INSTITUTE OF PHYSICS PUBLISHING PHYSICS IN MEDICINE AND BIOLOGY

Phys. Med. Biol. 50 (2005) 2739–2748 doi:10.1088/0031-9155/50/12/001

ADDENDUM

Addendum to the IPEMB code of practice for the

determination of absorbed dose for x-rays below 300 kV
generating potential (0.035 mm Al–4 mm Cu HVL)
IPEM Working Party: R J Aukett (Chair), J E Burns, A G Greener,
R M Harrison, C Moretti, A E Nahum and K E Rosser
Institute of Physics and Engineering in Medicine, Fairmount House, 230 Tadcaster Road,
York YO24 1ES, UK

Received 18 March 2005

Published 25 May 2005
Online at stacks.iop.org/PMB/50/2739

Abstract
This addendum to the code of practice for the determination of absorbed dose
for x-rays below 300 kV has recently been approved by the IPEM and introduces
three main changes: (i) Due to a lack of available data the original code
recommended a value of unity for kch in the very-low-energy range (0.035–
1.0 mm Al HVL). A single table of kch values, ranging from 1.01 to 1.07,
applicable to both designated chamber types is now presented. (ii) For medium-
energy x-rays (0.5–4 mm Cu HVL) methods are given to determine the absorbed
dose to water either at 2 cm depth or at the surface of a phantom depending
on clinical needs. Determination of the dose at the phantom surface is derived
from an in-air measurement and by extending the low-energy range up to 4 mm
Cu HVL. Relevant backscatter factors and ratios of mass energy absorption
coefficients are given in the addendum. (iii) Relative dosimetry: although
not normally forming part of a dosimetry code of practice a brief review of the
current literature on this topic has been added as an appendix. This encompasses
advice on techniques for measuring depth doses, applicator factors for small
field sizes, dose fall off with increasing SSD and choice of appropriate phantom
materials and ionization chambers.

Introduction

Three factors have made it necessary to publish an addendum to the kilovoltage x-ray code
(IPEMB 1996). First, the code did not include values of kch for very-low-energy x-rays. These
have now been determined. Second, it has become apparent that for medium-energy x-rays
in-air is preferable to in-phantom calibration in many circumstances. This is now given as an
alternative option and the relevant data are included. Third, several requests had been received
for advice on techniques for measuring depth doses, applicator factors for small field sizes
and dose fall off with increasing SSD. This would not normally form part of a dosimetry code

0031-9155/05/122739+10$30.00 © 2005 IOP Publishing Ltd Printed in the UK 2739

2740 IPEM Working Party

of practice. A brief review of the current literature on this topic has therefore been added as
an appendix.

1. Very-low-energy x-rays, 0.035–1 mm Al HVL (approximately 8–50 kV)

1.1. Background
The IPEMB kV code of practice (1996) recommends that the absorbed dose to water at
the surface1 of a full-scatter water-equivalent phantom (Dw,z=0 ) can be determined from the
reading of a thin-window parallel-plate ionization chamber with its window placed flush with
the surface of the phantom using the following formula:
!" # $
µ̄en
Dw,z=0 = MNK kch (1)
ρ w/air
z=0,φ

where M is the instrument reading corrected to the same ambient conditions as the calibration
factor. NK is the in-air chamber calibration factor which converts the reading to air kerma
under scatter-free conditions at the reference point of the chamber with the chamber assembly
replaced by air. It varies with the radiation quality of the incident beam in air and is valid for
the calibration field size, which is 5.3 cm diameter if the calibration factor is traceable to the
National Physical Laboratory. For a thin-window parallel-plate chamber the reference point
is the centre of the window. [(µ̄en /ρ)w/air ]z=0,φ is the ratio of the mass energy absorption
coefficients of water to air averaged over the photon spectrum at the surface of the water
phantom (z = 0) for field diameter φ. kch is a factor that accounts for the change in response
of the ionization chamber between the calibration in-air and the measurement at the surface of
a full-scatter water phantom. In this addendum, it will be called the chamber correction factor.
The product NK kch corrects the chamber reading to air kerma at the reference point of the
chamber with the chamber assembly replaced by water.

1.2. Need for new values of kch

At the time the IPEMB code was written there was very little information available on the
values of the chamber correction factors for parallel-plate ionization chambers. Hence, the
historic practice of assuming a value of unity for kch was endorsed by the code.
Work by Greener (2001), Ipe et al (2001), Perrin et al (2001) and by Dierker (1981) has
shown that kch differs significantly from unity (see table 1). All of the authors determined kch
by comparing the dose measured using the method recommended for low-energy x-rays with
that for very-low-energy x-rays in the IPEMB code of practice (IPEMB 1996). This method
is dependent on the value of the backscatter factor; Ipe et al (2001), Greener (2001) and Perrin
et al (2001) adopted values recommended by Grosswendt (1990), whereas Dierker (1981)
adopted values given in BJR Supplement 11 (BIR 1972).
It is recommended that the value of kch given in IPEMB 1996 is replaced with those
given in table 1. It is expected that kch may depend on measurement field size, chamber type
(M23342 or M23344), focal distance, phantom material and the amount of build-up material
in front of the chamber when it is placed at the surface of a phantom. There are insufficient
data to isolate these effects and so a mean value has been determined and the value of the
uncertainty increased accordingly.
1 Strictly the dose is determined not at the surface but at that small depth at which charge particle equilibrium is first

established.
Addendum to the IPEMB code of practice for the determination of absorbed dose for kV x-rays 2741

Table 1. The chamber correction factor (kch) for PTW type M23344 and M23342 chambers
provided with NK in-air calibration factor, at the surface of a full-scatter water phantom irradiated
with an x-ray beam of diameter 3–15 cm. The data are taken from Dierker (1981), Greener (2001),
Ipe (2001) and Perrin et al (2001). The estimated uncertainties are ±2% (SD).

HVL kch values for PTW chamber

(mm Al) types M23342 and M23344
0.04 1.01
0.06 1.01
0.10 1.01
0.12 1.02
0.15 1.02
0.2 1.03
0.3 1.03
0.4 1.04
0.5 1.05
0.6 1.06
0.8 1.06
1.0 1.07

When using equation (1) it should be noted that the value of NK depends not only on the
x-ray beam quality but also on the field size which was used for the calibration of the chamber
in air. This is because of ‘stem scatter’, i.e. radiation scattered into the collecting volume from
the body of the chamber. Values of NK will decrease with increasing in-air calibration field
size to a minimum value when the body of the chamber is fully irradiated.
It follows therefore that the values of kch will also depend on the field size used for the
calibration of the chamber and will increase with increasing in-air calibration field size. This
is important because different primary standard calibration laboratories may employ different
field sizes when calibrating very-low-energy ionization chambers in air. The values given in
table 1 apply to a calibration field size of 5.3 cm diameter, as used at the National Physical
Laboratory.
The value of kch was measured for a limited range of field sizes and source to chamber
distances but it is expected that the values quoted in table 1 are valid for conditions used in
normal clinical practice. However, it is expected that the value of kch will be dependent on
the phantom material. It is therefore recommended that only water, mix-D (Jones et al 1949)
and WT1 (Constantinou et al 1982) are used as phantom materials as these were used by the
above authors.

1.3. Build-up material

In the IPEMB 1996 kV code of practice it was recommended that when the secondary standard
is compared with the field instrument at the surface of a phantom then build-up material should
be added to bring the wall thickness to at least 8.5 mg cm−2. According to the code this build-
up material removes any electron contamination. This used the data available at the time to
estimate the amount of material required to provide full build-up. Recent data (AAPM 2001)
suggest that a wall thickness of 3 mg cm−2 is sufficient to provide full build-up up to 40 kV.
Monte Carlo calculations by Verhaegen and Shipley (Rosser et al 2003) indicate that the
front window of the PTW M23344 and M23342 is thick enough to provide full build-up
up to 50 kV.
It is therefore recommended that no build-up material is added when using the PTW
M23344 and M23342 chambers up to 50 kV. Note that the reference depth has therefore
2742 IPEM Working Party

changed from (8.5 − 3) = 5.5 mg cm−2 to 0; this will affect depth dose measurements, if these
have been made.

2. In-air calibration for medium-energy x-rays, 0.5–4 mm Cu HVL

(approximately 160–300 kV)

2.1. The need for an alternative procedure

Two alternative methods are recommended for the medium-energy range. Depth doses are
difficult to measure reproducibly near the surface (Harrison 1996, Smith 1996) whereas
backscatter factors can be calculated accurately (Grosswendt 1990, Knight 1992). Thus,
calibration in air gives a more accurate dose at the surface. Calibration at depth gives a more
accurate dose at depth.
The original code (IPEMB 1996) followed ICRU Report 23 (1973) in recommending a
protocol which gave a more accurate dose at depth. However, currently the dose at the surface
is often of more clinical importance. Therefore, the low-energy range is now extended to
allow it to be used up to 4 mm Cu. It is recommended that the choice between calibration
in-phantom or in-air in the range 0.5–4.0 mm Cu HVL is based on whether the primary clinical
requirement in a particular department is to know the dose at depth or at the surface more
accurately.
Thus, if the dose at depth is required more accurately, equation (1) of the original code
is used, together with its associated protocol. If the dose at the surface is required more
accurately, equation (4) and its associated protocol in the original code are used.
New values of mass energy absorption coefficient ratios (for in-air spectra) and new
backscatter factors are required. These are included below.

2.2. Tables of (µ̄en /ρ)w/air

The tables in the original code (IPEMB 1996) were taken from work by Knight (1996). These
do not extend up to 4 mm Cu and the spectra on which the data were based are no longer
readily available. The values given in the AAPM Protocol (2001) were based on a global fit
to several sources including Knight (1996).
It is therefore recommended that the values of the mass energy absorption coefficient
ratios for in-air spectra given in AAPM (2001) are used for in-air calibration over the medium-
energy range. For convenience, these are reproduced in table 2. For full details on the origin
of this data the user should refer to AAPM (2001).

2.3. Tables of backscatter factor

The tables in the original code (IPEMB 1996) were derived as best values from a review
of the Monte Carlo work by Grosswendt (1990) and Knight (1992) and the experimental
measurements by Klevenhagen (1989). The work of Knight (1992) extended up to 5 mm Cu,
but only for 25 cm SSD. AAPM (2001) used values interpolated from Grosswendt (1990)
alone, after first comparing it with the same other two sources. Members of the working party
have independently compared the work of Grosswendt (1990) with that of Knight (1992) from
0.5 to 4.0 mm Cu HVL and found good agreement (within ±1%).
Smith (1996) has pointed out that the Monte Carlo data given by all of the above
authors have been calculated for the spectra produced with open applicators. It is therefore
recommended that the values of backscatter factor given in Grosswendt (1990) are used for
Addendum to the IPEMB code of practice for the determination of absorbed dose for kV x-rays 2743

Table 2. Ratio of the mean mass energy absorption coefficient, water to air, for the primary
spectrum (free-in-air) for medium-energy x-rays. Uncertainty ±1.5% (1 SD). Reproduced from
AAPM (2001) by kind permission.

HVL [(µ̄en /ρ)w/air ]air

(mm Cu) (all field diameters)
0.5 1.050
0.6 1.056
0.8 1.068
1.0 1.076
1.5 1.085
2.0 1.089
3.0 1.100
4.0 1.106
5.0 1.109

Table 3. Backscatter factors Bw for open applicators as a function of HVL, field diameter and
SSD. Statistical uncertainty ±0.5% (1 SD). Reproduced from Grosswendt (1990).

Field diameter (cm)

SSD HVL
(cm) (mm Cu) 1 2 3 5 10 15 20
10 0.486 1.052 1.108 1.150 1.217 1.311 1.348 1.362
0.831 1.045 1.102 1.142 1.208 1.307 1.347 1.364
1.596 1.036 1.078 1.112 1.165 1.246 1.281 1.294
2.457 1.029 1.064 1.091 1.136 1.206 1.237 1.249
3.358 1.024 1.052 1.075 1.113 1.172 1.198 1.209
(4.93) (1.017) (1.038) (1.055) (1.083) (1.127) (1.148) (1.157)

20 0.486 1.053 1.110 1.155 1.234 1.354 1.416 1.447

0.831 1.047 1.101 1.146 1.218 1.338 1.402 1.435
1.596 1.037 1.082 1.118 1.179 1.284 1.343 1.373
2.457 1.028 1.065 1.095 1.146 1.232 1.285 1.314
3.358 1.022 1.050 1.074 1.115 1.186 1.229 1.254
(4.93) (1.018) (1.039) (1.058) (1.089) (1.142) (1.176) (1.196)

30 0.486 1.052 1.108 1.155 1.236 1.368 1.439 1.479

0.831 1.046 1.100 1.145 1.220 1.345 1.420 1.462
1.596 1.037 1.082 1.118 1.179 1.284 1.351 1.390
2.457 1.029 1.063 1.095 1.146 1.240 1.300 1.335
3.358 1.021 1.051 1.076 1.119 1.197 1.250 1.281
(4.93) (1.018) (1.038) (1.056) (1.088) (1.149) (1.191) (1.215)

50 0.486 1.052 1.111 1.157 1.241 1.377 1.452 1.499

0.831 1.047 1.102 1.147 1.224 1.358 1.445 1.495
1.596 1.037 1.081 1.117 1.178 1.296 1.370 1.418
2.457 1.030 1.063 1.094 1.147 1.250 1.318 1.360
3.358 1.021 1.052 1.077 1.120 1.204 1.264 1.302
(4.93) (1.018) (1.040) (1.058) (1.090) (1.154) (1.197) (1.228)

100 0.486 1.052 1.111 1.160 1.242 1.384 1.463 1.513

0.831 1.047 1.103 1.149 1.226 1.367 1.457 1.516
1.596 1.037 1.082 1.118 1.183 1.303 1.384 1.437
2.457 1.031 1.065 1.095 1.148 1.250 1.324 1.370
3.358 1.021 1.052 1.078 1.122 1.210 1.270 1.311
(4.93) (1.018) (1.040) (1.058) (1.091) (1.157) (1.206) (1.240)
2744 IPEM Working Party

in-air calibration with open applicators over the medium-energy range. For convenience these
are reproduced in table 3.
It should be noted that the values given for 4.93 mm Cu HVL are for a mono-energetic
beam of 200 keV and are included only to enable interpolation between 3.358 and 4.0 mm Cu.
Also the values given in the table are raw (unsmoothed) data and contain statistical fluctuations
of about ±0.5% (1 SD).
There is thus a combined uncertainty of about ±1% (1 SD). For this reason, Bw may be
interpolated linearly between field sizes and between HVLs. The uncertainties in the data do
not justify greater precision.
A review of the measured data by Smith (1996) has demonstrated that the backscatter
factors for closed PMMA applicators are larger than those for open ended ones. The increase
is about 1% of the scatter component per millimetre thickness of the PMMA end plate. A
typical end plate is about 3.2 mm thick. It is therefore recommended that for closed ended
PMMA applicators the backscatter factor should be calculated using
Bw,closed = 1 + ((Bw,open − 1) × 1.032) (2)
where Bw,closed is the backscatter factor for the closed applicator and Bw,open is the backscatter
factor for an open-ended applicator taken from the data in table 3.
The uncertainties in the data do not justify using different values for different thicknesses
of PMMA end plate within the range normally encountered.

Appendix. Relative dosimetry: the measurement of depth doses

and applicator factors

Several requests have been received for advice on techniques for measuring depth doses,
applicator factors for small field sizes and dose fall off with increasing SSD on kilovoltage
x-ray machines. This probably reflects the fact that although such techniques have been in
use for many years they are much less frequently used, and therefore much less well known,
than those for megavoltage machines. Relative dosimetry has not previously formed part of an
IPEM dosimetry code of practice. However, the working party decided to add a brief review
of the current literature on this topic as an appendix.
The review which follows represents only a summary of the state of the art at the time of
writing. The reader should refer to the original articles and to subsequent publications.

A.1. Phantom materials

Comparison of depth dose measurements from several centres (Harrison 1997) has shown
that the variation between centres which use a variety of phantom materials is greater than
between those which use only real water. A limited direct comparison between real water,
WT1 water-equivalent resin (Constantinou et al 1982) and PMMA at 2 and 5 cm depth using
300 kVp x-rays (Nisbet et al 1999) has shown a significant difference between real water and
PMMA but not between real water and WT1. A more detailed comparison at 0–9 cm depth
using 100 and 300 kVp x-rays (Allen Li et al 1997) showed significant differences between
water and polystyrene or PMMA but not between real water and water-equivalent resin.
It is recommended that measurements should be made in real water. Water-equivalent
resin phantoms may be used for a particular machine and kVp once their validity has been
established by comparing depth dose measurements with real water for one applicator size.
Other phantom materials should not be used until a more extensive direct comparison has been
published.
Addendum to the IPEMB code of practice for the determination of absorbed dose for kV x-rays 2745

The phantom dimensions should each be sufficiently large that any further increase would
cause no significant change in the instrument reading.

A.2. Ionization chambers

Allen Li et al (1997) used various cylindrical ionization chambers, parallel-plate chambers
designed for electrons and parallel-plate chambers designed for soft x-rays to measure depth
doses for 100 and 300 kVp x-rays. Generally, all the ionization chambers agreed within
±2%. The exception was that at depths of 1 cm or less the depth doses measured with the
parallel-plate chambers designed for electrons were 3% or more lower than those measured
with a Farmer-type chamber.
Rosser (1996) compared depth doses measured using an NE2561 cylindrical ionization
chamber and an NACP electron chamber with Monte Carlo calculations for 100 kVp x-rays.
The depth doses measured with the NACP chamber were 7% higher than the Monte Carlo
at 7 cm depth. Rosser (1998) also compared the air kerma calibration of several ionization
chambers in the range 0.15–4.0 mm Cu HVL. Relative to 1 mm Cu the sensitivity of the
cylindrical and soft x-ray chambers remained within ±4% over the range. However, the
calibration factor for the NACP chamber was 25% higher at 0.15 mm Cu compared to
1 mm Cu.
Aukett et al (1999) measured applicator factors with various ionization chambers for
fields between 7 and 2 cm diameter using 50 and 100 kVp x-rays. The cylindrical chambers
and parallel-plate chambers designed for soft x-rays gave results which agreed within ±2%.
The only electron chamber (NACP) gave factors which were 3–6% higher than this.
It is recommended that measurements should be made with ionization chambers which
are approximately air or water equivalent, i.e. whose air kerma or dose calibration varies by
±5% or less over the range 0.15–4.0 mm Cu HVL. Farmer-type chambers may be assumed
to comply with this requirement, as may the NE 2561 and 2611. Most electron chambers
will not.

A.3. Build-up and waterproof sleeves

Measurements with soft x-ray chambers (Aukett et al 1999) have shown that significant
electron build-up occurs for medium-energy and even for low-energy x-rays. The thickness
required to achieve full build-up at 100 kVp was approximately 5 mg cm−2.
It is recommended that when measurements at medium or low energies are to be made
with parallel-plate chambers designed for soft x-rays the wall thickness required to achieve
full build-up should first be determined. Where the inherent wall thickness is approximately
50 mg cm−2 or more it may be assumed that sufficient build-up has been obtained even for
300 kVp x-rays (AAPM 2001). This is the case for most Farmer-type chambers. (The NE
2571, for example, has a wall 65 mg cm−2 thick.) However, at medium energy care should
be taken with some Farmer-type chambers (e.g., the NE 2581) where the wall is made from
conducting plastic which may be less than 40 mg cm−2 thick.
When measuring build-up most plastics are suitable. However, some materials (e.g.,
photocopy acetate) may contain significant traces of high atomic number elements. Care
should be taken to avoid these. As discussed earlier no build-up is required for measurements
at very low energy when using the PTW M23344 or M23342 chambers.
Monte Carlo calculations for a Farmer-type cylindrical ionization chamber
(Ma and Seuntjens 1997) have shown that the correction factors for 1 mm thick waterproof
sleeves made from PMMA, nylon and polystyrene vary by 0.9, 1.5 and 1.9%, respectively,
2746 IPEM Working Party

between 300 and 50 kVp. For a 2 mm thick sleeve, the factors vary by 1.9, 3.0 and 3.8%.
There is also a variation with depth. At 100 kVp for a 3 mm thick sleeve the values of these
factors vary by 0.3, 0.5 and 0.7%, respectively, between depths of 0 and 7 cm. No correction
was found to be required at 300 kVp for PMMA, nylon or polystyrene sleeves up to 3 mm
thick at a depth of 2 cm in water.
Latex sleeves often contain a fine powder such as magnesium silicate (talc). Early reports
(e.g. Law and Foster 1987, Hanson et al 1988) suggest that such a powder may contaminate
the chamber and affect its sensitivity and energy response.
It is recommended that waterproof sleeves should be made from PMMA and should not
be more than 1.5 mm thick. Latex sleeves should be avoided.

A.4. Inverse square law

The sides of an applicator are a potential source of scattered x-rays and therefore of deviations
from the inverse square law. It has been assumed for many years that in most cases this is
not significant. However, measurements by Aukett et al (1999) have shown that for some
applicator designs deviations may be significant particularly for smaller applicators. For a
2.5 cm diameter, 10 cm SSD Philips RT100 applicator the dose rate measured at the end of
the applicator was 4% higher than that calculated by applying the inverse square law to the
dose rate at 0.5 cm from the end.
It is recommended that when the inverse square law is used its validity should first be
confirmed by measurement with at least the smallest of the applicators concerned. Most
parallel-plate chambers designed for electrons are adequate for this purpose; bulky electron
chambers (such as the Vinten 631) are not.

A.5. Small applicators

For applicators of 1 cm diameter the beam size is not sufficient for any of the recommended
ionization chambers to be used in a conventional way. For 1.5 cm diameter also this may be
difficult.
In some cases, a small cylindrical ionization chamber (e.g. the Scanditronix RK) can be
used orientated end-on (instead of perpendicular to the beam axis). However, in such cases
it is difficult to determine the position of the effective centre of the volume accurately. For
this reason, cylindrical chambers should only be used end-on if the length of the air volume is
10 mm or less. Wilks and Soni (2000) have suggested a means of measuring applicator factors
using a parallel-plate ionization chamber whose diameter is larger than the applicator.
There is often no alternative to using other types of detector, such as semiconductors,
diamond detectors, Gafchromic film or TLD. Ma et al (1999) have shown that when
semiconductor diodes are used for measurements with kV x-rays correction factors must
be applied. These corrections change by a factor of 0.25 between 300 and 50 kVp in air and
with depth in water at 300 kVp by a factor of 0.72 between the surface and 15 cm. Significant
changes with field size could also therefore be expected.
Seuntjens et al (1999) have used both Monte Carlo calculations and measurements to
determine correction factors for use with Riga type diamond detectors (PTW Freiburg). These
rise with beam energy at the surface by a factor of 1.04 between 80 and 200 kVp. In the worst
case, at 80 kVp, the correction falls with depth by a factor of 0.88 between the surface and
10 cm. Changes with field size might therefore be expected to be significant. However, the
values of these factors are not yet as well established as those used to correct depth ionization
curves for electron beams.
Addendum to the IPEMB code of practice for the determination of absorbed dose for kV x-rays 2747

It is recommended that measurements with small applicators should only be carried out by
centres with sufficient expertise and equipment to confirm the validity of their technique and
the values of any correction factors required. This applies in all cases where measurements
with a conventional ionization chamber orientated perpendicular to the beam axis are not
possible. Even lithium borate TLD and Gafchromic film may require at least dose-linearity
corrections. Where sufficient expertise and equipment are not available the centre concerned
should:
(a) Prohibit the clinical use of smaller applicators and replace them by lead cut-outs used
with larger applicators.
(b) Determine the backscatter factors and depth doses for these cut-outs from standard tables.

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