For this discussion assignment, I am answering each portion of the discussion separately

Discuss the role of AAPM TG-51:

The American Association of Physicists in Medicine (AAPM) Task Group 51 (TG-51) protocol stands as a
guideline for calibrating clinical electron and megavoltage photon beams in water. Developed as an
integral component of ensuring that radiation doses during treatments are precise, the TG-51 has several
roles. It's instrumental in reference dosimetry, where it provides methodologies for determining dose
values. By offering a standardized approach, it ensures that medical physicists, regardless of their
institution, have a consistent method for calibrations. Furthermore, as a standardized guideline of quality
assurance, TG-51 ensures the safety and efficacy of radiation therapy treatments.[1]

Here is a summary of how TG-51 measurements are performed[1]:

 The measurements are performed in water, as previously mentioned. For photons, the reference
depth is 10 cm, while for electrons, it varies based on the energy of the beam and is typically at
the depth of maximum dose, R 100. A waterproof, vented ionization chamber that is calibrated in a
cobalt-60 beam (or, alternatively, with a cross-calibration in a clinical beam) is used. The
chamber's calibration factor, NDW, should be available prior to measurement. The ion chamber is
then placed at the appropriate depth in a water phantom, ensuring that the chamber's stem is
perpendicular to the beam's direction to minimize perturbations. Since ion chamber readings
are affected by atmospheric conditions, corrections are applied based on the temperature and
pressure at the time of measurement. This corrects the readings to standard conditions. The
beam quality is specified by the percent depth dose, PDD 10, for photons, and by the half-value
depth, R50, for electrons. The beam quality is used to derive correction factors and to compare
with tabulated data. The dose to water at the reference depth, D w, is determined by a formula
that takes into account the ion chamber reading, the chamber's calibration factor, and various
correction factors. The correction factors include polarity effects, re-combination effects, and
other factors specific to the ion chamber geometry and construction. Consistency checks are
performed to ensure that the measurements and calculations are reasonable and align with
expected values.

Why did AAPM TG-51 replace TG-21 protocol?

The transition from the earlier TG-21 protocol (released in 1983) to TG-51 (released in 1999) came about
for several crucial reasons. With the advancement in ionization chamber design and new detectors, an
updated protocol was essential. TG-51 is also considered simpler than TG-21, reducing potential errors
during calibration. Unlike TG-21, which was based on air, TG-51 utilizes water as the calibration medium.
[1,2]
Given the radiological similarities between water and human tissue, this makes TG-51 more fitting.
Moreover, the newer protocol leverages updated physical data, which was not accessible during TG-21's
time, ensuring enhanced accuracy. Here is a highlighted list of differences I found between TG-51 and
TG21[1,2]:

 Updated Stopping-Power Ratios: TG-51 uses updated values for the stopping-power ratios for
air to water. These updated ratios are essential for converting the chamber reading (measured in
 air) to the absorbed dose in water. TG-51 utilizes the more recent data available from the
International Commission on Radiation Units and Measurements (ICRU) Report 49.
 Photon Beam Quality Specification: While TG-21 utilized the concept of "TPR20,10" (the tissue
phantom ratio at 20 cm and 10 cm depths) for photon beam quality specification, TG-51
switched to using the percentage depth dose, PDD 10, at 10 cm depth. This change made the
measurements simpler and more straightforward.
 Electron Beam Quality Specification: For electron beams, TG-51 uses R 50, the depth of 50%
dose, to specify beam quality. TG-21, on the other hand, used a combination of practical range
and R80, the depth of 80% dose. The use of R 50 in TG-51 is more directly related to the beam's
mean energy and simplifies the process.
 Updated Ion Chamber Calibration Protocols: TG-51 recommends that ion chambers be
calibrated in a cobalt-60 gamma ray beam, resulting in a dose-to-water calibration coefficient,
NDW. This is a shift from TG-21, which utilized a dose-to-air calibration coefficient derived from a
chamber calibrated in air. The move to dose-to-water calibration in TG-51 simplifies the
conversion process to determine the dose in water.
 Consideration of Chamber Type and Material: TG-51 provides more detailed correction factors
for various ion chamber types, including thimble and parallel plate chambers, and considers the
chamber wall and electrode materials in the corrections.

The incorporation of these updated physical data and other refinements in TG-51 led to more accurate
and streamlined dose calibrations, ensuring the consistent and safe delivery of radiation treatments.

What protocol do other countries use to calibrate their linear accelerators

The US and Canada use TG-51 protocol. Other countries have also adopted robust calibration protocols.
The International Atomic Energy Agency (IAEA), for instance, endorses the TRS-398 protocol, which finds
favor in many regions outside Canada and the US. The European Society for Therapeutic Radiology and
Oncology (ESTRO) also collaborates with IAEA in promoting TRS-398. [3] While the British Institute of
Radiology (BIR) historically had its unique protocol, many UK centers have gravitated towards universally
recognized standards like TG-51 or TRS-398. However, it's worth noting that the choice of protocol can be
influenced by local regulations, historical precedence, and the equipment in use.

Which protocol does your facility follow? Why?

At St. Jude Children’s Research Hospital, we use the TG-51 protocol for photon beams and TRS-398 for
proton beams. I reached out to physicists from our department to understand why we don't use TRS-398
for both. The consensus was twofold:

1) Photon treatments preceded the installation of the proton center in our department, and an
established TG-51 procedure was already in place for both photon and electron beams.

2) It is standard in the US to use TG-51 for photon beams, and physicists from our center wish to remain
consistent with other centers across the country.

It's also worth mentioning that TG-51 is not intended for proton beams. A new report, TG-224 [4], can be
used for comprehensive annual and monthly proton therapy QA. However, this report is relatively new
and has not yet been finalized. The latest update was in 2019. In the near future, I predict a shift from
TRS-398 to TG-224 for proton beam calibrations in the US.
References:

1- Almond PR, Biggs PJ, Coursey BM, et al. AAPM's TG-51 protocol for clinical reference dosimetry
of high-energy photon and electron beams. Med Phys. 1999;26(9):1847-70.
2- AAPM Radiation Therapy Committee Task Group 21. A protocol for the determination of
absorbed dose from high-energy photon and electron beams. Med Phys. 1983;10(6):741-771.
3- 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. IAEA Technical Reports Series No. 398. Vienna: IAEA; 2000.
4- AAPM Radiation Therapy Committee Task Group 224. Comprehensive Proton Therapy Machine
Quality Assurance. Med Phys. 2019; 46(8):e678-e705.