A readout system for highly sensitive diamond detectors for FLASH dosimetry.

Accurate dosimetry of ultra-high dose-rate beams using diamond detectors remains challenging, primarily due to the elevated photocurrent peaks exceeding the input dynamics of precision electrometers. This work aimed at demonstrating the effectiveness of compact gated-integration electronics in conditioning the current peaks (>20 mA) generated by a highly sensitive (S ≃ 26 nC/Gy) custom-made diamond photoconductor under electron FLASH irradiation, as well as in real-time monitoring of beam dose and dose-rate. For the emerging FLASH technology, this study provided a new perspective on using commercially available diamond dosimeters with high sensitivity, currently employed in conventional radiotherapy.

Advanced Electrospun Composites Based on Polycaprolactone Fibers Loaded with Micronized Tungsten Powders for Radiation Shielding.

Exposure to high levels of radiation can cause acute, long-term health effects, such as acute radiation syndrome, cancer, and cardiovascular disease. This is an important occupational hazard in different fields, such as the aerospace and healthcare industry, as well as a crucial burden to overcome to boost space applications and exploration. Protective bulky equipment made of heavy metals is not suitable for many advanced purporses, such as mobile devices, wearable shields, and manned spacecrafts. In the latter case, the in-space manufacturing of protective shields is highly desirable and remains an unmet need. Composites made of polymers and high atomic number fillers are potential means for radiation protection due to their low weight, good flexibility, and good processability. In the present work, we developed electrospun composites based on polycaprolactone (polymer matrix) and tungsten powder for application as shielding materials. Electrospinning is a versatile technology that is easily scalable at an industrial level and allows obtaining very lightweight, flexible sheet materials for wearables. By controlling tungsten powder size, we engineered homogeneous, stable and processable suspensions to fabricate radiation composite shielding sheets. The shielding capability was assessed by an in vivo model on prototype composite sheets containing 80 w% of W filler in a polycaprolactone (PCL) fibrous matrix by means of irradiation tests (X-rays) on mice. The obtained results are promising; as expected, the shielding effectivity of the developed composite material increases with the thickness/number of stacked layers. It is worth noting that a thin barrier consisting of 24 layers of the innovative shielding material reduces the extent of apoptosis by 1.5 times compared to the non-shielded mice.

Dosimetric characteristics of electron beams produced by two mobile accelerators, Novac7 and Liac, for intraoperative radiation therapy through Monte Carlo simulation.

The Novac7 and Liac are linear accelerators (linacs) dedicated to intraoperative radiation therapy (IORT), which produce high energy, very high dose-per-pulse electron beams. The characteristics of the accelerators heads of the Novac7 and Liac are different compared to conventional electron accelerators. The aim of this work was to investigate the specific characteristics of the Novac7 and Liac electron beams using the Monte Carlo method. The Monte Carlo code BEAMnrc has been employed to model the head and simulate the electron beams. The Monte Carlo simulation was preliminarily validated by comparing the simulated dose distributions with those measured by means of EBT radiochromic film. Then, the energy spectra, mean energy profiles, fluence profiles, photon contamination, and angular distributions were obtained from the Monte Carlo simulation. The Spencer-Attix water-to-air mass restricted collision stopping power ratios (sw,air) were also calculated. Moreover, the modifications of the percentage depth dose in water (backscatter effect) due to the presence of an attenuator plate composed of a sandwich of a 2 mm aluminum foil and a 4 mm lead foil, commonly used for breast treatments, were evaluated. The calculated sw,air values are in agreement with those tabulated in the IAEA TRS-398 dosimetric code of practice within 0.2% and 0.4% at zref (reference depth in water) for the Novac7 and Liac, respectively. These differences are negligible for practical dosimetry. The attenuator plate is sufficient to completely absorb the electron beam for each energy of the Novac7 and Liac; moreover, the shape of the dose distribution in water strongly changes with the introduction of the attenuator plate. This variation depends on the energy of the beam, and it can give rise to an increase in the maximum dose in the range of 3%-9%.

Optically stimulated luminescence system as an alternative for radiochromic film for 2D reference dosimetry in UHDR electron beams.

Radiotherapy is part of the treatment of over 50% of cancer patients. Its efficacy is limited by the radiotoxicity to the healthy tissue. FLASH-RT is based on the biological effect that ultra-high dose rates (UHDR) and very short treatment times strongly reduce normal tissue toxicity, while preserving the anti-tumoral effect. Despite many positive preclinical results, the translation of FLASH-RT to the clinic is hampered by the lack of accurate dosimetry for UHDR beams. To date radiochromic film is commonly used for dose assessment but has the drawback of lengthy and cumbersome read out procedures. In this work, we investigate the equivalence of a 2D OSL system to radiochromic film dosimetry in terms of dose rate independency. The comparison of both systems was done using the ElectronFlash linac. We investigated the dose rate dependence by variation of the (1) modality, (2) pulse repetition frequency, (3) pulse length and (4) source to surface distance. Additionally, we compared the 2D characteristics by field size measurements. The OSL calibration showed transferable between conventional and UHDR modality. Both systems are equally independent of average dose rate, pulse length and instantaneous dose rate. The OSL system showed equivalent in field size determination within 3 sigma. We show the promising nature of the 2D OSL system to serve as alternative for radiochromic film in UHDR electron beams. However, more in depth characterization is needed to assess its full potential.

A diamond detector based dosimetric system for instantaneous dose rate measurements in FLASH electron beams.

Objective.A reliable determination of the instantaneous dose rate (I-DR) delivered in FLASH radiotherapy treatments is believed to be crucial to assess the so-called FLASH effect in preclinical and biological studies. At present, no detectors nor real-time procedures are available to do that in ultra high dose rate (UH-DR) electron beams, typically consisting ofµs pulses characterized by I-DRs of the order of MGy/s. A dosimetric system is proposed possibly overcoming the above reported limitation, based on the recently developed flashDiamond (fD) detector (model 60025, PTW-Freiburg, Germany).Approach.A dosimetric system is proposed, based on a flashDiamond detector prototype, properly modified and adapted for very fast signal transmission. It was used in combination with a fast transimpedance amplifier and a digital oscilloscope to record the temporal traces of the pulses delivered by an ElectronFlash linac (SIT S.p.A., Italy). The proposed dosimetric systems was investigated in terms of the temporal characteristics of its response and the capability to measure the absolute delivered dose and instantaneous dose rate (I-DR). A 'standard' flashDiamond was also investigated and its response compared with the one of the specifically designed prototype.Main results. Temporal traces recorded in several UH-DR irradiation conditions showed very good signal to noise ratios and rise and decay times of the order of a few tens ns, faster than the ones obtained by the current transformer embedded in the linac head. By analyzing such signals, a calibration coefficient was derived for the fD prototype and found to be in agreement within 1% with the one obtained under reference60Co irradiation. I-DRs as high as about 2 MGy s-1were detected without any undesired saturation effect. Absolute dose per pulse values extracted by integrating the I-DR signals were found to be linear up to at least 7.13 Gy and in very good agreement with the ones obtained by connecting the fD to a UNIDOS electrometer (PTW-Freiburg, Germany). A good short term reproducibility of the linac output was observed, characterized by a pulse-to-pulse variation coefficient of 0.9%. Negligible differences were observed when replacing the fD prototype with a standard one, with the only exception of a somewhat slower response time for the latter detector type.Significance.The proposed fD-based system was demonstrated to be a suitable tool for a thorough characterization of UH-DR beams, providing accurate and reliable time resolved I-DR measurements from which absolute dose values can be straightforwardly derived.

Development and optimization of a beam shaper device for a mobile dedicated IOERT accelerator.

PURPOSE: The aim of this study was to design and build a prototype beam shaper to be used on a dedicated mobile accelerator that protects organs at risk within the radiation field and conforms the beam to the target geometry during intraoperative electron radiotherapy (IOERT). A dosimetric characterization of the beam shaper device was performed based on Monte Carlo (MC) simulations, as well as experimental data, at different energies, field sizes, and source to skin distances. METHODS: A mobile light intraoperative accelerator (LIAC(®), Sordina, Italy) was used. The design of the beam shaper prototype was based on MC simulations (BEAMnrc∕OMEGA and DOSXYZnrc code) for a selection of materials and thicknesses, as well as for dosimetric characterization. Percentage depth dose (PDD) and profile measurements were performed using a p-type silicon diode and a commercial water phantom, while output factors were measured using a PinPoint ion chamber in a PMMA phantom. Planar doses in planes of interest were carried out using radiochromic films (Gafchromic(TM) EBT and EBT2) in PMMA and in a Solid Water(®) phantom. Several experimental set-ups were investigated with the beam shaper device fixed on the top of the phantom, varying both the short side of the rectangular field and the air gap between the device and the phantom surface, simulating the clinical situation. The output factors (OFs) were determined using different geometrical set-ups and energies. RESULTS: The beam shaper prototype consists of four blades sliding alongside each other and mounted on a special support at the end of the 10 cm diameter PMMA circular applicator. Each blade is made of an upper layer of 2.6 cm of Teflon(®) and a lower layer of 8 mm of stainless steel. All rectangles inscribed in a 5 cm diameter can be achieved in addition to any "squircle-shaped" field. When one side of the rectangular field is held constant and the second side is reduced, both R(50) and R(max) move towards the phantom surface. Comparing the PDDs obtained with the 5 cm circular applicator and with a 4.4 × 4.4 cm(2) square field (that is the equivalent square of the 5 cm circular field) obtained with the beam shaper, a different behavior was observed in the region extending from the surface to a depth of 50% of the maximum dose. Isodoses measured for rectangular fields used for clinical cases (i.e., 4 × 9 cm(2) 8 MeV) are shown, with different air gaps. For each energy investigated, the normalized OFs slowly increase, when the length of the side decreases down to about 4 cm, and then rapidly decreases for smaller field widths. MC simulation showed an excellent agreement with experimental data (<2%). CONCLUSIONS: The beam shaper device is able to provide square∕rectangular∕squircle fields with adequate dose homogeneity for mobile dedicated accelerators, thus allowing conformal treatment with IOERT. Monte Carlo simulation can be a very useful tool to simulate any clinical set up and can be used to create a data set to calculate MUs, thereby increasing the accuracy of the delivered dose during IOERT procedures.

Design, realization, and characterization of a novel diamond detector prototype for FLASH radiotherapy dosimetry.

PURPOSE: FLASH radiotherapy (RT) is an emerging technique in which beams with ultra-high dose rates (UH-DR) and dose per pulse (UH-DPP) are used. Commercially available active real-time dosimeters have been shown to be unsuitable in such conditions, due to severe response nonlinearities. In the present study, a novel diamond-based Schottky diode detector was specifically designed and realized to match the stringent requirements of FLASH-RT. METHODS: A systematic investigation of the main features affecting the diamond response in UH-DPP conditions was carried out. Several diamond Schottky diode detector prototypes with different layouts were produced at Rome Tor Vergata University in cooperation with PTW-Freiburg. Such devices were tested under electron UH-DPP beams. The linearity of the prototypes was investigated up to DPPs of about 26 Gy/pulse and dose rates of approximately 1 kGy/s. In addition, percentage depth dose (PDD) measurements were performed in different irradiation conditions. Radiochromic films were used for reference dosimetry. RESULTS: The response linearity of the diamond prototypes was shown to be strongly affected by the size of their active volume as well as by their series resistance. By properly tuning the design layout, the detector response was found to be linear up to at least 20 Gy/pulse, well into the UH-DPP range conditions. PDD measurements were performed by three different linac applicators, characterized by DPP values at the point of maximum dose of 3.5, 17.2, and 20.6 Gy/pulse, respectively. The very good superimposition of three curves confirmed the diamond response linearity. It is worth mentioning that UH-DPP irradiation conditions may lead to instantaneous detector currents as high as several mA, thus possibly exceeding the electrometer specifications. This issue was properly addressed in the case of the PTW UNIDOS electrometers. CONCLUSIONS: The results of the present study clearly demonstrate the feasibility of a diamond detector for FLASH-RT applications.

A new solution for UHDP and UHDR (Flash) measurements: Theory and conceptual design of ALLS chamber.

Ultra-High dose-per-pulse regimens (UHDP), necessary to trigger the "FLASH" effect, still pose serious challenges to dosimetry. Dosimetry plays a crucial role, both to significantly improve the accuracy of the radiobiological experiments necessary to fully understand the mechanisms underlying the effect and its dependencies on the beam parameters, and to be able to translate such effect into clinical practice. The standard ionization chamber in UHDP region is significantly affected by the effects of the electric field generated by the enormous density of charges produced by the dose pulse. This work describes the theory and the conceptual design of a gas chamber (the ALLS chamber) which overcomes the above-mentioned problems.

Application of a novel diamond detector for commissioning of FLASH radiotherapy electron beams.

PURPOSE: A diamond detector prototype was recently proposed by Marinelli et al. (Medical Physics 2022, https://doi.org/10.1002/mp.15473) for applications in ultrahigh-dose-per-pulse (UH-DPP) and ultrahigh-dose-rate (UH-DR) beams, as used in FLASH radiotherapy (FLASH-RT). In the present study, such so-called flashDiamond (fD) was investigated from the dosimetric point of view, under pulsed electron beam irradiation. It was then used for the commissioning of an ElectronFlash linac (SIT S.p.A., Italy) both in conventional and UH-DPP modalities. METHODS: Detector calibration was performed in reference conditions, under 60 Co and electron beam irradiation. Its response linearity was investigated in UH-DPP conditions. For this purpose, the DPP was varied in the 1.2-11.9 Gy range, by changing either the beam applicator or the pulse duration from 1 to 4 µs. Dosimetric validation of the fD detector prototype was then performed in conventional modality, by measuring percentage depth dose (PDD) curves, beam profiles, and output factors (OFs). All such measurements were carried out in a motorized water phantom. The obtained results were compared with the ones from commercially available dosimeters, namely, a microDiamond, an Advanced Markus ionization chamber, a silicon diode detector, and EBT-XD GAFchromic films. Finally, the fD detector was used to fully characterize the 7 and 9 MeV UH-DPP electron beams delivered by the ElectronFlash linac. In particular, PDDs, beam profiles, and OFs were measured, for both energies and all the applicators, and compared with the ones from EBT-XD films irradiated in the same experimental conditions. RESULTS: The fD calibration coefficient resulted to be independent from the investigated beam qualities. The detector response was found to be linear in the whole investigated DPP range. A very good agreement was observed among PDDs, beam profiles, and OFs measured by the fD prototype and reference detectors, both in conventional and UH-DPP irradiation modalities. CONCLUSIONS: The fD detector prototype was validated from the dosimetric point of view against several commercial dosimeters in conventional beams. It was proved to be suitable in UH-DPP and UH-DR conditions, for which no other commercial real-time active detector is available to date. It was shown to be a very useful tool to perform fast and reproducible beam characterizations in standard clinical motorized water phantom setups. All of the previously mentioned demonstrate the suitability of the proposed detector for the commissioning of UH-DR linac beams for preclinical FLASH-RT applications.

Development of an ultra-thin parallel plate ionization chamber for dosimetry in FLASH radiotherapy.

BACKGROUND: Conventional air ionization chambers (ICs) exhibit ion recombination correction factors that deviate substantially from unity when irradiated with dose per pulse magnitudes higher than those used in conventional radiotherapy. This fact makes these devices unsuitable for the dosimetric characterization of beams in ultra-high dose per pulse as used for FLASH radiotherapy. PURPOSE: We present the design, development, and characterization of an ultra-thin parallel plate IC that can be used in ultra-high dose rate (UHDR) deliveries with minimal recombination. METHODS: The charge collection efficiency (CCE) of parallel plate ICs was modeled through a numerical solution of the coupled differential equations governing the transport of charged carriers produced by ionizing radiation. It was used to find out the optimal parameters for the purpose of designing an IC capable of exhibiting a linear response with dose (deviation less than 1%) up to 10 Gy per pulse at 4 µ $\umu$ s pulse duration. As a proof of concept, two vented parallel plate IC prototypes have been built and tested in different ultra-high pulse dose rate electron beams. RESULTS: It has been found that by reducing the distance between electrodes to a value of 0.25 mm it is possible to extend the dose rate operating range of parallel plate ICs to ultra-high dose per pulse range, at standard voltage of clinical grade electrometers, well into several Gy per pulse. The two IC prototypes exhibit behavior as predicted by the numerical simulation. One of the so-called ultra-thin parallel plate ionization chamber (UTIC) prototypes was able to measure up to 10 Gy per pulse, 4 µ $\umu$ s pulse duration, operated at 300 V with no significant deviation from linearity within the uncertainties (ElectronFlash Linac, SIT). The other prototype was tested up to 5.4 Gy per pulse, 2.5 µ $\umu$ s pulse duration, operated at 250 V with CCE higher than 98.6% (Metrological Electron Accelerator Facility, MELAF at Physikalisch-Technische Bundesanstalt, PTB). CONCLUSIONS: This work demonstrates the ability to extend the dose rate operating range of ICs to ultra-high dose per pulse range by reducing the spacing between electrodes. The results show that UTICs are suitable for measurement in UHDR electron beams.

A new calculation method for the free electron fraction of an ionization chamber in the ultra-high-dose-per-pulse regimen.

The free electron fraction is the fraction of electrons, produced inside the cavity of an ionization chamber after irradiation, which does not bind to gas molecules and thereby reaches the electrode as free electrons. It is a fundamental quantity to describe the recombination processes of an ionization chamber, as it generates a gap of positive charges compared to negative ones, which certainly will not undergo recombination. The free electron fraction depends on the specific chamber geometry, the polarizing applied voltage and the gas thermodynamic properties. Therefore, it is necessary to evaluate such fraction in an accurate and easy way for any measurement condition. In this paper, a simple and direct method for evaluating the free electron fraction of ionization chambers is proposed. We first model the capture process of the electrons produced inside an ionization chamber after the beam pulse; then we present a method to evaluate the free electron fraction based on simple measurements of collected charge, by varying the applied voltage. Finally, the results obtained using an Advanced Markus chamber irradiated with a Flash Radiotherapy dedicated research Linac (ElectronFlash) to estimate the free electron fraction are presented. The proposed method allows the use of a conventional ionization chamber for measurements in ultra-high-dose-per-pulse (UHDP) conditions, up to values of dose-per-pulse at which the perturbation of the electric field due to the generated charge can be considered negligible.

Point scintillator dosimetry in ultra-high dose rate electron "FLASH" radiation therapy: A first characterization.

FLASH radiation therapy is a novel technique combining ultra-high dose rates (UHDR) with very short treatment times to strongly decrease normal tissue toxicity while preserving the anti-tumoral effect. However, the radiobiological mechanisms and exact conditions for obtaining the FLASH-effect are still under investigation. There are strong indications that parameters defining the beam structure, such as dose per pulse, instantaneous dose rate and pulse repetition frequency (PRF) are of importance. UHDR irradiations therefore come with dosimetric challenges, including both dose assessment and temporal ones. In this work, a first characterization of 6 real-time point scintillating dosimeters with 5 phosphors (Al2O3:C,Mg; Y2O3:Eu; Al2O3:C; (C38H34P2)MnBr4 and (C38H34P2)MnCl4, was performed in an UHDR pulsed electron beam. The dose rate independence of the calibration was tested by calibrating the detector at conventional and UHDR. Dose rate dependence was observed, however, further investigation, including intermediate dose rates, is needed. Linearity of the response with dose was tested by varying the number of pulses and a linearity with R2> 0.9989 was observed up to at least 200 Gy. Dose per pulse linearity was investigated by variation of the pulse length and SSD. All point scintillators showed saturation effects up to some extent and the instantaneous dose rate dependence was confirmed. A PRF dependence was observed for the Al2O3:C,Mg and Al2O3:C- based point scintillators. This was expected as the luminescence decay time of these materials exceeds the inter-pulse time.

Radiation protection measurements around a 12 MeV mobile dedicated IORT accelerator.

PURPOSE: The aim of this study is to investigate radioprotection issues that must be addressed when dedicated accelerators for intraoperative radiotherapy (IORT) are used in operating rooms. Recently, a new version of a mobile IORT accelerator (LIAC Sordina SpA, Italy) with 12 MeV electron beam has been implemented. This energy is necessary in some specific pathology treatments to allow a better coverage of thick lesions. At an electron energy of 10 MeV, leakage and scattered x-ray radiation (stray radiation) coming from the accelerator device and patient must be considered. If the energy is greater than 10 MeV, the x-ray component will increase; however, the most meaningful change should be the addition of neutron background. Therefore, radiation exposure of personnel during the IORT procedure needs to be carefully evaluated. METHODS: In this study, stray x-ray radiation was measured and characterized in a series of spherical projections by means of an ion chamber survey meter. To simulate the patient during all measurements, a polymethylmethacrylate (PMMA) slab phantom with volume 30 x 30 x 15 cm3 and density 1.19 g / cm3 was used. The PMMA phantom was placed along the central axis of the beam in order to absorb the electron beams and the tenth value layer (TVL) and half value layer (HVL) of scattered radiation (at 0 degrees, 90 degrees, and 180 degrees scattering angles) were also measured at 1 m of distance from the phantom center. Neutron measurements were performed using passive bubble dosimeters and a neutron probe, specially designed to evaluate ambient dose equivalent H*(10). RESULTS: The x-ray equivalent dose measured at 1 m along the beam axis at 12 MeV was 260 microSv/Gy. The value measured at 1 m at 90 degrees scattering angle was 25 microSv/Gy. The HVL and TVL values were 1.1 and 3.5 cm of lead at 0 degrees, and 0.4 and 1 cm at 90 degrees, respectively. The highest equivalent dose of fast neutrons was found to be at the surface of the phantom on the central beam axis (2.9 +/- 0.6 microSv/Gy), while a lower value was observed below the phantom (1.6 +/- 0.3 microSv/Gy). The neutron dose equivalent at 90 degrees scattering angle and on the floor plane on the beam axis below the beam stopper was negligible. CONCLUSIONS: Our data confirm that neutron exposure levels around the new dedicated IORT accelerator are very low. Mobile shielding panels can be used to reduce x-ray levels to below regulatory levels without necessarily providing permanent shielding in the operating room.

Detector for monitoring potential bleeding during electron intraoperative radiotherapy.

PURPOSE: The aim of this work is to develop a bleeding detector integrated into the acrylic circular applicators for specific mobile linacs. Thus, a bleeding detector has been developed based on a capacitive sensor to be used with plastic applicators, as in the case of LIAC HWL from Sordina IORT Technologies SpA. According to the clinical impact, we have selected 0.5 cm as the minimum depth of fluid that should be detected. METHODS: An experiment was developed using water-simulating blood. Two setups were considered: non-beveled applicators with 7 cm and 10 cm diameter. Measurements were done for applicators 0° and 45° tilted, both with respect to the horizontal surface, in order to mimic the worst clinical scenario according to the irradiation gantry and applicator bevel angle. The behavior of the detector under irradiation was analyzed and the impact of the stray radiation on the detector was also evaluated. RESULTS: The detector was able to distinguish the presence of liquid at a minimum height of 0.5 cm. A linear behavior was obtained for both setups. We have also verified that the LIAC HWL radiation does not affect the measurements nor does the detector interfere with the stray radiation. The bleeding detector is a quasi-digital capacitive sensor with low-cost, high linearity, and easy to install. CONCLUSIONS: With this detector it is possible to perform a continuous monitoring of the liquid measurements even during the irradiation phase. Thus, it can operate not only as a pre-treatment detector but also as a continuous one.

Evaluation of dosimetric properties of shielding disk used in intraoperative electron radiotherapy: A Monte Carlo study.

A shielding disk is used for IOERT procedures to absorb radiation behind the target and protect underlying healthy tissues. Setup variation of shielding disk can affect the corresponding in-vivo dose distribution. In this study, the changes of dosimetric parameters due to the disk setup variations is evaluated using EGSnrc Monte Carlo (MC) code. The results can help treatment team to decide about the level of accuracy in the setup procedure and delivered dose to the target volume during IOERT.

Use of parallel-plate ionization chambers in reference dosimetry of NOVAC and LIAC® mobile electron linear accelerators for intraoperative radiotherapy: a multi-center survey.

PURPOSE: LIAC® and NOVAC are two mobile linear accelerators dedicated to intraoperative radiation therapy (IORT), generating electron beams in the energy range of 3-12 MeV. Due to high dose-per-pulse (up to 70 mGy per pulse), in 2003 the Italian National Institute of Health (ISS) stated that "for the measure of dose to water in reference conditions, ionization chambers cannot be employed and no published dosimetry protocol can be used". As a consequence, ferrous sulphate (or, alternatively alanine) dosimetry was recommended. Based on a retrospective multi-center survey, a comparison with ferrous sulphate dosimetry is now used to validate the parallel-plate ionization chambers for reference dosimetry of NOVAC and LIAC. METHODS: The IAEA TRS-398 dosimetry protocol was applied except for the reference irradiation setup and the determination of the ion-recombination correction factor ks . Moreover the depth of maximum dose (R100 ) instead of zref as measurement depth was chosen by the majority of centers, thus implying a renormalization of the beam-quality correction factor kQ,Qo , based on water-air stopping power ratios. Regarding the ks determination, a previously published method, independent of ferrous sulphate dosimetry, was adopted. All the centers participating in this study had used both ferrous sulphate dosimeters and ionization chambers in water phantoms for dosimetry under reference conditions. RESULTS: The mean percentage difference between ionization chambers and ferrous sulphate dosimetry was -0.5% with a dispersion of 3.9% (2σ). Moreover, the uncertainty analysis allowed the agreement between ionization chambers and ferrous sulphate dosimetry to be verified. These results did not show any significant dependence on electron energy, thus indirectly confirming kQ,Qo renormalization. The results from the centers using zref as the measurement depth were similar to the other data, but further focused studies could aim at investigating possible dependences of the dose differences on the chosen reference depth. CONCLUSION: The present study confirms that parallel-plate ionization chambers can properly and accurately substitute ferrous sulphate detectors in reference dosimetry of LIAC and NOVAC mobile linear accelerators. Therefore, we hope that the most commonly used protocols for reference dosimetry in external-beam radiotherapy will be updated in order to provide guidance in the calibration of electron beams from linear accelerators dedicated to IORT, so that users may benefit from specific, authoritative and up-to-date recommendations.