A round-robin gamma stereotactic radiosurgery dosimetry interinstitution comparison of calibration protocols.

PURPOSE: Absorbed dose calibration for gamma stereotactic radiosurgery is challenging due to the unique geometric conditions, dosimetry characteristics, and nonstandard field size of these devices. Members of the American Association of Physicists in Medicine (AAPM) Task Group 178 on Gamma Stereotactic Radiosurgery Dosimetry and Quality Assurance have participated in a round-robin exchange of calibrated measurement instrumentation and phantoms exploring two approved and two proposed calibration protocols or formalisms on ten gamma radiosurgery units. The objectives of this study were to benchmark and compare new formalisms to existing calibration methods, while maintaining traceability to U.S. primary dosimetry calibration laboratory standards. METHODS: Nine institutions made measurements using ten gamma stereotactic radiosurgery units in three different 160 mm diameter spherical phantoms [acrylonitrile butadiene styrene (ABS) plastic, Solid Water, and liquid water] and in air using a positioning jig. Two calibrated miniature ionization chambers and one calibrated electrometer were circulated for all measurements. Reference dose-rates at the phantom center were determined using the well-established AAPM TG-21 or TG-51 dose calibration protocols and using two proposed dose calibration protocols/formalisms: an in-air protocol and a formalism proposed by the International Atomic Energy Agency (IAEA) working group for small and nonstandard radiation fields. Each institution's results were normalized to the dose-rate determined at that institution using the TG-21 protocol in the ABS phantom. RESULTS: Percentages of dose-rates within 1.5% of the reference dose-rate (TG-21+ABS phantom) for the eight chamber-protocol-phantom combinations were the following: 88% for TG-21, 70% for TG-51, 93% for the new IAEA nonstandard-field formalism, and 65% for the new in-air protocol. Averages and standard deviations for dose-rates over all measurements relative to the TG-21+ABS dose-rate were 0.999±0.009 (TG-21), 0.991±0.013 (TG-51), 1.000±0.009 (IAEA), and 1.009±0.012 (in-air). There were no statistically significant differences (i.e., p>0.05) between the two ionization chambers for the TG-21 protocol applied to all dosimetry phantoms. The mean results using the TG-51 protocol were notably lower than those for the other dosimetry protocols, with a standard deviation 2-3 times larger. The in-air protocol was not statistically different from TG-21 for the A16 chamber in the liquid water or ABS phantoms (p=0.300 and p=0.135) but was statistically different from TG-21 for the PTW chamber in all phantoms (p=0.006 for Solid Water, 0.014 for liquid water, and 0.020 for ABS). Results of IAEA formalism were statistically different from TG-21 results only for the combination of the A16 chamber with the liquid water phantom (p=0.017). In the latter case, dose-rates measured with the two protocols differed by only 0.4%. For other phantom-ionization-chamber combinations, the new IAEA formalism was not statistically different from TG-21. CONCLUSIONS: Although further investigation is needed to validate the new protocols for other ionization chambers, these results can serve as a reference to quantitatively compare different calibration protocols and ionization chambers if a particular method is chosen by a professional society to serve as a standardized calibration protocol.

A prototype, glassless densitometer traceable to primary optical standards for quantitative radiochromic film dosimetry.

PURPOSE: To evaluate a prototype densitometer traceable to primary optical standards and compare its performance to an EPSON Expression(®) 10000XL flatbed scanner (the Epson) for quantitative radiochromic film (RCF) dosimetry. METHODS: A prototype traceable laser densitometry system (LDS) was developed to mitigate common film scanning artifacts, such as positional scan dependence and high noise in low-dose regions, by performing point-based measurements of RCF suspended in free-space using coherent light. The LDS and the Epson optical absorbance scales were calibrated up to 3 AU, using reference materials calibrated at a primary standards laboratory and a scanner calibration factor (SCF). Calibrated optical density (OD) was determined for 96 Gafchromic(®) EBT3 film segments before and after irradiation to one of 16 dose levels between 0 and 10 Gy, exposed to (60)Co in a polymethyl-methacrylate (PMMA) phantom. The sensitivity was determined at each dose level and at two rotationally orthogonal readout orientations to obtain the sensitometric response of each RCF dosimetry system. LDS rotational scanning dependence was measured at nine angles between 0°and 180°, due to the expected interference between coherent light and polarizing EBT3 material. The response curves were fit to the analytic functions predicted by two physical response models: the two-parameter single-hit model and the four-parameter percolation model. RESULTS: The LDS and the Epson absorbance measurements were linear to primary optical standards to within 0.2% and 0.3% up to 2 and 1 AU, respectively. At higher densities, the LDS had an over-response (2.5% at 3 AU) and the Epson an under-response (3.1% and 9.8% at 2 and 3 AU, respectively). The LDS and the Epson SCF over the applicable range were 0.968% ± 0.2% and 1.561% ± 0.3%, respectively. The positional scan dependence was evaluated on each digitizer and shown to be mitigated on the LDS, as compared to the Epson. Maximum EBT3 rotational dependence was found to have a strong dependence on dose (0.1% and 34% at 30 mGy and 5 Gy, respectively). The preferred EBT3 polymerization axis angle was constant within experimental uncertainties. In its most sensitive orientation, the LDS-measured EBT3 sensitivity was 7.13 × 10(-4) ± 9.2 × 10(-6) AU/mGy, which represented a 4.5 fold increase over the Epson of 1.58 × 10(-4) ± 9.8 × 10(-6) AU/mGy. To first order approximations, EBT3 response was linear up to 500 mGy to within 0.80% and to within 7.5% for the most sensitive LDS and the Epson orientations, respectively. The corresponding single-hit and percolation model relative residual norms were 0.082 and 0.074 for LDS as compared to 0.29 and 0.18 for the Epson, which represented a significant increase in LDS-measured agreement with the simple physical model. Less sensitive LDS and the Epson orientations showed a marked decrease in the physical model agreement, which suggested that suboptimal readout device characteristics may be the origin of the complex sensitometric functional forms currently required for accurate RCF dosimetry. CONCLUSIONS: The prototype densitometer was shown to be superior to a conventional scanner for quantitative RCF dosimetry based on physical models of film response. The Epson was shown to be a reliable tool for routine RCF dosimetry in a clinical setting, yet calibration to primary optical standards did not mitigate the necessity for complex, empirical functional form fitting.

Determination of the intrinsic energy dependence of LiF:Mg,Ti thermoluminescent dosimeters for 125I and 103Pd brachytherapy sources relative to 60Co.

PURPOSE: To determine the intrinsic energy dependence of LiF:Mg,Ti thermoluminescent dosimeters (TLD-100) for (125)I and (103)Pd brachytherapy sources relative to (60)Co. METHODS: LiF:Mg,Ti TLDs were irradiated with low-energy brachytherapy sources and with a (60)Co teletherapy source. The brachytherapy sources measured were the Best 2301 (125)I seed, the OncoSeed 6711 (125)I seed, and the Best 2335 (103)Pd seed. The TLD light output per measured air-kerma strength was determined for the brachytherapy source irradiations, and the TLD light output per air kerma was determined for the (60)Co irradiations. Monte Carlo (MC) simulations were used to calculate the dose-to-TLD rate per air-kerma strength for the brachytherapy source irradiations and the dose to TLD per air kerma for the (60)Co irradiations. The measured and MC-calculated results for all irradiations were used to determine the TLD intrinsic energy dependence for (125)I and (103)Pd relative to (60)Co. RESULTS: The relative TLD intrinsic energy dependences (relative to (60)Co) and associated uncertainties (k = 1) were determined to be 0.883 ± 1.3%, 0.870 ± 1.4%, and 0.871 ± 1.5% for the Best 2301 seed, OncoSeed 6711 seed, and Best 2335 seed, respectively. CONCLUSIONS: The intrinsic energy dependence of TLD-100 is dependent on photon energy, exhibiting changes of 13%-15% for (125)I and (103)Pd sources relative to (60)Co. TLD measurements of absolute dose around (125)I and (103)Pd brachytherapy sources should explicitly account for the relative TLD intrinsic energy dependence in order to improve dosimetric accuracy.

Determination of air-kerma strength for the 192Ir GammaMedplus iX pulsed-dose-rate brachytherapy source.

PURPOSE: Pulsed-dose-rate (PDR) brachytherapy was originally proposed to combine the therapeutic advantages of high-dose-rate (HDR) and low-dose-rate brachytherapy. Though uncommon in the United States, several facilities employ pulsed-dose-rate brachytherapy in Europe and Canada. Currently, there is no air-kerma strength standard for PDR brachytherapy (192)Ir sources traceable to the National Institute of Standards and Technology. Discrepancies in clinical measurements of the air-kerma strength of the PDR brachytherapy sources using HDR source-calibrated well chambers warrant further investigation. METHODS: In this research, the air-kerma strength for an (192)Ir PDR brachytherapy source was compared with the University of Wisconsin Accredited Dosimetry Calibration Laboratory transfer standard well chambers, the seven-distance technique [B. E. Rasmussen et al., "The air-kerma strength standard for 192Ir HDR sources," Med. Phys. 38, 6721-6729 (2011)], and the manufacturer's stated value. Radiochromic film and Monte Carlo techniques were also employed for comparison to the results of the measurements. RESULTS: While the measurements using the seven-distance technique were within + 0.44% from the manufacturer's determination, there was a + 3.10% difference between the transfer standard well chamber measurements and the manufacturer's stated value. Results showed that the PDR brachytherapy source has geometric and thus radiological qualities that exhibit behaviors similar to a point source model in contrast to a conventional line source model. CONCLUSIONS: The resulting effect of the pointlike characteristics of the PDR brachytherapy source likely account for the differences observed between well chamber and in-air measurements.

Microionization chamber air-kerma calibration coefficients as a function of photon energy for x-ray spectra in the range of 20-250 kVp relative to 60Co.

PURPOSE: To investigate the applicability of a wide range of microionization chambers for reference dosimetry measurements in low- and medium-energy x-ray beams. METHODS: Measurements were performed with six cylindrical microchamber models, as well as one scanning chamber and two Farmer-type chambers for comparison purposes. Air-kerma calibration coefficients were determined at the University of Wisconsin Accredited Dosimetry Calibration Laboratory for each chamber for a range of low- and medium-energy x-ray beams (20-250 kVp), with effective energies ranging from 11.5 keV to 145 keV, and a (60)Co beam. A low-Z proof-of-concept microchamber was developed and calibrated with and without a high-Z silver epoxy on the collecting electrode. RESULTS: All chambers composed of low-Z materials (Z ≤ 13), including the Farmer-type chambers, the scanning chamber, and the PTW TN31014 and the proof-of-concept microchambers, exhibited air-kerma calibration coefficients with little dependence on the quality of the beam. These chambers typically exhibited variations in calibration coefficients of less than 3% with the beam quality, for medium energy beams. However, variations in air-kerma calibration coefficients of greater than 50% were measured over the range of medium-energy x-ray beams for each of the microchambers containing high-Z collecting electrodes (Z > 13). For these high-Z chambers, which include the Exradin A14SL and A16 chambers, the PTW TN31006 chamber, the IBA CC01 chamber, and the proof-of-concept chamber containing silver, the average variation in air-kerma calibration coefficients between any two calibration beams was nearly 25% over the entire range of beam qualities investigated. CONCLUSIONS: Due to the strong energy dependence observed with microchambers containing high-Z components, these chambers may not be suitable dosimeters for kilovoltage x-ray applications, as they do not meet the TG-61 requirements. It is recommended that only microchambers containing low-Z materials (Z ≤ 13) be considered for air-kerma calibrations for reference dosimetry in low- and medium-energy x-ray beams.

Photon beam audits for radiation therapy clinics: a pilot mailed dosemeter study in Turkey.

A thermoluminescent dosemeter (TLD) mailed dose audit programme was performed at five radiotherapy clinics in Turkey. The intercomparison was organised by the University of Wisconsin Radiation Calibration Laboratory (UWRCL), which was responsible for the technical aspects of the study including reference irradiations, distribution, collection and evaluation. The purpose of these audits was to perform an independent dosimetry check of the radiation beams using TLDs sent by mail. Acrylic holders, each with five TLD chips inside and instructions for their irradiation to specified absorbed dose to water of 2 Gy, were mailed to all participating clinics. TLD irradiations were performed with a 6 MV linear accelerator and (60)Co photon beams. The deviations from the TL readings of UWRCL were calculated. Discrepancies inside the limits of ±5 % between the participant-stated dose, and the TLD-measured dose were considered acceptable. One out of 10 beams checked was outside this limit, with a difference of 5.8 %.

Experimental and Monte Carlo determination of the TG-43 dosimetric parameters for the model 9011 THINSeed brachytherapy source.

PURPOSE: AAPM TG-43 brachytherapy dosimetry parameters for a new, smaller diameter 1251 brachytherapy source (THINSeed, model 9011) were determined using LiF:Mg,Ti thermoluminescent dosimeter (TLD-100) microcubes and Monte Carlo simulations. METHODS: Two polymethyl methacrylate phantoms were machined to hold TLD-100 microcubes at specific locations for the experimental determination of the radial dose function, dose-rate constant, and anisotropy functions of the new source. The TG-43 parameters were also calculated using Monte Carlo simulations. For comparison, the model 6711 source was also investigated. RESULTS: Experimental results for both models 9011 and 6711 sources showed good agreement with Monte Carlo values, as well as with previously published values. CONCLUSIONS: The TG-43 parameters for the new source model are similar to those of model 6711; however, they represent two separate sources and TG-43 parameters used in treatment planning must be source specific.

Air-kerma strength determination of a 169Yb high dose rate brachytherapy source.

The increased demand for high dose rate (HDR) brachytherapy as an alternative to external beam radiotherapy has led to the introduction of a HDR brachytherapy isotope 169Yb. This source offers a dose rate similar to 192Ir HDR sources, at about one fourth the effective photon energy. This work presents the calibration of this source in terms of air-kerma strength, based on an adaptation of the current, National Institute of Standards and Technology traceable, in air measurement technique currently used for 192Ir HDR sources. Several additional measurement correction factors were required, including corrections for air scatter, air attenuation, and ion recombination. A new method 169Yb is introduced for determining the ion chamber calibration coefficient Nk(169Yb). An uncertainty analysis was also performed, indicating an overall measurement expanded uncertainty in the air-kerma strength (k=2) of 2.2%.

LiF:Mg,Ti TLD response as a function of photon energy for moderately filtered x-ray spectra in the range of 20-250 kVp relative to 60Co.

The response of LiF:Mg,Ti thermoluminescent dosimeters (TLDs) as a function of photon energy was determined using irradiations with moderately filtered x-ray beams in the energy range of 20-250 kVp relative to the response to irradiations with 60Co photons. To determine if the relative light output from LiF:Mg,Ti TLDs per unit air kerma as a function of photon energy can be predicted using calculations such as Monte Carlo (MC) simulations, measurements from the x-ray beam irradiations were compared with MC calculated results, similar to the methodology used by Davis et al. [Radiat. Prot. Dosim. 106, 33-43 (2003)]. TLDs were irradiated in photon beams with well-known air kerma rates using the National Institute of Standards and Technology traceable M-series x-ray beams in the range of 20-250 kVp. For each x-ray beam, several sets of TLDs were irradiated for times corresponding to different air kerma levels to take into account any dose nonlinearity. TLD light output was then compared to that from several sets of TLDs irradiated at similar corresponding air kerma levels using a 60Co irradiator. The MC code MCNP5 was used to account for photon scatter and attenuation in the holder and TLDs and was used to calculate the predicted relative TLD light output per unit air kerma for irradiations with each of the experimentally used photon beams. The measured relative TLD response as a function of photon energy differed by up to 13% from the MC calculations. We conclude that MC calculations do not accurately predict the relative response of TLDs as a function of photon energy, consistent with the conclusions of Davis et al. [Radiat. Prot. Dosim. 106, 33-43 (2003)]. This is likely due to complications in the solid state physics of the thermoluminescence process that are not incorporated into the simulation.

A new internal pair production branching ratio of 90Y: the development of a non-destructive assay for 90Y and 90Sr.

(90)Y is utilized as a therapeutic radioisotope in radiolabeled monoclonal antibodies and in microspheres for targeted radiation therapy of the liver. Currently, the widely used dose calibrator assay of (90)Y can have uncertainties exceeding +/-10%. A non-destructive assay using spectroscopy is possible by reducing the currently published uncertainty (+/-12%) in the internal pair production branching ratio for the 0(+)-0(+) transition of (90)Zr. A high-purity germanium detector was used to determine the branching ratio to be (31.86+/-0.47) x 10(-6).

The US radiation dosimetry standards for 60Co therapy level beams, and the transfer to the AAPM accredited dosimetry calibration laboratories.

This work reports the transfer of the primary standard for air kerma from the National Institute of Standards and Technology (NIST) to the secondary laboratories accredited by the American Association of Physics in Medicine (AAPM). This transfer, performed in August of 2003, was motivated by the recent revision of the NIST air-kerma standards for 60Co gamma-ray beams implemented on July 1, 2003. The revision involved a complete recharacterization of the two NIST therapy-level 60Co gamma-ray beam facilities, resulting in new values for the air-kerma rates disseminated by the NIST. Some of the experimental aspects of the determination of the new air-kerma rates are briefly summarized here; the theoretical aspects have been described in detail by Seltzer and Bergstrom ["Changes in the U.S. primary standards for the air-kerma from gamma-ray beams," J. Res. Natl. Inst. Stand. Technol. 108, 359-381 (2003)]. The standard was transferred to reference-class chambers submitted by each of the AAPM Accredited Dosimetry Calibration Laboratories (ADCLs). These secondary-standard instruments were then used to characterize the 60Co gamma-ray beams at the ADCLs. The values of the response (calibration coefficient) of the ADCL secondary-standard ionization chambers are reported and compared to values obtained prior to the change in the NIST air-kerma standards announced on July 1, 2003. The relative change is about 1.1% for all of these chambers, and this value agrees well with the expected change in chambers calibrated at the NIST or at any secondary-standard laboratory traceable to the new NIST standard.

Low dose fraction behavior of high sensitivity radiochromic film.

A high sensitivity (HS) model of radiochromic film is receiving increasing use. The film's linear sensitometric response in the range of 0.5-40 Gy would make this film an ideal candidate for complex dosimetry applications that require tissue equivalence. This study investigates the potential use for clinical dosimetry of typical radiotherapy fractions at relatively low doses (0.5-5 Gy). The experiment involved exposing 25 pre-exposed pieces of HS film to five equal fractions of doses from 0.5 to 5 Gy 24 hours apart. The cumulative dose for each film was carefully monitored and optical density measurements were used as the sole determination of film response to dose. The average behavior of the various fractionation schemes was roughly consistent with previous observations of the MD-55 radiochromic film with about twice the overall sensitivity as expected. However, at low doses and low dose increments, unexpected variations beyond a well-documented low dose nonlinearity were observed. These unexpected variations may indicate complex polymer kinetics at low doses. This type of film would require extra care beyond that described in TG-55 for accurate use at low doses or low dose fraction schemes.

The effect of ambient pressure on well chamber response: experimental results with empirical correction factors.

For some air-communicating well-type chambers used for low-energy brachytherapy source assay, deviations from expected values of measured air kerma strength were observed at low pressures associated with high altitudes. This effect is consistent with an overcompensation by the air density correction to standard atmospheric temperature and pressure (P(TP)). This work demonstrates that the P(TP) correction does not fully compensate for the high altitude pressure effects that are seen with air-communicating chambers at low photon energies in the range of 20-100 keV. Deviations of up to 18% at a pressure corresponding to an approximate elevation of 8500 ft for photon energies of 20 keV are possible. For high-energy photons and for high-energy beta emitters in air-communicating chambers the P(TP) factor is applicable. As expected, the ambient pressure does not significantly affect the response of pressurized well chambers (within 1%) to either low- or high-energy photons. However, when used with beta emitters, pressurized chambers appear to exhibit a slight dependence on the ambient pressure. Using measured data, the response and correction factors were determined for three models of air-communicating well chambers for low-energy photon sources at various pressures corresponding to elevations above sea level. Monte Carlo calculations were also performed which were correlated with the experimental findings. A more complete study of the Monte Carlo calculations is presented in the accompanying paper, "The effect of ambient pressure on well chamber response: Monte Carlo calculated results for the HDR1000 Plus."

A thermoluminescent dosimetry postal dose inter-comparison of radiation therapy centres in Malaysia.

A thermoluminescent dosimetry (TLD) postal dose inter-comparison was carried out amongst radiotherapy centres in Malaysia. The aim of this TLD inter-comparison was to compare the uniformity involved in the measurement of absorbed dose among the participating centres. A set of 5 TLD chips placed within acrylic trays were mailed to all participating centres for irradiation to an absorbed dose to water of 2 Gy. Measurements were made for 6 MV and 60Co photon beams. Results show an agreement of +/- 5% for all but three radiotherapy centres. The ratios of the TLD readings to that of the reference centre are comparable with other national/regional dose inter-comparisons. The importance of a proper ongoing quality assurance program is essential in maintaining the consistency and uniformity of doses delivered.

The effect of spectra on calibration and measurement with mammographic ionization chambers.

Mammographic imaging uses x-ray tubes with molybdenum, rhodium, or tungsten anodes with the produced bremsstrahlung filtered by thin sheets of molybdenum, rhodium, or aluminum. The National Institute of Standards and Technology, the Accredited Dosimetry Calibration Laboratories, and several manufacturers offer calibrations of mammography ionization chambers with reference x-ray beams with different radiation qualities in the range 23-40 kVp. The energy response of ten commercially available chambers was determined for these reference radiation qualities using the Attix variable-length free-air chamber. The evaluated chambers are designed with thin entrance windows of varying thickness and composition. The chambers show variation in their air kerma response as a function of beam radiation quality. This response with beam radiation quality may affect the measurement of clinical beam half value layer (HVL) and the determination of the mean glandular dose. The combined effect of the chamber's energy dependence and HVL measurement affects the mean glandular dose calculation resulting in differences ranging from -1.8% to +2.5%.

Calibration of new high dose rate 192Ir sources.

The increased popularity of high dose rate (HDR) brachytherapy in the treatment of neoplastic disease has resulted in the introduction of new or redesigned 192Ir sources by various manufacturers. In order to provide accurate clinical dosimetry, accurate calibration of these sources is required. In this work, two new sources are calibrated with the standard, NIST traceable, in-air calibration technique. These sources are the Varian VariSource (VS2000) and the newly redesigned Nucletron MicroSelectron source. An uncertainty budget was performed to determine the overall uncertainty of the measurement, and a total relative expanded uncertainty (k = 2) of 2.15% was calculated. The results of the source calibration using the in-air technique and that obtained based upon the 1991 standard calibration all lie well within this uncertainty. In addition to the in-air calibration, contact autoradiographs of the sources were made with International Specialty Products model HD810 radiochromic film to demonstrate the sources relative dose distributions.

Assessment of the linear reference air kerma rate of 192Ir wires.

In this study, a procedure to test the linear reference air kerma rate of 192Ir wires using a well-type chamber is described. The method is based on a special lead insert with a 1 cm acrylic aperture that provides a differential response of the well chamber. The wire is considered divided into 1 cm parts. Using an external positioning system it is possible to place every part of the wire at the aperture position in the lead insert allowing measurement of each 1 cm making up the length of the wire. By means of a set of equations that take into account the contribution of all parts of the wire, in all possible positions, the relative linear reference air kerma rate is obtained. The estimated uncertainties of this procedure are about 2 to 3%. So, a well chamber and the specific inserts allow the measurements of total and linear reference air kerma rate for 192Ir wires.

The water-equivalence of phantom materials for 90Sr-90Y beta particles.

Intravascular brachytherapy requires that the dose be specified within millimeters of the source. High dose gradients near brachytherapy sources require that the source-detector distance be accurately known for dosimetry purposes. Solid phantoms can be designed to accommodate these stringent requirements. This study reports dosimeter readings from 90Sr-90Y sources measured in water, A150, polystyrene and in an epoxy-based water-equivalent plastic. Measurements showed that while A150 and the epoxy-based plastic agreed well with water when the surface of the source contacted the detector housing, the relative response in the phantoms decreased with increasing depth in phantom, falling to approximately 0.55 those of water at a depth of 5 mm. Readings in polystyrene were within 4% of those in water between 1 and 2 mm depth. However, while polystyrene followed water more closely than the other two materials, at greater depths the relative response in polystyrene to water varied from 0.65 to 1.34. When the density of the materials is accounted for, the relative response in A150 is nearly constant with increasing areal density. Furthermore, the response in A150 shows the closest agreement with that in water of any of the solid materials for higher areal densities. For values below 0.3 g/cm2, polystyrene shows the closest agreement with water.

AAPM protocol for 40-300 kV x-ray beam dosimetry in radiotherapy and radiobiology.

The American Association of Physicists in Medicine (AAPM) presents a new protocol, developed by the Radiation Therapy Committee Task Group 61, for reference dosimetry of low- and medium-energy x rays for radiotherapy and radiobiology (40 kV < or = tube potential < or = 300 kV). It is based on ionization chambers calibrated in air in terms of air kerma. If the point of interest is at or close to the surface, one unified approach over the entire energy range shall be used to determine absorbed dose to water at the surface of a water phantom based on an in-air measurement (the "in-air" method). If the point of interest is at a depth, an in-water measurement at a depth of 2 cm shall be used for tube potentials > or = 100 kV (the "in-phantom" method). The in-phantom method is not recommended for tube potentials < 100 kV. Guidelines are provided to determine the dose at other points in water and the dose at the surface of other biological materials of interest. The protocol is based on an up-to-date data set of basic dosimetry parameters, which produce consistent dose values for the two methods recommended. Estimates of uncertainties on the final dose values are also presented.