboratory may be able to provide a calibration
coefficient N Df msr
,w,Q0
for an msr field that does not have exactly the same beam
quality as the clinical msr field. In that case:

41
 f f f f ,f
Dw,msr ,w,Q k Q ,Q (11)
= M Qmsr N Dmsr msr msr
Q msr msr 0 msr 0

3.2.1.3. Chamber calibrated for the conventional reference field,

without generic beam quality correction factors available

In the case that no generic beam quality correction factors for the calibration
field with reference to the msr field are available, a third approach has to be
followed. In this case, the absorbed dose to water for the msr field is given by:

= M Qmsr N Dref,w,Q k Qref,Q k Qmsr ,Qref (12)

f f f f f ,f
Dw,msr
Q msr msr 0 0 msr

where MQf msr is the reading of the dosimeter in the msr field  fmsr corrected for
msr
influence quantities, such as pressure, temperature, incomplete charge collection,
polarity effects, etc., N Df ref,w,Q0 is the calibration coefficient in terms of absorbed
dose to water of the ionization chamber measured at the standards laboratory
for a conventional 10  cm × 10  cm reference calibration field fref with beam
quality Q0, kQf ref,Q0 is a factor to correct for the difference between the response of
the ionization chamber in a conventional calibration field  fref with beam quality
Q0 at the standards laboratory and the response of the ionization chamber in a
conventional 10  cm × 10  cm reference field  fref with a beam quality Q using
, f ref
the same machine as the msr field  fmsr, and k Qf msr msr ,Q
is a factor to correct for the
difference between the response of the ionization chamber in a conventional
10 cm × 10 cm reference field  fref with beam quality Q using the same machine
as the machine specific reference field  fmsr and the response of the ionization
chamber in the msr field  fmsr with beam quality Qmsr.
As previously explained, the need for an msr field arose from the
impossibility of realizing a 10  cm × 10  cm field using the treatment machine
to perform dosimetry according to a conventional dosimetry protocol. Where
a 10  cm × 10  cm field cannot be realised, fref is referred to as a hypothetical
10 cm × 10 cm reference field [8]. The beam quality correction factor kQf ref,Q0 can
thus be obtained from Ref. [1] or Refs [2, 7], for which the beam quality Q of the
hypothetical 10 cm × 10 cm reference field needs to be determined according to
the guidance in Section 5.3.3.
Since the hypothetical reference field fref cannot be established
, f ref
experimentally, a direct measurement of k Qf msr msr ,Q
is not possible. If an experimental
f msr , f ref
determination of k Qmsr,Q0 were available (e.g. measured by a PSDL), a value could
be inferred as:

42
 f ,f
f ,f
k Qmsr ,Qref
k Qmsr ,Qref = msr
f
0
(13)
msr
k Qref,Q
0

where kQf ref,Q0 is taken from Ref. [1] or Refs [2, 7].

With a Monte Carlo simulation, it is possible to establish a 10 cm × 10 cm
reference field virtually and calculate the beam quality correction factor as:

f f
f ,f
Dw,msr
Q Dair,
msr
Q
k Qmsr ,Qref = f
msr
f
msr
(14)
msr
Dw,refQ Dair,
ref
Q

In some cases, establishing the hypothetical reference field in the Monte

Carlo simulation may not only require modification to the secondary and tertiary
collimators, but also to the primary collimator (as for example is the case in
CyberKnife), which could have a substantial influence on the beam quality.
For beams with a flattening filter providing a uniform lateral beam profile,
, f ref
the factor k Qf msr msr ,Q
equals unity in most cases for the detectors recommended in
this COP. Comparing Eqs (12) and (11) shows that this is equivalent to assuming
, f ref
that k Qf msr
msr ,Q0
equals kQf ref,Q0. For practical implementation of these equations it may
, f ref
be sufficient to estimate an uncertainty on the assumption that k Qf msr msr ,Q
 = 1.
Figure 12 summarizes the three approaches.
For the application to FFF beams, the complication arises that the value
f
k Qref,Q for the FFF beam may be different from those tabulated in existing COPs,
0
such as Ref. [1] or Refs [2, 7]. For this reason, kQf ref,Q0 in Eq. (12) is replaced with
the product of two factors to account for the difference between the response of
the ionization chamber in the hypothetical FFF beam of quality QFFF = Q and that
in a beam WFF with beam quality QWFF , for which the beam quality index is the
same as for the beam quality Q5. For clarity, a superscript index ‘FFF’ has been
included for all beam qualities of FFF beams and a superscript index ‘WFF’ has
been included for all beam qualities of beams WFF:

f f f f f f ,f
Dw,msr
Q FFF
= M Qmsr
FFF N D,w,Q k WFF
ref
Q
ref
,Q
k QrefFFF ,Q WFF k Qmsr
FFF
ref
,Q FFF
0
(15)
msr msr 0 msr

where kQf refWFF,Q is the beam quality correction factor obtained from Refs [1, 2, 7]
0
or an equivalent COP for a beam WFF with the same beam quality index as the
one determined for the FFF beam and kQf refFFF,Q WFF is the factor that accounts for the

5
This condition means that TPR20,10(10)[QWFF] = TPR20,10(10)[Q] or %dd(10,10)x[QWFF] =
%dd(10,10)x[Q], but the beam qualities are not identical.

43
 f f f
Dwmsr
,Q msr
= M Qmsr × N Dmsr
msr,w,Q msr
(1)
f f f ,f
= M Qmsr × N Dref,w,Q × k Qmsr ,Qref
msr 0 msr 0
(2)
f f f f ,f
= M Qmsr × N Dref,w,Q × k Qref,Q × k Qmsr ,Qref (3)
msr 0 0 msr

FIG. 12.  Schematic overview of the dosimetry of small static fields with reference to a machine
specific reference field according to the formalism of this COP. The arrows and formulas
labelled (1), (2) and (3) correspond with the approaches of Section 3.2.1.1, 3.2.1.2 and 3.2.1.3,
respectively. (Reproduced from Ref. [8] with the permission of the American Association of
Physicists in Medicine.)

different response of the ionization chamber in the FFF and the WFF beam. Two
effects contribute to the value of kQf refFFF,Q WFF : one is the different response of the
ionization chamber due to the different charged particle spectra of both beam
qualities changing stopping-power ratios and perturbation correction factors,
and the second one is the volume averaging because of the non-uniformity of
the lateral beam profile in the FFF beam (the typical quasi-conical 2-D profile)6.
The volume averaging correction factor can differ significantly from unity if
there is substantial field non-uniformity as is the case in FFF beams. Details of
the calculation of kQf refFFF,Q WFF are given in Appendix I.

6
Note that this approach is different from the one adopted in Ref. [7], where the volume
averaging correction factor is not considered as a contribution to the beam quality correction
factor but is included as a correction factor to the ionization chamber reading.

44
3.2.2. Measurement in plastic water substitute phantoms

While current dosimetry protocols (Refs  [1,  2,  7]) advise determination
of absorbed dose to water in a water phantom at a reference depth zref, it is
acknowledged that there are situations when, for the user, it is more convenient
to perform the measurements in a plastic water substitute phantom but still
determine the absorbed dose to water, Dw, from these measurements.
For the absorbed dose to water formalism, Seuntjens et al. [101] introduced
a modification to the basic equation that, applied to Eq. (8), can be translated into:
f
Dw,msr
Q msr ref
f
(z ) = M plastic,
msr
Q msr
(zeq,plastic ) N Df ,w,Q
ref
0
f ,f
k Qmsr ,Qref k Qw,plastic (16)
msr 0 msr

Qmsr (zeq,plastic ) is the ionization chamber reading in a plastic water

f
where Mplastic,
msr

substitute phantom corrected for influence quantities and k Qw,plastic msr

is called the
phantom dose conversion factor. The depth in a plastic water substitute phantom
zeq,plastic is equivalent to the reference depth in water zref, scaled according
to the ratio of electron densities (see Attix eq.  (13.49a) [13]). In general, an
equivalent point is defined as a point where the photon fluence is the same.
With the assumption that Compton scattering dominates photon interactions,
ensuring equivalence in photon fluence requires scaling, by electron density, of
all dimensions involved (i.e. depth, field size, phantom size), while keeping the
SDD constant. In practice, for phantoms with electron density similar to that of
water, the effect of scaling of some of these dimensions (i.e. phantom size and
field size) introduces a negligible effect, while corrections can be introduced
when the SDD cannot be preserved.
The phantom dose conversion factor k Qw,plastic msr
can be determined
experimentally as a ratio of ionization chamber readings corrected for influence
quantities in the water phantom at depth zref and in the plastic water substitute
phantom at depth zeq,plastic. Its theoretical determination is more complicated and
relies on Monte Carlo calculations or on the application of the scaling theorem
(see Ref. [13] for details). As an example for broad beams, values of k Qw,plastic msr
for Solid Water and for PMMA, calculated by Seuntjens et al. [101], are shown
in Fig. 13 as a function of the photon beam quality specifiers TPR20,10(10) and
%dd(10,10)x. It can be seen that k Qw,plastic msr
varies between approximately 0.960 and
0.980 for PMMA, and between approximately 0.997 and 1.010 for Solid Water.
For a PMMA phantom, k Qw,plastic msr
from Monte Carlo calculations and
experiments agree within 0.2% despite the rather large depth scaling correction.
For Solid Water, larger differences have been found between Monte Carlo
calculations and experiments, notably from phantom to phantom, which although
yielding an average difference of 0.3% (Monte Carlo always larger) still point
to a variation in the water equivalency between different phantoms. This is

45
FIG. 13.  Example values of the phantom dose conversion factor for Solid Water (Gammex
RMI 457) and PMMA in a 10 cm × 10 cm reference field based on Monte Carlo calculations.
Note that the correspondence between %dd(10,10)x and TPR20,10(10) is only approximate.
(Reproduced from Ref. [101] with the permission of the American Association of Physicists in
Medicine.)

associated with heterogeneities in the phantom due to manufacturing variability

in the plastic. Computed tomography scanning or radiographing of the plastic
water substitute material may help in QA for the purpose of reference dosimetry
in such phantoms [102].

3.2.3. Determination of field output factors

For the dosimetry of clinical fields, relative to the reference dosimetry of

an msr field, field output factors are used (see Section 2.3.2.1). These factors are
also called total scatter factors [12, 32, 103], or relative dose factors [104]. The
, f msr
field output factor WQf clin
clin,Qmsr
with respect to the machine specific reference field
fmsr is defined as the ratio of absorbed dose to water in the clinical field  fclin with
beam quality Qclin and absorbed dose to water in the machine specific reference
field  fmsr with beam quality Qmsr:

f
f ,f
Dw,clinQ
WQclin ,Qmsr = f
clin
(17)
clin msr
Dw,msr
Q msr

46
 These field output factors are used to convert absorbed dose to water for the
machine specific reference field  fmsr to the absorbed dose to water for the clinical
field  fclin. For machines that can establish the conventional 10  cm × 10  cm
reference field  fref, ‘msr’ in Eq.  (17) and accompanying text is replaced with
‘ref’. This applies to the remainder of this section.
Field output factors are derived from a ratio of detector readings
according to:

f
f ,f
M Qclin f ,f
WQclin ,Qmsr = f
clin
k Qclin ,Qmsr (18)
clin msr
M Qmsr clin msr
msr

It is clear from this equation that a ratio of readings is not equal to a

field output factor; rather such ratios will need to be multiplied by an output
correction factor to obtain the field output factor. Only if the reading of the
detector is directly proportional to the absorbed dose to water at a point and the
proportionality factor remains constant does the output correction factor become
unity. Even calorimeters or transfer instruments require output correction factors
for the smallest fields. For some detectors that are very small and have an energy
independent response, such as radiochromic film, a liquid ionization chamber or
an organic scintillator, the output correction factors may be close to unity. The
perfect small field detector, however, does not exist.
, f msr
The output correction factor kQf clin
clin,Qmsr
can be determined as a directly
measured value, an experimental generic value or a Monte Carlo calculated
generic value:

f f
f ,f
Dw,clinQ Ddet,
clin
Q
k Qclin ,Qmsr = f
clin
f
clin
(19)
clin msr
Dw,msr
Q Ddet,
msr
Q
msr msr

As explained in Section 2.3.2.1, if a suitable detector for the entire range

of field sizes from fmsr to fclin is not available, it is advised to use an ionization
chamber for field sizes down to an intermediate field  fint as small as possible but
without small field conditions, and to use a suitable small field detector such as a
diode only for measurements in smaller fields, thereby limiting the effect of the
energy dependence. Using this intermediate field method (IFM), the field output
factor is obtained through the equation:

WQclin ,Qmsr = éêWQclin ,Qint ùú éêWQint ,Qmsr ùú (20)

f ,f f ,f f ,f
clin msr ë clin int û det ë int msr û IC

47
where ‘det’ refers to the small field detector and ‘IC’ refers to the ionization
chamber.
Using the definition of the field output factor given in Eq.  (18), this
equation becomes:

é M f clin ù é M f int ù
f ,f ê Q f ,f ú ê Qint f int , f msr ú
WQclin ,Qmsr = ê f clin k Qclin ,Qint ú ê f msr k Qint ,Qmsr ú (21)
clin msr
ê MQ int clin int
ú ê MQ ú
ë int û det ë msr û IC

making it clear that two output correction factors are required, one for each
detector. However, in the absence of small field conditions for the intermediate
field, éëê kQintint,Qmsrmsr ùûú   ≈  1 for well designed ionization chambers. Having to correct
f ,f
IC
only from the intermediate field fint to the clinical field fclin minimizes the
contribution from the small field detector to the overall correction, especially the
influence of low energy photon scatter.

3.3. REFERENCE CONDITIONS

Reference conditions are described by a set of values of influence quantities

for which a calibration coefficient 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.
For radiotherapy machines that can generate the conventional
10 cm × 10 cm reference field at 100 cm SSD or SDD, the reference conditions
given in COPs like Refs [1, 2, 7] are used. For machines where the conventional
10 cm × 10 cm reference field cannot be established, specific reference conditions
related to the msr field are used. The reference conditions for the determination of
beam quality and absorbed dose to water for msr fields are given in Section 5.3.
A compilation of msr fields for some common radiotherapy machines is given in
Table 2.

48
TABLE 2.  msr FIELDS FOR COMMON RADIOTHERAPY MACHINES

Machine type msr field

CyberKnife 6 cm diameter fixed collimator

TomoTherapy 5 cm × 10 cm field

Gamma Knife 1.6 cm or 1.8 cm diameter collimator helmet,

all sources simultaneously out

Brainlab micro MLC add-on For example 9.8 cm × 9.8 cm or 9.6 cm × 10.4 cm

SRS cone add-ons The closest to a 10 cm × 10 cm equivalent square msr

field achievable

49
 4.  DETECTORS AND EQUIPMENT

This chapter provides a general background on the characteristics of

detectors suitable for reference dosimetry of msr fields and relative dosimetry
of small fields, and provides guidance on detectors to be used for applying this
COP. Distinction has to be made between detector requirements for dosimetry
of the conventional 10  cm × 10  cm reference field and those for dosimetry of
smaller fields; particularly for the relative dosimetry of small (non-msr) fields,
the requirements can be substantially different. For a review on characteristics of
radiation detectors for dosimetry and imaging see Ref. [105].

4.1. EQUIPMENT FOR MACHINE SPECIFIC REFERENCE DOSIMETRY

Accuracy requirements for conventional reference dosimetry and for msr

dosimetry are expected to be the same. The reference conditions will, however,
be different. Although this places some restrictions on the type of equipment that
can be used, the requirements for equipment used for msr dosimetry are expected
to be largely the same as those applicable to the dosimetry of conventional
reference fields [1, 2]. Equipment considered for msr dosimetry will include, but
not be limited to, smaller ionization chambers and phantoms with geometries and
materials different from those used for conventional reference dosimetry. Thus,
only ionometric measurements are considered for reference dosimetry in this
COP. The basic advice remains that for msr dosimetry, an ionization chamber be
used in a water phantom to determine the reference absorbed dose to water at the
user’s radiotherapy machine.
Traditionally, an ionometric dosimeter system for radiotherapy contains the
following components [106]:

(a) One or more ionization chambers, including the permanently attached

cable and connector. It is advised that the ionization chambers chosen be
specifically designed for the intended purpose (modality, radiation quality
etc.).
(b) One or more phantoms with waterproof sleeves if needed.
(c) A measuring assembly (electrometer), often separately calibrated in terms
of charge or current per scale division.
(d) One or more stability check devices, specifically designed for the chosen
ionization chamber.
(e) Calibrated thermometer and barometer.

51
 Component (a) will be reviewed in Section  4.1.1 and component (b) in
Section 4.1.2. The other components (c, d and e) are adequately documented in
existing protocols and no special requirements relating to them will be discussed
in this COP.

4.1.1. Ionization chambers for msr reference dosimetry

Ideally, ionization chambers used for photon beam measurements in a water

phantom are water equivalent and do not perturb the radiation fluence, and have a
dose rate and directionally independent response, high sensitivity (good signal to
noise ratio, reasonable time to acquire the signal), good stability (short and long
term), linear response with absorbed dose to water, limited energy dependence,
low leakage and negligible cable effect. While many of these characteristics can
only be met approximately, thimble ionization chambers have been proven to be
robust, simple and suitable for clinical reference dosimetry in msr fields in water
or solid phantoms.
The size restriction on an ionization chamber for msr dosimetry is that the
outer boundaries of the detector be at least a distance rLCPE away from the field
edges (at 50% absorbed dose level). In use, the chamber needs to be aligned in
such a way that the radiation fluence is approximately uniform over the chamber
cavity. The construction of the chamber is to be as homogeneous as possible,
but it is recognized that for technical reasons the central electrode is likely to be
made of a material different from that of the chamber walls. Indeed, the choice
of materials may play an important role in ensuring that the energy response of
the chamber does not vary considerably. It is also necessary for the air cavity not
to be sealed so that it will equilibrate rapidly with the ambient temperature and
air pressure. Finally, it is preferable that the reference ionization chambers be
waterproof, so they can be used directly in water phantoms.
As an ionization chamber is an instrument of high precision, it is advised
that the performance of the chamber type be sufficiently tested in radiotherapy
beams. Guidance for commercially available ion chambers to be used in generic
msr fields with dimensions equal to or larger than 6 cm × 6 cm will be covered
in Section  4.1.1.1, while guidance for fields smaller than 6  cm × 6  cm will be
given in Section  4.1.1.2. The rationale for this field size limit is based on the
largest ionization chamber dimensions (i.e. Farmer types) used for conventional
reference dosimetry and the rLCPE of the highest energy beams advised in this COP
(note for example that for an 18 MV beam the field size limit would be larger).

52
4.1.1.1. Equivalent square msr field size fmsr ≥ 6 cm × 6 cm

Modern radiotherapy machines have two main generic designs, namely with
and without a beam flattening filter. For beams WFF, the reference ionization
chambers are robust air filled chambers that are often waterproof and are simple
to use for reference in-phantom measurements. The chamber cavity volumes are
between about 0.3 cm3 and 1 cm3 (many have a volume around 0.6 cm3), a size
range that balances between the need for sufficient sensitivity and the ability
to measure at a point. Chambers with these volumes also have good signal to
noise ratio and negligible leakage effects [107]. The requirements are met in
cylindrical chambers with an air cavity of internal diameter around 6.4 mm and
an internal length around 24 mm, which is typical for Farmer type chambers. In
use, the chamber needs to be aligned in such a way that the radiation fluence is
approximately uniform over the cross-section of the chamber cavity. It is advised
for FFF beams that the reference ionization chamber have a length shorter than
that of a typical Farmer type chamber given the non-uniformity of the lateral
beam profile [108]. Typical volumes for these chambers are between 0.1  cm3
and 0.3  cm3. If Farmer type chambers are used, a correction for the profile
non-uniformity has to be applied which can amount to 1.5% for 6 MV FFF beams
[76, 81].
A critical analysis of 27 cylindrical ionization chambers used in
conventional megavoltage photon beams was published in Ref. [107] in which
most of the Farmer type chambers as well as the NE 2611 chambers were found
to show good performance compared with the specifications for reference class
chambers listed in Table  3. Also, a number of smaller-volume chambers were
found to be suitable for reference dosimetry. The characteristics of a number
of commercially available ionization chambers for msr dosimetry are given
in Table  4. The performance of each individual ionization chamber has to be
verified to comply with the criteria given in Table 3.

4.1.1.2. Equivalent square msr field size fmsr < 6 cm × 6 cm

Since LCPE conditions are a requirement for machine specific reference

fields, the field edges are at least a distance rLCPE away from the outer boundaries
of the reference ionization chamber. Based on their size, msr fields are not small
fields (except in the case of Gamma Knife machines, see below), but some
common reference detectors are too large to fulfil the rLCPE criterion mentioned.
For example, for 6  MV beams between 3  cm × 3  cm and 5  cm × 5  cm LCPE
exists, but a Farmer type chamber is too large for such field sizes; dosimetry
under these circumstances would result in an underestimation of the absorbed

53
TABLE 3.  SPECIFICATIONS FOR REFERENCE CLASS IONIZATION
CHAMBERS FOR REFERENCE DOSIMETRY OF msr FIELDS, fmsr [107]

Parameter Specification

Chamber settling Monitoring chamber response with accumulated dose: equilibrium is

reached in less than 5 minutes; the initial and equilibrium readings
agree within 0.5%.

Leakage Smaller than 0.1% of the chamber reading.

Polarity effect Smaller than 0.4% of the chamber reading. The polarity energy
dependence is less than 0.3% between 60Co and 10 MV photons.

Recombination 1. The correction is linear with dose per pulse.

correction 2. Initial recombination (the dose rate or dose per pulse independent
part of the total charge recombination) is below 0.2% at polarizing
voltages around 300 V.
3. For pulsed beams, a plot of 1/MQ (charge reading) vs 1/V
(polarizing voltage) is linear at least for practical values of V.
4. For continuous beams, a plot of 1/MQ vs 1/V2 is linear, describing
the effect of general recombination. The presence of initial
recombination disturbs the linearity but this is normally a small
effect, which may be neglected.
5. The difference in the initial recombination correction obtained
with opposite polarities is less than 0.1%.

Chamber stability Change in calibration coefficient over a typical recalibration period

of 2 years below 0.3%. Same figure for long term (>5 y) stability.

Chamber material Wall material not exhibiting temperature and humidity effects.

Note: Chamber types that potentially do not meet these criteria but have been proven to be
suitable for reference dosimetry of the Gamma Knife are marked in Table 5.

dose to water on the central axis because of volume averaging and other effects
described in Section 2.1.1.2.
Le Roy et al. [109] evaluated 24 small volume ionization chambers
(0.007  cm3 to 0.057  cm2) of eight different types to determine whether these
could be used for reference dosimetry in high energy photon beams with field
sizes down to 2 cm × 2 cm (only measurements in a 60Co gamma ray beam were
performed). They advise that the polarization voltage across the chamber be
chosen such that the electric field strength is between 100 and 200 V/mm. Based
upon this study, the authors concluded that only three of the chamber types tested

54
 TABLE 4. CHARACTERISTICS OF CYLINDRICAL IONIZATION CHAMBERS FOR REFERENCE DOSIMETRY OF
msr FIELDS fmsr ≥ 6 cm × 6 cm

Wall Central
Cavity Cavity Cavity
Ionization chamber type Wall material thickness electrode Waterproof
volume (cm3) length (mm) radius (mm)
(g/cm2) material

Capintec PR-06C/G Farmer 0.65 22.0 3.2 C-552a 0.050 C-552a N

Exradin A2 Spokas 0.53 11.4 4.8 C-552a 0.176 C-552a Y

Exradin A12 Farmer 0.65 24.2 3.1 C-552a 0.088 C-552a Y

Exradin A12S 0.25 11.6 3.1 C-552a 0.088 C-552a Y

Exradin A19 0.63 25.0 3.1 C-552a 0.088 C-552a Y

FZH TK 01 0.4 12.0 3.5 Delrinc 0.071 —b Y

Nuclear Assoc 30-751 Farmer 0.69 23.0 3.1 Delrinc 0.056 Aluminium Y

Nuclear Assoc 30-752 Farmer 0.69 23.0 3.1 Graphite 0.072 Aluminium Y

NE 2505/3, 3A Farmer 0.6 24.0 3.2 Graphite 0.065 Aluminium N

NE 2571 Farmer 0.6 24.0 3.2 Graphite 0.065 Aluminium N

55
56
TABLE 4. CHARACTERISTICS OF CYLINDRICAL IONIZATION CHAMBERS FOR REFERENCE DOSIMETRY OF
msr FIELDS fmsr ≥ 6 cm × 6 cm (cont.)

Wall Central
Cavity Cavity Cavity
Ionization chamber type Wall material thickness electrode Waterproof
volume (cm3) length (mm) radius (mm)
(g/cm2) material

NE 2611 0.33 9.2 3.7 Graphite 0.090 Aluminium N

(hollow)

PTW 23331 rigid 1.0 22.0 4.0 PMMAd,e 0.060 Aluminium N

PTW 23332 rigid 0.3 18.0 2.5 PMMAd,e 0.054 Aluminium N

PTW 23333 (3 mm cap) 0.6 21.9 3.1 PMMAd,e 0.059 Aluminium N

PTW 30001 Farmer 0.6 23.0 3.1 PMMAd,e 0.045 Aluminium N

PTW 30010 Farmer 0.6 23.0 3.1 PMMAd,e 0.057 Aluminium N

PTW 30002/30011 Farmer 0.6 23.0 3.1 Graphite 0.079 Graphite N

PTW 30004/30012 Farmer 0.6 23.0 3.1 Graphite 0.079 Aluminium N

PTW 30006/30013 Farmer 0.6 23.0 3.1 PMMAd,e 0.057 Aluminium Y

 TABLE 4. CHARACTERISTICS OF CYLINDRICAL IONIZATION CHAMBERS FOR REFERENCE DOSIMETRY OF
msr FIELDS fmsr ≥ 6 cm × 6 cm (cont.)

Wall Central
Cavity Cavity Cavity
Ionization chamber type Wall material thickness electrode Waterproof
volume (cm3) length (mm) radius (mm)
(g/cm2) material

PTW 31003/31013 Semiflex 0.3 16.3 2.8 PMMAd,e 0.078 Aluminium Y

SNC 100700-0 Farmer 0.6 24.4 3.1 PMMAd 0.060 Aluminium N

SNC 100700-1 Farmer 0.6 24.4 3.1 Graphite 0.085 Aluminium N

Victoreen Radocon II 555 0.1 23.0 2.4 Polystyrene 0.117 —b N

Victoreen 30-348 0.3 18.0 2.5 PMMAd 0.060 —b N

Victoreen 30-351 0.6 23.0 3.1 PMMAd 0.060 —b N

Victoreen 30-349 1.0 22.0 4.0 PMMAd 0.060 —b N

Victoreen 30-361 0.4 22.3 2.4 PMMAd 0.144 —b N

IBA FC-65P Farmer 0.65 23.1 3.1 Delrinc 0.057 Aluminium Y

IBA FC-65G Farmer 0.65 23.1 3.1 Graphite 0.073 Aluminium Y

57
58
TABLE 4. CHARACTERISTICS OF CYLINDRICAL IONIZATION CHAMBERS FOR REFERENCE DOSIMETRY OF
msr FIELDS fmsr ≥ 6 cm × 6 cm (cont.)

Wall Central
Cavity Cavity Cavity
Ionization chamber type Wall material thickness electrode Waterproof
volume (cm3) length (mm) radius (mm)
(g/cm2) material

IBA FC-23C Farmer 0.23 8.8 3.1 C-552a 0.070 C-552a Y

IBA CC13 0.25 10.0 3.0 C-552a 0.070 C-552a Y

a
Air equivalent electrically conducting plastic consisting of a mixture of polyvinylidene fluoride, carbon black and silica.
b
—: no information available.
c
Polyoxymethylene (CH2O). Delrin is a trade name.
d
Polymethylmethacrylate (C5H8O2), also known as acrylic. Trade names are Lucite, Plexiglas or Perspex.
e
Like most chamber types with non-conductive plastic walls, the chamber wall has an inner conductive layer made of graphite. For this chamber
type, the thickness and density of the graphite layer are supplied in the chamber specifications.
were suitable for use as reference class chambers for small beam dosimetry
(Exradin A1SL, IBA CC04 and IBA CC01), whereas issues with ion collection
efficiency and polarity effects were noted for some chambers. The chamber
specifications given in Table 3 are adopted in this COP for msr dosimetry when
the equivalent square msr field size is smaller than 6 cm × 6 cm.
A representative case of very small msr fields corresponds to the circular
field of Gamma Knife machines, with diameters of 1.6 cm or 1.8 cm. It is noted
that these are still fields that exhibit LCPE given the much smaller rLCPE of 60Co,
which is about 0.6 cm [94]. The criterion for the outer boundaries of the reference
ionization chamber to be at least that distance away from the field edges limits the
range of suitable ionization chambers. Fortunately, some of the microchambers
listed in Table 5 that do not fulfil the criteria of Table 3 for high energy X ray
beams do fulfil those for Gamma Knife. This can partially be explained by the
fact that only a small portion of the stem is irradiated, meaning that the polarity
effects observed in broad beams [109] with these chamber types are not observed
in Gamma Knife measurements [110].
For msr dosimetry in fields with equivalent square msr field size smaller
than 6 cm × 6 cm, the largest chamber cavity dimension is restricted to around
7 mm, and this requirement is usually met in ionization chambers with volumes
smaller than about 0.3  cm3. This criterion could in principle be expressed as a
function of field size and energy, but the limit of 7 mm ensures that for a 10 MV
beam, all fields with an equivalent square size down to about 4  cm fulfil the
condition of LCPE, while for 6  MV this is the case down to about 3  cm, and
for 60Co gamma ray beams it is the case down to about 2 cm. The fact that for
Gamma Knife fields, the beam quality correction factors for ionization chambers
marked in Table 5 remain small, even for the smaller field sizes of 1.8 cm and
1.6 cm, can be understood by the size of the cavity, with typical values between
2 and 4 mm for these detectors such that full lateral charge buildup, which may
not be achieved at the outer edges of the detector, is still partially achieved
within the additional wall material thickness. This reasoning of course ignores
the fact that at the interface between the phantom material and the wall there is
an additional component of charged particle disequilibrium, and the interplay of
this effect with the absence of LCPE could result in a perturbation correction
factor different from the one for a broad beam. Table 5 gives a list of commercial
small volume ionization chambers recommended for msr dosimetry in this COP
in fields with equivalent square msr field size smaller than 6  cm × 6  cm. The
chambers recommended in this COP for Gamma Knife are marked in Table 5.

59
60
TABLE 5. CHARACTERISTICS OF IONIZATION CHAMBERS SUITABLE FOR REFERENCE DOSIMETRY OF msr
FIELDS fmsr < 6 cm × 6 cm

Wall Central
Cavity Cavity Cavity
Ionization chamber type Wall material thickness electrode Waterproof
volume (cm3) length (mm) radius (mm)
(g/cm2) material

Capintec PR-05P minia 0.07 5.5 2.0 C-552 0.220 C-552 N

Exradin A1 mini Shonka (2 mm cap) 0.057 5.7 2.0 C-552 0.176 C-552 Y

Exradin A1SL mini Shonka slimlinea 0.057 5.7 2.1 C-552 0.176 C-552 Y

Exradin A14 micro Shonkaa 0.016 2.0 2.0 C-552 0.176 C-552 Y

Exradin A14SL micro Shonka 0.016 2.1 2.1 C-552 0.194 C-552 Y
slimlinea

Exradin A14P micro planara 0.002 1.0 2.0 C-552 0.176 C-552 Y

Exradin A16 microa 0.007 1.7 1.2 C-552 0.088 C-552 Y

Exradin A18 thimble 0.125 4.9 2.5 C552 0.176 C-552 Y

IBA CC01a 0.01 3.6 1.0 C-552 0.088 Steel Y

IBA CC04a 0.04 3.6 2.0 C-552 0.070 C-552 Y

 TABLE 5. CHARACTERISTICS OF IONIZATION CHAMBERS SUITABLE FOR REFERENCE DOSIMETRY OF msr
FIELDS fmsr < 6 cm × 6 cm (cont.)

Wall Central
Cavity Cavity Cavity
Ionization chamber type Wall material thickness electrode Waterproof
volume (cm3) length (mm) radius (mm)
(g/cm2) material

IBA CC08 0.08 4.0 3.0 C-552 0.070 C-552 Y

IBA CC13 0.13 5.8 3.0 C-552 0.070 C-552 Y

IBA CC13-S 0.13 5.8 3.0 PEEK/C-552 0.154 C-552 Y

Nuclear Assoc 30-750 0.03 3.6 2.0 C-552 0.068 C-552 Y

Nuclear Assoc 30-749 0.08 4.0 3.0 C-552 0.068 C-552 Y

Nuclear Assoc 30-744 0.13 5.8 3.0 C-552 0.068 C-552 Y

PTW 31010 Semiflex 0.125 6.5 2.8 PMMAb,c 0.078 Aluminium Y

PTW 31014 PinPointa 0.015 5.0 1.0 PMMAc 0.085 Aluminium Y

PTW 31015 PinPoint 0.030 5.0 1.45 PMMAc 0.085 Aluminium Y

61
62
TABLE 5. CHARACTERISTICS OF IONIZATION CHAMBERS SUITABLE FOR REFERENCE DOSIMETRY OF msr
FIELDS fmsr < 6 cm × 6 cm (cont.)

Wall Central
Cavity Cavity Cavity
Ionization chamber type Wall material thickness electrode Waterproof
volume (cm3) length (mm) radius (mm)
(g/cm2) material

PTW 31016 PinPoint 3Da 0.016 2.9 1.45 PMMAc 0.085 Aluminium Y

Victoreen Radocon II 555 0.1 4.3 2.5 Delrind 0.529 —e N

a
Chambers that potentially do not meet the criteria of Table 3 but have been proven to be suitable for reference dosimetry of the Gamma Knife [110].
b
Polymethylmethacrylate (C5H8O2), also known as acrylic. Trade names are Lucite, Plexiglas or Perspex.
c
Like most chamber types with non-conductive plastic walls, the chamber wall has an inner conductive layer made of graphite. For this chamber
type, the thickness and density of the graphite layer are supplied in the chamber specifications.
d
Polyoxymethylene (CH2O). Delrin is a trade name.
e
—: data not available.
4.1.2. Phantoms

Water is advised as the reference medium for measurements leading to the

determination of absorbed dose to water and beam quality in photon beams. For
some treatment machines, the use of water phantoms for reference dosimetry
is possible but impractical, and therefore, solid phantoms may be necessary. In
those situations only, a water equivalent plastic or similar solid phantom material
may be used for reference dosimetry and for the measurement of beam quality
indices. If solid phantoms are used, it is essential that the detector be placed
accurately, with its measurement point on the radiation beam’s central axis at
the water equivalent depth zeq,plastic. Today, commercially available solid materials
used in radiotherapy dosimetry have well controlled densities and well defined
atomic properties, and can be machined for accurate positioning of dosimeters.
Solid phantoms are machined in different forms and shapes, depending on
particular applications. They may be shaped as slab phantoms, cubes, cylinders,
spheres, hemispheres and other geometrical shapes. For additional details on
geometry requirements see Section 5.2.2. Ideally, the solid phantom material is
water equivalent, that is, its absorption and scattering properties are the same
as those of water. The elemental composition (in fractions by weight), nominal
density, mean atomic number, mean excitation energy and depth in plastic
equivalent to 10 cm depth in water of some common phantom materials used as
water substitutes are provided in Section 5.3.4. Note that for the determination
of the phantom dose conversion factor in Eq. (16) and its subsequent use for
reference dosimetry, any potential inhomogeneities or air pockets are taken into
account if the slab order is kept the same in all measurements performed in that
solid phantom.

4.2. EQUIPMENT FOR RELATIVE DOSIMETRY IN SMALL AND

NON-REFERENCE FIELDS

The equipment used for relative dosimetry in small fields introduces

additional challenges such as the need for using detectors with a small volume,
the ability for high spatial resolution measurements and the need to overcome
positioning problems. Meeting all quoted requirements is a challenge for detector
design. The following sections will first outline generic characteristics of
detectors suitable for small field dosimetry, including ‘ideal’ characteristics, and
then provide specific guidance for detectors and phantoms to be used for relative
dosimetry.

63
4.2.1. General characteristics of detectors for small field dosimetry

It is prudent to assume that a detector used for dosimetry in large fields

will not perform well in small fields until the contrary is proven by its adequate
characterization specifically for use in small fields. For example, ionization
chambers are often not suitable in the presence of high absorbed dose gradients.
Volume averaging and substantial perturbations in the absence of LCPE
compromise their use for dosimetry of small photon fields. Generic characteristics
of suitable detectors for small field dosimetry are summarized in Table 6 [12].

TABLE 
6.  CHARACTERISTICS OF DETECTORS FOR RELATIVE
DOSIMETRY IN SMALL FIELDS [12]

Detector properties Guidance Comments

Stability Short term detector response is Correction for instabilities over

better than 0.1% for a total time can be made provided the
accumulated absorbed dose of effect is consistent and
many hundreds of kGy from recalibration is not frequently
multiple exposures. required.

Dose linearity Linearity is better than 0.1% over

an absorbed dose range of at least
three orders of magnitude
(e.g. 0.01–10 Gy).

Dose rate linearity Clinical linear accelerators are The range of dose rates is typical
typically operated at average for WFF and FFF beams.
dose rates of 0.1–0.4 Gy/s;
detector is linear to better
than 0.1% over the range of
operation of the linac.

Dose per pulse A detector’s response with Typical dose per pulse operating
linearity changing dose per pulse remains conditions are 0.2–2.0 mGy per
stable to better than 0.1% after pulse.
correction for ion recombination.

Energy dependence The useful energy range of An ideal detector is constructed

of detector response the detectors for small field to be energy independent with
MV radiotherapy is from macroscopic interaction
60
Co to 10 MV. coefficients (μen/ρ for photons
and S/ρ for electrons) having a
constant ratio to those of water
in the energy interval of interest.

64
TABLE 
6.  CHARACTERISTICS OF DETECTORS FOR RELATIVE
DOSIMETRY IN SMALL FIELDS [12] (cont.)

Detector properties Guidance Comments

Spatial resolution The choice of a suitable detector The requirement for spatial
in terms of spatial resolution is resolution is set by the gradients
usually based on a trade-off in the quantity to be measured.
between a high signal to noise
ratio and a small dosimeter size.

Size of detector The detector size is such that the

volume averaging correction is
not larger than 5%.

Orientation The response of a detector is Detectors do not, in general,

ideally independent of the have an isotropic response,
orientation of the detector and either a correction is
with respect to the beam and required to account for the
the variation is less than 0.5% angular response or, more
for angles of less than 60° commonly, the beam incidence
between the beam axis and is fixed (i.e. irradiation from end
the detector axis. or side) to minimize the effect.

Background signal Any form of signal leakage that The zero dose reading of a
would contribute to increased detector will affect the low dose
background readings is at least limit of the device and the signal
three orders of magnitude lower to noise ratio.
than the detector response
per Gy.

Environmental factors Correction over the full range Measurements are ideally
of working conditions enables independent of temperature,
any influence to be reduced to atmospheric pressure and
better than 0.3%. humidity changes or are
corrected accurately for these
influence quantities.

Note: These characteristics are based on the assumption that leakage is negligible and
appropriate polarity and recombination corrections are applied.

The ideal detector for small field dosimetry samples the fluence at a point,
is water equivalent, and has a linear response, which is energy independent and
absorbed dose (fluence) rate independent. Although water calorimeters are the
most water equivalent instruments and have no known energy dependent or
absorbed dose rate dependent response, they are not practical instruments for

65
routine use. The most commonly used detector in relative dosimetry is the air
filled ionization chamber. The minimum chamber size, however, is determined
by considerations related to the magnitude of the ionization produced in the
cavity volume as compared to the background signal from other chamber
components such as stem and cable. For every ionization chamber there will
always be a field size below which volume averaging becomes unacceptably
large. Below that size, only liquid ion chambers or solid state detectors are
suitable for dosimetry, with even those exhibiting substantial perturbations for
the smallest field sizes.
Relative dosimetry of small fields often involves the determination of
central axis depth dose distributions, tissue phantom ratios or tissue maximum
ratios, lateral beam profiles and field output factors as a function of field size
and shape. The choice of the most appropriate detectors for the specific type of
measurement is made according to the parameter being measured. As no ideal
detector exists, it is advised to use two or three different types of detectors suitable
for a particular measurement so that redundancy in the results can provide more
confidence and assurance that no significant dosimetry errors are being made.
For the determination of field output factors, the volume averaging
effect may be a limiting factor in the choice of detector; therefore the detector
size is such that the radiation fluence is fairly uniform over the detector area
(see Sections  2.1.5 and 3.1.4). Other properties that affect the performance for
field output factor determination are the field size dependence of the response
of the detector owing to its energy dependence, absorbed dose (fluence) rate
dependence, water equivalence and overall perturbation.
For the experimental determination of beam profiles, a detector’s spatial
resolution, directional response, energy response and absorbed dose rate
dependence are important parameters to consider. Volume averaging effects
and detector material properties affect the measurement of the beam penumbra.
Non-uniform directional response may lead to distortion of the shape of the
measured profile. Absorbed dose rate dependence may manifest itself by an
overestimation of absorbed dose values by some percentage in part of the profile.
Detectors exhibiting absorbed dose rate dependence are not the appropriate
choice, unless a correction is made for the absorbed dose rate effect. This is
especially relevant for FFF beams, where dose rates or dose per pulse values
are higher than for beams with a flattening filter. Also, the contribution of low
energy photons to absorbed dose may be a problem with some detectors. For the
determination of depth dose distributions, the influence of low energy scattered
photons increases with depth, and therefore the lack of water equivalence,
resulting in the energy dependence of some detectors such as diodes, resulting in
an over-response. For the smallest fields, where no in-scatter of photons on the

66
central axis occurs, the effect of beam hardening may dominate over the effect of
scatter contributions, resulting in the opposite behaviour.
Fluence perturbation and detector size effects, together with positioning
difficulties, are the most important problems encountered in almost all dosimetric
systems used for measurements in small photon beams. Detector composition is
also important; if high Z material is used in the detector’s construction, the energy
fluence of secondary electrons is altered (see Section  2.1.5). Such detectors
(e.g. ionization chambers with a metal central electrode) may exhibit changes
in response as field size changes. When such detectors are calibrated under
larger beam conditions, their energy response needs to be considered, as there
are differences between large and small beams in terms of the energy spectra of
the photons and electrons detected. Corrections depend not only on the sensitive
medium of the detector but also to a greater extent on the detailed construction of
the detector and surrounding materials.
For accurate measurements in small fields, it is thus important that
each detector is radiographed before use, at more than one rotational position
(e.g. orthogonal views), to identify any potential problems and assess the
construction and symmetry of the device. This will also make it possible to
determine the location of the sensitive volume of the detector, which may differ
from external marks or information provided by the manufacturer to an extent
significantly affecting small field dosimetry [111]. Where necessary, the angular
response is also measured to confirm any asymmetries and determine how to take
these into account [59].
Many types of dosimeters have been used for small beam relative
dosimetry, and it must be emphasized that no single detector stands out as
having characteristics close to the ideal ones. For this reason, in contrast to the
situation for reference dosimetry, it is not possible to advise using a particular
type of detector for particular relative measurements. The wide range of detectors
whose use is described in the literature includes vented air and liquid ionization
chambers, silicon diodes, diamond detectors, plastic and organic scintillators,
radiographic and radiochromic films, metal oxide semiconductor field-effect
transistors (MOSFETs), thermoluminescent dosimeters (TLDs), optically
stimulated luminescence detectors (OSLDs), radio photoluminescence glass rods
and alanine. The items below provide an overview of these detectors.

—— Classical vented ionization chambers of a volume of 0.3–0.6 cm3 are not

suitable for relative dosimetry in small beams as their size is too large and
they underestimate the absorbed dose to water on the central axis of a small
field [8]. These ion chambers are to be avoided for profile measurements as
corrections for volume averaging effects are unacceptably large.

67
 —— Small vented air ionization chambers of a volume of 0.01–0.3  cm3
(minichambers, pinpoint chambers) were reported to be suitable for the
measurements of field parameters down to 2 cm × 2 cm [91, 109]. They have
favourable energy response to low energy photons and uniform directional
response. They are also independent of absorbed dose rate. Stem and cable
effects need to be checked and corrected for. It is also advised that the
polarity effect be carefully checked and corrected for. Examples of small
chambers are given in Table 5, but it is advised that their characteristics be
checked before use.
—— Microionization chambers of a volume of 0.002–0.01 cm3 (microchambers)
have a very small measuring volume and the volume averaging effect is
less pronounced, but they have limitations with regard to their reduced
sensitivity. The reduced response of microchambers to a given absorbed
dose to water means that signal leakage can be significant if not corrected
for, particularly in low absorbed dose regions of the beam [109, 112, 113].
It is advised that care be exercised when using microchambers in larger
beams, as some authors reported that with an increase in the amount of
chamber cable irradiated, the magnitude of radiation induced signal
increased [112]. Examples of microchambers are given in Table 5, but it is
advised that their characteristics be checked before use.
—— Liquid ionization chambers (LICs) are filled with dielectric liquid instead of
air. Because of the higher density of liquid, the chamber signal per detector
volume is significantly larger than that for an air filled ionization chamber of
the same volume; therefore, these small chambers are particularly attractive
for small field dosimetry. In addition, they are nearly water equivalent,
which reduces the chamber perturbation effects compared to air filled
chambers. LICs require a bias voltage of 800 V or more. Their response is
dose rate dependent because of substantial recombination effects, and it is
advised that this be corrected for in profile measurements [114–117]. Cable
and stem effects need to be checked and corrected for because the signal
may increase substantially owing to the irradiation of a part of the cable.
Also the temperature dependence of these chambers can have sufficient
influence to necessitate corrections [118]. The only commercial liquid
ionization chamber was the PTW 31018. This chamber, however, is no
longer available.
—— Silicon diodes generally have a sensitive volume small enough (typically
<0.2 mm3) so that the volume averaging effects are small. However, their
angular dependence is not uniform owing to the internal construction and
materials used, and can vary by 3% in magnitude [119]. For this reason,
it is advised that they only be used with the axis of symmetry parallel to
the beam axis. Diodes are known to over-respond to low energy photons

68
 owing to the differences in mass energy absorption coefficients of silicon
and water at keV energies. However, in small fields, where the scattered
radiation is reduced, the contribution of low energy photons is rather low.
Care needs to be taken to select an appropriate type of diode. Unshielded
diodes (‘electron diodes’) were reported to have properties better suited to
small field dosimetry than shielded diodes (‘photon diodes’) [120–123],
but output correction factors are needed for field sizes below 1 cm owing
to the effect of their mass density compared to water [37]. Shielded diodes
are energy compensated, to absorb some of the low energy scattered
photons, and contain high density material (e.g. tungsten) [121]. However,
the presence of tungsten increases the fluence of secondary electrons in
silicon owing to the higher mass energy absorption coefficient of tungsten,
for lower energy photon beams. This causes over-response of the diode.
It was shown that the response of shielded diodes is not completely
independent of changes in field size and the depth of measurement [121].
The increase in the contribution of low energy scattered photons with depth
results in an over-response of shielded diodes. However, some diodes have
been reported to exhibit under-response at large depths [58, 124] that was
attributed to the absorbed dose rate dependent response. In small fields,
the use of unshielded diodes is advised. For measurements in very small
fields, stereotactic diodes are used. Diodes have a limited lifetime and
their sensitivity depends on accumulated absorbed dose. For this reason
it is advised that the constancy of their relative response be verified
periodically.
—— Diamond detectors exhibit high sensitivity and their response is
almost independent of energy owing to the relatively constant ratio of
stopping-power and mass energy absorption coefficients of diamond to
water. They have uniform directional response [125]. Natural diamond
based detectors are small in one dimension (<0.5  mm), but their lateral
sizes vary because of the diamond selection process. Their absorbed dose
rate dependence is significant and needs to be corrected for [126–129],
and they require substantial pre-irradiation. It is advised that care be taken
in ensuring that the diamond detector is biased correctly, otherwise it
can be damaged. It is noted that natural diamond detectors are no longer
commercially available and have been replaced by artificial chemical
vapour deposition (CVD) diamonds [130–132]. The latter detectors are
used without bias voltage and have been shown to be suitable for small
field dosimetry [57, 133], but output correction factors are needed for field
sizes below 1 cm owing to the effect of their mass density compared to
water [47].

69
 —— Plastic and organic scintillators are based on the production of light in
the scintillator during its irradiation. The light is carried by an optical fibre
to a photomultiplier tube located outside the irradiation room. Scintillator
response is generally linear in the absorbed dose to water range of
therapeutic interest [134]. Various studies have indicated that perturbation
correction factors for plastic and organic scintillators in small fields are close
to unity [56, 100, 135, 136]. These detectors are almost water equivalent in
terms of electron density and atomic composition. Typically, they match
the water mass stopping-power and mass energy absorption coefficient to
within ±2% for the range of beam energies in clinical use including the keV
region. Scintillators are nearly energy independent and can be used directly
for relative absorbed dose determination. Plastic scintillation dosimeters
can be made very small (about 1 mm3 or less) and yet provide adequate
sensitivity for clinical dosimetry. The main complication in the use of
plastic scintillators is the correction for the Cerenkov light generated in
the optical fibre. Various correction methods have been developed, among
which spectral filtration and the use of hollow core fibres have proven to
be most successful [137]. The signal to noise ratio of plastic scintillators
is generally low and their response degrades with accumulated dose, but
owing to their high spatial resolution, flat energy dependence and small
size, plastic scintillators can be used for small beam dosimetry applications.
The only commercially available device is the Exradin W1, which is listed
with its characteristics in Table 7.
—— Radiographic and radiochromic film dosimetry for small field
measurements is attractive owing to superior spatial resolution in 2-D, but
is to be used with caution. Radiographic films are known for their limited
absorbed dose range, energy dependence and orientation dependence [138].
They exhibit over-response at low absorbed dose to water levels outside
the field owing to their increased sensitivity to low energy photons. Careful
control of the radiographic film processing and readout procedures is
essential for accurate dosimetry. This problem is largely resolved by using
radiochromic films that self-develop and require no chemical processing
to get an image of the absorbed dose distribution [139]. Radiochromic
films are not sensitive to ambient light and do not require a darkroom
for their processing, but they were reported to be sensitive to ultraviolet
radiation [140]. For megavoltage beams, radiochromic films are nearly
tissue equivalent and show little energy dependence. However, depending
on the composition, they show varying degrees of energy dependence in the
kilovoltage X ray region [139, 141]. They are water resistant. Radiochromic
films can be read with a suitable (flat-bed) scanner. The readout procedures
require accurate absorbed dose to water calibration, including careful

70
 investigation of spatial non-uniformity of the film response, scanner
response and dependence of signal on film orientation [142]. The film
signal continues to develop for several hours after irradiation; therefore
film scanning is performed in the same post-irradiation interval as for
the calibration film. Some other disadvantages reported by various
authors include film darkening and temperature sensitivity effects [140].
Nevertheless, its high spatial resolution, water resistance, insensitivity to
light and lack of need for processing give radiochromic film a considerable
advantage over radiographic film. Radiochromic film can be advised for
measurements of small beam profiles, penumbrae and field output factors
where changes in the spectral components of a beam can occur and can
affect the output factor measurements.
—— Other detectors: MOSFETs, TLDs, OSLDs, radiophotoluminescent (RPL)
glass dosimeters, alanine
●● MOSFETs are generally used for in vivo dosimetry. Owing to their small
size, they have high spatial resolution. However, MOSFET detectors
exhibit energy and directional dependence, poor signal to noise ratio
and inadequate reproducibility [143]. They also have a rather short
lifespan [144]. Overall, the literature [24, 144] does not support their use
for small field dosimetry.
●● TLDs are well established for absorbed dose audit programmes and
hospital in vivo dosimetry [145,  146]. TLDs most commonly used in
medical applications are LiF:Mg,Ti, LiF:Mg,Cu,P and Li2B4O7:Mn,
because of their tissue equivalence. TLDs are available in various forms
(e.g. powder, chips, microchips, rods, ribbon). LiF:Mg,Ti is one of the
most commonly used TLD materials. Its response is linear over a range
of absorbed dose values, although it increases in the absorbed dose region
above 1–2  Gy (supralinear behaviour). To derive the absorbed dose to
water from the thermoluminescence reading response, non-linearity
corrections have to be applied, together with other correction factors,
such as fading and energy correction, if a TLD is calibrated with a
different beam quality than that used for the measurement. For accurate
small beam dosimetry, TLDs require careful handling and control of
readout procedures to achieve measurement uncertainty of 2% or better.
They have been shown to require small corrections in small fields [100].
●● OSLDs are based on a principle similar to that of TLDs. Instead of heat,
light (from a laser) is used to release the trapped energy in the form of
luminescence. Typical OSLDs use carbon-doped aluminium oxide
(Al2O3:C) in the form of small chips (≈1  mm3), rods, mini-dots and
nano-dots. They can be coupled with optical fibre and laser based readout
systems for on-line readout or used as passive dosimeters, similarly to

71
 TLDs. OSLDs exhibit high sensitivity over the wide range of absorbed
dose rates and absorbed dose to water levels used in radiotherapy. OSLDs
exhibit similar linearity, energy and dose rate dependence as TLDs.
Precise OSL dosimetry is presently performed by some institutions [147].
●● Radiophotoluminescent (RPL) glass dosimeters are accumulation type
solid state dosimeters that use the phenomenon of radiophotoluminescence
to measure absorbed dose. The material used is silver activated
phosphate glass. The dosimeters come in the shape of small glass rods
(e.g. diameter 1.5 mm, length 8–12 mm). When silver activated phosphate
glass is exposed to radiation, stable luminescence centres are created in
silver ions. The readout technique uses pulsed ultraviolet laser excitation.
The readout area is smaller than the dosimeter size, i.e. diameter 1.5 mm,
length 6 mm in the standard readout mode and diameter 1.5 mm, length
0.6 mm in the high absorbed dose mode, which is convenient for small
beam dosimetry. A photomultiplier tube registers the orange fluorescence
emitted by the glass. RPL signal is not erased during the readout, thus
the dosimeter can be re-analysed several times, and the measured
data reproduced. Glass dosimeters were reported to have adequate
reproducibility; they have a linear response in the therapy absorbed dose
range, good spatial resolution, flat energy response from keV to MeV
energies [148] and very low fading [149]. RPL glass dosimetry systems
are commercially available. Their use for small beam dosimetry has been
reported by a few authors [148, 149].
●● Alanine is often quoted as a suitable dosimeter because it is close to water
equivalent, but the pellets with which radiotherapy level dosimetry is
achieved are usually quite large (e.g. typically 5 mm diameter and 2.5 mm
thickness) and are thus also prone to substantial volume averaging.
Smaller pellets are available (e.g. 2.5 mm diameter and 2.5 mm nominal
length pellets from the UK National Physical Laboratory (NPL) [57] or
the minipellets of 1 mm diameter and 3 mm length in Ref. [150]). Another
problem with alanine dosimetry is its comparatively low sensitivity,
requiring absorbed doses greater than 10 Gy to obtain a reproducibility of
less than 0.5%. Nevertheless, the advantage of alanine is that its density
and macroscopic interaction coefficients are close to those of water, so the
only substantial perturbation is the volume averaging effect, which can
be calculated from measured beam profiles (see Eq. (5) and examples in
Appendix I). Even though the necessary instrumentation is in general not
available in hospitals, readout services are provided by some standards
laboratories and universities.

72
 A list of commercially available silicon diode, diamond, liquid ionization
chamber and organic scintillator detectors is given in Table  7. For the sake of
clarity it is worth mentioning that diodes discussed in this section, usually called
‘scanning diodes’, have different construction than diodes used for in vivo
dosimetry.
To summarize, liquid ion chambers, silicon diodes, diamond detectors,
organic scintillators, radiochromic film, TLDs and OSL dosimeters are
considered suitable for relative dosimetry of small photon fields and are advised
for use in radiotherapy clinics by this COP, after their proper characterization for
the purpose.

4.2.2. Phantoms

Dosimetric and geometric phantoms for relative dosimetry and dose

verification of small field treatments may include the following:

—— Simple water filled calibration phantoms without a scanning system.

—— Full scatter 3-D water phantoms (also known as 3-D radiation field
analysers) typically used for the measurement of scanned dosimetric data.
It is critical that they are commissioned for alignment, orthogonality,
distance accuracy and hysteresis effects before use [151].
—— Water equivalent plastic cylinders, spheres, hemispheres, cubes and other
shapes containing cavities for inserting ionization chambers, diodes or
TLDs, possibly including sliced sections for films. Some contain a space
for diode or ionization chamber arrays.
—— Phantoms with adjustable measurement planes and chamber cavities, which
rigidly attach to stereotactic frames or index precisely to imaging and
treatment couch tops.

Prior to the use of plastic water substitute phantoms for dosimetry purposes,
their commissioning is a mandatory step in order to check the uniformity of
the phantom material and derive any relevant correction factors. A computed
tomography examination of the solid slabs is a useful QA test that can help in
verifying homogeneity. Ionization chamber measurements in plastic water
substitute phantoms are prone to effects such as charge buildup and temperature
inhomogeneities, and it needs to be verified that they have no effect on the
measurements. Plastics usually have low thermal conductivity; the dosimeter
temperature needs to be established by direct measurement at the position of
the detector and/or by leaving sufficient time for thermal equilibration with the
room [152].

73
74
TABLE 7. SILICON DIODE, DIAMOND, LIQUID IONIZATION CHAMBER AND ORGANIC SCINTILLATOR
DETECTORS FOR SMALL FIELD DOSIMETRY

Diameter or
Geometric Thickness of Reference pointb
Sensitive side length of
Detector form of sensitive volume (from flat face/tip) Shielded
volume (mm3) sensitive area
sensitive areaa (mm) (mm)c
(mm)

IBA PFD3G diode 0.19 Disc 2 0.06 <0.9 Y

IBA EFD3G diode 0.19 Disc 2 0.06 <0.9 N

IBA SFD diode 0.017 Disc 0.6 0.06 <0.9 N

PTW 31018 liquid ion chamberd 1.7 Disc 2.5 0.35 1.0 Y

PTW 60008 dioded 0.03 Disc 1.13 0.03 2.0c Y

PTW 60012 dioded 0.03 Disc 1.13 0.03 0.8c N

PTW 60016 diode 0.03 Disc 1.13 0.03 2.4c Y

PTW 60017 diode 0.03 Disc 1.13 0.03 1.3c N

PTW 60018 diode 0.3 Disc 1.13 0.25 1.3c N

PTW 60003 natural diamond 1–6 Variable <4 0.1–0.4 1.0c N

 TABLE 7. SILICON DIODE, DIAMOND, LIQUID IONIZATION CHAMBER AND ORGANIC SCINTILLATOR
DETECTORS FOR SMALL FIELD DOSIMETRY (cont.)

Diameter or
Geometric Thickness of Reference pointb
Sensitive side length of
Detector form of sensitive volume (from flat face/tip) Shielded
volume (mm3) sensitive area
sensitive areaa (mm) (mm)c
(mm)

PTW 60019 CVD diamondd 0.004 Disc 2.2 0.001 1.0c N

Sun Nuclear EDGE Detector 0.019 Square 0.8 0.03 0.3 Y

Exradin W1 (Standard Imaging) 2.4 Cylinder 1.0 3.0 1.5e N

Note: Characteristics stated by the manufacturers.

a
“Disc” refers to a geometry where the diameter is larger than the thickness of the detectors, while “cylinder” refers to a detector with a diameter
smaller than its length.
b
The reference point quoted is with respect to the flat face of the detector, for the stem orientation parallel to the beams’ central axis.
c
Note that for the PTW detectors, the data represent water equivalent thickness, not geometrical distance.
d
No longer commercially available.
e
Location of the centre of the scintillating detection volume when irradiated from top.

75
 5.  CODE OF PRACTICE FOR REFERENCE DOSIMETRY
OF MACHINE SPECIFIC REFERENCE FIELDS

5.1. GENERAL

This section provides a COP for machine specific reference dosimetry

(msr beam calibration) in clinical high energy photon beams. It is based on the
use of an ionization chamber that has been calibrated in terms of absorbed dose
to water ND,w,Q0 or ND,w,Qmsr in a standards laboratory’s reference beam of quality
Q0 or Qmsr.

5.2. DOSIMETRY EQUIPMENT

5.2.1. Ionization chambers

Guidance regarding ionization chambers is given in Section  4.1.1. Only

cylindrical ionization chambers that fulfil the specifications of a reference class
ionization chamber as summarized in Table 3 are advised for msr dosimetry in
high energy photon beams. For msr fields with equivalent square msr field size
equal to or larger than 6 cm × 6 cm, Farmer type chambers or other reference class
chambers such as those listed in Table 4 are used. For msr fields with equivalent
square msr field size smaller than 6 cm × 6 cm, smaller ionization chambers such
as those listed in Table 5 are used to ensure that the outer edges of the detector
volume are at least a distance rLCPE away from the field edges (defined at 50%
of the dose maximum, in consistency with the definition of field size given in
Section 2.1.2). As discussed in Section 3.1.3, the rLCPE (in cm) is given by:

rLCPE = 8.369´ TPR 20,10 (10) - 4.382 (22)

or

rLCPE = 77.97´10 -3 ´%dd (10,10) x - 4.112 (23)

The reference point of a cylindrical chamber for the purpose of calibration

at the standards laboratory and for measurements under reference conditions in
the user’s beam is taken to be on the chamber axis at the centre of the cavity
volume. This point is positioned at the reference depth zref in a water phantom.
For practical considerations on the use of ionization chambers, such as the
time required to equilibrate, evaluation of and correction for leakage currents,

77
and corrections for influence quantities, such as temperature, atmospheric
pressure, humidity, polarity effects and recombination, the same guidance as in
Ref.  [1] applies; this is summarized in Section  5.4. It is advised that if a field
instrument is used, it be cross-calibrated against a calibrated reference chamber
in the conventional reference field fref = 10 cm × 10 cm or in the msr field fmsr as
described in Section 5.5.

5.2.2. Phantoms and chamber sleeves

Guidance regarding phantoms and chamber sleeves is given in conventional

COPs [1, 2, 7]. Water is advised as the reference medium for the determination
of absorbed dose to water and beam quality in photon beams. It is advised that
the phantom extend at least 5 cm beyond all four sides of the field size employed
at the depth of measurement and also that it extend to at least 5 cm beyond the
maximum depth of measurement.
In horizontal beams, the window of the phantom is made of plastic and
is of thickness twin between 0.2 cm and 0.5 cm. The water equivalent thickness
(in g/cm2) of the phantom window is taken into account when evaluating the
depth at which the chamber is to be positioned; the thickness is calculated as
the product twin ρplastic where ρplastic is the mass density of the plastic (in g/cm3).
For non-waterproof chambers, a waterproofing sleeve is used, made of PMMA
and preferably not thicker than 1.0 mm. The air gap between the chamber wall
and the waterproofing sleeve is sufficient (0.1–0.3 mm) to allow the air pressure
in the chamber to equilibrate; for this reason the use of a thin rubber sheath is
not advised7. The same waterproofing sleeve that was used for calibration of
the user’s ionization chamber is also used for reference dosimetry. If it is not
possible to use the same waterproofing sleeve that was used during calibration at
the standards laboratory, then another sleeve of the same material and of similar
thickness is used.
There might be situations where it is more convenient to use a plastic water
substitute phantom than water. In that case, even though this is not the preferred
option, a high quality water equivalent plastic or similar solid phantom material,
such as those listed in Table 20, may be used. It is advised that the procedures
described in Section 5.3.4 be followed to determine the depth in the plastic water
substitute phantom that corresponds to the reference depth in the water phantom
and the phantom dose conversion factor.

7
Another known reason is that the talcum powder often used in the sheaths may occlude
the ventilation hole, ‘sealing’ the chamber expected to be open to ambient air.

78
5.3. DETERMINATION OF ABSORBED DOSE TO WATER IN
THE msr FIELD,  fmsr

5.3.1. Reference conditions

The reference conditions for determination of absorbed dose to water are

specified in Table 8 for high energy photon beams, in Table  9 for CyberKnife
machines, in Table 10 for TomoTherapy machines and in Table 11 for Gamma
Knife machines.

TABLE 8.  REFERENCE CONDITIONS FOR THE DETERMINATION OF

ABSORBED DOSE TO WATER IN HIGH ENERGY PHOTON BEAMS

Influence quantity Reference value or reference characteristics

Phantom material Water

Phantom shape and size At least 30 cm × 30 cm × 30 cm

Chamber type Cylindrical

Measurement depth zref 10 g/cm2

Reference point of chamber On the central axis at the centre of the cavity volume

Position of reference point of chamber At the measurement depth zref

SSD/SDD 100 cm or the closest achievablea

Field size 10 cm × 10 cmb or size of the msr fieldc

a
If the reference absorbed dose to water has to be determined for an isocentric set-up, the
source-to-axis distance of the accelerator is used, even if this is not 100 cm.
b
The field size is defined at the surface of the phantom for an SSD type set-up, whereas for
a source-to-axis distance type set-up it is defined at the plane of the detector, placed at the
reference depth in the water phantom at the isocentre of the machine.
c
The equivalent square msr field size, S, as close as possible to 10 cm but not smaller than
4 cm and not larger than 12 cm. The aspect ratio of rectangular fields (largest dimension/
smallest dimension) is as close as possible to unity.

79
TABLE 9.  REFERENCE CONDITIONS FOR THE DETERMINATION OF
ABSORBED DOSE TO WATER IN HIGH ENERGY PHOTON BEAMS ON
CYBERKNIFE MACHINES

Influence quantity Reference value or reference characteristics

Phantom material Water

Phantom shape and size At least 30 cm × 30 cm × 30 cm

Chamber type Cylindrical

Measurement depth zref 10 g/cm2

Reference point of chamber On the central axis at the centre of the cavity volume

Position of reference point of chamber At the measurement depth zref

SDD 80 cm

Field shape and size Circular, maximum available, fixed collimator

(6 cm diameter)

TABLE 10.  REFERENCE CONDITIONS FOR THE DETERMINATION OF

ABSORBED DOSE TO WATER IN HIGH ENERGY PHOTON BEAMS ON
TOMOTHERAPY MACHINES

Influence quantity Reference value or reference characteristics

Phantom material Water

Phantom shape and size At least 30 cm × 30 cm × 30 cm

Chamber type Cylindrical

Measurement depth zref 10 g/cm2

Reference point of chamber On the central axis at the centre of the cavity volume

Position of reference point of chamber At the measurement depth zref

SSD/SDD 85 cma

Field shape and size Rectangular (5 cm × 10 cm for TomoTherapy HiArt)

a
The reference SSD or SDD (for source-to-axis distance set-up) is that used for clinical
treatments.

80
TABLE 11.  REFERENCE CONDITIONS FOR THE DETERMINATION OF
ABSORBED DOSE TO WATER ON GAMMA KNIFE MACHINES

Influence quantity Reference value or reference characteristics

Phantom material Water or plastic (polystyrene, ABS, Solid Water, etc.)a

Phantom shape and size Hemispherical atop a cylinder, 16 cm diameter

Chamber type Microchamber, cylindrical

Measurement depth zref Centre of the hemisphereb

Reference point of chamber On the central axis at the centre of the cavity volume

Position of reference point of chamber At the centre of the hemisphere

SSD 32 cm

Field size Circular, maximum available

(1.6 or 1.8 cm diameter)c

a
Different designs have been reported, but the more common type advised in Gamma Knife
systems is the hemisphere atop a water filled or compact polystyrene cylinder.
b
In polystyrene phantoms this is usually a depth of 8 cm, for PMMA it is 7 cm.
c
For Gamma Knife machines, the maximum field size available depends on the model:
1.8 cm diameter for the standard model (Gamma Knife 4 or 4C) and 1.6 cm diameter for the
Perfexion (PFX) model. For Rotating Gamma System (RGS) machines, the maximum field
size available is 1.8 cm diameter. The msr field is the field generated with all sources out.

5.3.2. Machine specific determination of absorbed dose to water

5.3.2.1. High energy X ray WFF beams

The formalism for the determination of absorbed dose to water in the msr
field fmsr is detailed in Section  3.2.1. The measurement is performed using an
ionization chamber with its reference point positioned at the reference depth zref
in a water phantom8. Depending on the availability of a calibration coefficient

8
If a water equivalent plastic phantom is used, the expressions are modified according
to the description given in Section 3.2.2.

81
for the ionization chamber, one of the three different methods outlined in
Section 3.2.1 is used to determine the absorbed dose to water in a water phantom:

(a) A calibration coefficient, N Df msr,w,Qmsr

, in terms of absorbed dose to water
for the ionization chamber in a reference beam of quality Qmsr in the msr
field  fmsr is available; this is the preferred option, although at present few
standards laboratories offer this type of calibration. The absorbed dose to
water for the fmsr field, in a beam of quality Qmsr, at the reference depth zref
in water and in the absence of the ionization chamber is given by:

f f f
Dw,msr
Q msr
= M Qmsr N Dmsr
msr ,w,Q msr
(24)

If the conventional reference field  fref  = 10 cm × 10 cm can be established

at the machine, in Eq. (24)  fmsr will be replaced by fref and the beam quality
Qmsr by Q.
(b) A calibration coefficient, N Df ref,w,Q0, in terms of absorbed dose to water for the
ionization chamber in a standards laboratory’s reference beam of quality
Q0 in the conventional reference field  fref = 10 cm × 10 cm is available, as
, f ref
well as a beam quality correction factor k Qf msr msr ,Q0
to correct for the use of the
calibration coefficient in the fmsr field. The absorbed dose to water for the
fmsr field, in a beam of quality Qmsr, at the reference depth zref in water and
in the absence of the ionization chamber is given by:

f f f f ,f
Dw,msr
Q = M Qmsr N Dref,w,Q k Qmsr ,Qref (25)
msr msr 0 msr 0

When the calibration beam quality Q0 is 60Co, the generalized symbol for
, f ref , f ref
the beam quality correction factor k Qf msr
msr ,Q0
can be simplified to kQf msr msr
.
If the conventional reference field  fref  = 10 cm × 10 cm can be established
at the machine, in Eq. (25) fmsr will be replaced by fref and the beam quality
Qmsr by Q. In addition, as the resulting double superscript fref in k can be
removed (there is no need to consider different types of reference fields),
Eq.  (25) reduces to the formalism given in conventional COPs, showing
consistency between those and the present COP.
, f ref
While Eq. (25) is meant to be applied using k Qf msr msr ,Q0
that are directly
measured or calculated for the fmsr field, based on current knowledge and
, f ref
uncertainty estimates it can be assumed that k Qf msr msr ,Q0
 = kQf ref,Q0 , where Q refers
to the hypothetical conventional reference field of the machine. Data
for the beam quality correction factor kQf ref , short notation for kQf ref,Q0 with
reference to Q0 = 60Co and fref = 10 cm × 10 cm, in WFF beams are given in
Table 12 for a range of ionization chambers, consistent with the kQ data in
Refs [1, 2, 7].

82
 f
TABLE 12. kQref DATA FOR THE CONVENTIONAL fref FIELD (10 cm × 10 cm) FOR REFERENCE IONIZATION
CHAMBERS IN WFF LINACS, AS A FUNCTION OF THE BEAM QUALITY INDICES TPR20,10(10) AND %dd(10,10)x

Ion chamber
TPR20,10(10) = 0.630 0.660 0.690 0.720 0.750
↓ %dd(10,10)x = 63.4 65.2 67.6 70.5 73.9

Capintec PR-06C/G Farmer 0.997 0.994 0.991 0.988 0.982

Exradin A2 Spokas 0.998 0.997 0.995 0.992 0.988

Exradin A12 Farmer 0.998 0.996 0.993 0.990 0.984

Exradin A12S 0.996 0.994 0.991 0.987 0.981

Exradin A19 0.996 0.993 0.990 0.985 0.980

Nuclear Assoc 30-751 Farmer 0.996 0.993 0.990 0.985 0.979

Nuclear Assoc 30-752 Farmer 0.997 0.995 0.992 0.989 0.983

NE 2505/3, 3A Farmer 0.996 0.994 0.992 0.989 0.984

NE 2571 Farmer 0.997 0.994 0.992 0.989 0.984

NE 2611 0.996 0.993 0.991 0.988 0.984

PTW 23331 rigid 0.996 0.992 0.989 0.985 0.980

83
 f

84
TABLE 12. kQref DATA FOR THE CONVENTIONAL fref FIELD (10 cm × 10 cm) FOR REFERENCE IONIZATION
CHAMBERS IN WFF LINACS, AS A FUNCTION OF THE BEAM QUALITY INDICES TPR20,10(10) AND %dd(10,10)x
(cont.)

Ion chamber
TPR20,10(10) = 0.630 0.660 0.690 0.720 0.750
↓ %dd(10,10)x = 63.4 65.2 67.6 70.5 73.9

PTW 23332 rigid 0.996 0.993 0.989 0.984 0.978

PTW 23333 (3 mm cap) 0.996 0.993 0.989 0.985 0.979

PTW 30001 Farmer 0.996 0.993 0.989 0.985 0.979

PTW 30010 Farmer 0.996 0.993 0.989 0.985 0.979

PTW 30002/30011 Farmer 0.996 0.993 0.991 0.987 0.982

PTW 30004/30012 Farmer 0.998 0.995 0.993 0.989 0.984

PTW 30006/30013 Farmer 0.996 0.993 0.989 0.984 0.978

PTW 31003/31013 Semiflex 0.996 0.993 0.989 0.984 0.978

SNC 100700-0 Farmer 0.997 0.994 0.991 0.986 0.979

SNC 100700-1 Farmer 0.998 0.996 0.994 0.990 0.984

 f
TABLE 12. kQref DATA FOR THE CONVENTIONAL fref FIELD (10 cm × 10 cm) FOR REFERENCE IONIZATION
CHAMBERS IN WFF LINACS, AS A FUNCTION OF THE BEAM QUALITY INDICES TPR20,10(10) AND %dd(10,10)x
(cont.)

Ion chamber
TPR20,10(10) = 0.630 0.660 0.690 0.720 0.750
↓ %dd(10,10)x = 63.4 65.2 67.6 70.5 73.9

Victoreen Radocon III 555 0.993 0.989 0.985 0.979 0.973

Victoreen 30-348 0.995 0.991 0.988 0.982 0.976

Victoreen 30-351 0.995 0.991 0.988 0.983 0.977

Victoreen 30-349 0.995 0.991 0.988 0.983 0.978

Victoreen 30-361 0.995 0.991 0.988 0.983 0.977

IBA FC-65P (Wellhöfer IC 69) Farmer 0.997 0.994 0.992 0.986 0.979

IBA FC-65G (Wellhöfer IC 70) Farmer 0.998 0.997 0.994 0.989 0.983

Note: See Appendix I for details.

85
 If the calibration beam quality Q0 is not 60Co, the beam quality correction
factor can be derived from the ratio of values for Q and Q0, as both are
relative to 60Co. Hence, kQf ref,Q0 is obtained from the values in Table  12 as
follows:

f
f k Qref
k Qref,Q = f
(26)
0
k Qref
0

(c) A calibration coefficient, N Df ref,w,Q0 , in terms of absorbed dose to water for the
ionization chamber in a standards laboratory’s reference beam of quality
Q0 in the conventional reference field  fref = 10 cm × 10 cm is available, but
there is no beam quality correction factor available to correct for the use of
the calibration coefficient in the fmsr field. The absorbed dose to water for
the fmsr field, in a beam of quality Qmsr, at the reference depth zref in water
and in the absence of the ionization chamber is given by:

f f f f f ,f
Dw,msr
Q = M Qmsr N Dref,w,Q k Qref,Q k Qmsr ,Qref (27)
msr msr 0 0 msr

This requires that the beam quality Q of the hypothetical conventional

reference field of the machine (see Section 3.2.1.3) be estimated in order to
adopt beam quality correction factors kQf ref from Ref. [1] or from Refs [2, 7].
The determination of the beam quality index is detailed in Section  5.3.3,
and the values of kQf ref for a range of ionization chambers for generic WFF
beams are given in Table 12. Based on current knowledge and uncertainty
, f ref
estimates, it can be assumed that k Qf msr msr ,Q
 = 1, which is consistent with the
, f ref
assumption k Qf msr
msr ,Q0
 =  k
f ref
Q,Q0 in Eq. (25); note that these equalities hold only
within the uncertainty estimates discussed in Appendix I.

In Eqs (24–27), MQf msr is the reading of the ionization chamber in the field
msr
fmsr corrected for influence quantities, such as pressure, temperature, incomplete
charge collection, polarity effects, etc. (see Section 5.4).

5.3.2.2. FFF high energy X ray beams

For FFF high energy X ray beams, the formalism is essentially the same;
in particular, options (a) and (b) in the previous section remain unaltered. For
f
the application of option (c), values of kQref (the short notation for kQf ref,Q0 when
Q0 =  60Co) for a range of ionization chambers for FFF photon beams as well as

86
for the two specific machine types CyberKnife and TomoTherapy are given in
Table 13. These data include a generic volume averaging correction factor9.

5.3.2.3. 60Co gamma ray beams

For 60Co gamma ray beams such as in the Gamma Knife, only option (b)
, f ref
is considered (see Eq. (25)). The factor k Qf msr msr ,Q0
with reference to a chamber
f ref 60
calibration N D,w,Q0 with Q0  =  Co is close to unity for most chambers suitable
for reference dosimetry in these treatment machines. Note, however, that as
reference dosimetry in Gamma Knife beams is usually performed in plastic
phantoms (ABS or Solid Water), the correction factors include the conversion to
, f ref
absorbed dose to water. Values of k Qf msr
msr ,Q0
for the Gamma Knife models Perfexion
and 4C are given in Table 14.

5.3.3. Determination of the beam quality when the conventional fref cannot
be realized

As already emphasized, some treatment machines cannot realize the

conventional reference field of 10 cm × 10 cm. However, case (c) in Sections 5.3.2.1
and 5.3.2.2 is based on the use of the beam quality correction factor kQf ref,Q0 . To this
end, data for a hypothetical 10 cm × 10 cm reference field fref at the same machine
as for the fmsr field are required for the application of Eq. (27). These data can be
taken from Refs [1, 2, 7] using a beam quality index measured for the msr field,
which is subsequently related to that of the reference field.
The two beam quality indices defined for a 10 cm × 10 cm reference field,
TPR20,10(10) (defined in Ref.  [1]) and %dd(10,10)x (defined in Refs  [2,  7])
are considered in this COP. Both are derived from relevant measurements in a
field with equivalent square msr field size S, i.e. TPR20,10(S ) and %dd(10,S )x,
respectively. For machines that cannot realize a square field, an equivalent square
msr field size needs to be calculated. Both steps are described below.

5.3.3.1. Equivalent square msr field size

For flattened fields that exhibit a homogeneous lateral beam profile over
most of the field area, the equivalent square msr field sizes for rectangular and
circular fields can be derived from the tables of Ref. [32]. A subset of such data

9
Users wishing to investigate the data difference using a volume averaging correction
factor calculated specifically for their beam can find an example in Appendix I.

87
88
, f ref
TABLE 13. kQf msr
msr
DATA FOR THE CONVENTIONAL fref FIELD (10 cm × 10 cm) FOR REFERENCE IONIZATION
CHAMBERS IN FFF LINACS, AS A FUNCTION OF THE BEAM QUALITY INDICES TPR20,10(10) AND %dd(10,10)x,
AND FOR THE CYBERKNIFE AND TOMOTHERAPY MACHINES (cont.)

Ion chamber
TPR20,10(10) = 0.63 0.66 0.69 0.72 0.75
CyberKnife TomoTherapy
↓ %dd(10,10)x = 63.8 65.6 68.2 71.7 76.1

Capintec PR-06C/G Farmer 0.996 0.995 0.992 0.988 0.981 1.000 0.996

Exradin A2 Spokas 0.996 0.996 0.993 0.989 0.983 0.997 0.996

Exradin A12 Farmer 0.998 0.997 0.994 0.991 0.984 1.004 0.998

Exradin A12S 0.994 0.993 0.989 0.984 0.977 0.993 0.994

Exradin A19 0.995 0.995 0.991 0.987 0.981 1.002 0.995

Nuclear Assoc 30-751 Farmer 0.995 0.994 0.991 0.986 0.979 1.000 0.995

Nuclear Assoc 30-752 Farmer 0.997 0.996 0.993 0.990 0.983 1.002 0.997

NE 2505/3, 3A Farmer 0.996 0.996 0.993 0.990 0.985 1.003 0.996

NE 2571 Farmer 0.996 0.995 0.993 0.990 0.985 1.003 0.996

NE 2611 0.994 0.992 0.989 0.985 0.979 0.993 0.993

 , f ref
TABLE 13. kQf msr
msr
DATA FOR THE CONVENTIONAL fref FIELD (10 cm × 10 cm) FOR REFERENCE IONIZATION
CHAMBERS IN FFF LINACS, AS A FUNCTION OF THE BEAM QUALITY INDICES TPR20,10(10) AND %dd(10,10)x,
AND FOR THE CYBERKNIFE AND TOMOTHERAPY MACHINES (cont.)

Ion chamber
TPR20,10(10) = 0.63 0.66 0.69 0.72 0.75
CyberKnife TomoTherapy
↓ %dd(10,10)x = 63.8 65.6 68.2 71.7 76.1

PTW 23331 rigid 0.995 0.993 0.990 0.985 0.980 0.998 0.994

PTW 23332 rigid 0.995 0.993 0.988 0.983 0.976 0.995 0.994

PTW 23333 (3 mm cap) 0.995 0.993 0.990 0.985 0.978 0.998 0.995

PTW 30001 Farmer 0.995 0.994 0.990 0.986 0.979 0.999 0.995

PTW 30010 Farmer 0.995 0.994 0.990 0.986 0.979 0.999 0.995

PTW 30002/30011 Farmer 0.995 0.994 0.992 0.988 0.982 1.001 0.995

PTW 30004/30012 Farmer 0.997 0.996 0.994 0.990 0.984 1.003 0.997

PTW 30006/30013 Farmer 0.995 0.994 0.990 0.985 0.978 0.999 0.995

PTW 31003/31013 Semiflex 0.995 0.993 0.990 0.985 0.978 0.996 0.994

SNC 100700-0 Farmer 0.996 0.995 0.992 0.987 0.979 1.002 0.996

89
90
, f ref
TABLE 13. kQf msr
msr
DATA FOR THE CONVENTIONAL fref FIELD (10 cm × 10 cm) FOR REFERENCE IONIZATION
CHAMBERS IN FFF LINACS, AS A FUNCTION OF THE BEAM QUALITY INDICES TPR20,10(10) AND %dd(10,10)x,
AND FOR THE CYBERKNIFE AND TOMOTHERAPY MACHINES (cont.)

Ion chamber
TPR20,10(10) = 0.63 0.66 0.69 0.72 0.75
CyberKnife TomoTherapy
↓ %dd(10,10)x = 63.8 65.6 68.2 71.7 76.1

SNC 100700-1 Farmer 0.998 0.998 0.995 0.991 0.985 1.005 0.998

Victoreen Radocon III 555 0.992 0.990 0.985 0.979 0.973 0.995 0.991

Victoreen 30-348 0.993 0.991 0.987 0.981 0.973 0.994 0.992

Victoreen 30-351 0.994 0.992 0.988 0.984 0.977 0.998 0.993

Victoreen 30-349 0.994 0.992 0.988 0.983 0.978 0.997 0.993

Victoreen 30-361 0.994 0.992 0.988 0.983 0.976 0.998 0.993

IBA FC-65P (Wellhöfer IC 69) Farmer 0.996 0.995 0.992 0.987 0.978 1.002 0.996

IBA FC-65G (Wellhöfer IC 70) Farmer 0.997 0.997 0.994 0.990 0.983 1.004 0.998

Note: The correspondence between TPR20,10(10) and %dd (10,10)x is different from that for WFF beams.
 , f ref
TABLE 14.  CORRECTION FACTORS k Qf msr
msr ,Q0
FOR THE GAMMA KNIFE
MODELS PERFEXION AND 4C [110, 153]

Perfexion 4C
fmsr = 16 mm ∅ fmsr = 18 mm ∅
Chamber type
Solid Water ABS Water Solid Water ABS Water

PTW T31010 1.0037 1.0146 1.0001 0.9958 0.9990 0.9924

PTW T31016 1.0040 1.0110 0.9991 1.0014 1.0025 0.9964

Exradin A1SL 1.0046 1.0138 1.0006 1.0009 1.0014 0.9967

Exradin A14SL 1.0154 1.0194 1.0112 1.0116 1.0060 1.0058

Exradin A16 1.0167 1.0295 1.0127 1.0163 1.0217 1.0104

IBA CC01 1.0213 1.0292 1.0169 1.0203 1.0208 1.0157

IBA CC04 1.0107 1.0117 1.0062 1.0086 1.0049 1.0040

Capintec PR05-P 4.7 1.0059 1.0070 1.0010 1.0007 0.9960 0.9951

Capintec PR05-P 7.6 1.0025 1.0126 0.9976 0.9885 0.9972 0.9844

for the field sizes considered in this COP is given in Table  15. The equivalent
square msr field sizes for WFF beams are independent of energy.
For FFF beams, the contribution of scattered photons to the centre of the
field varies differently as a function of field size and depends also on the energy
of the beam. Data for the equivalent flattened square msr field size, based on
average values for 6–7  MV and 10  MV FFF beams described in the literature
are given in Tables 16 and 17 (see Appendix I for information on how these are
calculated). For Cyberknife, which has a steeper gradient in its lateral beam
profile, the 6 cm diameter msr field has an equivalent uniform square msr field
size of 5.0 cm.

91
TABLE 15.  EQUIVALENT SQUARE msr FIELD SIZE OF RECTANGULAR
FIELDS WITH DIMENSIONS X AND Y AND OF CIRCULAR FIELDS WITH
DIAMETER Ø FOR FLATTENED BEAMS

Y (cm)
12 11 10 9 8 7 6 5 4 3
X (cm)

12 12.0 11.5 10.9 10.3 9.6 8.9 8.1 7.2 6.2 5.1

11 11.0 10.5 9.9 9.3 8.6 7.8 7.0 6.0 5.0

10 10.0 9.5 8.9 8.3 7.5 6.8 5.9 4.8

9 9.0 8.5 7.9 7.2 6.5 5.7 4.7

8 8.0 7.5 6.9 6.2 5.4 4.5

7 7.0 6.5 5.9 5.1 4.3

6 6.0 5.5 4.8 4.1

5 5.0 4.5 3.8

4 4.0 3.4

3 3.0

12 11 10 9 8 7 6 5 4 3
Ø (cm)
10.7 9.8 8.9 8.0 7.1 6.2 5.4 4.5 3.6 2.7

5.3.3.2. Experimental determination of TPR20,10(10)

The beam quality index TPR20,10(10) is determined from the measurement

of TPR20,10 for the fmsr equivalent square field, S, which is subsequently used in
the analytical expression of Palmans [38] given below. The experimental set-up
for measuring TPR20,10(S ) is shown in Fig.  14 and the reference conditions
of measurement are given in Table  18. It is advised that the influence of
recombination effects at the two measurement depths be investigated and taken
into account if there is variation with depth. Although TPR is normally defined

92
TABLE 16.  EQUIVALENT UNIFORM SQUARE msr FIELD SIZE OF
RECTANGULAR FIELDS WITH DIMENSIONS X AND Y AND OF
CIRCULAR FIELDS WITH DIAMETER Ø FOR 6–7 MV FFF BEAMS

Y (cm)
12 11 10 9 8 7 6 5 4 3
X (cm)

12 11.2 10.8 10.3 9.8 9.2 8.5 7.8 7.0 6.0 5.0

11 10.4 9.9 9.4 8.9 8.3 7.6 6.8 5.9 4.9

10 9.5 9.1 8.6 8.0 7.3 6.6 5.7 4.8

9 8.7 8.2 7.6 7.0 6.3 5.5 4.6

8 7.8 7.3 6.7 6.1 5.3 4.5

7 6.8 6.3 5.8 5.1 4.3

6 5.9 5.4 4.8 4.0

5 4.9 4.4 3.8

4 4.0 3.4

3 3.0

12 11 10 9 8 7 6 5 4 3
Ø (cm)
10.2 9.4 8.6 7.8 7.0 6.1 5.3 4.4 3.5 2.7

Note: The values do not apply to CyberKnife beams. For Cyberknife, which has a steeper
gradient in its lateral beam profile, the 6 cm diameter msr field has an equivalent
uniform square msr field size of 5.0 cm.

strictly in terms of ratios of absorbed dose to water, for ‘non-small’ fields the
use of ionization ratios provides acceptable accuracy owing to the slow variation
with depth of water/air stopping-power ratios, their practically negligible field
size dependence and the assumed constancy of perturbation factors beyond the
depth of maximum dose.

93
TABLE 17.  EQUIVALENT UNIFORM SQUARE msr FIELD SIZE OF
RECTANGULAR FIELDS WITH DIMENSIONS X AND Y AND OF
CIRCULAR FIELDS WITH DIAMETER Ø FOR 10 MV FFF BEAMS

Y (cm)
12 11 10 9 8 7 6 5 4 3
X (cm)

12 10.5 10.2 9.8 9.3 8.8 8.2 7.5 6.7 5.9 4.9

11 9.8 9.5 9.0 8.5 8.0 7.3 6.6 5.7 4.8

10 9.1 8.7 8.2 7.7 7.1 6.4 5.6 4.7

9 8.3 7.9 7.4 6.8 6.2 5.4 4.5

8 7.5 7.1 6.6 5.9 5.2 4.4

7 6.7 6.2 5.7 5.0 4.2

6 5.8 5.3 4.7 4.0

5 4.9 4.4 3.7

4 3.9 3.4

3 3.0

12 11 10 9 8 7 6 5 4 3
Ø (cm)
9.7 9.0 8.3 7.6 6.8 6.0 5.2 4.4 3.5 2.7

The beam quality index for the conventional reference field fref
10 cm × 10 cm, TPR20,10(10), is derived from Ref. [38]:

TPR 20,10 (S ) + c(10 - S )

TPR 20,10 (10) = (28)
1 + c(10 - S )

where c  =  (16.15 ± 0.12) × 10−3, valid for 4  ≤  S  ≤  12, S being the equivalent

square msr field size in cm.

94
FIG. 14.  Experimental set-up for the measurement of TPR20,10( S). The SDD is kept constant
at 100 cm or as close to that distance as possible, and measurements are made with 10 g/cm2
and 20 g/cm2 of water over the reference point of the chamber. The field at the position of the
reference point of the chamber has an equivalent square msr field size S. Either a cylindrical
or a plane-parallel ionization chamber can be used (reproduced from Ref. [1]).

TABLE 18.  REFERENCE CONDITIONS FOR THE DETERMINATION OF

THE PHOTON BEAM QUALITY INDEX TPR20,10(S) IN HIGH ENERGY
PHOTON GENERATORS

Influence quantity Reference value or reference characteristics

Phantom material Water

Chamber type Cylindrical or plane-parallel with sufficient lateral

buildupa

Measurement depths 20 g/cm2 and 10 g/cm2

Reference point of chamber For cylindrical chambers, on the central axis at

the centre of the cavity volume; for plane-parallel
chambers, on the inner surface of the entrance
window at its centre

95
TABLE 18.  REFERENCE CONDITIONS FOR THE DETERMINATION OF
THE PHOTON BEAM QUALITY INDEX TPR20,10(S) IN HIGH ENERGY
PHOTON GENERATORS (cont.)

Influence quantity Reference value or reference characteristics

Position of reference point of chamber For cylindrical or plane-parallel chambers, at the

measurement depths

Orientation of chamber stem Perpendicular to the beam axis

SDD 100 cm or, for msr fields, the closest to 100 cm

achievable

Field shape and size at SDD 10 cm × 10 cm or the msr field

(the closest to 10 cm × 10 cm achievableb)

a
It is advised that the largest dimension of the chamber be smaller than the smallest side of the
field minus twice the rLCPE, or that the outer lateral edge of the detector volume be at least a
distance rLCPE away from the nearest field edge.
b
It is advised that the equivalent square msr field size, S, be as close as possible to 10 cm but
not smaller than 4 cm and not larger than 12 cm. The aspect ratio of rectangular fields (largest
dimension/smallest dimension) will be as close as possible to unity.

5.3.3.3. Experimental determination of %dd(10,10)x

The beam quality index %dd(10,10)x is determined from the measurement

of %dd(10) for the fmsr equivalent square field, S, which is subsequently used in
the analytical expression of Palmans [38] given below. The experimental set-up
for measuring %dd(10,S )x is shown in Fig.  15 and the reference conditions of
measurement are given in Table 19.
If the chamber used is cylindrical, its effective point of measurement will
be placed at the relevant measurement depths, while for a plane-parallel chamber,
the inner front face of the cavity will be positioned at the relevant depths. It is
advised that the influence of recombination effects at the two measurement depths
be investigated and taken into account if there is variation with depth. Although
%dd(10,10) is strictly defined in terms of ratios of absorbed dose to water, for
‘non-small’ fields the use of ionization ratios provides acceptable accuracy
owing to the slow variation with depth of water/air stopping-power ratios,
their practically negligible field size dependence and the assumed constancy of
perturbation factors beyond the depth of maximum dose.

96
FIG. 15.  Experimental set-up for the determination of %dd(10,S)x. The SSD is kept constant at
100 cm or as close to that distance as possible, and measurements are made at depths of  zmax
and 10 g/cm2 (usually derived from a depth-dose distribution). The field at the phantom surface
has an equivalent square msr field size S. Either a plane-parallel or a cylindrical ionization
chamber can be used. In the latter case, the chamber’s effective point of measurement is taken
into account (see Table 19) by shifting the measured depth ionization curve, with the centre
of the cavity as the point of measurement, upstream by 0.6 r, where r is the inner radius of the
cylindrical chamber [7].

No lead foil needs to be used in the measurements of %dd(10,S ) for WFF

beams with energies below 10 MV. However, for FFF beams of any energy, it is
recommended to introduce a 1 mm lead foil in the beam to eliminate the potential
effect of accelerator-produced electron contamination and obtain %dd(10,10)Pb.
The beam quality specifier %dd(10,10)x can then be obtained from %dd(10,10)Pb
using the relations in Ref. [2]. It is noted that according to guidance in Refs [2, 7],
for the conventional 10  cm × 10  cm reference field in 10  MV beams the
measurements are done using a lead foil.
The beam quality index for the conventional reference field fref
10 cm × 10 cm, %dd(10,10), is derived from Ref. [38]:

%dd (10, S ) + 80 c(10 - S )

%dd (10,10) = (29)
1 + c(10 - S )

97
TABLE 19.  REFERENCE CONDITIONS FOR THE DETERMINATION OF
THE PHOTON BEAM QUALITY INDEX %dd(10,S)x IN HIGH ENERGY
PHOTON GENERATORS

Influence quantity Reference value or reference characteristics

Phantom material Water

Chamber type Cylindrical or plane-parallel with sufficient lateral

buildupa

Measurement depths 10 g/cm2 and zmax

Reference point of chamber For cylindrical chambers at Peffb; for plane-parallel

chambers, on the inner surface of the entrance
window at its centre

Position of reference point of chamber For cylindrical or plane-parallel chambers, at the

measurement depths

Orientation of chamber stem Perpendicular to the beam axis

SSD 100 cm or, for msr fields, the closest to 100 cm

achievable

Field shape and size at SSD 10 cm × 10 cm or the msr field

(the closest to 10 cm × 10 cm achievablec)

a
It is advised that the largest dimension of the chamber be smaller than the field size minus
twice the rLCPE, or that the outer lateral edge of the detector volume be at least a distance rLCPE
away from the nearest field edge.
b
The effective point of measurement of a cylindrical chamber, Peff, is located 0.6 times the
cavity radius from the chamber axis towards the photon source.
c
It is advised that the equivalent square msr field size, S, be as close as possible to 10 cm but
not smaller than 4 cm and not larger than 12 cm. The aspect ratio of rectangular fields (largest
dimension/smallest dimension) will be as close as possible to unity.

where c = (53.4 ± 1.1) × 10−3, valid for 4 ≤ S ≤ 12, S being the equivalent square

msr field size in cm. For the range of beam qualities in this COP, the beam quality
index is assumed to correspond to %dd(10,10) [38], i.e.:

%dd (10,10) x = %dd (10,10) (30)

98
 If the SSD is not equal to 100 cm an additional correction is required. The
percentage depth dose at the SSD and a depth of 10 cm, obtained from Eq. (31),
is then denoted %ddSSD(10,10) , and %dd(10,10) is derived as:

TMR (10,11) NPSF (11)

%dd (10,10) = %dd SSD (10,10) ´ ´
æ SSD + 10 ÷ö æ SSD + 10 ÷ö
TMR çç10, 10÷÷ NPSF çç 10÷÷
èç SSD ø èç SSD ø (31)
æ 100 + z
max SSD + 10 ÷
ö 2

´ççç ÷
÷
çè 110 ÷
SSD + zmax ø

where TMR(z,S ) is the tissue maximum ratio at depth z in water for an equivalent
square field of size S (defined at the depth z) and NPSF(S ) is the normalized
peak-scatter factor for the field size S (see Ref. [32]). For SSD between 90 and
110 cm, a sufficiently accurate approximation is provided by omitting the TMR
and NPSF ratios in Eq. (31).

5.3.4. Measurement in plastic water substitute phantoms

In situations where it is more convenient to use a plastic water substitute

phantom than water, the absorbed dose to water can be derived from
measurements in a plastic phantom by incorporating a phantom dose conversion
factor k Qw,plastic
msr
into Eqs (24, 25, 27). For example, for case (b) in Section 5.3.2.1,
Eq. (25) becomes:

Q
f
Dw,msr
msr ref
f
(z ) = M plastic,
msr
Q msr
(zeq,plastic ) N Df ,w,Q
ref
0
f ,f
k Qmsr ,Qref k Qw,plastic (32)
msr 0 msr

Qmsr (zeq,plastic ) is the ionization chamber reading in the plastic water

f
where Mplastic,
msr

substitute phantom corrected for influence quantities and the other quantities
have the same meaning as before10. The phantom dose conversion factor in
Eq. (32) is determined experimentally as a ratio of ionization chamber readings
corrected for influence quantities in the water phantom at a depth zref and in the
plastic water substitute phantom at the equivalent depth zeq,plastic:

10
Note, however, that in the Gamma Knife, the calculations of overall correction factors
already incorporate the plastic conversion factor and the depth scaling, so neither the additional
correction factor nor an equivalent depth have to be accounted for.

99
 f
M w,msr
Q (zref )
k Qw,plastic = msr
(33)
msr f
M plastic,
msr
Q msr
(zeq,plastic )
It is emphasized that an accurate experimental determination has the
advantage that loss of homogeneity or air pockets originating during the
manufacturing process of the phantom material are taken into account provided
the plate order is kept unchanged. Note also that, for a given phantom, this
experimental procedure needs to be performed only once (it is advised that this
be verified periodically, within the standard QA procedures).
In Eqs  (32,  33), the depth in plastic water substitute phantom zeq,plastic is
taken to be equivalent to the reference depth in water zref, scaled according to the
ratio of electron densities (see Attix eq. (13.49a) [13]), i.e.:

æ Z ö÷
çç ÷
rw çè A ø÷
w
zeq,plastic = zref (34)
r plastic æ Z ö÷
çç ÷
çè A ÷ø
plastic

Note that it is advised that the field size be scaled according to the ratio of
electron densities and that the SDD has to be kept constant in an isocentric set-up
(or in case of an SSD set-up the change of SDD has to be corrected for). The
effects are small for materials with electron densities close to that of water [101],
but differences for PMMA are substantial.
Values of (Z/A)med can be found in Ref.  [154] for some plastic materials,
or calculated from the composition of the substance using the Bragg additivity
rule, i.e.:

æ Z ö÷ æZ ö
çç ÷
èç A ø÷ med
= åw èçççç A ÷÷÷÷ø (35)
i
i
i

where wi is the fraction by weight and Zi and Ai are the atomic number and
atomic mass of the constituent element i. Typical elemental compositions,
densities, mean atomic numbers, mean excitation energies, values of (Z/A)med and
depths equivalent to 10 cm of water for some plastic materials used in dosimetry
(and for water) are given in Table 20. For the correction for influence quantities
in the measurement of the ionization chamber reading in plastic water substitute
phantoms, the temperature needs to be monitored at the location of the cavity, or

100
 TABLE 20. ELEMENTAL COMPOSITION (FRACTION BY WEIGHT), NOMINAL AVERAGE DENSITY, MEAN
ATOMIC NUMBER, MEAN EXCITATION ENERGY, (Z/A)med AND Zeq,plastic(10) OF COMMON PHANTOM MATERIALS
USED AS WATER SUBSTITUTES

RW-1 RW-2 Solid

Water, Plastic Solid Water Virtual
Material ABSb PMMAa,d Polystyrenea water muscle RW-3 Water
liquida Water®c RMI-45®a,e Water™f
eqa eqa WT1a

H 0.111 9 0.054 0 0.092 5 0.080 5 0.077 4 0.132 0 0.070 0 0.075 9 0.080 9 0.081 0 0.077 0

C 0.877 7 0.628 2 0.599 8 0.922 6 0.794 0 0.830 0 0.904 1 0.672 2 0.672 0 0.687

N 0.068 2 0.010 0 0.024 0 0.024 0 0.022 7

O 0.888 1 0.179 4 0.319 6 0.038 0 0.040 0 0.008 0 0.198 4 0.199 0 0.188 6

Mg 0.009 0

Cl 0.009 6 0.001 3 0.001 0 0.001 3

Ca 0.079 5 0.027 0 0.023 2 0.023 0 0.023 1

Ti 0.060 0 0.012 0

Br 0.000 3

Nominal
density ρplastic 0.998 1.066 1.030 1.190 1.060 0.970 1.110 1.045 1.030 1.020 1.030
(g/cm3)

101
 TABLE 20. ELEMENTAL COMPOSITION (FRACTION BY WEIGHT), NOMINAL AVERAGE DENSITY, MEAN

102
ATOMIC NUMBER, MEAN EXCITATION ENERGY, (Z/A)med AND Zeq,plastic(10) OF COMMON PHANTOM MATERIALS
USED AS WATER SUBSTITUTES (cont.)

RW-1 RW-2 Solid

Water, Plastic Solid Water Virtual
Material ABSb PMMAa,d Polystyrenea water muscle RW-3 Water
liquida Water®c RMI-45®a,e Water™f
eqa eqa WT1a

g
Z 6.60 5.56 6.62 5.85 5.29 5.29 6.25 5.48 5.96 5.95 5.97

I (eV) 78.0 70.0 69.9 74.0 68.7 59.8 71.3 67.1 68.7 68.6 69.2

(Z/A)med 0.555 1 0.526 2 0.544 6 0.539 4 0.537 7 0.564 5 0.531 6 0.536 4 0.539 5 0.539 5 0.537 5

zeq,plastic (10)h — 9.88 9.88 8.63 9.72 10.12 9.39 9.88 9.97 10.07 10.01

Note: Owing to significant discrepancies in density quoted by the manufacturers, it is advised that the phantom density always be determined
experimentally. For comparison, liquid water is also included.
a
See Refs [154–156].
b
Acrylonitrile butadiene styrene (ABS).
c
Nuclear Associates (New York, NY).
d
Polymethylmethacrylate, also known as acrylic. Trade names are Lucite, Plexiglas or Perspex.
e
Gammex/Sun Nuclear (Middleton, WI).
f
Med-Cal, Inc.
g
For the definition of mean atomic number, see, for instance, Refs [157, 158].
h
Equivalent depth in plastic, in cm, of zref = 10 cm. If zref ≠ 10 cm, the numbers in this row are multiplied by zref /10 cm.
the plastic phantom needs to be in thermal equilibrium with the room temperature
in which the measurement is performed.

5.4. CORRECTION FOR INFLUENCE QUANTITIES

This section summarizes

f msr
the procedures to correct the raw ionization
chamber reading raw MQmsr for influence quantities to obtain MQf msr using air filled
msr
reference ionization chambers11.

5.4.1. Air density correction

All ionization chambers recommended for reference dosimetry in this

COP are open to ambient air. The mass of air in the cavity will thus depend on
atmospheric conditions (temperature and pressure). The factor kTP to correct for
these conditions is given by:

(T + 273.15) P0
k TP = (36)
(T0 + 273.15) P

where T is the temperature in °C and P the pressure in kPa of the air in the
cavity of the ionization chamber, and T0 and P0 are the reference conditions for
temperature and pressure for which the calibration coefficient of the ionization
chamber is valid, i.e. 20°C (or 22°C for calibrations from standards laboratories
in North America) and 101.325 kPa, respectively.

5.4.2. Humidity

No correction is necessary for relative humidity if the ionization chamber is

used in a range of 20% to 80% relative humidity and has a calibration coefficient
valid at a relative humidity of 50%. In the unlikely case that the relative humidity
is outside the range of 20–80%, a correction factor is needed [1, 159].

5.4.3. Electrometer calibration factor kelec

When the ionization chamber and electrometer are calibrated separately,

the calibration coefficient for the ionization chamber is given in units Gy/C or

11
More background and details on these corrections can be found in Refs [1, 2, 7].

103
a multiple (e.g. mGy/nC or cGy/nC). The calibration factor kelec obtained for the
electrometer converts the electrometer reading to charge and is expressed in units
C/rdg. If the reading of the electrometer is in terms of charge, the electrometer
calibration factor is dimensionless. If the ionization chamber and the electrometer
are calibrated together, as one measurement assembly, no separate electrometer
calibration factor has to be applied.

5.4.4. Polarity correction

The correction factor for polarity in a given radiation beam is given by:

M + + M-
k pol = (37)
2M

where M+ and M− are the electrometer readings obtained at positive and negative
polarity, respectively and M is the electrometer reading taken at the polarity
used routinely. The polarity used routinely is the same as that used during the
calibration of the ionization chamber. For details on the situation where the
standards laboratory has not applied this correction during calibration, refer to
Ref. [1]. Given the observations discussed in Section 4, it is advised that attention
be paid to long stabilization times that may be required for small volume
ionization chambers. Polarity effects may also be field size dependent owing to
the varying portion of the stem being irradiated, hence it is important that this
effect be investigated for every ionization chamber used for small field dosimetry.

5.4.5. Recombination correction

The incomplete collection of charge in an ionization chamber cavity owing

to the recombination of ions requires the use of a correction factor ks. Two separate
effects take place: (i)  the recombination of ions formed by separate ionizing
particle tracks, termed general (or volume) recombination, which depends
on the density of ionizing particles and therefore on the dose rate; and (ii)  the
recombination of ions formed by a single ionizing particle track, referred to as
initial recombination, which is independent of the dose rate. Both effects depend
on the chamber geometry and on the applied polarizing voltage. In conventional
radiotherapy beams, initial recombination is generally less than 0.2%.
In continuous radiation, i.e. 60Co gamma rays, the two voltage method may
be used and a correction factor derived using the relation:

104
 æ V ö÷ 2
çç 1 ÷ - 1
ççè V ÷ø÷
ks = 2
(38)
æ V ö÷ 2 M
çç 1 ÷ - 1
ççè V ÷÷ø M
2 2

where M1 and M2 are the collected charges at the polarizing voltages V1 and V2,
M1 being the ionization chamber reading at the normal operating voltage V1 and
V2 being a lower voltage. This relation is based on a linear dependence of 1/M on
1/V 2, which describes the effect of general recombination in continuous beams.
For clinical purposes, general recombination can be considered negligible in
60
Co beams.
For pulsed beams, the recombination correction factor ks is derived using
the two voltage method [160]. This method assumes a linear dependence of 1/M
on 1/V (it is advised that this assumption be verified when commissioning a new
chamber) and uses the measured values of the collected charges M1 and M2 at the
polarizing voltages V1 and V2, respectively, measured using the same irradiation
conditions. V1 is the normal operating voltage and V2 a lower voltage; the
ratio V1/V2 is ideally equal to or larger than 3. The polarity effect will change with
the voltage, and M1 and M2 are each corrected for this effect using Eq. (37). The
recombination correction factor ks at the normal operating voltage V1 is obtained
from:

æM ö æ M ö2
k s = a 0 + a1 ççç 1 ÷÷÷ + a 2 ççç 1 ÷÷÷ (39)
çè M 2 ÷ø èç M 2 ø÷

where the constants ai are given in Table 21 for pulsed radiation [161].

For ks < 1.03, the correction can be approximated to within 0.1% using the
relation:

æM ö
ççç 1 ÷÷÷ - 1
çè M 2 ÷ø
ks = 1+ (40)
æV ö
ççç 1 ÷÷÷ - 1
èç V2 ø÷

Note that the correction factor ks evaluated using the two voltage method
in pulsed beams corrects for both general and initial recombination. In pulsed
beams, where general recombination is dominant, the recombination correction
for a given chamber will scale approximately linearly with dose rate.

105
 TABLE 21.  QUADRATIC FIT COEFFICIENTS, FOR THE
CALCULATION OF ks BY THE ‘TWO VOLTAGE’
TECHNIQUE IN PULSED RADIATION, AS A FUNCTION
OF THE VOLTAGE RATIO V1/V2 [161]

V1/V2 a0 a1 a2

2.0 2.337 −3.636 2.299

2.5 1.474 −1.587 1.114

3.0 1.198 −0.875 0.677

3.5 1.080 −0.542 0.463

4.0 1.022 −0.363 0.341

5.0 0.975 −0.188 0.214

If it is not known if the relation between 1/M and 1/V is linear, or if there is
any doubt about this, it is advised that a Jaffé plot of 1/M versus 1/V  be measured.
This is especially the case for some small volume ionization chambers in which
charge recombination effects may distort the saturation curve. Small volume
chambers may also exhibit asymmetric saturation curves for opposing polarities
(essentially a voltage dependent polarity effect). Given the observations discussed
in Section 4, it is advised that attention be paid to the long stabilization times that
may be required for small volume ionization chambers. For FFF beams, where
dose per pulse values are substantially larger than in WFF beams, studies have
shown that recombination can be treated in the same way and that the two voltage
technique is accurate under the same conditions as for WFF beams [162–165].

5.5. CROSS-CALIBRATION IN THE msr FIELD

For cross-calibrating a field ionization chamber in an msr field, the same

considerations as in Ref.  [1] apply. If a calibration coefficient for a reference
chamber (‘REF’) is available for a given msr field size fmsr, a field chamber may
be cross-calibrated against the calibrated reference. The chambers are compared
by alternately placing them in a water phantom with their reference points at zref;
the readings are corrected for influence quantities.

106
 The calibration coefficient of the field chamber (‘FIELD’) is given by:

é M f msr ù
é N f msr ù êë Qmsr úû REF é N f msr ù
êë D,w,Qmsr úû FIELD = é f msr ù êë D,w,Qmsr úû REF (41)
êë M Qmsr úû FIELD

The resulting calibration coefficient éê N Df msr ù

,w,Qmsr ûú can then be used
ë FIELD
for reference dosimetry in an msr field using Eq.  (24) for the same normal
atmospheric conditions of temperature and pressure as for the reference chamber
‘REF’.
If a calibration of the reference chamber in the msr field is not available,
a cross-calibration coefficient can be obtained with:

é D f msr ù
é N f msr ù êë w,Qmsr úû REF
êë D,w,Qmsr úû FIELD = é f msr ù (42)
êë M Qmsr úû FIELD

where éê Dw,f msr ù

Qmsr úû is obtained with Eqs (25) or (27) using the reference ionization
ë REF
chamber.

107
6.  CODE OF PRACTICE FOR RELATIVE DOSIMETRY OF
SMALL FIELDS

A full dosimetric characterization of small fields for clinical use requires

not only the calibration of the beam under reference conditions (addressed in the
previous section) but also the determination of field output factors, necessary
for the calculation of monitor units or treatment time, and measured central
axis percentage depth dose (PDD) distributions, tissue phantom ratios (TPR)
or tissue maximum ratios (TMR), and lateral beam profiles. This COP provides
guidance for measurements of field output factors and lateral beam profiles at the
measurement depth because of their importance in the determination of the field
size and the volume averaging correction. Guidance for the measurements of
relative dose distributions can be found in other publications, such as Ref. [166]
and, specifically for small fields, Refs [12, 167, 168].

6.1. EQUIPMENT

6.1.1. Detectors for relative dosimetry

The guidance regarding detectors for relative dosimetry is given in

Section 4.2.1. It must be emphasized that no ideal detector exists for measurements
in small fields. For the determination of both field output factors and lateral beam
profiles, the use of two or preferably three different types of suitable detectors is
therefore advised so that redundancy in the results can provide more confidence
and assurance that no significant dosimetry errors are being made. An example
could be a combination of detectors with correction factors above and below
unity (so that the product of these factors is close to one), such as a small air filled
ionization chamber, radiochromic film and an unshielded diode, or a diamond,
liquid ion chamber and an organic scintillator.

6.1.1.1. Detectors for measuring field output factors

A full discussion on detectors used for measurements of dosimetric

parameters for relative dosimetry is given in Chapter  4. As discussed in
Section 3.2.3, field output factors (see also the definition in Section 2.3.2.1) are
derived from a ratio of detector readings according to:

109
 f
f ,f
M Qclin f ,f
WQclin ,Qmsr = f
clin
k Qclin ,Qmsr (43)
clin msr
M Qmsr clin msr
msr

, f msr
where kQf clin
clin,Qmsr
is the output correction factor, which can be determined as
a directly measured value, an experimental generic value or a Monte Carlo
, f msr
calculated generic value. Data for kQf clin clin,Qmsr
as a function of field size are given in
Section 6.6 for different detectors and machines.
The minimum field size recommended for measurements with real
time detectors (those providing an instantaneous and potentially continuous
signal readout) and for off-line detectors (those that provide a readout after
post-processing) is such that the detector specific output correction factor is not
greater than ±5% for a particular machine. For this reason Tables 23–27 do not
, f msr
include kQf clin
clin,Qmsr
values outside this interval. It is understood that detectors or
machine configurations not included in the tables require an experimental or
Monte Carlo determination, but extrapolation of the tabulated values is to be
avoided.
As an example, according to the tabulated values, the PTW 60008 and
60016 shielded diodes are not to be used for field sizes smaller than 1 cm
(equivalent square) in WFF and FFF machines with 6 MV (Table 26) or 10 MV
(Table 27).
For the determination of field output factors, the volume averaging effect
will be one of the limiting issues for the choice of a detector. The detector size
f
is such that the volume averaging correction factor (k vol )Qclin for the small field of
clin
12 f
interest, fclin, in the beam of quality Qclin , is limited by 0.95 ≤  (k vol )Qclin  ≤ 1.05.
f clin clin
The volume averaging correction factor (k vol )Q is calculated using:
clin

(k vol )Q
f clin
=
òò A
w ( x, y)dx dy
(44)
clin
òò A
w ( x, y)OAR ( x, y)dx dy

where w(x,y) is a weighting function specific to the ionization chamber geometry,

described in Appendix  I, where examples of the calculation of the volume

12
Note that no procedure is provided to determine the beam quality Qclin of the clinical
field. It should be understood as the beam quality of a small field at a radiotherapy machine
for which the beam quality of the reference field is Qref or Qmsr. For the user, the only relevant
difference from the reference field is the field size, but the beam quality Qclin is explicitly used
to indicate that the charged particle spectrum at the measurement depth will be different from
the charged particle spectrum in the reference field.

110
averaging correction factor are given. It is advised that the field size dependence
of the detector’s response be smaller than 2% over the range of field sizes
measured. This number is a typical variation of the change in the response of
unshielded diodes for an increase of the equivalent square field size S by 5 cm.
As discussed be Section  4.2.1, a number of specialized detectors
(e.g. radiophotoluminescent detectors, plastic and organic scintillators) and
techniques to use them are available. Experience on their use is limited to workers
with specialized training and access to specialized equipment. It is advised that
users of these detectors develop significant expertise before using them for
measurements of clinical dosimetric parameters.
Dosimetry of small fields in non-water and heterogeneous media is beyond
the scope of this COP, but it is important to be aware that these conditions may
introduce significant energy and material dependent perturbations, and using
generic data for such conditions can result in significant clinical errors [169–172].

6.1.1.2. Detectors for measuring beam profiles

It is advised that for the experimental determination of lateral beam

profiles, detectors have high spatial resolution (requiring the use of detectors with
a small area perpendicular to the beam axis or quasi-continuous detectors such as
radiochromic film), limited energy dependence in their response and limited dose
rate or dose-per-pulse dependence (see Table 6 for limits).
Liquid ion chambers, unshielded diodes, microdiamonds and organic
scintillators have a small sensitive volume and are suitable for profile
measurements using a scanning system. Given the asymmetries in their
construction and the influence of stem irradiation effects, the orientation
is always such that the stem is parallel to the beam axis. It is advised that the
effect on the profiles of irradiating the stem and parts of the cables always be
investigated, minimized and, if possible, corrected for. Also, the effect of charge
recombination needs to be assessed and, if necessary, corrected for.
Radiochromic film is very suitable for lateral profile measurements, but
needs adequate readout and calibration procedures. Any other detector with a
dispersed radiosensitive agent (such as a gel dosimeter) needs to be thoroughly
investigated, characterized and benchmarked against other detectors.

6.1.2. Phantoms

Guidance regarding phantoms is given in Section 4.2.2.

111
6.2. IN-PHANTOM DETECTOR SET-UP

Accurate and reproducible measurements of beam profiles in small

fields require not only the choice of an appropriate detector in terms of its size
and composition but also the presence of a number of machine and detector
QA procedures in place with more stringent tolerances than for broad beam
dosimetry. These include procedures that verify jaw and collimator position,
beam alignment, alignment of the water phantom and the movement of the
scanning system with the beam, detector and electrometer functionality, etc.
It is beyond the scope of this COP to provide guidance on these QA procedures,
which can be found in other publications [12, 29, 31, 83, 168, 173–175].
For the determination of beam profiles and field output factors, accurate
set-up of the detector in a 3-D full scatter water tank is required [166]. For field
output factor measurements with off-line detectors that are not waterproof,
it could be more practical to perform the measurement in a solid, water equivalent
plastic phantom. Guidance on setting up such a detector for that purpose is also
given.

6.2.1. Detector orientation

The orientation of the detector axis with respect to the beam axis has an
influence on the shape of the measured profile or field output factor. A general
rule is that, whenever possible, the detector is oriented such that the smallest
dimension of its sensitive volume is perpendicular to the scanning direction. This
is, however, not always possible because of detector specific considerations such
as asymmetry of construction and the location of the stem.
Some microionization chambers designed specifically for relative
dosimetry in small beams show a particular sensitivity to irradiation of stem and
cable owing to their very small volume. To minimize this effect, the chamber is
oriented with its stem parallel to the beam axis, in order to ensure uniform stem
irradiation, while taking care that the cable is positioned to minimize its irradiated
length when full travel of the detector is allowed. The scanning orientation to
avoid is with the stem perpendicular to beam axis and parallel to the scanning
direction (c.f. orientation 3 in Fig. 18).
Scanning diodes have been widely used for the measurement of lateral
beam profiles, owing to their superior spatial resolution compared to ionization
chambers and higher signal. Shielded and unshielded diodes both have disk
shaped active volumes, with larger diameter than depth of their depleted regions,
which would reasonably suggest orienting the diode’s sensitive disk parallel to the
beam axis, in order to make best use of their spatial resolution. However, it has
been shown that this orientation produces asymmetric lateral profiles, owing to

112
distortions caused by the unequal distribution of material around the chip [176].
For scintillating fibre dosimeters, the technique used for the establishment of
the Cerenkov correction procedure affects the optimal detector direction for
scanning [137].
Advised orientations for various point detectors with respect to the beam’s
central axis, for relative dosimetry in small photon fields, are given in Table 22.

TABLE 22.  DETECTOR ORIENTATION, WITH RESPECT TO THE BEAM

CENTRAL AXIS, FOR RELATIVE DOSIMETRY IN SMALL PHOTON
FIELDS

Detector’s Lateral beam Field output

Detector type
geometrical reference profiles factors

Cylindrical micro ion chamber Axis Parallel or Perpendicular

perpendicular

Liquid ion chamber Axis Perpendicular Parallel

Silicon shielded diode Axis Parallel Parallel

Silicon unshielded diode Axis Parallel Parallel

Diamond detector Axis Parallel Parallel

Radiochromic film Film surface Perpendicular Perpendicular

Note: See Figs 18 and 19.

6.2.2. Placement of the detector’s reference point at the reference depth

The detector is placed with its reference point at the reference depth.
For each detector, this point may depend on the orientation of the detector
with respect to the radiation beam. For cylindrical ionization chambers in the
perpendicular orientation (with the major axis of the detector perpendicular to the
beam axis), it is the centre of the cavity volume of the chamber on the chamber
axis (the location on the central axis is usually specified by the manufacturer as
a given distance from the tip of the chamber), or it is sometimes indicated by
a fiducial mark. For cylindrical ionization chambers in the parallel orientation
(with the major axis of the detector parallel to the beam axis), it is the tip of the
ionization chamber. For solid state detectors, the reference point for orientation

113
of the stem parallel to the beam’s axis is usually specified by the manufacturer
with respect to the flat face or tip of the detector and often marked with a circle
(indicated in Table 7 for the detectors listed). For the perpendicular orientation
(with the major axis of the detector perpendicular to the beam axis) the centre of
the detector is used.

6.2.3. Detector alignment with beam central axis

For small field dosimetry, it is essential to ensure accurate alignment of the

detector with respect to the beam’s central axis given the sharp maximum and
steep gradients in lateral beam profiles. Figure 16 [90] illustrates that alignment
based on laser beams or the machine’s light field with typical tolerances of 1 mm
is not accurate enough for the measurement of field output factors for small
fields. After initial alignment based on lasers or light field, further refinement
of the alignment is thus required. This requires measurement of profiles in two
dimensions at the measurement depth.

6.2.3.1. Alignment of real time detectors

With real time detectors, the alignment of the detector with the central
axis of the beam can be achieved using the scanning system. These scans are

FIG. 16.  Demonstration of the influence of clinical set-up accuracy: the beam laser (solid
vertical line) is calibrated with a misalignment tolerance of less than 1 mm from the beam’s
central axis in a field of 5  mm width, but this does not ensure a negligible underestimation
of the profile maximum (reproduced from Ref.  [90] with the permission of the American
Association of Physicists in Medicine).

114
performed at slow speed, with an appropriate step size for the field (of the order of
0.1 mm for the smallest fields) and with attention to potential effects of hysteresis
of the scanning system. The alignment can be performed based either on the
centre of the two 50% profile levels or on the profile maximum assuming that the
beam profile is symmetric. At the same time this provides a measurement of the
FWHM field size specification. Given that tiny changes in the collimator position
can result in substantial changes of the absorbed dose to water at the centre of
the field, this alignment procedure and FWHM determination is performed every
time the field has been set or re-set by moving the collimator for MLC based
radiotherapy machines. The alignment has to be performed in two orthogonal
directions, and this may require an iterative procedure to determine the centre of
the field, accounting for the possibility of tiny phantom misalignments.
Note that for the measurement of depth dose profiles along the beam axis,
the centre of the field has to be determined at different depths and, based on that
information, the phantom and scanning system needs to be accurately aligned
with the beam central axis (CAX correction). For the procedures in this COP,
which are restricted to field output factor and lateral beam profile measurements,
this is not critical; however for the measurement of lateral beam profiles, it is
advised that they be measured at the same depth at which the output factors are
determined.

6.2.3.2. Lateral alignment of off-line detectors

The main problem with setting up an off-line detector is that the radiation-
induced signal cannot be observed immediately, and any radiation exposure
during alignment of the detector contributes to the signal. Thus, the detector
itself cannot be used to detect the centre of the field. Various methods have been
described to deal with this alignment problem, of which three are discussed
below. For MLC based radiotherapy machines, this alignment procedure and
FWHM determination is performed every time the field has been set or re-set by
moving the collimator.

(a) Off-line detector set-up using attachment system

A specially constructed attachment system on the scanning arm in a

scanning phantom can be used to allow a real time detector to be replaced
with a passive detector. This requires very accurate machining of the real
time and off-line detector holders to ensure accurate positioning of the
reference point of both detectors at the same location. Often, ancillary
parts (e.g. so-called stop thimbles for ionization chambers) can facilitate
the insertion of detectors in their holders with the required positioning

115
 accuracy. The user is referred to the product catalogue of the ionization
chamber manufacturer.

(b) Off-line detector set-up using film

This method is particularly suited for measurements in a solid water

equivalent phantom [177]. After preliminary lateral positioning of the
detector insert in a phantom slab at the correct SDD and aligned with the
beam axis based on lasers and/or light field, a radiochromic film is inserted
between the slab with the detector insert and the slab further away from
beam source to quantify any necessary additional lateral displacement of
the phantom. To enhance contrast, a dummy detector made of a high Z
material, or with a high Z material bead at the location of the reference
point, could be inserted. If necessary the procedure is repeated iteratively.
Once alignment within the required tolerance has been achieved, the
detector is inserted and the amount of phantom material necessary to
position the detector’s reference point at the measurement depth is added on
top or in front of the slab containing the detector insert. It is essential with
each handling for taking away or adding slabs that the lateral alignment of
the slab be adequately maintained.
In addition to this alignment procedure, a radiochromic film could be
inserted behind the slab containing the detector for each detector irradiation,
provided the detector contour can be clearly resolved on the exposed film.
This enables a volume averaging correction to be made for each individual
detector retrospectively, based on the measured lateral beam profiles and
the measured position of the detector with respect to the field. Ideally, a slab
with a special insert would be designed for this purpose, such that the slab
containing the detector does not have to be removed for every irradiation.

(c) Off-line detector set-up using an electronic portal imaging device

This method is suited for measurements in both a water phantom and a

solid water equivalent phantom [100]. After initial positioning of the
detector insert in the water phantom or a phantom slab at the correct SDD
and aligned with the beam axis based on lasers and/or light field, an image
of the irradiation set-up is taken using an electronic portal imaging device
(EPID) below or behind the phantom to quantify any necessary additional
lateral displacement of the detector holder in the scanning system or of the
solid phantom. An example of such an EPID image is shown in Fig. 17.
To enhance contrast, a dummy detector made of a high Z material, or with
a high Z material bead at the location of the reference point, is inserted.

116
FIG. 17.  EPID image showing the detector’s position using a marker and measurement of the
distance of the centre of the marker from the beam central axis, which was in this illustrative
example for a 1.8 cm × 1.8 cm field found to be within 0.25 mm [100] (courtesy of G. Azangwe,
National University of Science and Technology, Zimbabwe).

If necessary the procedure is repeated iteratively. Once alignment within the

required tolerance has been achieved, the detector is inserted in the detector
holder on the scanning system and moved to the previously determined
measurement point in the water phantom or, in the case of a solid phantom,
the correct amount of phantom material to position the detector’s reference
point at the measurement depth is added on top or in front of the slab
containing the detector insert. It is essential with each handling for taking
away or adding slabs that the lateral alignment of the slab be adequately
maintained. The EPID image usually does not have sufficient resolution
to work out retrospectively the volume averaging correction for each
individual detector based on the measured lateral beam profiles and the
measured position of the detector with respect to the field.

6.2.4. Set-up of SSD or SAD

The measurement of field output factors and lateral beam profile is

performed at the same SSD or source-to-axis distance (SAD) as was used for
reference dosimetry. For these relative measurements, the exact distance to the
beam source is not critical and tolerances used for reference dosimetry are always
sufficient.

117
6.3. MEASUREMENT OF LATERAL BEAM PROFILES

The detector is set-up as described in Section 6.2. The field is set using the
same method of collimation that would be used clinically (e.g. using cones, jaws,
MLCs, etc.).
The scanning speed and step size are chosen taking into account the
following considerations: (i) the disturbance of the water surface is minimized
(this can be checked by focusing the in-room cameras on the water surface),
(ii)  for small field sizes the speed is at its lowest value over the central beam
area, and (iii) the step size is chosen such that there are a large number of steps
over the entire range of the beam profile (typically a step size of 0.1  mm is
required).
It is advised that the measurements be performed by referencing the signal
of the field detector to that of a monitor detector to allow correction for temporal
variations in machine output during the measurements. It is important that any
device used to obtain the monitor signal not affect the measurement signal; thus
for small fields it is not acceptable to place a detector in the corner of the beam
as is typically done for large fields. Ideally, the monitor signal is taken from the
linac’s internal chamber signal, but this may not be possible in a clinical situation.
Alternatively, a transmission detector can be placed below the linac head or a
thick walled large area plane-parallel ionization chamber can be placed at a larger
depth than the field detector within the phantom. Accelerator heads of some of
the manufacturers contain dedicated locations for the introduction of a monitor
chamber in a manner that does not perturb the radiation field.
As with the use of any detectors that produce small signals, it is advised
that care be taken in the detector orientation (see  Section  6.2.1) to minimize
the effect of extra cameral current due to stem or cable signals. The acceptable
orientations for ionization chambers and real time solid state detectors such as
diodes and diamonds are illustrated in Figs 18  and 19. Note that for organic
scintillators only, orientation (2) in Fig. 19 is acceptable because of the Cerenkov
light induced in the cable [137].
Preferably, at least two different types of detectors are used and the results
compared to ensure a robust evaluation of beam profiles.

6.4. DETERMINATION OF ABSORBED DOSE AT zmax

Section 5.3.2 provides a methodology for determining the absorbed dose at

zref. However, the calibration of clinical treatment machines is often specified at
the depth of maximum dose, zmax. To determine the absorbed dose at this depth, it
is advised that the user, for a given beam, use the central axis depth dose profiles

118
FIG. 18.  Possible orientations of an ionization chamber for measurements of lateral beam
profiles (arrows indicate scanning directions in the paper plane while circle and crossed circle
symbols refer to scanning directions perpendicular to the paper plane).

(percentage depth dose data for SSD set-ups and TPR or TMR for SAD set-ups).
It is beyond the scope of this COP to provide guidelines for these measurements
(for guidance on the measurements of central axis depth dose profiles, see
Ref. [166] and, specifically for small fields, Refs [12, 167, 168]).

6.5. DETERMINATION OF IN-PHANTOM FIELD OUTPUT FACTORS

6.5.1. Reference conditions

In-phantom field output factors for clinical beams fclin are measured at the
same reference depth used for measurements in the msr field fmsr. Section 5.3.2
provides the methodology for determining the absorbed dose at zref under machine
specific reference conditions. According to Ref.  [1], zref is 10  g/cm2 for high
energy photons. However, at the time of writing this COP, data for CyberKnife
machines are only available referenced or defined at the depth of maximum dose

119
FIG. 19.  Possible orientations of a solid state detector (diode, diamond) for measurements of
lateral beam profiles (arrows indicate scanning directions in the paper plane while circle and
crossed circle symbols refer to scanning directions perpendicular to the paper plane).

zmax. Therefore, CyberKnife machines will be considered a special case until

more data are available. Note that this COP does not include guidance for the
measurement of in-air output factors. Guidance for this purpose can be found in
Refs [12, 166, 168, 178].

6.5.2. Determination of the equivalent square small field size

For the purpose of selecting output correction factors for each small field
size, the in-plane and cross-plane dosimetric field widths, defined as the FWHM
at the detector measurement depth, are derived from the lateral beam profiles
obtained as described in Section 6.3.
For rectangular small fields with uneven in-plane and cross-plane FWHMs,
the equivalent square small field size is given by the geometric mean [19], i.e.:

S clin = A B (45)

120
where A and B correspond to the in-plane and cross-plane dosimetric field
widths, defined as the FWHM at the measurement depth. Outside the condition
0.7 < A/B < 1.4, which is usually not violated except for the smallest equivalent
square small field sizes (below 0.6  cm), a larger uncertainty on the output
correction factor than that specified in Table 37 should be considered.
For circular small fields with a FWHM radius r:

S clin = r p = 1.77 r (46)

r corresponds to the radius of the circular field defined by the points where,
on average13, the dose level amounts to 50% of the maximum dose at the
measurement depth.
Note that this guidance is based on equal area of field sizes, which is
different from the rule used for equivalent square msr field sizes in broad beams,
based on equal photon scatter contributions.

6.5.3. Determination of field output factors

Field output factors, relating the absorbed dose to water of a clinical field
fclin to that of a reference field, fmsr or fref, are derived from a measured ratio of
detector readings multiplied by an adequate correction that converts the ratio
of measured readings into a ratio of values of absorbed dose to water. In this
section expressions are given for the case of a clinical field relative to a machine
specific reference field. They can also be used for a clinical field relative to a
conventional 10 cm × 10 cm reference field, in which case ‘msr’ in the text and
equations is replaced with ‘ref’.
, f msr
As already shown in Section  6.1.1.1, the field output factor, WQf clin clin,Qmsr
,
relative to the fmsr is defined by:

f
f ,f
M Qclin f ,f
WQclin ,Qmsr = f
clin
k Qclin ,Qmsr (47)
clin msr
M Qmsr clin msr
msr

where MQf clin

clin
and MQf msr are the readings of the detector (corrected for influence
msr
quantities) in the clinical field and the msr field, respectively. Values of the output
, f msr
correction factor kQf clin
clin,Qmsr
for a range of detectors are given in Tables 23 to 27,

13
To account for potential slight polar asymmetries and/or the effects of measurement
fluctuations.

121
valid at 10 cm depth in water (except for the CyberKnife, for which they are valid
at zmax). These factors include generic values for the volume averaging effect.
If the field output factor is determined with the intermediate field method
using two detectors, i.e. an ionization chamber down to an intermediate field  fint,
as small as possible but without small field conditions (which means that the
outer edge of the detector is at least a distance rLCPE away from any field edges),
and a suitable small field detector such as a diode for smaller fields, thereby
limiting the effect of energy dependence, then the field output factor is obtained
as follows:

é M f clin ù é M f int ù
f ,f ê Q f ,f ú ê Qint f int , f msr ú
WQclin ,Qmsr = ê f clin k Qclin ,Qint ú ê f msr k Qint ,Qmsr ú (48)
clin msr
ê M Qint clin int
ú ê MQ ú
ë int û det ë msr û IC

where ‘det’ refers to the small field detector and ‘IC’ to the ionization chamber.
The output correction factor éêkQf clin , f int ù
is obtained from the tabulated output
ë clin ,Qint úû det
correction factors with respect to the msr field as follows:

ék f clin , f msr ù
ék f clin , f int ù = êë Qclin ,Qmsr ûú det (49)
êë Qclin ,Qint úû det é f int , f msr ù
êëk Qint ,Qmsr úû det

In the absence of small field conditions for the intermediate field fint, the
output correction factor for the ionization chamber éê kQf intint,,fQmsrmsr ùú is assumed to be
ë û IC
unity for the ionization chambers recommended in this COP.

6.5.4. Some practical considerations

While the determination of the field output factors is based on a relative

measurement, it is still important to correct all readings of ionization chambers for
influence quantities. Since measurement sequences are often long, atmospheric
conditions can vary substantially. Recombination and polarity correction factors
can also depend on the field size. Note also that the response of many solid state
detectors also exhibits temperature dependence, and that recombination (or dose
rate dependence) may also be considerable and thus vary as the field output
changes.

122
 The overall measurement sequence consists of individual field size
measurements interleaving the reference field measurements. This means that the
reference field measurement is done before and after the measurement for each
non-reference field. This procedure is time consuming and may not be practical
in all clinical situations, but the number of different field sizes interleaved
between two reference field measurements is limited based on the known stability
characteristics of the beam. This enables correction for drifts of the beam output
and can help ensure that the reading for the reference field does not vary beyond
acceptable tolerance levels.
In the clinical treatment delivery sequence the collimator setting can be
approached in different ways (i.e. from a smaller or from a larger field size).
If the collimator control system allows for it, it is worth characterizing field output
factors for the treatment planning system as averages of the measurements taken
in the following two situations: (i) after the collimator is moved to a larger field
size and then back to the correct field size, and (ii) after the collimator is moved
to a smaller field size and then back to the correct field size. In this manner, the
influence of the hysteresis of the collimator is minimized by averaging the effect.

6.6. TABLES OF FIELD OUTPUT CORRECTION FACTORS

Detector specific field output correction factors as a function of the field

size are given in Tables 23 to 27 for CyberKnife, Tomotherapy and Gamma Knife
machines, and for 6 MV and 10 MV WFF and FFF linacs for which the msr field
has an equivalent square msr field size of 10 cm (if the msr field has a smaller
size the output correction factor can be derived as explained in Appendix II;
cf. Eq. (63)). The determination of the field output correction factors together
with an estimate of their uncertainty are given in Appendix II.
, f msr
It is noted that at present there are no kQf clin
clin,Qmsr
data available for other
detector types and for the Gamma Knife model 4C to include in Table 25.
Due to the rather large values of the output correction factors for some air
filled ionization chambers in certain field sizes, such chambers are unsuitable for
Gamma Knife output measurements with the 4  mm collimator. The chambers
PTW T31002 and T31010, which in addition are unsuitable with the 8  mm
collimator, have been excluded from Table 25.

123
 f ,f

124
TABLE 23. FIELD OUTPUT CORRECTION FACTORS kQclin ,Qmsr FOR CYBERKNIFE MACHINES, AS A FUNCTION
clin msr
OF THE DIAMETER OF CIRCULAR FIELDS (COLLIMATOR SETTING) FOR THE DETECTOR ORIENTATIONS
SPECIFIED IN TABLE 22 (cont.)

Circular field diameter (cm)

Detector
5.0 4.0 3.5 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5

Ionization chambers

Exradin A14SL micro Shonka slimline 1.000 1.000 1.000 1.000 1.001 1.002 1.010 1.026 1.047 — — —

Exradin A16 micro 1.000 1.000 1.000 1.000 1.001 1.003 1.007 1.014 1.021 1.032 1.050 —

IBA/Wellhöfer CC01 1.000 1.001 1.001 1.001 1.001 1.002 1.003 1.005 1.009 1.016 1.031 1.043

IBA/Wellhöfer CC04 1.000 1.000 1.000 1.000 1.001 1.002 1.009 1.020 1.035 — — —

IBA/Wellhöfer CC13/IC10/IC15 1.000 1.000 1.000 1.001 1.003 1.009 1.027 — — — — —

PTW 31002 Flexible 1.000 1.001 1.002 1.004 1.009 1.022 — — — — — —

PTW 31010 Semiflex 1.000 1.000 1.000 1.001 1.003 1.008 1.022 1.043 — — — —

PTW 31014 PinPoint 1.000 1.000 1.001 1.002 1.004 1.008 1.019 1.032 1.044 — — —

PTW 31016 PinPoint 3D 1.000 1.000 1.000 1.001 1.002 1.004 1.011 1.021 1.031 1.046 — —
 f ,f
TABLE 23. FIELD OUTPUT CORRECTION FACTORS kQclin ,Qmsr FOR CYBERKNIFE MACHINES, AS A FUNCTION
clin msr
OF THE DIAMETER OF CIRCULAR FIELDS (COLLIMATOR SETTING) FOR THE DETECTOR ORIENTATIONS
SPECIFIED IN TABLE 22 (cont.)

Circular field diameter (cm)

Detector
5.0 4.0 3.5 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5

Real time solid state dosimeters

IBA PFD3G shielded diode 1.000 0.999 0.998 0.996 0.993 0.989 0.983 0.978 0.974 0.969 0.963 0.959

IBA EFD3G unshielded diode 1.001 1.001 1.001 1.001 1.001 1.000 0.997 0.994 0.991 0.987 0.981 0.978

IBA SFD unshielded diode (stereotactic) 1.001 1.002 1.003 1.003 1.004 1.003 1.000 0.996 0.991 0.983 0.972 0.965

PTW 60008 shielded diode 1.000 1.000 0.999 0.998 0.996 0.991 0.981 0.972 0.962 0.951 — —

PTW 60012 unshielded diode 1.001 1.001 1.002 1.001 1.001 0.999 0.994 0.989 0.984 0.977 0.968 0.962

PTW 60016 shielded diode 1.000 0.999 0.998 0.996 0.993 0.987 0.978 0.969 0.962 0.953 — —

PTW 60017 unshielded diode 1.000 1.001 1.001 1.000 0.999 0.997 0.992 0.987 0.981 0.975 0.966 0.960

PTW 60018 unshielded diode (stereotactic) 1.000 1.001 1.000 1.000 0.998 0.995 0.990 0.984 0.979 0.973 0.965 0.961

PTW 60003 natural diamond 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.001 1.003 1.009 1.023 1.037

125
 f ,f

126
TABLE 23. FIELD OUTPUT CORRECTION FACTORS kQclin ,Qmsr FOR CYBERKNIFE MACHINES, AS A FUNCTION
clin msr
OF THE DIAMETER OF CIRCULAR FIELDS (COLLIMATOR SETTING) FOR THE DETECTOR ORIENTATIONS
SPECIFIED IN TABLE 22 (cont.)

Circular field diameter (cm)

Detector
5.0 4.0 3.5 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5

PTW 60019 CVD diamond 1.000 1.000 1.000 0.999 0.999 0.998 0.995 0.991 0.988 0.984 0.978 0.975

PTW 31018 liquid ion chamber 1.000 0.999 0.999 0.999 0.998 0.998 0.998 0.998 0.999 1.002 1.010 1.019

Sun Nuclear EDGE Detector 1.000 1.000 1.000 0.999 0.998 0.995 0.989 0.982 0.975 0.966 0.954 —

Standard Imaging W1 plastic scintillator 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000

Note: The msr field is 6 cm diameter and the reference depth is 1.5 cm.
 f ,f
TABLE 24. FIELD OUTPUT CORRECTION FACTORS kQclin ,Qmsr FOR TOMOTHERAPY MACHINES, AS A FUNCTION
clin msr
OF THE EQUIVALENT SQUARE FIELD SIZE (cont.)

Equivalent square field size, Sclin (cm)

Detector
5.0 4.0 3.5 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

Ionization chambers

Exradin A14SL micro Shonka slimline 1.000 1.000 1.000 1.000 1.000 1.002 1.010 1.027 — — — — —

Exradin A16 micro 1.000 1.000 1.000 1.000 1.001 1.003 1.008 1.017 1.027 1.043 — — —

IBA/Wellhöfer CC01 1.002 1.003 1.004 1.005 1.005 1.006 1.007 1.010 1.014 1.024 1.044 — —

IBA/Wellhöfer CC04 1.000 1.000 1.000 1.000 1.000 1.002 1.009 1.022 1.041 — — — —

IBA/Wellhöfer CC13/IC10/IC15 1.000 1.000 1.000 1.001 1.002 1.009 1.030 — — — — — —

PTW 31002 Flexible 1.000 1.001 1.001 1.004 1.009 1.023 — — — — — — —

PTW 31010 Semiflex 1.000 1.000 1.000 1.001 1.002 1.008 1.025 — — — — — —

PTW 31014 PinPoint 1.000 1.000 1.001 1.002 1.004 1.009 1.023 1.041 — — — — —

PTW 31016 PinPoint 3D 1.000 1.000 1.000 1.001 1.001 1.004 1.013 1.025 1.039 — — — —

127
 f ,f

128
TABLE 24. FIELD OUTPUT CORRECTION FACTORS kQclin ,Qmsr FOR TOMOTHERAPY MACHINES, AS A FUNCTION
clin msr
OF THE EQUIVALENT SQUARE FIELD SIZE (cont.)

Equivalent square field size, Sclin (cm)

Detector
5.0 4.0 3.5 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

Real time solid state dosimeters

IBA PFD3G shielded diode 0.999 0.998 0.997 0.995 0.992 0.986 0.976 0.968 0.961 0.952 — — —

IBA EFD3G unshielded diode 1.005 1.007 1.008 1.009 1.009 1.009 1.006 1.002 0.997 0.991 0.982 0.976 0.969

IBA SFD unshielded diode (stereotactic) 1.009 1.013 1.015 1.017 1.018 1.019 1.017 1.012 1.006 0.995 0.978 0.966 0.951

PTW 60008 shielded diode 1.000 1.000 0.999 0.998 0.995 0.990 0.977 0.962 — — — — —

PTW 60012 unshielded diode 1.005 1.008 1.009 1.010 1.010 1.008 1.003 0.996 0.988 0.978 0.963 0.953 —

PTW 60016 shielded diode 1.000 0.999 0.998 0.995 0.991 0.984 0.970 0.956 — — — — —

PTW 60017 unshielded diode 1.004 1.005 1.006 1.006 1.006 1.003 0.997 0.989 0.981 0.971 0.956 — —

PTW 60018 unshielded diode (stereotactic) 1.004 1.005 1.005 1.005 1.004 1.001 0.993 0.985 0.977 0.968 0.955 — —

PTW 60003 natural diamond 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.001 1.003 1.009 1.026 1.045 —

PTW 60019 CVD diamond 1.000 1.000 1.000 1.000 0.999 0.997 0.993 0.989 0.984 0.977 0.968 0.962 0.955
 f ,f
TABLE 24. FIELD OUTPUT CORRECTION FACTORS kQclin ,Qmsr FOR TOMOTHERAPY MACHINES, AS A FUNCTION
clin msr
OF THE EQUIVALENT SQUARE FIELD SIZE (cont.)

Equivalent square field size, Sclin (cm)

Detector
5.0 4.0 3.5 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

PTW 31018 liquid ion chamber 0.997 0.995 0.994 0.994 0.993 0.992 0.991 0.991 0.992 0.994 1.003 1.015 1.038

Sun Nuclear EDGE Detector 1.000 1.000 1.000 0.999 0.998 0.994 0.986 0.976 0.966 0.951 — — —

Standard Imaging W1 plastic scintillator 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000

Note: The msr field is 5 cm × 10 cm and the reference depth is 10 cm.

129
 , f msr
TABLE 25.  FIELD OUTPUT CORRECTION FACTORS kQf clin
clin ,Qmsr
FOR THE
GAMMA KNIFE MODEL PERFEXION, AS A FUNCTION OF THE
DIAMETER OF THE CIRCULAR COLLIMATOR [179]

Model Type 4 mm Ø 8 mm Ø 16 mm Ø

PTW T31006 Ionization chamber —a 1.025 1.000

PTW T31014 Ionization chamber —a 1.030 1.000

PTW T31015 Ionization chamber —a —a 1.000

PTW T31016 Ionization chamber (PinPoint 3D) —a 1.032 1.000

PTW T60008 Diode (photon/shielded) 0.951 0.971 1.000

PTW T60012 Diode (electron/unshielded) 0.965 0.996 1.000

PTW T60016 Diode (photon/shielded) 0.958 0.981 1.000

PTW T60017 Diode (electron/unshielded) 0.961 0.997 1.000

PTW T60003 Diamond detector (natural) —a 1.006 1.000

PTW T60019 Diamond detector (synthetic) 0.993 1.005 1.000

a
A large correction factor makes this chamber unsuitable for output measurements with this
collimator.

130
 , f msr
TABLE 26. FIELD OUTPUT CORRECTION FACTORS kQf clin
clin,Qmsr
FOR FIELDS COLLIMATED BY AN MLC OR SRS
CONE AT 6 MV WFF AND FFF MACHINES, AS A FUNCTION OF THE EQUIVALENT SQUARE FIELD SIZE (cont.)

Equivalent square field size, Sclin (cm)

Detector
8.0 6.0 4.0 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

Ionization chambers

Exradin A14SL micro Shonka slimline 1.000 1.000 1.000 1.000 1.000 1.002 1.010 1.027 — — — — —

Exradin A16 micro 1.000 1.000 1.000 1.000 1.001 1.003 1.008 1.017 1.027 1.043 — — —

IBA/Wellhöfer CC01 1.002 1.004 1.007 1.008 1.008 1.009 1.011 1.013 1.018 1.027 1.047 — —

IBA/Wellhöfer CC04 1.000 1.000 1.000 1.000 1.000 1.002 1.009 1.022 1.041 — — — —

IBA/Wellhöfer CC13/IC10/IC15 1.000 1.000 1.000 1.001 1.002 1.009 1.030 — — — — — —

PTW 31002 Flexible 1.000 1.000 1.001 1.004 1.009 1.023 — — — — — — —

PTW 31010 Semiflex 1.000 1.000 1.000 1.001 1.002 1.008 1.025 — — — — — —

PTW 31014 PinPoint 1.000 1.000 1.000 1.002 1.004 1.009 1.023 1.041 — — — — —

PTW 31016 PinPoint 3D 1.000 1.000 1.000 1.001 1.001 1.004 1.013 1.025 1.039 — — — —

131
 , f msr

132
TABLE 26. FIELD OUTPUT CORRECTION FACTORS kQf clin
clin,Qmsr
FOR FIELDS COLLIMATED BY AN MLC OR SRS
CONE AT 6 MV WFF AND FFF MACHINES, AS A FUNCTION OF THE EQUIVALENT SQUARE FIELD SIZE (cont.)

Equivalent square field size, Sclin (cm)

Detector
8.0 6.0 4.0 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

Real time solid state dosimeters

IBA PFD3G shielded diode 1.000 1.000 0.998 0.995 0.992 0.986 0.976 0.968 0.961 0.952 — — —

IBA EFD3G unshielded diode 1.005 1.009 1.014 1.016 1.016 1.015 1.012 1.008 1.004 0.998 0.988 0.983 0.976

IBA SFD unshielded diode (stereotactic) 1.008 1.017 1.025 1.029 1.031 1.032 1.030 1.025 1.018 1.007 0.990 0.978 0.963

PTW 60008 shielded diode 1.000 1.000 1.000 0.998 0.995 0.990 0.977 0.962 — — — — —

PTW 60012 unshielded diode 1.005 1.010 1.015 1.017 1.017 1.016 1.010 1.003 0.996 0.985 0.970 0.960 —

PTW 60016 shielded diode 1.000 1.000 0.999 0.995 0.991 0.984 0.970 0.956 — — — — —

PTW 60017 unshielded diode 1.004 1.007 1.010 1.011 1.011 1.008 1.002 0.994 0.986 0.976 0.961 0.952 —

PTW 60018 unshielded diode (stereotactic) 1.004 1.007 1.010 1.011 1.009 1.006 0.998 0.990 0.983 0.973 0.960 0.952 —

PTW 60003 natural diamond 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.001 1.003 1.009 1.026 1.045 —

PTW 60019 CVD diamond 1.000 1.000 1.000 1.000 0.999 0.997 0.993 0.989 0.984 0.977 0.968 0.962 0.955
 , f msr
TABLE 26. FIELD OUTPUT CORRECTION FACTORS kQf clin
clin,Qmsr
FOR FIELDS COLLIMATED BY AN MLC OR SRS
CONE AT 6 MV WFF AND FFF MACHINES, AS A FUNCTION OF THE EQUIVALENT SQUARE FIELD SIZE (cont.)

Equivalent square field size, Sclin (cm)

Detector
8.0 6.0 4.0 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

PTW 31018 liquid ion chamber 0.997 0.994 0.991 0.989 0.988 0.988 0.987 0.987 0.987 0.990 0.999 1.011 1.033

Sun Nuclear EDGE Detector 1.000 1.000 1.000 0.999 0.998 0.994 0.986 0.976 0.966 0.951 — — —

Standard Imaging W1 plastic scintillator 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000

Note: The reference depth is 10 cm.

133
 , f msr

134
TABLE 27. FIELD OUTPUT CORRECTION FACTORS kQf clin
clin,Qmsr
FOR SMALL FIELDS COLLIMATED BY AN MLC OR
SRS CONE AT 10 MV WFF AND FFF MACHINES, AS A FUNCTION OF THE EQUIVALENT SQUARE FIELD SIZE

Equivalent square field size, Sclin (cm)

Detector
8.0 6.0 4.0 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

Ionization chambers

Exradin A14SL micro Shonka slimline 1.000 1.000 1.000 1.000 1.000 1.002 1.010 1.027 — — — — —

Exradin A16 micro 1.000 1.000 1.000 1.000 1.001 1.003 1.008 1.017 1.027 1.043 — — —

IBA/Wellhöfer CC01 1.001 1.003 1.004 1.005 1.005 1.006 1.007 1.009 1.014 1.023 1.043 — —

IBA/Wellhöfer CC04 1.000 1.000 1.000 1.000 1.000 1.002 1.009 1.022 1.041 — — — —

IBA/Wellhöfer CC13/IC10/IC15 1.000 1.000 1.000 1.001 1.002 1.009 1.030 — — — — — —

PTW 31002 Flexible 1.000 1.000 1.001 1.004 1.009 1.023 — — — — — — —

PTW 31010 Semiflex 1.000 1.000 1.000 1.001 1.002 1.008 1.025 — — — — — —

PTW 31014 PinPoint 1.000 1.000 1.000 1.002 1.004 1.009 1.023 1.041 — — — — —

PTW 31016 PinPoint 3D 1.000 1.000 1.000 1.001 1.001 1.004 1.013 1.025 1.039 — — — —
 , f ref
TABLE 27. FIELD OUTPUT CORRECTION FACTORS kQf clin
clin ,Qref
FOR SMALL FIELDS COLLIMATED BY AN MLC OR
SRS CONE AT 10 MV WFF AND FFF MACHINES, AS A FUNCTION OF THE EQUIVALENT SQUARE FIELD SIZE
(cont.)

Equivalent square field size, Sclin (cm)

Detector
8.0 6.0 4.0 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

Real time solid state dosimeters

IBA PFD3G shielded diode 1.000 1.000 0.998 0.995 0.992 0.986 0.976 0.968 0.961 0.952 — — —

IBA EFD3G unshielded diode 1.003 1.005 1.008 1.009 1.009 1.008 1.005 1.000 0.996 0.989 0.980 0.974 0.967

IBA SFD unshielded diode (stereotactic) 1.005 1.010 1.015 1.018 1.018 1.018 1.015 1.010 1.003 0.992 0.974 0.962 —

PTW 60008 shielded diode 1.000 1.000 1.000 0.998 0.995 0.990 0.977 0.962 — — — — —

PTW 60012 unshielded diode 1.003 1.006 1.009 1.010 1.010 1.008 1.002 0.994 0.986 0.976 0.960 0.951 —

PTW 60016 shielded diode 1.000 1.000 0.999 0.995 0.991 0.984 0.970 0.956 — — — — —

PTW 60017 unshielded diode 1.002 1.004 1.006 1.006 1.005 1.003 0.996 0.988 0.980 0.969 0.954 — —

PTW 60018 unshielded diode (stereotactic) 1.002 1.004 1.006 1.006 1.004 1.000 0.992 0.984 0.976 0.966 0.953 — —

PTW 60003 natural diamond 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.001 1.003 1.009 1.026 1.045 —

135
 , f ref
TABLE 27. FIELD OUTPUT CORRECTION FACTORS kQf clin FOR SMALL FIELDS COLLIMATED BY AN MLC OR

136
clin ,Qref
SRS CONE AT 10 MV WFF AND FFF MACHINES, AS A FUNCTION OF THE EQUIVALENT SQUARE FIELD SIZE
(cont.)

Equivalent square field size, Sclin (cm)

Detector
8.0 6.0 4.0 3.0 2.5 2.0 1.5 1.2 1.0 0.8 0.6 0.5 0.4

PTW 60019 CVD diamond 1.000 1.000 1.000 1.000 0.999 0.997 0.993 0.989 0.984 0.977 0.968 0.962 0.955

PTW 31018 liquid ion chamber 0.998 0.996 0.994 0.994 0.993 0.993 0.992 0.992 0.993 0.995 1.005 1.017 1.039

Sun Nuclear EDGE Detector 1.000 1.000 1.000 0.999 0.998 0.994 0.986 0.976 0.966 0.951 — — —

Standard Imaging W1 plastic scintillator 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000

Note: The reference depth is 10 cm.

 Appendix I

DETERMINATION OF BEAM QUALITY CORRECTION FACTORS

FOR REFERENCE DOSIMETRY AND
THEIR UNCERTAINTY ESTIMATES

This appendix describes the procedures used to derive detector specific

values of the beam quality correction factors kQf ref and kQf msr msr
, f ref
for the reference
dosimetry of WFF linac beams, FFF beams, including CyberKnife and
TomoTherapy beams, and Gamma Knife 60Co beams; the values are given in
Chapter 5. For WFF beams, values of kQf ref , short notation for kQf ref,Q0 with reference
to Q0 = 60Co and fref = 10 cm × 10 cm (see Eqs (25, 27) and related text), are
given in Table 12. These values have been derived from data in Refs [1, 7]. For
FFF beams, additional information from the literature has been used to determine
volume averaging corrections, water to air stopping-power ratios and equivalent
square field sizes, leading to the kQf ref correction factors given in Table 13. For
, f ref , f ref
Gamma Knife beams, the values of kQf msr msr
, short notation for k Qf msr msr ,Q0
with
reference to Q0 = 60Co, given in Table 14 have been taken directly from the
literature.

I.1. LINAC BEAMS WITH FLATTENING FILTER (WFF BEAMS)

I.1.1. kQf ref values for WFF beams

f
k Qref values from Ref. [1], where they were denoted by kQ, for most chambers
recommended in this COP for the reference dosimetry of  fref = 10 cm × 10 cm
fields are given in Table 28. Values for these ionization chambers that have
also been provided in Ref. [7] are given in Table 29 along with values for three
chambers not included in Ref. [1]. The stated values of %dd(10,10)x have been
optimized such that for chambers included in both protocols the sum of the
squares of the differences between the kQf ref values in both tables is minimized.
Using this procedure, the recommended data for kQf ref for WFF beams given in
Table 29 were determined as a function of both beam quality indices, TPR20,10(10)
and %dd(10,10)x.

137
TABLE 28.  kQf ref DATA FOR THE fref = 10 cm × 10 cm FIELD FOR
REFERENCE IONIZATION CHAMBERS IN WFF LINACS AS A FUNCTION
OF TPR20,10(10) [1]

Ion chamber TPR20,10(10) = 0.630 0.660 0.690 0.720 0.750

Capintec PR-06C/G Farmer 0.997 0.994 0.991 0.988 0.982

Exradin A2 Spokas 0.998 0.997 0.995 0.992 0.988

Exradin A12 Farmer 0.998 0.996 0.993 0.990 0.984

Exradin A12Sa — — — — —

Exradin A19a — — — — —

Nuclear Assoc 30-751 Farmer 0.996 0.993 0.990 0.985 0.979

Nuclear Assoc 30-752 Farmer 0.997 0.995 0.992 0.989 0.983

NE 2505/3, 3A Farmer 0.996 0.994 0.992 0.989 0.984

NE 2571 Farmer 0.997 0.994 0.992 0.989 0.984

NE 2611 0.996 0.993 0.991 0.988 0.984

PTW 23331 rigid 0.996 0.992 0.989 0.985 0.980

PTW 23332 rigid 0.996 0.993 0.989 0.984 0.978

PTW 23333 (3 mm cap) 0.996 0.993 0.989 0.985 0.979

PTW 30001 Farmer 0.996 0.993 0.989 0.985 0.979

PTW 30010 Farmer 0.996 0.993 0.989 0.985 0.979

PTW 30002/30011 Farmer 0.996 0.993 0.991 0.987 0.982

PTW 30004/30012 Farmer 0.998 0.995 0.993 0.989 0.984

PTW 30006/30013 Farmer 0.996 0.993 0.989 0.984 0.978

PTW 31003/31013 Semiflex 0.996 0.993 0.989 0.984 0.978

138
 f
TABLE 28.  kQref DATA FOR THE fref = 10 cm × 10 cm FIELD FOR
REFERENCE IONIZATION CHAMBERS IN WFF LINACS AS A FUNCTION
OF TPR20,10(10) [1] (cont.)

Ion chamber TPR20,10(10) = 0.630 0.660 0.690 0.720 0.750

SNC 100700-0 Farmer 0.997 0.994 0.991 0.986 0.979

SNC 100700-1 Farmer 0.998 0.997 0.994 0.990 0.984

Victoreen Radocon III 555 0.993 0.988 0.985 0.979 0.973

Victoreen 30-348 0.995 0.991 0.988 0.982 0.976

Victoreen 30-351 0.995 0.991 0.988 0.983 0.977

Victoreen 30-349 0.995 0.991 0.988 0.983 0.978

Victoreen 30-361 0.995 0.991 0.988 0.983 0.977

IBA FC-65P (Wellhöfer IC 69) Farmer 0.997 0.994 0.992 0.986 0.979

IBA FC-65G (Wellhöfer IC 70) Farmer 0.998 0.997 0.994 0.989 0.983

a
Data not given in Ref. [1].

TABLE 29.  kQf ref DATA FOR THE fref = 10 cm × 10 cm FIELD FOR

REFERENCE IONIZATION CHAMBERS IN WFF LINACS AS A FUNCTION
OF %dd(10,10)x [7]

Ion chamber %dd(10,10)x = 63.4 65.2 67.6 70.5 73.9

Capintec PR-06C/G Farmer 0.997 0.995 0.993 0.989 0.984

Exradin A2 Spokasa — — — — —

Exradin A12 Farmer 0.997 0.994 0.991 0.987 0.981

Exradin A12S 0.996 0.994 0.991 0.987 0.981

Exradin A19 0.996 0.993 0.990 0.985 0.980

139
TABLE 29.  kQfref DATA FOR THE fref = 10 cm × 10 cm FIELD FOR
REFERENCE IONIZATION CHAMBERS IN WFF LINACS AS A FUNCTION
OF %dd(10,10)x [7] (cont.)

Ion chamber %dd(10,10)x = 63.4 65.2 67.6 70.5 73.9

Nuclear Assoc 30-751 Farmera — — — — —

Nuclear Assoc 30-752 Farmera — — — — —

NE 2505/3, 3A Farmera — — — — —

NE 2571 Farmer 0.996 0.994 0.991 0.987 0.981

NE 2611 0.999 0.996 0.993 0.989 0.984

PTW 23331 rigida — — — — —

PTW 23332 rigida — — — — —

PTW 23333 (3 mm cap)a — — — — —

PTW 30001 Farmera — — — — —

PTW 30010 Farmer 0.997 0.994 0.991 0.987 0.981

PTW 30002/30011 Farmer 0.997 0.994 0.991 0.987 0.982

PTW 30004/30012 Farmer 0.998 0.996 0.993 0.989 0.984

PTW 30006/30013 Farmer 0.995 0.993 0.990 0.986 0.980

PTW 31003/31013 Semiflex 0.996 0.994 0.991 0.986 0.981

SNC 100700-0 Farmera — — — — —

SNC 100700-1 Farmera — — — — —

Victoreen Radocon III 555a — — — — —

Victoreen 30-348a — — — — —

Victoreen 30-351a — — — — —

140
TABLE 29.  kQfref DATA FOR THE fref = 10 cm × 10 cm FIELD FOR
REFERENCE IONIZATION CHAMBERS IN WFF LINACS AS A FUNCTION
OF %dd(10,10)x [7] (cont.)

Ion chamber %dd(10,10)x = 63.4 65.2 67.6 70.5 73.9

Victoreen 30-349a — — — — —

Victoreen 30-361a — — — — —

IBA FC-65P (Wellhöfer IC 69) Farmer 0.996 0.994 0.990 0.986 0.980

IBA FC-65G (Wellhöfer IC 70) Farmer 0.996 0.994 0.991 0.987 0.981

a
Data not given in Ref. [7].

f
I.1.2. Uncertainties of the kQref values for WFF beams

The relative standard uncertainty of the kQf ref values in Ref.  [1] was
estimated to be 1%, while the uncertainty quoted in Ref. [7] was 0.5%. As the
latter estimate was based on more recent comparisons of measured and Monte
Carlo calculated data, it seems a priori reasonable to assume that Ref. [1] slightly
overestimated the overall uncertainty of the beam quality correction factors.
Further discussions [180] have, on the other hand, indicated that the lower
estimate in Ref.  [7] may be more applicable to particular reference chambers,
such as the NE  2571 (for which a considerable amount of experimental data
exist), while an underestimation could occur for chambers having less or no
experimental data available in other publications.
It is advised that the kQf ref values given in Table  12 as a function of
%dd(10,10)x be assigned an uncertainty component for the matching of
%dd(10,10)x to TPR20,10(10) data. After the optimization procedure described
above, the maximum difference in kQf ref at the highest beam qualities amounted
to 0.3%; therefore it can be assumed that the relative standard uncertainty for this
matching does not exceed 0.2%.
Based on current knowledge and uncertainty estimates, it is
assumed throughout this COP that in situations where a hypothetical field
fref = 10 cm × 10 cm needs to be considered (see Section 3.2.1.3), the same beam
quality correction factors can be used for the fmsr and fref fields in WFF beams;
hence, kQf msr
msr
, f ref
equals kQf ref for the hypothetical conventional reference field of
a machine. Additionally, as water to air stopping-power ratios are known to
vary by not more than 0.2% for field sizes from 10 cm × 10 cm down to about

141
3 cm × 3 cm, the range covering the fmsr field sizes for linac beams, a relative
standard uncertainty of 0.15% can be estimated for the sw,air contribution. These
, f ref
two contributions will only marginally increase the overall uncertainty of kQf msr msr
f ref
values compared with that of kQ .
Given that the 1% relative standard uncertainty in Ref.  [1] appears to be
a conservative estimate, it can be assumed that the combined relative standard
uncertainty of kQf ref and kQf msrmsr
, f ref
, including the two additional contributions
mentioned, will not exceed 1%. Because it is not the purpose of this COP to
review the data in Refs [1, 7], the recommended kQf ref values given in Table 12 are
estimated to have a relative standard uncertainty of 1%. If the chamber calibration
is made with a high energy photon beam of quality Q0, there is a correlation in the
ratio of two values with respect to 60Co (see Eq. (26)), and the relative standard
uncertainty of kQf ref,Q0 with reference to a calibration beam quality Q0  ≠  60Co is
assumed to be 1% as well.

I.1.3. Equivalent square msr field sizes of WFF beams

For WFF beams in which a 10 cm × 10 cm conventional reference field

cannot be established, the measured values of TPR20,10(S ) and %dd(10,S )x in a
machine specific reference field,  fmsr, are converted to the beam quality indices
TPR20,10(10) and %dd(10,10)x following the procedure described in Section 5.3.3.
If the  fmsr field is not square, then an equivalent square field size, S, has to
be determined based on the condition that the scatter component in equivalent
field sizes is the same. Using scatter functions from Ref. [32], it can be shown
that equivalent square field sizes of rectangular and circular fields depend very
little on the exact shape of the scatter function. It has been found that the scatter
function proposed in Ref. [32]:

SC (r )
s= = 1 - e -lr - mlre -lr (50)
SC (¥ )

with μ = 0.5, λ = 0.18 and SC(r) being the scatter component of a circular field
with radius r, fits well measured scatter components when the expression is
integrated over WFF beams of various field sizes, and therefore this function has
been used for this COP. The integration is performed over the field area using the
expression:

1 æ e -lr ö
SC field = òò çççl (1 - m) + ml 2e -lr ÷÷÷rdrdq (51)
2p field area ç è r ÷ø

142
 Figure 20 illustrates how the equivalent square field size of a rectangular
field is derived from the scatter components of rectangular and square fields. The
equivalent square msr field sizes in Table 15 have been calculated according to
this procedure.

I.2. FFF LINAC BEAMS

No kQf ref data were given for FFF beams in Ref.  [1], and discussions in
the literature indicate that data for FFF beams or beams with light filtration are
slightly different from those for WFF beams when kQf ref is given as a function of
TPR20,10(10) [34, 35, 37, 181–184]. Even though it is generally assumed that data
in Refs [2, 7] are valid for both WFF and FFF beams, there is also evidence that
f
k Qref values given as a function of %dd(10,10)x are slightly different for WFF and
FFF beams [34,  35,  37,  181–184], though the differences are smaller than for

FIG. 20.  Scatter components for 10  cm × X  cm rectangular fields (dashed curve, lower
horizontal axis) and square fields of size S (continuous curve, upper horizontal axis) in a
WFF beam calculated using Eq. (51). The example illustrates that a 10 cm × 5 cm rectangular
field has an equivalent square field size of 6.8 cm.

143
TPR20,10(10). There are three main issues to consider that lead to the differences
in kQf ref data between WFF and FFF beams:

(a) Differences in water to air stopping-power ratios (sw,air)Q as a function of

the beam quality index TPR20,10(10) or %dd(10,10)x;
(b) Differences in all types of ionization chamber perturbation correction
factors except for volume averaging as a function of the beam quality index
TPR20,10(10) or %dd(10,10)x;
(c) Volume averaging due to the non-uniform lateral beam profile of reference
fields in FFF beams.

The third issue is addressed in Ref. [7] as an additional correction factor in

the expression to determine absorbed dose to water, but no correction factors or
procedures for their determination were provided. A fourth issue to consider is
the reduced scatter component at the reference depth in FFF beams as compared
to WFF beams, which makes the equivalent square field size smaller than that
defined by the beam penumbrae [33]. To this end, either the field size for the
determination of the beam quality has to be larger than the 10  cm × 10  cm
reference field, such that the equivalent square field size is 10 cm × 10 cm, or
the equivalent square field size S of the 10 cm × 10 cm reference field has to be
determined so that the measured values of TPR20,10(S ) and %dd(10,S )x can be
converted to the beam quality indices TPR20,10(10) and %dd(10,10)x as described
in Section 5.3.3.

I.2.1. Water to air stopping-power ratios for FFF beams

The difference in water to air stopping-power ratios (sw,air)Q between

heavily filtered and unfiltered or lightly filtered beams has been the subject of
debate since the 1980s [34,  35,  37,  181–184]. Many of these discussions were
based on beams that either had non-clinical characteristics, such as those used in
the past in some national metrology institutes, or on clinical beams not in current
use. A relatively recent paper that compared Monte Carlo calculated water to air
stopping-power ratios for FFF and WFF beams assumed that FFF beams have no
filtration at all [34], while FFF beams in clinical use always have some minimal
filtration to prevent electrons emerging from the target from reaching the patient
and to reduce backscatter from the collimator into the monitor chamber, which
would complicate the modelling of beam output as a function of field size and
shape [108].
The only set of (sw,air)Q data available for FFF beams currently in clinical
use is from the Monte Carlo calculations by Dalaryd et al. [37], and these data
have been used to calculate the WFF–FFF differences as a function of beam

144
quality for this COP. The data are shown in Fig. 21, where the values of the beam
quality indices are those reported in the publication. Strictly speaking, these
(sw,air)Q values need to be corrected for the effect of the reduced equivalent square
field size, but this was found to result in very small differences, about 0.06% for
the data as a function of %dd(10,10)x, and varying from less than 0.03% to 0.1%
for the data as a function of TPR20,10(10). One data point of the dataset (marked
as a triangle in Fig.  21) was disregarded because it represented a FFF beam
with a very low beam quality index and it skewed the difference because no
corresponding low beam quality value for the WFF beams was present in the
dataset. It is assumed that even though the extrapolation of the curves in Fig. 21
to lower beam quality indices is less accurate (potentially closer estimates are
provided by the dashed lines), the difference between the two curves is better
represented by omitting this data point.
Thus, for FFF beams, the kQf ref values from Refs [1, 7] have been corrected
for these differences; the applied correction factors as a function of TPR20,10(10)
and %dd(10,10)x are given in Table  30. The values chosen for %dd(10,10)x in
this table are the result of the optimization to match kQf ref for FFF beams as a
function of TPR20,10(10) and %dd(10,10)x described in Section I.2.4.

I.2.2. Ionization chamber perturbation correction factors for FFF beams

There are at present no data in the literature on the difference in ionization

chamber perturbation correction factors between WFF and FFF beams as a
function of the beam quality indices. For the chamber wall perturbation correction
factor, it is known that it depends on the water to air stopping-power ratio as
well as on the wall to air stopping-power ratio, and that the dependence on beam
quality index is smaller than the dependence on water to air stopping-power ratio.
Given the lack of data, it is assumed in this COP that the dependence of
ionization chamber perturbation correction factors as a function of the beam
quality indices is the same as for WFF beams, and the kQf ref data are not corrected
for this potential difference.

I.2.3. Volume averaging correction factors for FFF beams

The non-uniformity of the lateral beam profiles of reference fields in

FFF beams results in an under-response of the reference ionization chambers that
is relatively large compared to the scale of the dose variation at the centre of these
reference fields. It has, for example, been shown that the dose averaged over
the dimensions of a Farmer ionization chamber in the 6 cm diameter reference
field of a CyberKnife machine is about 1% lower than the dose at the centre
of the field [76, 81]. Reference [7] explicitly introduced a new correction factor

145
FIG. 21.  Water to air stopping-power ratios (sw,air )Q  for clinical WFF and FFF beams
calculated by the Monte Carlo method [37]. The triangular data point on the left was
disregarded in the analysis, as explained in the text. The solid lines represent quadratic fits
used to calculate the difference in (sw,air )Q between WFF and FFF beams. The dashed lines
represent potentially better estimates for the extrapolations to low beam quality indices, but
it can be assumed that the differences are well described by the extrapolated solid curves
(reproduced with the permission of the American Association of Physicists in Medicine).

146
TABLE 30.  RATIOS OF WATER TO AIR STOPPING-POWER RATIOS FOR
FFF AND WFF BEAMS USED AS CORRECTION FACTORS IN THIS CODE
AS A FUNCTION OF THE BEAM QUALITY INDICES TPR20,10(10) AND
%dd(10,10)x

TPR20,10(10) 0.630 0.660 0.690 0.720 0.750

FFF WFF
(s w,air ) TPR 20 ,10 (10)
(s w,air ) TPR 20 ,10 (10)
0.999 0.998 0.997 0.996 0.994

%dd(10,10)x 63.8 65.6 68.2 71.7 76.1

FFF WFF
(s w,air )%dd(10,10) (s w,air )%dd(10,10) 0.998 0.998 0.998 0.998 0.998
x x

in the equation to determine absorbed dose to water accounting for this volume
averaging effect, but no values were provided for the correction factors.
The volume averaging correction factor is defined as the dose averaged over
a volume of water in homogeneous water where the water volume coincides with
the volume displaced by the ionization chamber. Kawachi et al. [81] proposed an
expression for calculating the volume averaging correction factor from measured
lateral beam profiles:

(k vol )Q
f ref
=
òò A
d xd y
(52)
òò A
OAR ( x, y)dxdy

where x and y are the coordinates on the axes orthogonal to the beam central
axis, A is the area of the projection of the sensitive volume of the chamber on a
plane orthogonal to the beam axis and OAR(x,y) is the off-axis ratio, which is
the 2-D lateral beam profile at the measurement depth normalized to the central
axis. Equation (52), however, does not account for the change of the longitudinal
extent of an ionization chamber depending on the lateral position. A more
accurate expression is given by:

(k vol )Q
f ref
=
òò A
w ( x, y)dxdy
(53)
òò A
w ( x, y)OAR ( x, y)dxdy

147
where w(x,y) is a weighting function representing the extension of the air cavity
of the ionization chamber along the beam axis as a function of the beam lateral
coordinates.
As an example, the volume averaging correction factor is calculated for a
Farmer chamber in the 6 cm diameter reference field of a CyberKnife machine
using Eqs (52, 53) for the four geometrical models of varying simplification of
the ionization chamber described in Fig. 22.
For the four models in Fig. 22, the weights w(x,y) in Eq. (53) are calculated
as the length of the chord defined by the intersection of the line at lateral offsets x
and y parallel to the beam axis and the chamber:

A:w ( x, y) = 1, -L 2 £ y £ L 2 and x = 0

B:w ( x, y) = R 2 - x 2 , -L 2 £ y £ L 2 and x £ R

ìïw x, y = R 2 - x 2 ,
ïï ( ) -L 2 £ y < Lce -L 2 and x £ R
ïï
C:í 2
ïïw ( x, y) = R 2 ( y - L 2) - x 2 , L - L 2 £ y £ L 2 and x £ R y - L 2
ïï 2 ce
Lce - L
ïîï (Lce - L)

ìïw x, y = R 2 - x 2 - R 2 - x 2 , -L 2 £ y < L -L 2 and x < R

ïï ( ) ce ce ce
ïï
ïïw ( x, y) = R 2 - x 2 , -L 2 £ y < Lce -L 2 and Rce £ x
D:ïí
ïï ï 2
ïïw ( x, y) = R 2
( y-L 2) y -L 2
2
- x 2 , Lce -L 2 £ y £ L 2 and x £ R
ïï (Lce - L) L ce - L
ïî

and w(x,y) = 0 for any point at a position not defined in the expressions above.
The resulting volume averaging correction factors are given in Table 31.
If model D is considered to be the most accurate chamber representation,
then Eq. (52) overestimates slightly the volume averaging effect because it assigns
too much weight to the peripheral radial regions of the chamber. However, it is
clear that all models yield results within reasonable agreement. For this reason,
the volume averaging correction is calculated in this COP for FFF beam types in
clinical use according to model A, i.e. a simple integration over a line having the
length of the thimble ionization chamber.

148
FIG. 22.  Upper panel: illustration (not to scale) of the four models considered for the
calculation of the volume averaging correction for a thimble ionization chamber in an
FFF beam: (A) a line shaped detector of 2.3 cm length, (B) a cylinder of 2.3 cm length and
0.6 cm diameter, (C) a cylinder of 2.12 cm length and 0.6 cm diameter with a conical tip of
0.18 cm length (corresponding to a Farmer type cavity volume without a central electrode),
and (D) a cylinder of 2.12 cm length and 0.6 cm diameter with a conical tip of 0.18 cm length
and a cylindrical central electrode of 2.12  cm length and 0.11  cm diameter (corresponding
to a Farmer type chamber with central electrode). Lower panel: lateral beam profile of a
CyberKnife [83] used for illustrating the calculation of the volume averaging correction.

149
 TABLE 31.  VOLUME AVERAGING CORRECTION
f
FACTORS (k vol )Qref
(calculated with Eqs (52) or (53) using the weighting factors
w(x,y) of the four models illustrated in Fig. 22)
f ref
Method (k vol )Q
Eq. (52) (Kawachi) 1.011 6

Eq. (53) Model A 1.010 8

Eq. (53) Model B 1.011 4

Eq. (53) Model C 1.010 5

Eq. (53) Model D 1.010 5

Measured lateral beam profiles were extracted from the literature for
Varian TrueBeam [27], Siemens Artiste [185], TomoTherapy HiArt [186] and
CyberKnife [83] machines. For the FFF beams in an Elekta Versa HD, beam
profiles were kindly provided by W. Lechner from the Medical University of
Vienna. For the Varian TrueBeam and Elekta Versa HD, profiles for nominal
accelerator potentials of 6  MV and 10  MV were included in the calculations.
Figure  23 shows the volume averaging effect (the reciprocal of the volume
averaging correction factor) for these beam profiles. It can be observed that,
except for the CyberKnife, the volume averaging effect is very similar for all
beams with nominal accelerator potentials of 6–7 MV. The same can be concluded
for 10 MV beams. The much larger volume averaging effect for CyberKnife can
be explained by a combination of the influence of the closer measuring distance
and the narrower primary collimator.
As a result of a fitting procedure for these data it was found that, except for
the CyberKnife, the volume averaging effects in Fig. 23 are reproduced within
0.05% for chamber lengths up to 2.4  cm by the following expression for the
correction factor:

2
-3 æ 100 ö÷
k
f ref
( vol )Q = 1 + ( 6.2 ´ 10 -3
× TPR 20,10 (10 ) - 3.57 ´ 10 ) ççè SDD ÷÷ø × L2 (54)
× ç

where L is the length, in cm, of the thimble ionization chamber and SDD is the
source-to-detector distance (which equals the source-to-surface distance, SSD,

150
FIG. 23.  Volume averaging effect (the reciprocal of the volume averaging correction factor)
for various FFF beams based on measured profiles and calculated using Eq. (53) according to
model A in Fig. 22.  Source-to-surface distances (SSD) and depths (d), both in cm, for which
the profiles have been measured are indicated in the legends. The full lines are quadratic fits
with only the coefficient of the second order term as free parameter (the zero-th and first order
terms being fixed at 1 and 0).

plus the measurement depth), in cm. The assumption is made that the field size is
defined at a distance of 100 cm from the photon source.
Using %dd(10,10)x the following expression was found to provide similar
accuracy:
æ 100 ö÷ 2 2
= 1 + (5.9 ´10 -5 ×%dd (10,10) X - 3.38 ´10 -3 )× çç
f ref
(k vol )Q çè SDD ÷÷ø
× L (55)

For CyberKnife machines, these expressions are not adequate due to the
considerably larger volume averaging effects. An accurate expression for the
volume averaging correction factor for CyberKnife machines at an SSD of 80 cm
and a measurement depth of 1.5 cm was found to be:
f ref
(k vol )Q = 1 + 1.9´10 -3 × L2 (56)

Table  32 gives the generic volume averaging correction factors for

different ionization chambers as a function of TPR20,10(10) or beam type used
in this COP. They are all based on Eq. (54) and an SDD of 100 cm, except for

151
CyberKnife where they are based on Eq.  (56). For TomoTherapy machines,
TPR20,10(10) = 0.645 was selected as a typical value derived from literature data;
it corresponds to a 10 cm × 10 cm hypothetical reference field. These values have
been used in the calculation of the generic values of kQf ref for FFF beams given in
Table 13.
f
If the measurement is performed at a different SDD or if a specific (k vol )Qref
is available, determined directly from a measured lateral beam profile, the generic
f
k Qref can be multiplied by the ratio of the specific volume averaging correction
factor as follows (values are given in Table 32):

ék f ref ù specific
specific Table 12 ê( vol )Q ú
(kQf ) ref
( f
= k Qref ) ë
ék
û
f ref ù Table 32
ê( vol )Q ú (57)
ë û

specific
where éê(k vol )Qref ùú
f f
represents the ‘better’ estimate of (k vol )Qref .
ë û
f
I.2.4. k Qref values for FFF beams

k Qref values (with reference to Q0 =  60Co) for FFF beams as a function of
f

TPR20,10(10) have been obtained as the product of the kQf ref values for WFF beams
in Table 12, correction factors for the difference in water to air stopping-power
ratio from Table 30 and the volume averaging correction factors from Table 32.
The recommended set of kQf ref values for FFF beams is given in Table 13.
To obtain the %dd(10,10)x corresponding to the TPR20,10(10) values in the
table in a way similar to that used for WFF beams, a separate table of kQf ref as a
function of %dd(10,10)x was built for a range of initial %dd(10,10)x estimates.
These kQf ref values were obtained as the product of interpolated kQf ref values from
Table 12, correction factors for the difference in water to air stopping-power ratio
derived from the fits in Fig. 21 and volume averaging corrections calculated with
Eq.  (55). New estimates of the corresponding %dd(10,10)x were then obtained
by iteratively minimizing the sum of the squares of differences between the
f
k Qref values in both tables and recalculating the correction factors for the difference
in water to air stopping-power ratios and the volume averaging corrections for
the new estimates of %dd(10,10)x in each step of the iteration. This procedure
leads to the values of %dd(10,10)x given in Table 30, and the product of the three
factors results in the kQf ref values of Table 13. Note that kQf msr
msr
, f ref
values are assumed
f ref
to be identical to the tabulated kQ values.
There is evidence from measured or Monte Carlo calculated data to support
these values, but it is mostly restricted to CyberKnife or TomoTherapy machines.
For the CyberKnife beams, an experimental investigation compared the response

152
 f
TABLE 32. GENERIC VOLUME AVERAGING CORRECTION FACTORS (k vol )Qref

(TomoTherapy
Ion chamber TPR20,10(10) = 0.63 0.66 0.69 0.72 0.75 CyberKnife
HiArt)a

Capintec PR-06C/G Farmer 1.002 1.003 1.003 1.004 1.005 1.009 1.002

Exradin A2 Spokas 1.000 1.001 1.001 1.001 1.001 1.002 1.001

Exradin A12 Farmer 1.002 1.003 1.004 1.005 1.006 1.011 1.003

Exradin A12S 1.000 1.001 1.001 1.001 1.001 1.003 1.001

Exradin A19 1.002 1.003 1.004 1.006 1.007 1.012 1.003

Nuclear Assoc 30-751 Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

Nuclear Assoc 30-752 Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

NE 2505/3, 3A Farmer 1.002 1.003 1.004 1.005 1.006 1.011 1.002

NE 2571 Farmer 1.002 1.003 1.004 1.005 1.006 1.011 1.002

NE 2611 1.000 1.000 1.001 1.001 1.001 1.002 1.000

PTW 23331 rigid 1.002 1.003 1.003 1.004 1.005 1.009 1.002

PTW 23332 rigid 1.001 1.002 1.002 1.003 1.003 1.006 1.001

153
 f

154
TABLE 32. GENERIC VOLUME AVERAGING CORRECTION FACTORS (k vol )Qref (cont.)

(TomoTherapy
Ion chamber TPR20,10(10) = 0.63 0.66 0.69 0.72 0.75 CyberKnife
HiArt)a

PTW 23333 (3 mm cap) 1.002 1.003 1.003 1.004 1.005 1.009 1.002

PTW 30001 Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

PTW 30010 Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

PTW 30002/30011 Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

PTW 30004/30012 Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

PTW 30006/30013 Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

PTW 31003/31013 Semiflex 1.001 1.001 1.002 1.002 1.003 1.005 1.001

SNC 100700-0 Farmer 1.002 1.003 1.004 1.005 1.006 1.011 1.003

SNC 100700-1 Farmer 1.002 1.003 1.004 1.005 1.006 1.011 1.003

Victoreen Radocon III 555 1.002 1.003 1.004 1.005 1.006 1.010 1.002

Victoreen 30-348 1.001 1.002 1.002 1.003 1.003 1.006 1.001

Victoreen 30-351 1.002 1.003 1.004 1.005 1.006 1.010 1.002

 f
TABLE 32. GENERIC VOLUME AVERAGING CORRECTION FACTORS (k vol )Qref (cont.)

(TomoTherapy
Ion chamber TPR20,10(10) = 0.63 0.66 0.69 0.72 0.75 CyberKnife
HiArt)a

Victoreen 30-349 1.002 1.003 1.003 1.004 1.005 1.009 1.002

Victoreen 30-361 1.002 1.003 1.004 1.004 1.005 1.009 1.002

IBA FC-65P (Wellhöfer IC 69) Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

IBA FC-65G(Wellhöfer IC 70) Farmer 1.002 1.003 1.004 1.005 1.006 1.010 1.002

Note: Calculated using Eq. (56) for the CyberKnife and Eq. (54) at an SDD = 100 cm for all other FFF beams.
a
For TomoTherapy machines, TPR20,10(10) = 0.645 is used as a typical value derived from literature data; it corresponds to a 10 cm × 10 cm
hypothetical reference field.

155
of a PTW 30013 Farmer chamber in water at 5  cm depth with that of alanine
, f ref
dosimeters [76, 82]. The results were presented in the form of k Qf msr msr ,Q
, but from
, f ref
the data reported, the value of kQf msr msr
can be calculated to be 0.991 ± 0.016 [76]
and 0.989 ± 0.016 [82]. While these results are approximately 1% lower than
the value given in Table  13, the difference is within the uncertainties of the
, f ref
measurement. Various authors have calculated kQf msr msr
data by the Monte Carlo
method, either from detailed simulations of the ionization chamber geometry [51]
or by calculation of the contributing factors in the equation for beam quality
correction factors [81,  187,  188]. Because the latter three papers only include
values not corrected for volume averaging, data with and without the volume
averaging correction factors from Table 32 applied are shown in Table 33. Good
agreement between the Monte Carlo calculated data and the data of Table 13 can
be observed for all chambers investigated.
For TomoTherapy machines, only two experimental investigations are
related to ionization chamber types recommended in this COP for reference
dosimetry [189, 190]. The response of a NE 2611 chamber was compared with
, f ref
that of alanine, resulting in kQf msr
msr
 = 0.996 [189], which can be compared to the
0.993 value in Table 13. Another publication compared the response of NE 2611
, f ref
and NE 2571 chambers with alanine, obtaining kQf msr msr
values of 0.992 and 1.010,
respectively [190]; these can be compared to the corresponding values of 0.993
and 1.003 in Table 13. Other experimental studies [190, 191], as well as Monte
Carlo calculations [28, 30], have confirmed that the data for an A1SL chamber
also agree with values calculated using the method described in this Appendix
to arrive at the data in Table  13. Monte Carlo calculations for some of the
chambers recommended in this COP, obtained either from detailed simulations
of the chamber geometry [186] or by calculation of the contributing factors in the
equation for beam quality correction factors, have also been reported [192]; they
are compared in Table  34 with the values recommended in this COP, and they
again show good agreement.

I.2.5. Uncertainties of kQf ref values for FFF beams

The uncertainty of kQf ref values for WFF beams needs to be combined with
those for the correction of the water to air stopping-power ratio, the assumption
that perturbation correction factors are the same as for WFF beams and the
volume averaging correction factor.
The uncertainty on the correction of the water to air stopping-power ratio
has been estimated by assuming an asymmetric triangular distribution with the
WFF data as upper limit, the Xiong and Rogers data [35] as lower limit and the
values from Dalaryd et al. [37] as mode. For the data as a function of TPR20,10(10)
this results in a relative standard uncertainty of 0.2%, while for the data as a

156
TABLE 33.  COMPARISON OF MONTE CARLO CALCULATED VALUES
OF k Qf , f a FOR CYBERKNIFE MACHINES FROM FOUR REFERENCES
msr

msr
ref

AND THOSE OBTAINED IN THIS CODE

f , f ref a
Ionization chamber k Qmsr
msr

Reference [51] [187] [81] [188] This COP

0.996 0.995 0.993

Exradin A12
1.006 (1.007) (1.006) 1.004

0.995 0.991
Exradin A12S
(0.998) 0.993

0.992
NE 2571
1.003 1.003

0.994 0.991
NE 2561/2611
(0.996) 0.993

0.989 0.989
PTW 30001
(0.999) 0.999

0.992 0.991
PTW 30002
(1.002) 0.999

0.993 0.993
PTW 30004
(1.003) 1.003

1.000 0.989 0.991 0.989

PTW 30006/30013
(0.999) (1.001) 0.999

Note: For each chamber, the upper row corresponds to values without a volume averaging
correction factor and the lower row to corrected values (those within parenthesis have
been derived from the published values using the generic volume averaging correction
factors in Table 32).
a f ,f
k Qmsr ,Qref with reference to Q0 = 60Co.
msr 0

function of %dd(10,10)x the resulting relative standard uncertainty is negligible

(<0.05%).
For the generic volume averaging correction factors used in the calculations,
a relative standard uncertainty of 0.2% has been assumed based on (i)  the
agreement of the generic data with those calculated for the individual beams,
(ii) the simplification made by using model A in Fig. 22, (iii) uncertainties of the
ionization chamber geometries, and (iv) the assumption of generic beam profiles

157
TABLE 34.  COMPARISON OF MONTE CARLO CALCULATED VALUES
OF k Qf , f a FOR TOMOTHERAPY HIART MACHINES FROM TWO
msr

msr
ref

REFERENCES AND THOSE USED IN THIS CODE

f , f ref a
Ionization chamber k Qmsr
msr

Reference [186] [192] This COP

0.996
Exradin A12
1.000 0.998

0.995 0.994
NE 2571
0.997 (0.997) 0.996

0.995 0.993
PTW 30006/30013
0.997 (0.997) 0.995

Note: For each chamber, the upper row corresponds to values without a volume averaging
correction factor and the lower row to corrected values (those within parenthesis have
been derived from the published values using the generic volume averaging correction
factors in Table 32).
a f ,f
k Qmsr ,Qref with reference to Q0 = 60Co.
msr 0

established from variations of profiles measured by different authors for the same
machine type.
Given the slow variation of other correction factors with beam quality, the
assumption that they are the same for FFF and WFF beams was estimated to result
in an additional uncertainty contribution of not more than 0.1%. The resulting
estimation of the combined relative standard uncertainty of the recommended
f
k Qref values for FFF beams given in Table 13 is therefore 1%. Based on current
knowledge and uncertainty estimates, it is assumed that kQf msr
msr
, f ref
equals kQf ref for the
hypothetical conventional reference field of the machine. No data are available
on the variation of the water to air stopping-power ratios with field size, but
given that the photon scatter contribution at the measurement point is smaller for
FFF beams than for WFF beams, it can be assumed that this variation of water to
air stopping-power will be even smaller for FFF beams. Thus, the same relative
standard uncertainty of 0.15% for the sw,air contribution is deemed appropriate.
, f ref
This contribution will only marginally increase the overall uncertainty of kQf msr msr
f ref
values as compared to the uncertainty of kQ values.
Similar considerations as for WFF beams apply concerning the uncertainty
component for the matching of %dd(10,10)x to TPR20,10(10) data and when the
calibration beam quality Q0 is not 60Co, but another FFF linac beam.

158
I.2.6. Equivalent uniform square field sizes of FFF beams

In FFF beams, the scatter for a given field size is smaller than in WFF beams
due to the non-uniform lateral beam profile. As a result, for a 10  cm × 10  cm
reference field, the equivalent uniform square field side is smaller than 10 cm.
Measured ratios of ionization chamber readings as a function of field
size show that the scatter function of FFF beams is very similar to that of WFF
beams and, especially for equivalent square field sides smaller than 12  cm,
cannot be distinguished; hence, the scatter function given in Eq. (50) can be used
for FFF beams. In the integration over the field area, however, a function F(r)
describing the radial dependence of the lateral beam profile has to be introduced14:

1 æ e -lr ö
SC field = òò çççl (1 - m) + ml 2e -lr ÷÷÷ F (r )rdrdq (58)
2p field area ç è r ÷ø

Note that Eq. (51) for WFF beams is only a special case of Eq. (58), with
F(r) = 1. Using the same approach as for WFF beams, i.e. defining field sizes to
be equivalent if their scatter components, calculated with Eq. (58), are the same,
equivalent uniform square field sizes were calculated for square, circular and
rectangular fields in FFF beams using published lateral beam profiles measured
at the depth of maximum dose. The results for 6–7 MV and 10 MV beams were
obtained as averages of all available data for each nominal accelerating potential,
and provided as generic values for 6–7  MV and 10  MV beams in Tables  16
and 17, respectively.
Samples of the values are shown in Fig. 24, which illustrates the dependence
of the relation between different field shapes for 6–7  MV and 10  MV beams;
these differ due to the difference in the non-uniform lateral beam profiles. The
equivalent flattened square field size on the ordinate axis is not to be confused
with an equivalent square field in a WFF beam but rather here is a (virtual)
uniform field with the same photon spectrum as the non-uniform msr or ref field
in the FFF beam. Since having different FFF fields with the same equivalent
uniform square field size means that they have the same scatter component,
equivalent square field sizes of circular or rectangular FFF fields can be obtained
from Fig. 24 using the same procedure as in Fig. 20.

14
For simplicity it is assumed that FFF beams have radial symmetry, but any 2-D profile
could be used in the integration.

159
FIG. 24.  Equivalent uniform square field sizes of msr fields of various shapes and dimensions
in FFF beams with nominal accelerating potentials of 6 MV (upper panel) and 10 MV (lower
panel). The dimension of the FFF field, represented on the horizontal axis, refers to the size of
square fields, the diameter of circular fields or the width X of rectangular fields with a length
of 10 cm.

160
 Appendix II

DETERMINATION OF FIELD OUTPUT CORRECTION FACTORS

AND THEIR UNCERTAINTY ESTIMATES

Following the considerable amount of research in small megavoltage photon

beam dosimetry during recent years, there is a large amount of experimental and
Monte Carlo calculated data available for detector specific15 output correction
, f msr
factors, kQf clin
clin,Qmsr
, particularly for certain solid state detectors and ionization
chambers on the central axis of 6 MV beams. Unfortunately, the published data
are rather scattered for certain field sizes, especially for the smallest fields, and
lack homogeneity with regard to the SSD or SDD used, the depth of measurement
or calculation, the definition of field size at the surface or at a reference depth,
etc. To further complicate the determination of average values for the different
detectors and their subsequent statistical analysis, most of the published data
lack a proper estimation of the uncertainty in the various steps involved in the
determination of the correction factors given by the different authors.

II.1. SELECTION OF DATASETS FOR DERIVING FIELD OUTPUT

CORRECTION FACTORS

To derive small field output correction factors from the literature for the
range of small field detectors considered in this COP, three types of datasets have
been considered:

(i) Reference detectors, perturbation free except for volume averaging

When available, experimental data were obtained by comparing the field

size dependence of the small field detector with that of another small field
(reference) detector which can be assumed to be perturbation free except for
volume averaging. This is the case for reference detectors with radiological
properties and densities that are not too different from the corresponding
values for water, and, since they enter Eq. (47) as a ratio, it can be assumed
that no other correction than volume averaging is required. Examples
of such reference detectors are alanine, TLDs, organic scintillators and
, f msr
radiochromic film. For these detectors, the kQf clin
clin,Qmsr
values for the small
field detector were derived from the published data as follows:

15
Monte Carlo calculations of simplified detector geometries are not considered in
this section.

161
 f ,f
M Q [ ref ]´ k vol [ ref ] M Q [ ref ]
k Qclin ,Qmsr [sfd ] = clin msr
(59)
clin msr M Q [sfd ] M Q [sfd ]
clin msr

where the generic notation MQ[#] denotes the reading of detector # in the
field of quality Q, ‘ref’ refers to the reference detector, which is assumed to
be perturbation free except for volume averaging, and ‘sfd’ stands for the
small field detector. The factor kvol[ref] is the volume averaging correction
factor for the reference detector in the clinical small field; this correction
is assumed to be unity for the reference field (i.e. no volume averaging
correction is required for the 10 cm × 10 cm field).
In some cases the published data had already been calculated in this manner
by the authors. In other cases the authors had corrected both the small field
readings of the reference detector and those of the small field detector for
volume averaging and reported ‘residual’ correction factors, i.e. a correction
accounting for all fluence perturbation effects except for volume averaging.
In the latter case, the reported ‘residual’ correction factors have been
multiplied by an estimated kvol[sfd], i.e. the volume averaging correction
factor for the small field detector in the clinical small field. In most cases,
the values according to Eq.  (59) have been derived from the raw data
provided in the publication’s tables, by private communication with the
authors or, if neither of these two was available, by digitizing graphs from
the publications. If more than one reference dosimeter fulfilling the criterion
of being ‘perturbation free except for volume averaging’ was used in a
study, average values of the numerator of Eq. (59) for those detectors were
used. This was the case, for example, with the Azangwe et al. dataset [100],
which reported values for a number of detector types, including two types
of TLDs, two alanine systems and two organic scintillators.

(ii) Reference detector with known output correction factors

Many publications are available in which a range of small field detectors

have been compared but none of them can be considered ‘perturbation free
except for volume averaging’. If output correction factors are available
for one of these detectors, which based on a substantial set of independent
data differ from one another by not more than 5%, experimental output
correction factors for the other detectors have been derived as follows:

f ,f
f ,f
M Q [ ref ]´ k Qclin ,Qmsr [ ref ] M Q [ ref ]
k Qclin ,Qmsr [sfd ] = clin clin msr msr
(60)
clin msr M Q [sfd ] M Q [sfd ]
clin msr

162
 Examples of such suitable reference detectors are unshielded diodes,
stereotactic diodes, natural and artificially grown diamonds and liquid
ionization chambers.

(iii) Monte Carlo calculated output correction factors

Output correction factors from Monte Carlo simulations were derived

according to the expressions given in the international formalism by
Alfonso et al. [8] (see eq. (10)), i.e.:

f ,f
Dw,Q Dw,Q
k Qclin ,Qmsr [sfd ] = clin msr
(61)
clin msr Ddet,Q [sfd ] Ddet,Q [sfd ]
clin msr

where the generic notation Dw,Q stands for the average absorbed dose to
water scored in a small voxel at the reference point in homogeneous water
in a field of quality Q and Ddet,Q[sfd] is the average dose scored in the
small field detector in a field of quality Q. In most publications, the output
correction factors according to Eq. (61) were calculated by the authors, and
in some cases they have been derived from published raw data.
Data obtained with a ‘hybrid procedure’, combining Monte Carlo calculated
field output factors in water, determined from the dose scored in a small
water voxel, with measured ratios of detector readings (as for example
in Ref. [193]) were not used because even for the best commissioned Monte
Carlo model it cannot be assumed that the simulation and the measurement
correspond to the same particle fluence distribution. Such ‘hybrid’ data can,
however, play an important role in the commissioning of a Monte Carlo
model [194, 195].

The field size used for each data point was the equivalent field size at the
measurement depth. For a SAD set-up, the nominal or stated field size corresponds
to the size at the detector position. For SSD set-ups, the field size specified at the
phantom surface has been scaled accounting for the divergence of the beam, i.e.
at measurement depths of 5  cm and 10  cm this requires multiplying the stated
field size by a factor 1.05 and 1.10, respectively. Preference has been given to
measured field sizes, but if these were not available, nominal field sizes have
been used. All data were assumed to apply to a measurement depth of 10 cm in
water. Values obtained at the depth of maximum dose were not considered. For
detectors not showing a substantial field size dependence in square field sizes
above 3 cm, published data obtained at 5 cm depth were assumed to be valid at
10 cm depth. For detectors exhibiting a substantial field size dependence for sizes

163
above 3  cm, such as unshielded diodes, a linear field size dependent correction
was applied based on data from publications where measurements at both depths
were reported.
All the selected published results were renormalized to a 10 cm × 10 cm
reference field size (hence fref = 10 cm × 10 cm). In many publications, data had
been normalized to a smaller intermediate field size (commonly square field sizes
of 3 cm, 4 cm or 5 cm), but data for a 10 cm × 10 cm reference field had been
given as well. In situations where data for a 10 cm × 10 cm reference field were
not available, average ratios of the output correction factors for the same detector
in the intermediate field size obtained from other publications have been used to
renormalize the data. For field sizes that were slightly non-square (e.g. even if
they are nominally square, measured FWHM field sizes could be rectangular),
as well as for circular collimated fields, the equivalent square of small field
sizes was taken as the square having the same area as the rectangular or circular
collimated field following the observations by Cranmer-Sargison et al. [19].

II.2. MEAN VALUES AND UNCERTAINTY ESTIMATES

Mean values of the field output correction factors and uncertainty estimates
have been derived following as closely as possible Ref.  [10], according to a
procedure adapted from Ref. [11]:

(i) Based on the detailed uncertainty estimates made by some authors

[50,  136,  196], uncertainties for the datasets used in the present analysis
have been taken as 1% for all the field sizes in Monte Carlo calculations,
1% for the experimental values with fields larger than 1  cm × 1  cm,
and 2% for the experimental values with fields equal to or smaller than
1  cm × 1  cm. These uncertainties are considered overall uncertainties
of type B, henceforth referred to as u B1. This common choice precludes
any bias due to the uncertainties quoted by the authors of the different
datasets, here assumed to be identical for all the sets within each modality,
experimental or Monte Carlo.
It is emphasized that measurements for the smallest field sizes are
always troublesome, mainly due to the alignment of each detector, which
justifies the criteria above. Monte Carlo calculations for these fields are in
principle not affected by this constraint, although there are other important
contributions to their uncertainty (see step (iii)).
(ii) For each detector, the entire set of data for all field sizes (experimental and
Monte Carlo) has been fitted with respect to the field size S by a function
having the form:

164
 10-a
-
f ,f 1+ d ×e b
k Qclin ,Qref (S ) = S-a
+ c × (S - 10) (62)
clin ref
-
1+ d ×e b

where the data are weighted by the uncertainties of step (i). The coefficient
d can only take the binary values of d  =  +1 or d  =  −1. Data outside the
99% confidence level prediction interval are filtered out and the fit re-done
to determine the final coefficients a, b and c. This step thus yields estimates
, f ref
of the weighted mean k Qf clin
clin,Qref
values as a function of the field size. Note
that the equation contains a normalization forcing the fit to be equal
to 1 for the 10 cm × 10 cm field size. For machines that cannot establish
, f msr
the 10 cm × 10 cm reference field, kQf clin clin,Qmsr
values were derived from the
values given by Eq. (62) as follows:

f ,f
f ,f
k Qclin ,Qref (S )
k Qclin ,Qmsr (S ) = f
clin
,f
ref
(63)
clin msr
k Qmsr ,Qref (S msr )
msr ref

where Smsr is the equivalent square small field size of the machine specific
reference field fmsr.
(iii) An overall type B standard uncertainty, uB, for each field size and detector
type has been estimated from the range of data values, including the
experimental and Monte Carlo values. This is evaluated by assuming that
the limiting values ±L of the data range for each field size correspond to the
95% confidence limits of a normal (Gaussian) distribution; thus uB = L/2.
Note that this is a compromise between assuming a rectangular (u B = L/ 3 )
or a triangular (u B = L/ 6 ) distribution for the data (see Refs [111, 197]).
This overall uB is assumed to correspond to the contribution of possibly
correlated items and details not accounted for in the different publications.
For example, the reading of many detectors often requires elaborate
procedures and corrections, and all measurements are relative to a given
reference detector (of diverse type) whose response often also requires
non-trivial corrections. Also, Monte Carlo data do not account for the
possible influence of the radiation source type (which is particularly
important for the smallest field sizes), there are unknown differences
between a detector’s design (blueprints on which the simulation geometry
is based) and its actual production by the manufacturer, and there are
details about the detector’s operation that cannot be simulated [114]. In
both modalities of data, differences between detectors of the same model
and manufacturer and accelerator-to-accelerator differences are also often
ignored.

165
 For some detectors and/or field sizes, there are only one or two datasets
available and the method does not yield a realistic estimate of uB; in those
few cases the uncertainty has been taken to be as for a similar detector type.
, f msr
(iv) The combined standard uncertainty for the mean kQf clin clin,Qmsr
values, uc,
becomes strongly dominated by the uB above, which is about one order of
magnitude larger than u B1, especially for the smallest beam sizes. Adding
u B to uB in uc would involve some degree of double counting; hence, the
1
uncertainty weights in the fits of step (ii) are used only to weight differently
experimental vs Monte Carlo data for certain field sizes.

II.3. DATASETS AND GRAPHS OF THE STATISTICAL ANALYSIS

Details on the sources of experimental data used in this COP to derive

, f msr
small field output correction factors kQf clin
clin,Qmsr
are given in Table  35, along
with information on the reference detectors and experimental conditions
used for deriving output correction factors in each dataset. Table  36 gives the
corresponding information for the Monte Carlo calculated correction factors.
Detector and machine specific field output correction factors are given in
Tables 23 to 27.
The most substantial collection of data is available for linac beams with
nominal accelerating potentials of 6 MV at a measurement depth of 10 cm. No
indication for significant differences in field output correction factors was found
between MLC collimated beams and stereotactic cone shaped beams, represented
as a function of the equivalent square small field size, confirming earlier
observations [56, 136, 198]. Similarly, no significant differences in data between
FFF and WFF beams were observed, confirming earlier findings reported in the
literature [57, 196, 216].
All the data for 6 MV beams at the reference depth of 10 cm and with
reference to 10 cm × 10 cm conventional reference fields are shown in Figs 25–30
and discussed in the following two paragraphs. In the legends of these six figures,
a distinction is made between experimentally derived values and Monte Carlo
calculated data; additional information is given for some data to distinguish
between different datasets from the same publication. The thick continuous line
and uncertainty bars (enveloped by thin continuous lines) describe the weighted
mean values and their combined expanded uncertainty with a coverage factor of
k = 2 (i.e. at 95% confidence level). The horizontal line sets the limits (0.95–1.05)
within which correction factors are recommended in this COP. Data indicated by
an arrow are discarded during the fitting procedure because they differ by more
than 3 standard deviations from the fitted values.
Text cont. on p. 186.

166
 TABLE 35. SOURCES OF MEASURED DATA, REFERENCE DETECTORS AND EXPERIMENTAL CONDITIONS FOR
THE DETERMINATION OF SMALL SQUARE (SF) AND CIRCULAR (CF) FIELD OUTPUT CORRECTION FACTORS
FOR 6 MV AND 10 MV LINAC BEAMS

SSD Measurement
Publication Small field detectors Reference detector Eq. Beam type/field range
(cm) depth (cm)

Archambault et al. [198] Exradin A16, IBA CC13 Organic scintillator (59) Varian Clinac 90 10
iX/standard MLC,
SF 1–5 cm

Azangwe et al. [100] IBA SFD, IBA PFD, TLD-100, TLD microcubes, (59) Elekta Synergy/Brainlab 90 10
IBA EFD, PTW 60003, alanine (NPL), alanine micro MLC,
PTW 60019, PTW 31018, (Technical University of SF 0.6–6 cm
IBA CC01, IBA CC04, Denmark (DTU)),
IBA CC13, PTW 31014, two organic scintillators
PTW 31016, PTW 31010, (DTU)
PTW 31013

Bassinet et al. [177] Sun Nuclear EDGE, EBT2 radiochromic film, (59) Novalis/m3 micro 100 10
PTW 60016, PTW 60017, TLD microcubes MLC & Varian Clinac
PTW 31018, PTW 60003, 2100/m3 micro MLC,
PTW 31014, IBA SFD SF 0.6–8 cm

Bucciolini et al. [199] PTW 31006 Scanditronix-SFD (60) Elekta SL75-5/standard 95 5

unshielded diode MLC, SF 1–9 cm

167
 TABLE 35. SOURCES OF MEASURED DATA, REFERENCE DETECTORS AND EXPERIMENTAL CONDITIONS FOR

168
THE DETERMINATION OF SMALL SQUARE (SF) AND CIRCULAR (CF) FIELD OUTPUT CORRECTION FACTORS
FOR 6 MV AND 10 MV LINAC BEAMS (cont.)

SSD Measurement
Publication Small field detectors Reference detector Eq. Beam type/field range
(cm) depth (cm)

Cranmer-Sargison et al. [200] PTW 60008, PTW 60012, IBA SFD unshielded diode (60) Varian iX + standard 100 10
PTW 60016, PTW 60017 MLC, Elekta
Synergy/MLCi2,
SF 0.55–5.5 cm,

Crop et al. [201] PTW 31006, PTW 60003 PTW 60003 natural (60) Elekta SLi 95 5
diamond or radiochromic plus/ModuLeaf,
film SF 1–7 cm

Eaton et al. [202] PTW 31010 PTW 60003 natural (60) Siemens 95 5
diamond Oncor/ModuLeaf,
SF 1.05–9.45 cm

Fippel et al. [203] PTW 60008, PTW 31006, PTW 60003 natural (60) Elekta SLi plus/standard 100 10
PTW 31002 diamond MLC, SF 2.2–5.5 cm

Francescon et al. [50] PTW 31014 PTW 60012 unshielded (60) Siemens Primus/ 90 10
diode standard MLC & Elekta
Synergy/standard MLC,
SF 0.45–3 cm
 TABLE 35. SOURCES OF MEASURED DATA, REFERENCE DETECTORS AND EXPERIMENTAL CONDITIONS FOR
THE DETERMINATION OF SMALL SQUARE (SF) AND CIRCULAR (CF) FIELD OUTPUT CORRECTION FACTORS
FOR 6 MV AND 10 MV LINAC BEAMS (cont.)

SSD Measurement
Publication Small field detectors Reference detector Eq. Beam type/field range
(cm) depth (cm)

Godwin et al. [204] Sun Nuclear EDGE, EBT2 radiochromic film (59) Elekta Synergy/mini 100 10
Exradin A16, IBA CC01, MLC Apex SF
IBA CC13 0.5–13 cm

Griessbach et al. [205] PTW 60003, PTW 60008, PTW 60003 natural (60) Siemens Mevatron 100 5
PTW 60012 diamond or PTW 60012 KD-2/Brainlab m3
unshielded diode micro MLC,
SF 0.63–8.4 cm

Haryanto et al. [206] PTW 60008, PTW 31006, PTW 60003 natural (60) Elekta SLi plus/standard 100 10
PTW 31002 diamond MLC, SF 1.1–5.5 cm

Krauss [207] PTW 60008, PTW 60012, PTW 31018 liquid ion (60) Varian Clinac 90 10
PTW 31002, PTW 31016 chamber 2300C-D/standard MLC,
SF 1–7 cm

Lambert et al. [208] PTW 60003, PTW 31002 Organic scintillator (50) Varian Clinac 100 5
21iX/standard MLC,
SF 1.05–9.45 cm

169
 TABLE 35. SOURCES OF MEASURED DATA, REFERENCE DETECTORS AND EXPERIMENTAL CONDITIONS FOR

170
THE DETERMINATION OF SMALL SQUARE (SF) AND CIRCULAR (CF) FIELD OUTPUT CORRECTION FACTORS
FOR 6 MV AND 10 MV LINAC BEAMS (cont.)

SSD Measurement
Publication Small field detectors Reference detector Eq. Beam type/field range
(cm) depth (cm)

Lechner et al. [57] IBA PFD, IBA EFD, Mini-alanine (NPL) (59) Elekta Synergy/Brainlab 90 10
IBA SFD, PTW 60008, micro MLC, SF
PTW 60019, PTW 31018, 0.65–4.25 cm
IBA CC01, IBA CC04,
IBA CC13, PTW 31014,
PTW 31016, PTW 31010

Marsolat et al. [132] PTW 60003 PTW 60017 unshielded (60) Varian Clinac 100 10
diode 2100/microMLC,
SF 0.6–8 cm

Martens et al. [193] PTW 31006 PTW 60003 natural (60) Elekta SLi plus/standard 95 5
diamond MLC, SF 1–8 cm

Ralston et al. [56] IBA PFD, IBA EFD, Organic scintillator (59) Varian Novalis Tx/high 90 10
IBA SFD, PTW 60012 definition MLC, SF and
CF 0.35–6 cm

Ralston et al. [133] PTW 60019 Organic scintillator (59) Varian Novalis Tx/high 90 10
definition MLC, SF and
CF 0.35–6 cm
 TABLE 35. SOURCES OF MEASURED DATA, REFERENCE DETECTORS AND EXPERIMENTAL CONDITIONS FOR
THE DETERMINATION OF SMALL SQUARE (SF) AND CIRCULAR (CF) FIELD OUTPUT CORRECTION FACTORS
FOR 6 MV AND 10 MV LINAC BEAMS (cont.)

SSD Measurement
Publication Small field detectors Reference detector Eq. Beam type/field range
(cm) depth (cm)

Sauer and Wilbert [24] IBA SFD, IBA PFD, PTW 60003 natural (60) Elekta Synergy/ 100 5
PTW 60003, PTW 31006 diamond or microMLC,
Scanditronix-SFD SF 0.4–8 cm
unshielded diode

Schwedas et al. [194] PTW 60008, PTW 60012, PTW 60003 natural (60) Siemens 90 10
PTW 31002, PTW 31006 diamond Primus/standard MLC,
SF 1–5 cm

Stasi et al. [195] Wellhöfer IC15, PTW 60003 natural (60) Varian Clinac 600 100 10
Exradin A14SL, diamond C-D/standard MLC,
Exradin A16, PTW 31006 SF 1.1–5.5 cm

Tanny et al. [196] Sun Nuclear EDGE, Exradin W1 organic (59) Varian TrueBeam/micro 100 10
Exradin A14SL, scintillator MLC, SF and
Exradin A16, CF 0.66–3.3 cm
Exradin A26, PTW 31014

Underwood et al. [197] PTW 60017, PTW 60019 Exradin W1 organic (59) Varian TrueBeam 95 5
scintillator STx/micro MLC,
SF and CF 0.66–3.3 cm

171
 TABLE 36. SOURCES OF MONTE CARLO DATA, COMPUTER CODE USED AND CONDITIONS FOR THE

172
CALCULATION OF SMALL SQUARE (SF) FIELD OUTPUT CORRECTION FACTORS

Monte Carlo system/ SSD Calculation

Publication Small field detectors Beam type/field range
code (cm) depth (cm)

Andreo et al. [11] PTW 60019 Penelope/penEasy Varian Clinac iX/standard 100 10
EGSnrc/egs_chamber MLC, SF 0.55–4.4 cm

Benmakhlouf [209] PTW 60016, PTW 60017, Penelope/penEasy Varian Clinac iX/standard 100 10
Benmakhlouf et al. [210] PTW 60018, PTW 60019, MLC, SF 0.55–4.4 cm
PTW 31016, PTW 31018,
PTW 60003, IBA PFD,
IBA EFD, IBA SFD,
IBA CC01

Cranmer-Sargison et al. [211] PTW 60016, PTW 60017, BEAMnrc/DOSRZnrc Varian iX/standard MLC, 100 10
IBA SFD SF 0.50–5.5 cm

Czarnecki et al. [48, 49] PTW 60016, PTW 60017, BEAMnrc/EGSnrc Siemens KD/standard MLC, 90 10
PTW 31010, PTW 31014, SF 0.5–4 cm
PTW 31016

Francescon et al. [50] PTW 60012, Sun Nuclear BEAMnrc/egs_chamber Novalis Tx/standard MLC, 90 10
EDGE, PTW 31014, SF 0.53–2.1 cm
PTW 31018, Exradin A16
 TABLE 36. SOURCES OF MONTE CARLO DATA, COMPUTER CODE USED AND CONDITIONS FOR THE
CALCULATION OF SMALL SQUARE (SF) FIELD OUTPUT CORRECTION FACTORS (cont.)

Monte Carlo system/ SSD Calculation

Publication Small field detectors Beam type/field range
code (cm) depth (cm)

Kamio et al. [212] Exradin W1, PTW 60012, BEAMnrc/EGSnrc Varian Clinac 90 10
PTW 31018, PTW 60003, 21EX/Millennium MLC,
Exradin A14, SF 0.5–3 cm
Exradin A1SL, alanine

Papaconstadopoulos et al. [213] Exradin W1, Exradin D1V, BEAMnrc/EGSnrc Novalis Tx/standard MLC, 90 5
PTW 60019, SF 0.53–2.1 cm
PTW 31018

Underwood et al. [214] Exradin W1, PTW 60012, BEAMnrc/egs_chamber Varian Clinac iX, 100 5
PTW 31018, PTW 60003, SF 0.26–1.6 cm
Exradin A14,
Exradin A1SL, alanine

Wang et al. [215] IBA CC01 EGSnrc/Cavity Varian Clinac iX, 100 5
SF 0.5–6 cm

173
 (a)

(b)

f ,f
FIG. 25.  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the field
clin ref
size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm, in
water on the central axis of 6 MV photon beams, for two shielded diodes, two unshielded diodes
and two microionization chambers. The uncertainty estimates shown correspond to those for
the individual detectors, which exclude the data indicated by arrows (see Section II.2).

174
 (c)

(d)

f ,f
FIG. 25. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the
clin ref
field size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm,
in water on the central axis of 6 MV photon beams, for two shielded diodes, two unshielded
diodes and two microionization chambers. The uncertainty estimates shown correspond to
those for the individual detectors, which exclude the data indicated by arrows (see Section II.2).

175
 (e)

(f)

f ,f
FIG. 25. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the
clin ref
field size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm,
in water on the central axis of 6 MV photon beams, for two shielded diodes, two unshielded
diodes and two microionization chambers. The uncertainty estimates shown correspond to
those for the individual detectors, which exclude the data indicated by arrows (see Section II.2).

176
 (a)

(b)

f ,f
FIG. 26.  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the field size
clin ref
(in logarithmic scale) and at a depth of 10  cm, for a reference field size 10  cm × 10  cm in
water on the central axis of 6 MV photon beams, for unshielded diodes and the PTW 60019
microdiamond. The uncertainty estimates shown correspond to the global values for detectors
of a given type provided in Table 37.

177
 (c)

(d)

f ,f
FIG. 26. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the
clin ref
field size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm
in water on the central axis of 6 MV photon beams, for unshielded diodes and the PTW 60019
microdiamond. The uncertainty estimates shown correspond to the global values for detectors
of a given type provided in Table 37.

178
 (e)

(f)

f ,f
FIG. 26. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the
clin ref
field size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm
in water on the central axis of 6 MV photon beams, for unshielded diodes and the PTW 60019
microdiamond. The uncertainty estimates shown correspond to the global values for detectors
of a given type provided in Table 37.

179
 (a)

(b)

f ,f
FIG. 27.  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the field size
clin ref
(in logarithmic scale) and at a depth of 10  cm, for a reference field size 10  cm × 10  cm in
water on the central axis of 6 MV photon beams, for shielded diodes. The uncertainty estimates
shown correspond to the global values for detectors of a given type provided in Table 37.

180
 (c)

(d)

f ,f
FIG. 27. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function
clin ref
of the field size (in logarithmic scale) and at a depth of 10  cm, for a reference field size
10 cm × 10 cm in water on the central axis of 6 MV photon beams, for shielded diodes. The
uncertainty estimates shown correspond to the global values for detectors of a given type
provided in Table 37.

181
 (a)

(b)

f ,f
FIG. 28.  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the field
clin ref
size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm in
water on the central axis of 6 MV photon beams, for the PTW 60003 natural diamond detector
and the PTW 31018 liquid ion chamber. The uncertainty estimates shown correspond to the
global values for detectors of a given type provided in Table 37.

182
 (a)

(b)

f ,f
FIG. 29.  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the field
clin ref
size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm
in water on the central axis of 6  MV photon beams, for microionization chambers. The
uncertainty estimates shown correspond to the global values for detectors of a given type
provided in Table 37.

183
 (c)

(d)

f ,f
FIG. 29. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function
clin ref
of the field size (in logarithmic scale) and at a depth of 10  cm, for a reference field size
10  cm × 10  cm in water on the central axis of 6  MV photon beams, for microionization
chambers. The uncertainty estimates shown correspond to the global values for detectors of a
given type provided in Table 37.

184
 (e)

(f)

f ,f
FIG. 29. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function
clin ref
of the field size (in logarithmic scale) and at a depth of 10  cm, for a reference field size
10  cm × 10  cm in water on the central axis of 6  MV photon beams, for microionization
chambers. The uncertainty estimates shown correspond to the global values for detectors of a
given type provided in Table 37.

185
 (g)

f ,f
FIG. 29. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function
clin ref
of the field size (in logarithmic scale) and at a depth of 10  cm, for a reference field size
10  cm × 10  cm in water on the central axis of 6  MV photon beams, for microionization
chambers. The uncertainty estimates shown correspond to the global values for detectors of a
given type provided in Table 37.

For six small field detectors, Fig. 25 shows the data compilation for linac
beams with nominal accelerating potentials of 6 MV at 10 cm depth, the results
of the fits according to Eq.  (62) and the uncertainties estimated according to
the procedure outlined in this Appendix. This figure shows data for pairs of
similar detector types (two shielded diodes, two unshielded diodes and two
microionization chambers) to illustrate that the procedure used for uncertainty
estimation yields values that depend substantially on the nature and amount of
data available for a given detector. They are, for example, less reliable when only
a small number of data sets are available. Given that there is no reason to assume
that for similar detectors the uncertainties vary significantly, detectors have
been grouped as follows: shielded diodes, unshielded diodes, microionization
chambers and mini-ionization chambers. The average uncertainty estimates for
each of these groups have been accepted as applicable to all the detectors of that
group. The PTW 60019 microdiamond detector has been added to the group of
unshielded diodes because its correction factors and uncertainty estimates are
very similar. The PTW 60003 natural diamond and PTW 31018 liquid ionization
chamber have been considered separately because no similar detector types

186
 (a)

(b)

f ,f
FIG. 30.  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the field size
clin ref
(in logarithmic scale) and at a depth of 10  cm, for a reference field size 10  cm × 10  cm in
water on the central axis of 6 MV photon beams, for mini-ionization chambers (note that some
data points at small field sizes fall outside the plotted area). The uncertainty estimates shown
correspond to the global values for detectors of a given type provided in Table 37.

187
 (c)

(d)

f ,f
FIG. 30. (cont.)  Detector specific output correction factors, k Qclin ,Qref (S), as a function of the
clin ref
field size (in logarithmic scale) and at a depth of 10 cm, for a reference field size 10 cm × 10 cm
in water on the central axis of 6 MV photon beams, for mini-ionization chambers (note that
some data points at small field sizes fall outside the plotted area). The uncertainty estimates
shown correspond to the global values for detectors of a given type provided in Table 37.

188
are present in the data compilation. For the PTW 60003 natural diamond, an
additional reason for this separate treatment is that the spread of data points
can be assumed to account for the range of the natural diamond sizes used in
the detector construction, as specified by the manufacturer, and its influence on
the volume averaging correction. Based on this approach, all available data for
6 MV beams with their fits and uncertainty estimates, according to the grouping
described, are shown in Figs 26–30.
For nominal beam accelerating potentials other than 6  MV and for
measurement depths other than 10  cm, the amount of data is limited. Using
the available data, a comparison has been made between 6  MV and 10  MV
beams and for three different measurement depths (10  cm, 5  cm and zmax).
The fitting procedures were exactly the same as for the 6 MV beams at 10 cm
depth. Figure 31 shows the fits for the two energies and at the three depths for
the PTW 60017 unshielded diode, illustrating, as a representative example, the
observations made for all detectors. Because it was observed that the linear
term in Eq. (62) is always smaller in absolute value for 10 MV beams than for
6 MV beams and also systematically decreases in absolute value with decreasing
depth, graphs (b) and (d) show the same data with the linear term subtracted. In
summary, the following observations were made:

—— On average, the ratio of the linear terms (i.e. coefficient c in Eq. (62)) for
10 MV and 6 MV beams is 0.6; this can be explained by the higher mean
energy of the primary beam and thus also the higher mean energy of the
scatter component.
—— On average, the ratio of the linear terms (i.e. coefficient c in Eq. (62)) at
5 cm depth and at 10 cm depth amounts to 0.85, while the ratio of the linear
terms at zmax and at 10 cm depth amounts to 0.35; this can be explained by
the increase of the scatter component with depth.
—— After subtracting the linear term in Eq.  (62) the remaining part of the
correction factors was always within the expanded uncertainty interval of
the fit to all 6 MV data at 10 cm depth; nevertheless, the fit to the data at
zmax was found to be systematically closer to unity than at the other depths,
which was reflected in a reduction of the sigmoid term in Eq.  (62) by
20–60% depending on the detector type.
—— When taking into account the equivalent square small field size at the
measurement depth, the field output correction factors do not depend on
the SDD (observations made for the CyberKnife at distances ranging from
65 cm to 100 cm [217]).

189
 (a)

(b)

f ,f
FIG. 31.  Fits to detector specific output correction factors, k Qclin ,Qref (S), as a function of the
clin ref
field size (in logarithmic scale) for the PTW 60017 unshielded diode for 6  MV and 10  MV
photon beams at a depth of 10 cm in water (graphs (a) and (b)) and for 6 MV photon beams at
depths of 10 cm, 5 cm and zmax (graphs (c) and (d)), for a reference field size 10 cm × 10 cm.
Graphs (b) and (d) represent the same data as graphs (a) and (c) but with the linear term of
Eq. (62) subtracted.

190
 (c)

(d)

f ,f
FIG. 31. (cont.)  Fits to detector specific output correction factors, k Qclin ,Qref (S), as a function
clin ref
of the field size (in logarithmic scale) for the PTW 60017 unshielded diode for 6 MV and 10 MV
photon beams at a depth of 10 cm in water (graphs (a) and (b)) and for 6 MV photon beams at
depths of 10 cm, 5 cm and zmax (graphs (c) and (d)), for a reference field size 10 cm × 10 cm.
Graphs (b) and (d) represent the same data as graphs (a) and (c) but with the linear term of
Eq. (62) subtracted.

191
 The only exception to these observations was the Sun Nuclear EDGE
shielded diode, for which the difference between data for 6  MV and 10  MV
beams was larger than the expanded uncertainty. This could be due to the
particular construction of this detector with the stem and contacts lateral to the
position of the diode, but since this was related to a limited set of data it could
also be an isolated outlier; hence this detector has not been treated differently
from the others in the generation of the data tables.
The fitting parameters a, b, c and d obtained for the 6  MV beams at a
measurement depth of 10  cm (i.e. the fits shown in Figs  26–30) were used to
calculate the data in Table 26. The relative standard uncertainties (coverage factor
k = 1) for the different groups of detectors are given in Table 37. The calculation
of the field output correction factors in Table 27 for 10 MV beams at a depth of
10 cm in water used the same parameters a, b and d in Eq. (62) as for the 6 MV
beam data in Table 26, while the value used for parameter c was 0.6 times the
value for 6 MV beams.
For the CyberKnife, data in Table 23 have been calculated with a reduction
of 40% applied to the sigmoid term, and the value used for parameter c was
0.35 times the value for 6 MV beams at a depth of 10 cm, consistent with the
observations above. By this approach, good agreement was found between
published data for the CyberKnife [51,  76,  136,  217–219] and the data from
Table  23. For TomoTherapy machines, data in Table  24 used the fitting
parameters for the 6 MV beams at a measurement depth of 10 cm, but normalized
to the equivalent square field size of the 5 cm × 10 cm msr field.

192
 TABLE 37. RELATIVE STANDARD UNCERTAINTIES OF THE FIELD OUTPUT CORRECTION FACTORS
IN TABLE 26

Square small Unshielded diodes and Shielded diodes Mini IC Micro IC PTW 60003 PTW 31018
field size S/cm PTW 60019 microDiamond (%) (%) (%) (%) natural diamond (%) liquid ion chamber (%)

0.4 0.9 — — — 2.9 2.2

0.5 0.8 — — 3.2 2.2 1.7

0.6 0.7 1.3 — 2.5 1.7 1.4

0.8 0.6 0.9 3.4 1.6 1.1 1.0

1.0 0.5 0.7 2.5 1.1 0.7 0.9

1.2 0.5 0.6 1.8 0.8 0.6 0.9

1.5 0.5 0.6 1.2 0.6 0.4 0.8

2.0 0.4 0.5 0.7 0.4 0.4 0.8

2.5 0.4 0.4 0.5 0.4 0.4 0.7

3.0 0.4 0.4 0.4 0.4 0.4 0.6

3.5 0.4 0.4 0.4 0.4 0.5 0.6

193
 TABLE 37. RELATIVE STANDARD UNCERTAINTIES OF THE FIELD OUTPUT CORRECTION FACTORS

194
IN TABLE 26 (cont.)

Square small Unshielded diodes and Shielded diodes Mini IC Micro IC PTW 60003 PTW 31018
field size S/cm PTW 60019 microDiamond (%) (%) (%) (%) natural diamond (%) liquid ion chamber (%)

4.0 0.3 0.4 0.4 0.4 0.5 0.5

5.0 0.3 0.3 0.4 0.4 0.5 0.4

6.0 0.3 0.3 0.3 0.3 0.4 0.4

8.0 0.3 0.2 0.3 0.3 0.3 0.2

Note: Listed per group of small field detector types as described in the text.
 REFERENCES

[1] INTERNATIONAL ATOMIC ENERGY AGENCY, Absorbed Dose Determination in

External Beam Radiotherapy: An International Code of Practice for Dosimetry Based
on Standards of Absorbed Dose to Water, Technical Reports Series No. 398, IAEA,
Vienna (2000).
[2] ALMOND, P.R., et al., AAPM’s TG-51 protocol for clinical reference dosimetry of
high-energy photon and electron beams, Med. Phys. 26 (1999) 1847–1870.
[3] BERLAND, V.A., et al., “Determination of the absorbed dose of photon (1–50 MeV)
and electron beams (5–50  MeV) in external radiation therapy”, National Code of
Practice RD-50-691-89 (STANDARTOV, I., Ed.), Izdatelstvo Standartov,
Moscow (1990) (in Russian).
[4] LILLICRAP, S.C., OWEN, B., WILLIAMS, J.R., WILLIAMS, P.C., Code of Practice
for high-energy photon therapy dosimetry based on the NPL absorbed dose calibration
service, Phys. Med. Biol. 35 (1990) 1355–1360.
[5] DEUTSCHES INSTITUT FÜR NORMUNG, Dosismessverfahren nach der
Sondenmethode für Photonen- und Elektronenstrahlung, Teil 2: Ionisationsdosimetrie,
Deutsche Norm DIN 6800-2, DIN, Berlin (1997).
[6] NETHERLANDS COMMISSION ON RADIATION DOSIMETRY, Code of Practice
for the Absorbed Dose Determination in High Energy Photon and Electron Beams,
Rep. NCS-18, NSC, Delft (2008).
[7] McEWEN, M., et al., Addendum to the AAPM’s TG-51 protocol for clinical reference
dosimetry of high-energy photon beams, Med. Phys. 41 (2014) 041501-1–20.
[8] ALFONSO, R., et al., A new formalism for reference dosimetry of small and nonstandard
fields, Med. Phys. 35 (2008) 5179–5186.
[9] INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Preventing
Accidental Exposures from New External Beam Radiation Therapy Technologies,
Publication 112, Pergamom Press, Elsevier, Amsterdam (2009).
[10] BIPM JOINT COMMITTEE FOR GUIDES IN METROLOGY, Evaluation of
Measurement Data: Guide to the Expression of Uncertainty in Measurement (GUM),
JCGM 100:2008, BIPM, Sévres (2008).
[11] ANDREO, P., BURNS, D.T., SALVAT, F., On the uncertainties of photon mass energy-
absorption coefficients and their ratios for radiation dosimetry, Phys. Med. Biol. 57
(2012) 2117–2136.
[12] INSTITUTE OF PHYSICS AND ENGINEERING IN MEDICINE, Small Field MV
Photon Dosimetry, IPEM Rep. 103, IPEM, York (2010).
[13] ATTIX, F.H., Introduction to Radiological Physics and Radiation Dosimetry, John
Wiley & Sons, New York (1986).
[14] PAPACONSTADOPOULOS, P., On the Detector Response and the Reconstruction of
the Source Intensity Distribution in Small Photon Fields, PhD Thesis, McGill
Univ. (2016).
[15] WUERFEL, J., Dose measurements in small fields, Med. Phys. Int. 1 (2013) 81–90.
[16] INTERNATIONAL ELECTROTECHNICAL COMMISSION, Medical Electrical
Equipment: Glossary of Defined Terms, IEC TR 60788, IEC, Geneva (2004).

195
[17] DE VLAMYNCK, K., et al., Dose measurements compared with Monte Carlo
simulations of narrow 6 MV multileaf collimator shaped photon beams, Med. Phys. 26
(1999) 1874–1882.
[18] DAS, I.J., DING, G.X., AHNESJÖ, A., Small fields: Nonequilibrium radiation
dosimetry, Med. Phys. 35 (2008) 206–215.
[19] CRANMER-SARGISON, G., CHARLES, P.H., TRAPP, J.V., THWAITES, D.I.,
A methodological approach to reporting corrected small field relative outputs, Radiother.
Oncol. 109 (2013) 350–355.
[20] DERREUMAUX, S., et al., Mesure de la dose absorbée dans les faisceaux de photons
de très petites dimensions utilisés en radiothérapie stéréotaxique, Rep. DRPH/SER
2008-18, Institut de radioprotection et de sûreté nucléaire, Fontenay-aux-Roses (2008).
[21] EKLUND, K., AHNESJÖ, A., Fast modelling of spectra and stopping-power ratios
using differentiated fluence pencil kernels, Phys. Med. Biol. 53 (2008) 4231–4247.
[22] SANCHEZ-DOBLADO, F., et al., Ionization chamber dosimetry of small photon fields:
A Monte Carlo study on stopping-power ratios for radiosurgery and IMRT beams, Phys.
Med. Biol. 48 (2003) 2081–2099.
[23] EKLUND, K., AHNESJÖ, A., Modeling silicon diode dose response factors for small
photon fields, Phys. Med. Biol. 55 (2010) 7411–7423.
[24] SAUER, O.A., WILBERT, J., Measurement of output factors for small photon beams,
Med. Phys. 34 (2007) 1983–1988.
[25] HUQ, M.S., University of Pittsburgh Cancer Institute and UPMC CancerCenter,
personal communication, 2014.
[26] SJÖSTRÖM, D., BJELKENGREN, U., OTTOSSON, W., BEHRENS, C.F.,
A beam-matching concept for medical linear accelerators, Acta Oncol. 48
(2009) 192–200.
[27] CHANG, Z., et al., Commissioning and dosimetric characteristics of TrueBeam system:
Composite data of three TrueBeam machines, Med. Phys. 39 (2012) 6981–7018.
[28] THOMAS, S.D., MacKENZIE, M., ROGERS, D.W.O, FALLONE, B.G., A Monte
Carlo derived TG-51 equivalent calibration for helical tomotherapy, Med. Phys. 32
(2005) 1346–1353.
[29] LANGEN, K.M., et al., QA for helical tomotherapy: Report of the AAPM Task Group
148, Med. Phys. 37 (2010) 4817–4853.
[30] ZEVERINO, M., AGOSTINELLI, S., PUPILLO, F., TACCINI, G., Determination of
the correction factors for different ionization chambers used for the calibration of the
helical tomotherapy static beam, Radiother. Oncol. 100 (2011) 424–428.
[31] SHARMA, S.C., OTT, J.T., WILLIAMS, J.B., DICKOW, D., Commissioning and
acceptance testing of a CyberKnife linear accelerator, J. Appl. Clin. Med. Phys. 8
(2007) 119–125.
[32] BRITISH INSTITUTE OF RADIOLOGY, Central Axis Depth Dose Data for Use in
Radiotherapy Departments: 1996, BJR Supplement 25, BIR, London (1996).
[33] SAUER, O.A., Determination of the quality index (Q) for photon beams at arbitrary
field sizes, Med. Phys. 36 (2009) 4168–4172.
[34] ANDREO, P., On the beam quality specification of high-energy photons for radiotherapy
dosimetry, Med. Phys. 27 (2000) 434–440.

196
[35] XIONG, G., ROGERS, D.W.O., Relationship between %dd(10)x and stopping-power
ratios for flattening filter free accelerators: A Monte Carlo study, Med. Phys. 35
(2008) 2104–2109.
[36] PALMANS, H., National Physical Laboratory, personal communication, 2015.
[37] DALARYD, M., KNÖÖS, T., CEBERG, C., Combining tissue-phantom ratios to
provide a beam-quality specifier for flattening filter free photon beams, Med. Phys. 41
(2014) 111716-1–6.
[38] PALMANS, H., Determination of the beam quality index of high-energy photon beams
under nonstandard reference conditions, Med. Phys. 39 (2012) 5513–5519.
[39] TASK GROUP 21, RADIATION THERAPY COMMITTEE, AMERICAN
ASSOCIATION OF PHYSICISTS IN MEDICINE, A protocol for the determination of
absorbed dose from high‐energy photon and electron beams, Med. Phys. 10
(1983) 741–771.
[40] INTERNATIONAL ATOMIC ENERGY AGENCY, Absorbed Dose Determination in
Photon and Electron Beams: An International Code of Practice, Technical Reports
Series No. 277, IAEA, Vienna (1987).
[41] ANDREO, P., NAHUM, A., “Absolute dose determination under reference conditions”,
Handbook of Radiotherapy Physics: Theory and Practice (MAYLES, P., NAHUM, A.,
ROSENWALD, J.-C., Eds), Taylor & Francis, Boca Raton, FL (2007) 333–366.
[42] CAPOTE, R., et al., An EGSnrc Monte Carlo study of the microionization chamber for
reference dosimetry of narrow irregular IMRT beamlets, Med. Phys. 31
(2004) 2416–2422.
[43] BOUCHARD, H., SEUNTJENS, J., Ionization chamber-based reference dosimetry of
intensity modulated radiation beams, Med. Phys. 31 (2004) 2454–2465.
[44] WULFF, J., ZINK, K., KAWRAKOW, I., Efficiency improvements for ion chamber
calculations in high energy photon beams, Med. Phys. 35 (2008) 1328–1336.
[45] CROP, F., et al., The influence of small field sizes, penumbra, spot size and measurement
depth on perturbation factors for microionization chambers, Phys. Med. Biol. 54
(2009) 2951–2969.
[46] BOUCHARD, H., SEUNTJENS, J., KAWRAKOW, I., A Monte Carlo method to
evaluate the impact of positioning errors on detector response and quality correction
factors in nonstandard beams, Phys. Med. Biol. 56 (2011) 2617–2637.
[47] SCOTT, A.J., KUMAR, S., NAHUM, A.E., FENWICK, J.D., Characterizing the
influence of detector density on dosimeter response in non-equilibrium small photon
fields, Phys. Med. Biol. 57 (2012) 4461–4476.
[48] FENWICK, J.D., KUMAR, S., SCOTT, A.J., NAHUM, A.E., Using cavity theory to
describe the dependence on detector density of dosimeter response in non-equilibrium
small fields, Phys. Med. Biol. 58 (2013) 2901–2923.
[49] CZARNECKI, D., ZINK, K., Monte Carlo calculated correction factors for diodes and
ion chambers in small photon fields, Phys. Med. Biol. 58 (2013) 2431–2444.
[50] CZARNECKI, D., ZINK, K., Corrigendum: Monte Carlo calculated correction factors
for diodes and ion chambers in small photon fields, Phys. Med. Biol. 59 (2014) 791–794.

197
[51] FRANCESCON, P., CORA, S., SATARIANO, N., Calculation of k f clin, f msr for several
Qclin,Qmsr
small detectors and for two linear accelerators using Monte Carlo simulations, Med.
Phys. 38 (2011) 6513–6527.
[52] FRANCESCON, P., KILBY, W., SATARIANO, N., CORA, S., Monte Carlo simulated
correction factors for machine specific reference field dose calibration and output factor
measurement using fixed and iris collimators on the CyberKnife system, Phys. Med.
Biol. 57 (2012) 3741–3758.
[53] CHARLES, P.H., et al., The effect of very small air gaps on small field dosimetry, Phys.
Med. Biol. 57 (2012) 6947–6960.
[54] UNDERWOOD, T.S.A., WINTER, H.C., HILL, M.A., FENWICK, J.D., Detector
density and small field dosimetry: Integral versus point dose measurement schemes,
Med. Phys. 40 (2013) 082102-1–082102-16.
[55] CHARLES, P.H., et al., Monte Carlo-based diode design for correction-less small field
dosimetry, Phys. Med. Biol. 58 (2013) 4501–4512.
[56] RALSTON, A., LIU, P., WARRENER, K., McKENZIE, D., SUCHOWERSKA, N.,
Small field diode correction factors derived using an air core fibre optic scintillation
dosimeter and EBT2 film, Phys. Med. Biol. 57 (2012) 2587–2602.
[57] LECHNER, W., PALMANS, H., SÖLKNER, L., GROCHOWSKA, P., GEORG, D.,
Detector comparison for small field output factor measurements in flattening filter free
photon beams, Radiother. Oncol. 109 (2013) 356–360.
[58] FRANCESCON, P., BEDDAR, S., SATARIANO, N., DAS, I.J., Variation of k f clin, f msr
Qclin,Qmsr
for the small-field dosimetric parameters percentage depth dose, tissue-maximum ratio,
and off-axis ratio, Med. Phys. 41 (2014) 101708-1–14.
[59] McKERRACHER, C., THWAITES, D.I., Notes on the construction of solid-state
detectors, Radiother. Oncol. 79 (2006) 348–351.
[60] DAS, I.J., KASE, K.R., Higher energy: Is it necessary, is it worth the cost for radiation
oncology? Med. Phys. 19 (1992) 917–925.
[61] INTERNATIONAL COMMISSION ON RADIATION UNITS AND
MEASUREMENTS, Prescribing, Recording, and Reporting Photon-Beam Intensity-
Modulated Radiotherapy Therapy (IMRT), ICRU Rep. 83, ICRU Bethesda, MD (2010).
[62] IZEWSKA, J., International Atomic Energy Agency, personal communication, 2014.
[63] FOLLOWILL, D., IROC Houston Quality Assurance Center, personal
communication, 2014.
[64] SEUNTJENS, J., DUANE, S., Photon absorbed dose standards, Metrologia 46
(2009) S39–S58.
[65] McEWEN, M.R., DuSAUTOY, A.R., Primary standards of absorbed dose for electron
beams, Metrologia 46 (2009) S59–S79.
[66] KRAUSS, A., The PTB water calorimeter for the absolute determination of absorbed
dose to water in 60Co radiation, Metrologia 43 (2006) 259–272.
[67] KRAUSS, A., KAPSCH, R.-P., Calorimetric determination of kQ factors for NE 2561
and NE 2571 ionization chambers in 5 cm × 5 cm and 10 cm × 10 cm radiotherapy
beams of 8 MV and 16 MV photons, Phys. Med. Biol. 52 (2007) 6243–6259.

198
[68] KRAUSS, A., KAPSCH, R.-P., Corrigendum: Calorimetric determination of kQ factors
for NE 2561 and NE 2571 ionization chambers in 5 cm × 5 cm and 10 cm × 10 cm
radiotherapy beams of 8 MV and 16 MV photons, Phys. Med. Biol. 53 (2008) 1151–1152.
[69] KRAUSS, A., KAPSCH, R.-P., ROUIJAA, M., “Calorimetric determination of
kQ factors for NE2561 ionization chambers in 3 cm × 3 cm beams of 6 MV and 10 MV
photons”, Standards, Applications and Quality Assurance in Medical Radiation
Dosimetry (IDOS) (Proc. Int. Symp. Vienna, 2010), Vol. 1, IAEA,
Vienna (2011) 209–218.
[70] DE PREZ, L.A., “Small field dosimetry in high energy photon beams based on water
calorimetry”, Standards, Applications and Quality Assurance in Medical Radiation
Dosimetry (IDOS) (Proc. Int. Symp. Vienna, 2010), Book of Extended Synopses, IAEA,
Vienna (2011) CD-ROM, 291–292.
[71] DUANE, S., et al., An absorbed dose calorimeter for IMRT dosimetry, Metrologia 49
(2012) S168–S173.
[72] RENAUD, J., MARCHINGTON, D., SEUNTJENS, J., SARFEHNIA, A., Development
of a graphite probe calorimeter for absolute clinical dosimetry, Med. Phys. 40
(2013) 020701-1–6.
[73] SANCHEZ-DOBLADO, F., et al., A new method for output factor determination in
MLC shaped narrow beams, Phys. Med. 23 (2007) 58–66.
[74] DJOUGUELA, A., et al., The dose-area product, a new parameter for the dosimetry of
narrow photon beams, Z. Med. Phys. 16 (2006) 217–227.
[75] PICARD, S., BURNS, D.T., ROGER, P., “The BIPM graphite calorimeter standard for
absorbed dose to water”, Standards, Applications and Quality Assurance in Medical
Radiation Dosimetry (IDOS) (Proc. Int. Symp. Vienna, 2010), Vol. 1, IAEA,
Vienna (2011) 55–65.
[76] PANTELIS, E., et al., On the implementation of a recently proposed dosimetric
formalism to a robotic radiosurgery system, Med. Phys. 37 (2010) 2369–2379.
[77] SHARPE, P.H.G., SEPHTON, J.P., “Alanine dosimetry at NPL: The development of a
mailed reference dosimetry service at radiotherapy dose levels”, Techniques for High
Dose Dosimetry in Industry, Agriculture and Medicine (Proc. Symp. Vienna, 1998),
IAEA-TECDOC-1070, IAEA, Vienna (1999) 183–189.
[78] ANTON, M., Uncertainties in alanine/ESR dosimetry at the Physikalisch-Technische
Bundesanstalt, Phys. Med. Biol. 51 (2006) 5419–5440.
[79] SHARPE, P.H.G., SEPHTON, J.P., “Therapy level alanine dosimetry at the NPL”,
Alanine Dosimetry for Clinical Applications (Proc. 216th PTB Seminar, Braunschweig,
2006), PTB-Dos-51, Physikalisch-Technische Bundesanstalt, Braunschweig (2006).
[80] ANTON, M., KAPSCH, R.-P., KRYSTEK, M., RENNER, F., Response of the
alanine/ESR dosimetry system to MV x-rays relative to 60Co radiation, Phys. Med.
Biol. 53 (2008) 2753–2770.
[81] KAWACHI, T., et al., Reference dosimetry condition and beam quality correction factor
for CyberKnife beam, Med. Phys. 35 (2008) 4591–4598.

199
[82] PANTELIS, E., et al., “On the implementation of a recently proposed dosimetric
formalism to a robotic radiosurgery system”, Standards, Applications and Quality
Assurance in Medical Radiation Dosimetry (IDOS) (Proc. Int. Symp. Vienna, 2010),
Book of Extended Synopses, IAEA, Vienna (2011) CD-ROM, 61–62.
[83] ANTYPAS, C., PANTELIS, E., Performance evaluation of a CyberKnife® G4
image-guided robotic stereotactic radiosurgery system, Phys. Med. Biol. 53
(2008) 4697–4718.
[84] DRZYMALA, R.E., WOOD, R.C., LEVY, J., Calibration of the Gamma Knife using a
new phantom following the AAPM TG51 and TG21 protocols, Med. Phys. 35
(2008) 514–521.
[85] GOETSCH, S.J, et al., Physics of rotating gamma systems for stereotactic radiosurgery,
Int. J. Radiat. Oncol. Biol. Phys. 43 (1999) 689–696.
[86] SOMIGLIANA, A., et al., Dosimetry of Gamma Knife and linac-based radiosurgery
using radiochromic and diode detectors, Phys. Med. Biol. 44 (1999) 887–897.
[87] MELTSNER, S.G., DEWERD, L.A., Air kerma based dosimetry calibration for the
Leksell Gamma Knife, Med. Phys. 36 (2009) 339–350.
[88] PALMANS, H., “Small and composite field dosimetry: The problems and recent
progress”, Standards, Applications and Quality Assurance in Medical Radiation
Dosimetry (IDOS) (Proc. Int. Symp. Vienna, 2010), Vol. 1, IAEA,
Vienna (2011) 161–180.
[89] DERREUMAUX, S., BOISSERIE, G., BRUNET, G., BUCHHEIT, I., SARRAZIN, T.,
“Concerns in France about the dose delivered to the patients in stereotactic radiation
therapy”, Standards, Applications and Quality Assurance in Medical Radiation
Dosimetry (IDOS) (Proc. Int. Symp. Vienna, 2010), Vol. 1, IAEA, Vienna (2011) 273–286.
[90] DIETERICH, S., SHEROUSE, G.W., Experimental comparison of seven commercial
dosimetry diodes for measurement of stereotactic radiosurgery cone factors, Med.
Phys. 38 (2011) 4166–4173.
[91] LAUB, W.U., WONG, T., The volume effect of detectors in the dosimetry of small
fields used in IMRT, Med. Phys. 30 (2003) 341–347.
[92] GONZALEZ-CASTAÑO, D.M, et al., A convolution model for obtaining the response
of an ionization chamber in static non standard fields, Med. Phys. 39 (2012) 482–491.
[93] LOOE, H.K., et al., The dose response functions of ionization chambers in photon
dosimetry: Gaussian or non-Gaussian? Z. Med. Phys. 23 (2013) 129–143.
[94] LI, X.A., SOUBRA, M., SZANTO, J., GERIG, L.H., Lateral electron equilibrium and
electron contamination in measurements of head‐scatter factors using miniphantoms
and brass caps, Med. Phys. 22 (1995) 1167–1170.
[95] KALACH, N.I., ROGERS, D.W., Which accelerator photon beams are ‘clinic-like’ for
reference dosimetry purposes? Med. Phys. 30 (2003) 1546–1555.
[96] SIBATA, C.H., MOTA, H.C., BEDDER, A.S., HIGGINS, P.D., SHIN, K.H., Influence
of detector size in photon beam profile measurements, Phys. Med. Biol. 36
(1991) 621–631.
[97] HIGGINS, P.D., SIBATA, C.H., SISKIND, L., SOHN, J.W., Deconvolution of detector
size effect for small field measurement, Med. Phys. 22 (1995) 1663–1666.

200
 [98] GARCIA-VICENTE, F., DELGADO, J.M, PERAZA, C., Experimental determination
of the convolution kernel for the study of the spatial response of a detector, Med.
Phys. 25 (1998) 202–207.
[99] PANTELIS, E., et al., Dosimetric characterization of CyberKnife radiosurgical photon
beams using polymer gels, Med. Phys. 35 (2008) 2312–2320.
[100] AZANGWE, G., et al., Detector to detector corrections: A comprehensive experimental
study of detector specific correction factors for beam output measurements for small
radiotherapy beams, Med. Phys. 41 (2014) 072103-1–16.
[101] SEUNTJENS, J., OLIVARES, M., EVANS, M., PODGORSAK, E., Absorbed dose to
water reference dosimetry using solid phantoms in the context of absorbed-dose
protocols, Med. Phys. 32 (2005) 2945–2953.
[102] TELLO, V.M., TAILOR, R.C., HANSON, W.F., How water equivalent are water‐
equivalent solid materials for output calibration of photon and electron beams? Med.
Phys. 22 (1995) 1177–1189.
[103] KHAN, F.M., The Physics of Radiation Therapy, 4th edn, Lippincott Williams &
Wilkins, Philadelphia, PA (2010).
[104] PODGORSAK, E.B., “External photon beams: Physical aspects”, Radiation Oncology
Physics: A Handbook for Teachers and Students, Vienna, IAEA (2005) 161–217.
[105] SECO, J., CLASIE, B., PARTRIDGE, M., Review on the characteristics of radiation
detectors for dosimetry and imaging, Phys. Med. Biol. 59 (2014) R303–R347.
[106] INTERNATIONAL ELECTROTECHNICAL COMMISSION, Medical Electrical
Equipment: Dosimeters with Ionization Chambers as Used in Radiotherapy,
IEC 60731:2011, IEC, Geneva (2011).
[107] McEWEN, M.R., Measurement of ionization chamber absorbed dose kQ factors in
megavoltage photon beams, Med. Phys. 37 (2010) 2179–2193.
[108] GEORG, D., KNÖÖS, T., McCLEAN, B., Current status and future perspective of
flattening filter free photon beams, Med. Phys. 38 (2011) 1280–1293.
[109] LE ROY, M., et al., Assessment of small volume ionization chambers as reference
dosimeters in high-energy photon beams, Phys. Med. Biol. 56 (2011) 5637–5650.
[110] JOHANSSON, J., et al., “Monte Carlo calculated and experimentally verified correction
factors for clinical reference dosimetry for the Leksell Gamma Knife®: Application of a
new IAEA dosimetry formalism”, paper presented at the 16th Int. Mtg of the Leksell
Gamma Knife Society, Sydney, 2012.
[111] ANDREO, P., PALMANS, H., MARTEINSDÓTTIR, M., BENMAKHLOUF, H.,
CARLSSON-TEDGREN, Å., On the Monte Carlo simulation of small-field
micro-diamond detectors for megavoltage photon dosimetry, Phys. Med. Biol. 61
(2016) L1–L10.
[112] AGOSTINELLI, S., GARELLI, S., PIERGENTILI, M., FOPPIANO, F., Response to
high-energy photons of PTW31014 PinPoint ion chamber with a central aluminum
electrode, Med. Phys. 35 (2008) 3293–3301.
[113] LEYBOVICH, L.B., SETHI, A., DOGAN, N., Comparison of ionization chambers of
various volumes for IMRT absolute dose verification, Med. Phys. 30 (2003) 119–123.

201
[114] ANDERSSON, J., et al., A comparison of different experimental methods for general
recombination correction for liquid ionization chambers, Phys. Med. Biol. 57
(2012) 7161–7175.
[115] TÖLLI, H., SJÖGREN, R., WENDELSTEN, M., A two-dose-rate method for general
recombination correction for liquid ionization chambers in pulsed beams, Phys. Med.
Biol. 55 (2010) 4247–4260.
[116] PARDO-MONTERO, J., GOMEZ, F., Determining charge collection efficiency in
parallel-plate liquid ionization chambers, Phys. Med. Biol. 54 (2009) 3677–3689.
[117] CHUNG, E., DAVIS, S., SEUNTJENS, J., Experimental analysis of general ion
recombination in a liquid-filled ionization chamber in high-energy photon beams, Med.
Phys. 40 (2013) 062104-1–7.
[118] GOMEZ, F., GONZALEZ-CASTAÑO, D., DIAZ-BOTANA, P., PARDO-MONTERO,
J., Study of the PTW microLion chamber temperature dependence, Phys. Med. Biol. 59
(2014) 2705–2712.
[119] WESTERMARK, M., ARNDT, J., NILSSON, B., BRAHME, A., Comparative
dosimetry in narrow high-energy photon beams, Phys. Med. Biol. 45 (2000) 685–702.
[120] EKLUND, K., AHNESJÖ, A., Modeling silicon diode energy response factors for use in
therapeutic photon beams, Phys. Med. Biol. 54 (2009) 6135–6150.
[121] EKLUND, K., Modeling Silicon Diode Dose Response in Radiotherapy Fields Using
Fluence Pencil Kernels, PhD Thesis, Uppsala Univ. (2010).
[122] SCOTT, A.J., NAHUM, A.E., FENWICK, J.D., Monte Carlo modeling of small photon
fields: Quantifying the impact of focal spot size on source occlusion and output factors,
and exploring miniphantom design for small-field measurements, Med. Phys. 36
(2009) 3132–3144.
[123] YIN, Z., HUGTENBURG, R., BEDDOE, A.H., Response corrections for solid-state
detectors in megavoltage photon dosimetry, Phys. Med. Biol. 49 (2004) 3691–3702.
[124] HEYDARIAN, M., HOBAN, P.W., BEDDOE, A.H., A comparison of dosimetry
techniques in stereotactic radiosurgery, Phys. Med. Biol. 41 (1996) 93–110.
[125] McKERRACHER, C., THWAITES, D.I., Verification of the dose to the isocentre in
stereotactic plans, Radiother. Oncol. 64 (2002) 97–107.
[126] BUCCIOLINI, M., et al., Diamond detector versus silicon diode and ion chamber in
photon beams of different energy and field size, Med. Phys. 30 (2003) 2149–2154.
[127] DE ANGELIS, C., et al., An investigation of the operating characteristics of two
PTW diamond detectors in photon and electron beams, Med. Phys. 29 (2002) 248–254.
[128] LAUB, W.U., KAULICH, T.W., NÜSSLIN, F., Energy and dose rate dependence of a
diamond detector in the dosimetry of 4–25 MV photon beams, Med. Phys. 24
(1997) 535–536.
[129] LAUB, W.U., KAULICH, T.W., NÜSSLIN, F., A diamond detector in the dosimetry of
high-energy electron and photon beams, Phys. Med. Biol. 44 (1999) 2183–2192.
[130] BETZEL, G.T., LANSLEY, S.P., BALUTI, F., REINISCH, L., MEYER, J., Clinical
investigations of a CVD diamond detector for radiotherapy dosimetry, Phys. Med. 28
(2012) 144–152.

202
[131] CIANCAGLIONI, I., et al., Dosimetric characterization of a synthetic single crystal
diamond detector in clinical radiation therapy small photon beams, Med. Phys. 39
(2012) 4493–4501.
[132] MARSOLAT, F., et al., A new single crystal diamond dosimeter for small beam:
Comparison with different commercial active detectors, Phys. Med. Biol. 58
(2013) 7647–7660.
[133] RALSTON, A., TYLER, M., LIU, P., McKENZIE, D., SUCHOWERSKA, N.,
Over-response of synthetic microDiamond detectors in small radiation fields, Phys.
Med. Biol. 59 (2014) 5873–5881.
[134] ARCHAMBAULT, L., BEDDAR, A.S., GINGRAS, L., ROY, R., BEAULIEU, L.,
Measurement accuracy and Cerenkov removal for high performance, high spatial
resolution scintillation dosimetry, Med. Phys. 33 (2006) 128–135.
[135] GAGNON, J.-C., et al., Dosimetric performance and array assessment of plastic
scintillation detectors for stereotactic radiosurgery quality assurance, Med. Phys. 39
(2012) 429–436.
[136] MORIN, J., et al., A comparative study of small field total scatter factors and dose
profiles using plastic scintillation detectors and other stereotactic dosimeters: The case
of the CyberKnife, Med. Phys. 40 (2013) 011719-1–11.
[137] LIU, P.Z.Y., SUCHOWERSKA, N., LAMBERT, J., ABOLFATHI, P., McKENZIE, D.R.,
Plastic scintillation dosimetry: Comparison of three solutions for the Cerenkov
challenge, Phys. Med. Biol. 56 (2011) 5805–5821.
[138] PAI, S., et al., TG-69: Radiographic film for megavoltage beam dosimetry, Med.
Phys. 34 (2007) 2228–2258.
[139] DEVIC, S., Radiochromic film dosimetry: Past, present, and future, Phys. Med. 27
(2011) 122–134.
[140] NIROOMAND-RAD, A., et al., Radiochromic film dosimetry: Recommendations of
AAPM Radiation Therapy Committee Task Group 55, Med. Phys. 25 (1998) 2093–2115.
[141] BEKERAT, H., et al., Improving the energy response of external beam therapy (EBT)
GafChromicTM dosimetry films at low energies (≤100  keV), Med. Phys.  41
(2014) 022101-1–14.
[142] ALNAWAF, H., BUTSON, M.J., CHEUNG, T., YU, P.K.N., Scanning orientation and
polarization effects for XRQA radiochromic film, Phys. Med. 26 (2010) 216–219.
[143] RAMANI, R., RUSSELL, S., O’BRIEN, P., Clinical dosimetry using MOSFETs, Int. J.
Radiat. Oncol. Biol. Phys. 37 (1997) 959–964.
[144] FRANCESCON, P., et al., Use of a new type of radiochromic film, a new parallel-plate
micro-chamber, MOSFETs, and TLD 800 microcubes in the dosimetry of small beams,
Med. Phys. 25 (1998) 503–511.
[145] MARINELLO, G., “Radiothermoluminescent dosimeters and diodes”, Handbook of
Radiotherapy Physics: Theory and Practice (MAYLES, P., NAHUM, A.,
ROSENWALD, J.C., Eds), Taylor & Francis, Boca Raton, FL (2007) 303–320.
[146] IZEWSKA, J., HULTQVIST, M., BERA, P., Analysis of uncertainties in the
IAEA/WHO TLD postal dose audit system, Radiat. Meas. 43 (2008) 959–963.

203
[147] AGUIRRE, J.F., ALVAREZ, P., IBBOTT, G.S., FOLLOWILL, D.S., “Testing,
commissioning and validating an optically stimulated luminescence (OSL) dosimetry
system for mailed dosimetry at the Radiological Physics Center”, Standards,
Applications and Quality Assurance in Medical Radiation Dosimetry (IDOS) (Proc. Int.
Symp. Vienna, 2010), Vol. 2, IAEA, Vienna (2011) 411–421.
[148] ARAKI, F., MORIBE, N., SHIMONOBOU, T., YAMASHITA, Y., Dosimetric
properties of radiophotoluminescent glass rod detector in high-energy photon beams
from a linear accelerator and Cyber-Knife, Med. Phys. 31 (2004) 1980–1986.
[149] PERKS, J., GAO, M., SMITH, V., SKUBIC, S., GOETSCH, S., Glass rod detectors for
small field, stereotactic radiosurgery dosimetric audit, Med. Phys. 32 (2005) 726–732.
[150] ABREGO, F.C., CALCINA, C.S., DE ALMEIDA, A., DE ALMEIDA, C.E.,
BAFFA, O., Relative output factor and beam profile measurements of small radiation
fields with an L-alanine/K-band EPR minidosimeter, Med. Phys. 34 (2007) 1573–1582.
[151] MELLENBERG, D.E., DAHL, R.A., BLACKWELL, C.R., Acceptance testing of an
automated scanning water phantom, Med. Phys. 17 (1990) 311–314.
[152] BUTSON, M.J., CHEUNG, T., YU, P.K., Solid water phantom heat conduction: Heating
and cooling rates, J. Med. Phys. 33 (2008) 24–28.
[153] ANDREO, P., BENMAKHLOUF, H., Improved Reference and Relative Dosimetry of
Small Radiation Therapy Photon Beams, SSM Rep. 2014:26, Strålsäkerhetsmyndigheten,
Stockholm (2014).
[154] INTERNATIONAL COMMISSION ON RADIATION UNITS AND
MEASUREMENTS, Stopping Powers for Electrons and Positrons, ICRU Rep. 37,
ICRU, Bethesda, MD (1984).
[155] INTERNATIONAL COMMISSION ON RADIATION UNITS AND
MEASUREMENTS, Tissue Substitutes in Radiation Dosimetry and Measurement,
ICRU Rep. 44, ICRU, Bethesda, MD (1989).
[156] INTERNATIONAL COMMISSION ON RADIATION UNITS AND
MEASUREMENTS, Key Data for Ionizing-Radiation Dosimetry: Measurement
Standards and Applications, ICRU Rep. 90, ICRU, Bethesda, MD (2014).
[157] INTERNATIONAL COMMISSION ON RADIATION UNITS AND
MEASUREMENTS, Radiation Dosimetry: Electron Beams with Energies Between
1 and 50 MeV, ICRU Rep. 35, ICRU, Bethesda, MD (1984).
[158] INTERNATIONAL ATOMIC ENERGY AGENCY, The Use of Plane Parallel Ionization
Chambers in High Energy Electron and Photon Beams: An International Code of
Practice for Dosimetry, Technical Reports Series No. 381, IAEA, Vienna (1997).
[159] NIATEL, M.-T., Rayons X et γ: Influence de la vapeur d’eau sur l’ionisation de l’air
dans le cas d’une chamber à cavité, C. R. Hebd. Séances Acad. Sci. B268
(1975) 361–363.
[160] BOAG, J.W., CURRANT, J., Current collection and ionic recombination in small
cylindrical ionization chambers exposed to pulsed radiation, Br. J. Radiol. 53
(1980) 471–478.
[161] WEINHOUS, M.S., MELI, J.A., Determining Pion, the correction factor for
recombination losses in an ionization chamber, Med. Phys. 11 (1984) 846–849.

204
[162] PALMANS, H., THOMAS, R.A., DUANE, S., STERPIN, E., VYNCKIER, S.,
Ion recombination for ionization chamber dosimetry in a helical tomotherapy unit, Med.
Phys. 37 (2010) 2876–2889.
[163] WANG, Y., EASTERLING, S.B., TING, J.Y., Ion recombination corrections of
ionization chambers in flattening filter-free photon radiation, J. Appl. Clin. Med.
Phys. 13 (2012) 3758.
[164] KRY, S.F., POPPLE, R., MOLINEU, A., FOLLOWILL, D.S., Ion recombination
correction factors (Pion) for Varian TrueBeam high-dose-rate therapy beams, J. Appl.
Clin. Med. Phys. 13 (2012) 3803.
[165] LANG, S., HRBACEK, J., LEONG, A., KLÖCK, S., Ion-recombination correction for
different ionization chambers in high dose rate flattening-filter-free photon beams,
Phys. Med. Biol. 57 (2012) 2819–2827.
[166] DAS, I.J., et al., Accelerator beam data commissioning equipment and procedures:
Report of the TG-106 of the Therapy Physics Committee of the AAPM, Med. Phys. 35
(2008) 4186–4215.
[167] LOW, D.A., MORAN, J.M., DEMPSEY, J.F., DONG, L., OLDHAM, M., Dosimetry
tools and techniques for IMRT, Med. Phys. 38 (2011) 1313–1338.
[168] DAS, I.J., et al., Small fields and non-equilibrium condition photon beam dosimetry:
AAPM Task Group Report 155, Med. Phys. (in preparation).
[169] SAITOH, H., FUJISAKI, T., SAKAI, R., KUNIEDA, E., Dose distribution of narrow
beam irradiation for small lung tumor, Int. J. Radiat. Oncol. Biol. Phys. 53
(2002) 1380–1387.
[170] JONES, A.O., DAS, I.J., JONES, F.L., Jr., A Monte Carlo study of IMRT beamlets in
inhomogeneous media, Med. Phys. 30 (2003) 296–300.
[171] CHEUNG, J.Y., NG, B.K., YU, K.N., Dose enhancement close to platinum implants for
the 4, 6, and 10 MV stereotactic radiosurgery, Med. Phys. 31 (2004) 2787–2791.
[172] JONES, A.O., DAS, I.J., Comparison of inhomogeneity correction algorithms in small
photon fields, Med. Phys. 32 (2005) 766–776.
[173] INSTITUTE OF PHYSICS AND ENGINEERING IN MEDICINE, Physics Aspects of
Quality Control in Radiotherapy, IPEM Rep. 81, IPEM, York (1999).
[174] THWAITES, D.I., MIJNHEER, B., MILLS, J.A., “Quality assurance of external beam
radiotherapy”, Radiation Oncology Physics, IAEA, Vienna (2005) 407–450.
[175] KLEIN, E.E., et al., Task Group 142 report: Quality assurance of medical accelerators,
Med. Phys. 36 (2009) 4197–4212.
[176] BEDDAR, A.S., MASON, D.J., O’BRIEN, P.F., Absorbed dose perturbation caused by
diodes for small field photon dosimetry, Med. Phys. 21 (1994) 1075–1079.
[177] BASSINET, C., et al., Small fields output factors measurements and correction factors
determination for several detectors for a CyberKnife® and linear accelerators equipped
with microMLC and circular cones, Med. Phys. 40 (2013) 071725-1–13.
[178] ZHU, T.C., et al., Report of AAPM Therapy Physics Committee Task Group 74: In-air
output ratio, Sc, for megavoltage photon beams, Med. Phys. 36 (2009) 5261–5291.

205
[179] BENMAKHLOUF, H., JOHANSSON, J., PADDICK, I., ANDREO, P., Monte Carlo
calculated and experimentally determined output correction factors for small field
detectors in Leksell Gamma Knife Perfexion beams, Phys. Med. Biol. 60
(2015) 3959–3973.
[180] ANDREO, P., WULFF, J., BURNS, D.T., PALMANS, H., Consistency in reference
radiotherapy dosimetry: Resolution of an apparent conundrum when 60Co is the
reference quality for charged-particle and photon beams, Phys. Med. Biol. 58
(2013) 6593–6621.
[181] KOSUNEN, A., ROGERS, D.W.O., Beam quality specification for photon beam
dosimetry, Med. Phys. 20 (1993) 1181–1188.
[182] ROSS, C., SHORTT, K., ROGERS, D., DELAUNAY, F., “A test of TPR 20 10 as a
beam quality specifier for high energy photon beams”, Measurement Assurance in
Dosimetry (Proc. Int. Symp. Vienna, 1993), IAEA, Vienna (1994) 309–321.
[183] ROSSER, K., et al., “The NPL absorbed dose to water calibration service for high
energy photons”, Measurement Assurance in Dosimetry (Proc. Int. Symp. Vienna, 1993),
IAEA,Vienna (1994) 73–81.
[184] CEBERG, C., JOHNSSON, S., LIND, M., KNÖÖS, T., Prediction of stopping-power
ratios in flattening-filter free beams, Med. Phys. 37 (2010) 1164–1168.
[185] DZIERMA, Y., LICHT, N., NUESKEN, F., RUEBE, C., Beam properties and stability
of a flattening-filter free 7 MV beam: An overview, Med. Phys. 39 (2012) 2595–2602.
[186] STERPIN, E., MACKIE, T.R., VYNCKIER, S., Monte Carlo computed machine-
specific correction factors for reference dosimetry of TomoTherapy static beam for
several ion chambers, Med. Phys. 39 (2012) 4066–4072.
[187] ARAKI, F., Monte Carlo study of a Cyberknife stereotactic radiosurgery system, Med.
Phys. 33 (2006) 2955–2963.
[188] FRANCESCON, P., CORA, S., CAVEDON, C., SCALCHI, P., STANCANELLO, J.,
CyberKnife dosimetric beam characteristics: Comparison between experimental results
and Monte Carlo simulation, Robotic Radiosurgery 1 (2005) 71–80.
[189] DUANE, S., et al., SU‐FF‐T‐195: Dosimetry audit for tomotherapy using alanine/EPR,
Med. Phys. 33 (2006) 2093–2094.
[190] BAILAT, C.J., BUCHILLIER, T., PACHOUD, M., MOECKLI, R., BOCHUD, F.O., An
absolute dose determination of helical tomotherapy accelerator, TomoTherapy
High-Art II, Med. Phys. 36 (2009) 3891–3896.
[191] GAGO-ARIAS, A., et al., Correction factors for A1SL ionization chamber dosimetry in
TomoTherapy: Machine-specific, plan-class, and clinical fields, Med. Phys. 39
(2012) 1964–1970.
[192] JERAJ, R., MACKIE, T.R., BALOG, J., OLIVERA, G., Dose calibration of
nonconventional treatment systems applied to helical tomotherapy, Med. Phys. 32
(2005) 570–577.
[193] MARTENS, C., DE WAGTER, C., DE NEVE, W., The value of the PinPoint ion
chamber for characterization of small field segments used in intensity-modulated
radiotherapy, Phys. Med. Biol. 45 (2000) 2519–2530.

206
[194] SCHWEDAS, M., SCHEITHAUER, M., WIEZOREK, T., WENDT, T.G.,
Strahlenphysikalische Einflussgrößen bei der Dosimetrie mit verschiedenen
Detektortypen, Z. Med. Phys. 17 (2007) 172–179.
[195] STASI, M., BAIOTTO, B., BARBONI, G., SCIELZO, G., The behavior of several
microionization chambers in small intensity modulated radiotherapy fields, Med.
Phys. 31 (2004) 2792–2795.
[196] TANNY, S., SPERLING, N., PARSAI, E.I., Correction factor measurements for
multiple detectors used in small field dosimetry on the Varian Edge radiosurgery system,
Med. Phys. 42 (2015) 5370–5376.
[197] UNDERWOOD, T.S., ROWLAND, B.C., FERRAND, R., VIEILLEVIGNE, L.,
Application of the Exradin W1 scintillator to determine Ediode 60017 and
microDiamond 60019 correction factors for relative dosimetry within small MV and
FFF fields, Phys. Med. Biol. 60 (2015) 6669–6683.
[198] ARCHAMBAULT, L., et al., Water-equivalent dosimeter array for small-field external
beam radiotherapy, Med. Phys. 34 (2007) 1583–1592.
[199] BUCCIOLINI, M., RUSSO, S., BANCI BUONAMICI, F., PINI, S., SILLI, P.,
Dosimetric characterization of a bi-directional micromultileaf collimator for stereotactic
applications, Med. Phys. 29 (2002) 1456–1463.
[200] CRANMER-SARGISON, G., WESTON, S., EVANS, J.A., SIDHU, N.P.,
THWAITES, D.I., Implementing a newly proposed Monte Carlo based small field
dosimetry formalism for a comprehensive set of diode detectors, Med. Phys. 38
(2011) 6592–6602.
[201] CROP, F., et al., Monte Carlo modeling of the ModuLeaf miniature MLC for small field
dosimetry and quality assurance of the clinical treatment planning system, Phys. Med.
Biol. 52 (2007) 3275–3290.
[202] EATON, D., TWYMAN, N., THOMAS, S., Commissioning a miniature multileaf
collimator for small field radiotherapy, Med. Dosim. 35 (2010) 1–6.
[203] FIPPEL, M., HARYANTO, F., DOHM, O., NÜSSLIN, F., KRIESEN, S., A virtual
photon energy fluence model for Monte Carlo dose calculation, Med. Phys. 30
(2003) 301–311.
[204] GODWIN, G.A., SIMPSON, J.B., MUGABE, K.V., Characterization of a dynamic
multi-leaf collimator for stereotactic radiotherapy applications, Phys. Med. Biol. 57
(2012) 4643–4654.
[205] GRIESSBACH, I., LAPP, M., BOHSUNG, J., GADEMANN, G., HARDER, D.,
Dosimetric characteristics of a new unshielded silicon diode and its application in
clinical photon and electron beams, Med. Phys. 32 (2005) 3750–3754.
[206] HARYANTO, F., FIPPEL, M., LAUB, W., DOHM, O., NÜSSLIN, F., Investigation of
photon beam output factors for conformal radiation therapy: Monte Carlo simulations
and measurements, Phys. Med. Biol. 47 (2002) N133–N143.
[207] KRAUSS, H., The Quest for the Ideal Detector (2016),
http://www.wienkav.at/kav/kfj/91033454/physik/PTW/liquid.htm
[208] LAMBERT, J., et al., A prototype scintillation dosimeter customized for small and
dynamic megavoltage radiation fields, Phys. Med. Biol. 55 (2010) 1115–1126.

207
[209] BENMAKHLOUF, H., Key Data for the Reference and Relative Dosimetry of
Radiotherapy and Diagnostic and Interventional Radiology Beams, PhD Thesis,
Stockholm Univ. (2015).
[210] BENMAKHLOUF, H., SEMPAU, J., ANDREO, P., Output correction factors for nine
small field detectors in 6 MV radiation therapy photon beams: A PENELOPE Monte
Carlo study, Med. Phys. 41 (2014) 041711-1–12.
[211] CRANMER-SARGISON, G., WESTON, S., EVANS, J.A., SIDHU, N.P., THWAITES,
D.I., Monte Carlo modelling of diode detectors for small field MV photon dosimetry:
Detector model simplification and the sensitivity of correction factors to source
parameterization, Phys. Med. Biol. 57 (2012) 5141–5133.
[212] KAMIO, Y., BOUCHARD, H., Correction-less dosimetry of nonstandard photon fields:
A new criterion to determine the usability of radiation detectors, Phys. Med. Biol. 59
(2014) 4973–5002.
[213] PAPACONSTADOPOULOS, P., TESSIER, F., SEUNTJENS, J., On the correction,
perturbation and modification of small field detectors in relative dosimetry, Phys. Med.
Biol. 59 (2014) 5937–5952.
[214] UNDERWOOD, T.S., WINTER, H.C., HILL, M.A., FENWICK, J.D., Mass-density
compensation can improve the performance of a range of different detectors under
non-equilibrium conditions, Phys. Med. Biol. 58 (2013) 8295–8310.
[215] WANG, L.L., BEDDAR, S., Study of the response of plastic scintillation detectors in
small-field 6 MV photon beams by Monte Carlo simulations, Med. Phys. 38
(2011) 1596–1599.
[216] LARRAGA-GUTIERREZ, J.M., BALLESTEROS-ZEBADUA, P.,
RODRIGUEZ-PONCE, M., GARCIA-GARDUNO, O.A., DE LA CRUZ, O.O.,
Properties of a commercial PTW-60019 synthetic diamond detector for the dosimetry of
small radiotherapy beams, Phys. Med. Biol. 60 (2015) 905–924.
[217] FRANCESCON, P., KILBY, W., SATARIANO, N., Monte Carlo simulated correction
factors for output factor measurement with the CyberKnife system: Results for new
detectors and correction factor dependence on measurement distance and detector
orientation, Phys. Med. Biol. 59 (2014) N11–N17.
[218] WILCOX, E.E., DASKALOV, G.M., Evaluation of GAFCHROMIC® EBT film for
CyberKnife® dosimetry, Med. Phys. 34 (2007) 1967–1974.
[219] CHALKLEY, A., HEYES, G., Evaluation of a synthetic single-crystal diamond detector
for relative dosimetry measurements on a CyberKnife™, Br. J. Radiol. 87 (2014).

208
 ABBREVIATIONS

AAPM American Association of Physicists in Medicine

ABS acrylonitrile butadiene styrene
COP Code of Practice
CPE charged particle equilibrium
DAP dose–area product
FFF flattening filter free (beam)
FWHM full width at half maximum (dimension of the lateral beam
profile at 50% of its maximum value)
IAEA International Atomic Energy Agency
ICRU International Commission on Radiation Units and
Measurements
IMRT intensity modulated radiotherapy
IPEM Institute of Physics and Engineering in Medicine
IPSM Institute of Physical Sciences in Medicine
LAC large area parallel plane ionization chamber
LCPE lateral charged particle equilibrium
MLC multileaf collimator
MOSFET metal oxide semiconductor field-effect transistor
msr machine specific reference
NPL National Physical Laboratory
NPSF normalized peak scatter factor
PDD percentage depth dose
PMMA polymethylmethacrylate
PSDL primary standards dosimetry laboratory
PTB Physikalisch-Technische Bundesanstalt
SAD source-to-axis distance
SDD source-to-detector distance (in the case of an ionization
chamber this is commonly referred to as source-to-chamber
distance or SCD)
SFPM Société Française de Physique Médicale
SRS stereotactic radiosurgery
SSD source-to-surface distance
SSDL secondary standards dosimetry laboratory
TCPE transient charged particle equilibrium
TMR tissue maximum ratio
TPR tissue phantom ratio
VSL Van Swinden Laboratory (Dutch Primary Standards
Laboratory)
WFF with flattening filter (beam)

209
 CONTRIBUTORS TO DRAFTING AND REVIEW

Alfonso, R. Instituto Nacional de Oncologia y Radiobiologia, Cuba

Andreo, P. Karolinska University Hospital, Sweden

Capote, R. International Atomic Energy Agency

Christaki, K. International Atomic Energy Agency

Huq, M. Saiful University of Pittsburgh Cancer Institute and UPMC

CancerCenter, United States of America

Izewska, J. International Atomic Energy Agency

Johansson, J. Elekta Instrument AB, Sweden

Kilby, W. Accuray Inc., United States of America

Mackie, T.R. University of Wisconsin, United States of America

Meghzifene, A. International Atomic Energy Agency

Palmans, H. National Physical Laboratory, United Kingdom, and EBG

MedAustron GmbH, Austria

Seuntjens, J. McGill University, Canada

Ullrich, W. Brainlab AG, Germany

Vatnitsky, S. EBG MedAustron GmbH, Austria

211
@ No. 25

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16-37201
 R EL AT ED PUBL ICAT IONS
Atoms for Peace

ABSORBED DOSE DETERMINATION IN EXTERNAL BEAM

RADIOTHERAPY
Technical Reports Series No. 398
STI/DOC/010/398 (229 pp.; 2000)
ISBN: 92-0-102200-X Price: €51.00

IMPLEMENTATION OF THE INTERNATIONAL CODE OF PRACTICE

ON DOSIMETRY IN RADIOTHERAPY (TRS 398):
REVIEW OF TESTING RESULTS
IAEA-TECDOC-CD-1455 (2010)
ISBN: 978-92-0-100610-3 Price: €15.00

DOSIMETRY IN DIAGNOSTIC RADIOLOGY:

AN INTERNATIONAL CODE OF PRACTICE
Technical Reports Series No. 457
STI/DOC/010/457 (359 pp.; 2007)
ISBN: 92-0-115406-2 Price: €75.00

IMPLEMENTATION OF THE INTERNATIONAL CODE OF PRACTICE

ON DOSIMETRY IN DIAGNOSTIC RADIOLOGY (TRS 457):
REVIEW OF TEST RESULTS
IAEA Human Health Reports No. 4
STI/PUB/1498 (129 pp.; 2011)
ISBN: 978-92-0-114010-4  Price: €58.00

CALIBRATION OF REFERENCE DOSIMETERS

FOR EXTERNAL BEAM RADIOTHERAPY
Technical Reports Series No. 469
STI/DOC/010/469 (73 pp.; 2009)
ISBN: 978-92-0-110708-4 Price: €23.00

ACCURACY REQUIREMENTS AND UNCERTAINTIES IN RADIOTHERAPY

IAEA Human Health Series No. 31
STI/PUB/1679 (297 pp.; 2016)
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QUALITY ASSURANCE PROGRAMME FOR COMPUTED TOMOGRAPHY:

DIAGNOSTIC AND THERAPY APPLICATIONS
IAEA Human Health Series No. 19
STI/PUB/1557 (171 pp.; 2012)
ISBN: 978-92-0-128910-0 Price: €48.00

@ www.iaea.org/books
This is the first International Code of Practice
dedicated to the dosimetry of small static fields
used in radiotherapy. It is addressed to clinical
medical physicists using small static photon
fields with energies less than 10 MV, provided
with ionization chambers calibrated in terms of
absorbed dose to water traceable to a primary
standards dosimetry laboratory. It provides
consistent reference dosimetry traceable to
metrological primary standards and enables
common procedures for small field dosimetry
to be followed within a country. An overview
of the physics of small field dosimetry is
presented, followed by a general formalism for
reference dosimetry in small fields. Guidelines
for its practical implementation using suitable
detectors and methods for the determination
of field output factors are given for specific
clinical machines that use small static fields.

INTERNATIONAL ATOMIC ENERGY AGENCY

VIENNA
ISBN 978–92–0–105916–1
ISSN 0074–1914