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Handbook of Radiotherapy Physics

Theory and Practice, Second Edition
W. P. M. Mayles, A. E. Nahum, J.-C. Rosenwald

Principles and Basic Concepts in Radiation Dosimetry

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Alan Nahum
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 Chapter 5
Principles and Basic Concepts in Radiation Dosimetry
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Alan Nahum*

CONTENTS
5.1 Introduction............................................................................................................................................................. 56
5.2 The Stochastic Nature of Energy Deposition............................................................................................................ 56
5.3 Definitions of Dosimetric Quantities........................................................................................................................ 57
5.3.1 Absorbed Dose.............................................................................................................................................. 57
5.3.2 Kerma (and Exposure)................................................................................................................................... 58
5.3.3 Particle Fluence............................................................................................................................................. 59
5.3.4 Energy Fluence.............................................................................................................................................. 59
5.3.5 Planar Fluence............................................................................................................................................... 60
5.3.6 Fluence Rate.................................................................................................................................................. 60
5.4 Relations between Fluence and Dosimetric Quantities for Photons........................................................................... 60
5.4.1 Relation between Photon Fluence and Kerma................................................................................................ 60
5.4.2 Relation between Kerma and Absorbed Dose................................................................................................ 61
5.5 Charged-Particle Equilibrium (CPE); Partial CPE.................................................................................................... 62
5.6 Relation between Fluence and Dose for Charged Particles........................................................................................ 65
5.6.1 Stopping Power and CEMA.......................................................................................................................... 65
5.6.2 Delta-Ray Equilibrium.................................................................................................................................. 66
5.7 Cavity Theory........................................................................................................................................................... 66
5.7.1 Introduction.................................................................................................................................................. 66
5.7.2 The Fano Theorem........................................................................................................................................ 66
5.7.3 Cavity Theory for ‘Large’ Photon Detectors.................................................................................................. 67
5.7.4 Bragg–Gray Cavity Theory............................................................................................................................ 69
5.7.4.1 Introduction.................................................................................................................................... 69
5.7.4.2 Theory............................................................................................................................................ 70
5.7.4.3 When Does a Detector Behave in a Bragg–Gray Manner?................................................................ 70
5.7.4.4 Bragg-Gray (Unrestricted) Stopping-Power Ratios, Water-to-Detector............................................ 72
5.7.4.5 Is a Low-density Cavity in a Medium Irradiated by Kilovoltage X-Rays a Bragg–Gray Cavity?......... 72
5.7.5 The Spencer–Attix Modification of Bragg–Gray Theory................................................................................ 73
5.7.5.1 Introduction.................................................................................................................................... 73
5.7.5.2 Theory............................................................................................................................................ 74
5.7.5.3 Practical Implications of Spencer–Attix Theory............................................................................... 75
5.7.6 Departures from ‘Perfect’ Bragg–Gray Behaviour For Ionisation Chambers.................................................. 76
5.7.6.1 Introduction.................................................................................................................................... 76
5.7.6.2 The Various Sources of Ion-Chamber Perturbation.......................................................................... 77
5.7.7 General or ‘Burlin’ Cavity Theory................................................................................................................. 77
5.7.8 The Response of a Detector as it Varies from ‘Bragg–Gray’ to ‘Large Photon’............................................... 78
5.8 The Special Case of Small, Non-equilibrium, Megavoltage Photon Fields................................................................. 79
5.8.1 Introduction.................................................................................................................................................. 79
5.8.2 Absorbed Dose in a Uniform Medium Irradiated by a Small Photon Field..................................................... 79
5.8.3 Detector Response in Small Photon Fields..................................................................................................... 80

* Contributions by John Fenwick and Sudhir Kumar are gratefully

acknowledged.

55
 56
5.8.3.1 General............................................................................................................................................ 80
5.8.3.2 Response as a Function of Detector Type......................................................................................... 81
5.8.3.3 Small-Field Perturbation Factor for Air-filled Ionisation Chambers.................................................. 83
5.8.3.4 The Physics of ‘Bragg–Gray Breakdown’ in Small Fields.................................................................. 84
5.8.4 Mass-density Compensation to Improve Small-field Detector Response......................................................... 86
5.1 Introduction
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As described in Chapter 3, charged particles (including
those generated from uncharged-particle interactions –
see Chapter 4) lose energy when they interact with matter.
This energy is transferred to and absorbed by the irradi-
ated medium. This energy absorption is the basis for the
biological effects of radiotherapy that may ultimately result
in tumour eradication (see Chapter 6). The absorption of
(charged-particle kinetic) energy is expressed in terms of the
fundamental quantity absorbed dose; this chapter is dedi-
cated to radiation dosimetry, i.e. the determination (either
experimentally or theoretically) of the absorbed dose in mat-
ter irradiated by ionising radiation.
The success of radiotherapy depends on accurate knowl-
edge of the absorbed dose delivered to the patient under-
going treatment. So-called ‘dose–response curves’ for
tumour control and for normal-tissue damage (see Part B
and Chapter 44) are relatively steep, especially for certain
tumours and normal tissues. Consequently, a difference
of only a few per cent in the ‘target’ dose may separate
uncomplicated tumour eradication (or ‘control’) from
either failure to control the tumour through underdosage
or, assuming the dose is increased everywhere in the treat-
ment plan by the same factor, serious normal-tissue dam-
age through overdosage.
There are several different steps involved in the determina-
tion of the absorbed dose distribution in the patient. The first
step in the radiotherapy clinic involves measurements with a
detector (also known as a dosimeter) in a phantom (often water,
sometimes water-like plastic) placed in the radiation beam (or
more generally, radiation field). Such measurements include
determining the dose at a reference depth in a reference-size
field (see Chapter 19), relative doses at many positions in the
phantom to map out a complete dose distribution (see Chapter
20), and so-called in vivo doses on the patient’s skin during
treatment (see Section 48.3).
The detector yields the dose Ddet to its own sensitive mate-
rial via a calibration coefficient derived from a quantity of
charge, light, film blackening etc. The dose required is that at
the position r(x, y, z) in the medium, D med (r), in the absence of
the detector. The conversion of Ddet to Dmed is a fundamental
step requiring knowledge of the theoretical aspects of radia-
tion dosimetry. The same is true of the calculation of the dose
distribution inside the (heterogeneous) patient (see Part F).
This chapter covers the fundamental ideas and principles
involved in radiation dosimetry, independently of the par-
ticular detector being used. The characteristics of the vari-
ous detectors or dosimeters used in radiotherapy, as well as
the numerical values of the relevant quantities, are covered
principally in Part D. Comprehensive treatments of the
Part A: Fundamentals
experimental and theoretical aspects of radiation dosimetry
can be found in Greening (1981) and especially Andreo
et al. (2017). Whyte (1959), Kase and Nelson (1978), Johns
and Cunningham (1983), Rajan (1992) and Metcalfe et al.
(1997) are also useful references.
From the formal definitions of the quantities such as
absorbed dose and kerma given later in this chapter, one might
imagine that radiation dosimetry is an old, well-established
discipline. In reality, its history is rather tortuous. Following
Röntgen’s discovery of x-rays in 1895, the first radiation unit
proposed was based on its ionising power. Christen (1914)
was ahead of his time in advocating the quantity dose, defined
as ‘radiant energy per unit volume’. In 1928 the International
X-ray Unit Committee defined the Röntgen as:
‘the quantity of x-radiation which, when second-
ary electrons are fully utilised and the wall effect
of the chamber is avoided, produces in one cubic
centimetre of atmospheric air at 0 °C and 76 cm
mercury pressure, such a degree of conductivity
that one electrostatic unit of charge is measured at
saturation current.’
This quantity later became known as exposure (see
Section 5.3.2).
It was not until 1950 that the International Commission
on Radiation Units and Measurements (ICRU) formalised
the definition of dose in terms of ‘the quantity of energy
absorbed per unit mass (ergs per gram) of irradiated material
at the point of interest’ (ICRU 1951). In 1954, the ICRU
finally approved the term absorbed dose, with its unit the rad
defined as ‘100 ergs per gram’. The modern unit, the gray
(Gy), is exactly 100 rad (1 cGy = 1 rad). The meaning and for-
mal definition of absorbed dose were further refined, and its
modern form (see Section 5.3.1) given in ICRU report 33
(ICRU 1980) and carried through to report 60 (ICRU 1998)
and report 85, revised as report 85a (ICRU 2011).
5.2 The Stochastic Nature of
Energy Deposition
Absorbed dose is the result of the deposition of energy in
matter by radiation tracks. This is an inherently random pro-
cess, as Chapters 3 and 4 make clear. Consider a situation
where the energy, E, deposited in an ever-decreasing volume
(and therefore mass) centred on the same point in a uniform
medium, is determined for a series of irradiations of identical
duration. A plot is made of E divided by the mass m of the
volume for each separate irradiation. Figure 5.1 shows the
expected result.
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry
E/m
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D all those charged and uncharged ionising particles
Log m
FIGURE 5.1 Energy deposited per unit mass, plotted against the
mass, m, of the scoring volume, as this volume is gradually reduced in
size for a given incident radiation fluence (as defined in Section 5.3.3).
The shaded portion (cloud) represents the range where statistical fluctu-
ations become important as the volume (i.e. m) becomes smaller. (From
Rossi, H. H., Radiation Dosimetry, Vol. 1, Academic Press, New York,
1968.)
For large volumes (i.e. large Log m), E/m has the same
value, D, for repeated measurements, almost independent of
the volume.* Below a certain value of m, fluctuations start
to appear, which increase as m decreases. These are due to
the fact that energy is deposited through a finite number
of interactions along particle tracks; some volumes, if small
enough, will contain few or no tracks, while others may con-
tain many. Therefore, for a given particle fluence (see Section
5.3.3), below some magnitude of the elementary volume, the
randomness of energy deposition will become apparent.
The absorbed dose discussed in what follows is non-stochas-
tic; i.e. it is assumed to be determined in a mass element suffi-
ciently large for the fluctuations to be negligible. The subject
of fluctuations in the dose is generally dealt with under the
heading of microdosimetry (ICRU 1983; Goodhead 1987)
and falls outside the scope of this chapter (see Section 6.11.5).
5.3 Definitions of Dosimetric Quantities
5.3.1 Absorbed Dose
The absorbed dose is defined by ICRU (2011) as follows:
The absorbed dose, D, is ‘the quotient of de by dm,
where de is the mean energy imparted by ionising
radiation to matter of mass dm’:
de
D= (5.1)
dm
* For photons, the fall-off at large values of m or Log m corresponds to
attenuation of the radiation when the path length across the volume
becomes comparable with the mean free path for the particle interac-
tions; this consideration is not relevant here.
57
The unit of absorbed dose is the gray (Gy), which is equal
to 1 Joule per kilogram (J kg−1). ICRU (2011) defines the
energy imparted, ε, as the sum of all energy deposits (see later)
in the volume.
The mean energy imparted, e , by ionising radiation to the
matter in a volume is defined by the ICRU (2011) as:
e = Rin - Rout + SQ (5.2)
where
R in is the mean energy (excluding rest mass energies) of
that enter the volume
Rout is the mean energy (excluding rest mass energies) of
all those charged and uncharged ionising particles
that leave the volume
∑Q is the sum of all changes (decreases: positive sign,
increases: negative sign) of the rest mass energy of
nuclei and elementary particles in any nuclear trans-
formations that occur in the volume
R in and Rout are known as radiant energies.
Figure 5.2 illustrates the concept of the stochastic quantity
energy deposit. In Figure 5.2a, illustrating a Compton inter-
action (see Section 4.3.2.1) within the volume V, the energy
deposit ε is given by:
e = hn 1 - ( hn 2 + hn 3 + E ¢ ) (5.3)
where E' is the kinetic energy of the charged particle – of ini-
tial kinetic energy E – on leaving the volume V. Note that the
photon hn4 does not appear in Equation 5.3, as this photon
is not emitted within the volume V. The ΣQ term is also not
involved here.
The volume in Figure 5.2b involves γ-ray emission (hn1)
from a radioactive atom, pair production (kinetic energies
E1 and E2), and annihilation radiation as the positron comes
to rest (see Section 3.8). The energy deposit in this case is
given by:
e = 0 - 1.022 MeV + SQ (5.4)
where
SQ = hn 1 - 2mec 2 + 2mec 2 = hn 1 (5.5)
In Equation 5.4, the zero corresponds to the R in term;
‘1.022 MeV’ corresponds to the Rout term, comprising the
two annihilation γ-rays. The γ-ray energy hn1 arises from
a decrease in the rest mass of the nucleus; the −2mec2 term
is due to the creation of an electron–positron pair, i.e. an
increase in rest mass energy. Finally, the +2mec2 term is due
to the annihilation of an electron and a positron. Careful
thought is required in such examples.
Note that the quantity ε, defined as the sum of (single-
interaction) energy deposits in a volume, is stochastic; in
Equation 5.2, consistent with the definition of absorbed
dose, its mean value is used, which is non-stochastic.
 58
V
E'
hn1 E
hn3
hn2
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(a)
FIGURE 5.2 An illustration of the concept of the energy imparted to an elementary volume by radiation. (a) Compton interaction from an incom-
ing photon impinging on the volume V. (b) γ-ray emission from a radioactive atom resulting in pair production. (From Attix, F. H., Introduction
to Radiological Physics and Radiation Dosimetry, Wiley, New York, 1986. With permission.)
5.3.2 Kerma (and Exposure)
The quantity kerma* can be thought of as a step towards
absorbed dose. Conceptually, it is very close to exposure, the
first radiation quantity to be formally defined (see Section
5.1 and e.g. Greening 1981). Medical physicists working
with external-beam radiation therapy were, until around
2000, familiar with kerma (in air in a 60Co γ-ray beam) in
the context of the calibration of an ionisation chamber at a
National Standards Laboratory (see Section 19.3).† Kerma is
defined by the ICRU (2011) as follows:
The kerma, K, is ‘the quotient of dEtr by dm, where
dEtr is the mean sum of the initial kinetic ener-
gies of all the charged particles liberated in a mass
dm of a material by the uncharged particles incident
on dm’:
dE tr
K =
dm
The unit of kerma is the same as that of absorbed dose,
J kg–1 or gray (Gy). Kerma applies only to indirectly ionis-
ing (or uncharged) particles, which for our purposes, almost
always means photons, although neutrons also fall into this
category.
The quantity exposure is closely related to air kerma.
Exposure, usually denoted by X, is the quotient of dQ by dm,
where dQ is the absolute value of the total charge of the ions
of one sign produced in air when all the electrons (negatrons
and positrons) liberated by photons in air of mass dm are
completely stopped in air. Until the late 1970s, all ionisation
chambers were calibrated in terms of exposure; subsequently,
this was replaced by air kerma.
Attix (1968) described exposure thus:
Exposure is conceptually identical neither to kerma
nor absorbed dose, but it has characteristics of
* ‘kerma’ is an acronym for ‘kinetic energy released per unit mass’.
† The quantity kerma in air is still in official use to specify the ‘strength’
of the radioactive sources used in brachytherapy (see Section 51.3).
Part A: Fundamentals
hn = 0.5II MeV
e
hn4 V
q+
E2
hn1
E1
q-
hn = 0.5II MeV
(b)
both. Like kerma, it describes energy transferred to
electrons in a small volume at the point of interest,
but for exposure air is always taken as the reference
material, whether or not it is actually present. Like
kerma rate, the exposure rate is used to characterize
x- and γ-ray fields, and in fact has continued to be
used for this purpose in preference to kerma rate.
Exposure is similar to absorbed dose in one respect:
energy spent by the secondary electrons in generat-
ing bremsstrahlung contributes neither to the local
absorbed dose nor to the exposure.
Figure 5.3 illustrates the concept of kerma (and exposure).
It is important to realise that it is the initial kinetic energies
that are involved; the eventual fate of the charged particles
(e.g. whether they leave or do not leave the elementary vol-
ume) has no influence on kerma. In the volume in the figure,
the initial kinetic energies of the two electrons labelled e1
(5.6) contribute to the kerma, as both were generated in the vol-
ume. The fact that one of these electrons leaves the volume
with a residual kinetic energy E1 is irrelevant. The kinetic
energy E2 of the electron labelled e2 entering the volume
makes no contribution to kerma, as this electron was gener-
ated outside the volume.
,m
Air
e1
X or
rays
e2
E2 E1
e1
FIGURE 5.3 Illustration of the concepts of kerma (and exposure).
The two electrons labelled e1 contribute to the kerma; but the electron
labelled e2 does not. (Reproduced from Attix, F. H., Introduction to
Radiological Physics and Radiation Dosimetry, Wiley, New York, 1986.
With permission.)
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 59

It is emphasised that kerma includes the energy that the Let N be the number of particles striking a finite sphere
charged particles may re-radiate in the form of bremsstrah- surrounding point P (during a finite time interval). If the
lung photons (i.e. radiation losses). Kerma can be therefore sphere is reduced to an infinitesimal one at P with a cross
partitioned as follows (Attix 1979; Andreo et al. 2017): sectional area of da, then the fluence Φ is given by:

K = K col + K rad (5.7) dN

F = (5.11)
da
where This is usually expressed in units of m–2 or cm–2 (ICRU
‘col’ refers to ‘collisions’ with the atomic orbital electrons 2011). Note that fluence is a scalar quantity – the direction
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(i.e. electronic losses -see Section 3.2) of the radiation is not taken into account.
‘rad’ refers to radiation losses from interactions with the
atomic nuclei (see Section 3.4). We will be making significant use of fluence, differential in
energy E, often written as ΦE:
The collision kerma,* Kcol, is related to the (total) kerma by
dF
K col = K (1 - g ) (5.8) FE = (5.12)
dE
where g is the fraction of the initial kinetic energy of the elec- where dF is the fluence of particles of energy between E and
trons that is re-radiated as bremsstrahlung (in the particular E + dE.
medium of interest).† E max

Exposure and air kerma can be related to each other as The (total) fluence can be obtained from F =
ò0
F E dE .
follows. The product of the charge dQ (refer to the defini-
tion of exposure given earlier) and the mean energy required Similarly, the fluence, differential in solid angle Ω, can be
to produce one ion pair in air, often written as Wair/e (see defined as:
ICRU 2011 and Section 16.1), yields the electronic part of
dF
the energy transferred, i.e. dEtr (1 − g), and therefore, FW = (5.13)
dW
X (Wair / e) = K air (1 − g ) (5.9) where dF is the fluence of particles propagating within a
or solid angle dW around a specified direction.‡
The two differential quantities can be combined, yielding
X (Wair / e) = (K col )air (5.10) F W ,E , the fluence differential in solid angle and energy.

5.3.3 Particle Fluence
To calculate absorbed dose, we require quantities that describe
the radiation field, known as field quantities (Greening 1981)
or radiometric quantities (ICRU 2011). Particle fluence
(ICRU 2011), the number of particles per unit area, is a key
field quantity. The concept is illustrated in Figure 5.4.
Sphere Point P
Great circle, area da
Fluence can also be expressed as the quotient of the sum
of the track lengths of the particles crossing the elementary
sphere and the volume of the sphere§ (Chilton 1978; Papiez
and Battista 1994):
SDs
F = (5.14)
dV
This form is extremely useful when considering so-called cav-
ity integrals (see Section 5.7) which yield kerma or absorbed
dose by integrating (over energy) the fluence, differential in
energy (over the volume of interest), multiplied by the rel-
evant interaction coefficient.

Particle traversing Volume dV
sphere
FIGURE 5.4 Characterisation of the radiation field at a point P in terms
of the radiation traversing a sphere centred at P. (Adapted from Attix,
F. H., Introduction to Radiological Physics and Radiation Dosimetry,
Wiley, New York, 1986.)
* This quantity is sometimes called electronic (or ionisation) kerma
which would be consistent with the change from collision to elec-
tronic stopping power – see Section 3.2.2. However, ICRU Report
90 (2014) has recommended the continued use of collision kerma - see
Rogers and Townson (2019).
† g ≈ 0.003 in the case of cobalt-60 γ-rays in air (IAEA 1997).
5.3.4 Energy Fluence
Energy fluence is the product of fluence and particle energy.
Let R be the value of the total (radiant) energy (excluding
rest mass energy) carried by all the N particles in Figure 5.4
(i.e. the radiant energy). Then, the energy fluence Ψ is given
by (ICRU 2011):
dR
Y = (5.15)
da
‡ The specification of a direction requires two variables; in spheri-
cal coordinate systems with polar angle θ and azimuthal angle φ,
dΩ = sinθ dθ dφ.
§ This can be proved by noting that for a volume V and external sur-
face area S, the mean chord length is 4V/S (i.e. 4r/3 for a sphere of
radius r).
 60
If particles of only a single energy, E, are present, then R = E N
and Ψ = E Φ.
Exactly as for fluence, the energy fluence can be expressed
as differential in energy, solid angle or both.
5.3.5 Planar Fluence
Planar fluence is the number of particles crossing a fixed
plane in either direction (i.e. summed by scalar addition) per
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unit area of the plane (see Figure 5.5). One can also define a
vector quantity corresponding to net flow, but this is of lim-
ited use in dosimetry.* Planar fluence is a particularly useful
concept when dealing with beams of charged particles. In
certain situations, e.g. at small depths in a parallel electron
or proton beam, to first order, the planar fluence remains
constant as the depth increases; in contrast, fluence gener-
ally increases due to the change in direction of the charged
particle tracks (see Section 3.7). The difference between the
two quantities is illustrated in Figure 5.5.
5.3.6 Fluence Rate
All the quantities in Section 5.3 can be defined per unit
dF
time, e.g. the fluence rate F = and the energy fluence rate
dt
dY
Y = .
dt
Incoming beam
Scattering medium
Scattered rays
FIGURE 5.5 Schematic 2D illustration of the concept of planar flu-
ence. The number of particles crossing the two horizontal lines (of
equal length) is the same. This shows that the planar fluence in the
original beam direction remains constant, whereas the fluence, i.e. the
total track length in the two circles, is clearly greater on the down-
stream side of the scattering medium. (Adapted from Whyte, G. N.,
Principles of Radiation Dosimetry, Wiley, New York, 1959.)
* In radiation dosimetry, the effects of individual energy deposits are
added irrespective of the direction of the trajectories of the particles
giving rise to them, as Section 5.3.1 makes clear.
Part A: Fundamentals
5.4 Relations between Fluence and
Dosimetric Quantities for Photons
This section relates quantities concerning energy trans-
ferred to (i.e. kerma) or deposited in (i.e. absorbed dose)
a medium to the fluence that characterises the radiation
field. This will first be done for uncharged particles (pho-
tons), starting with the relation between fluence and kerma
(Section 5.4.1) before moving on to the relation between
fluence and absorbed dose (Section 5.4.2) via the impor-
tant concept of charged particle equilibrium (Section 5.5).
Subsequently, the corresponding fluence–dose relation for
charged particles will be derived (Section 5.6). Armed with
these fluence–absorbed dose relationships, we will then
be in a position to derive expressions describing detector
or dosimeter response, generally known as cavity theory
(Section 5.7).
5.4.1 Relation between Photon Fluence and Kerma
A small (or elementary) volume ΔV of material ‘med’, mass
Δm and density r = r med, is traversed by several photon tracks
of energy hn (see Figure 5.6).
To extract energy from particle tracks and transfer it to the
medium, we require an interaction coefficient. We start from
the definition of the mass energy transfer coefficient m tr (hn )/r
(see Section 4.5.3 and ICRU 2011):
m tr (hn ) 1 dRtr
= (5.16)
r r dl R
where dRtr is the mean (radiant) energy that is transferred
to the kinetic energy of charged particles by interactions of
uncharged particles, of incident radiant energy R, in travers-
ing a distance dl (R = N hn for N photons traversing ΔV). It
follows that the mean energy transferred to charged particles
by the ith photon of track length dli is:
dE tr,i = hn dli m tr (hn ) (5.17)
FIGURE 5.6 Schematic representation of photon tracks, each of energy
hn, crossing an elementary volume ΔV of material ‘med’, with density
rmed. (Adapted from Andreo, P., Burns, D. T., Nahum, A. E., Seuntjens,
J. and Attix, F. H., Fundamentals of Ionizing Radiation Dosimetry,
Wiley-VCH, Weinheim, 2017.)
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 61

and therefore, the sum of energy transferred to charged-

where g med , the fraction of the energy transferred to charged
particle kinetic energy in the volume is:
particles that is converted into bremsstrahlung, is a medium-
specific average value for the photon energy spectrum and
S dE tr,i = hn S dli m tr (hn )
i i can be calculated from Equations 5.20 and 5.22.
Dividing both sides by the mass of the volume Δm, writing
5.4.2 Relation between Kerma
Dm = rDV on the right-hand side of the equation, and re-
grouping some of the terms: and Absorbed Dose
Having established a relationship between kerma and fluence
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S dE tr,i S dli m tr (hn ) S dli æ m (hn ) ö in the previous section, if absorbed dose can be related to
tr
i
= hn i
= hn i ç ÷
Dm r DV DV è r ø med kerma, then a relationship between absorbed dose and fluence
for photons can also be established. The absorbed dose in the
Recognising that on the left-hand side the sum of energy medium, Dmed, is given by the mean value of energy imparted
transferred divided by the mass is kerma K med (cf. Equation to an elementary volume (per unit mass), whereas kerma is the
5.6) and that the sum of the tracklengths divided by the vol- energy transferred to this volume (per unit mass). However,
ume is the fluence Φ (cf. Equation 5.14), we arrive at: the charged particles can leave the elementary volume, taking
their residual kinetic energy with them. This is illustrated in
æ m (hn ) ö
K med = ç tr ÷ hn F med (5.18) Figure 5.7. Note that the quantity denoted in the figure by
è r ø med E trn is the net energy transferred to electrons within the layer,
where the medium ‘med’ has been made explicit. Alternatively, excluding that part of the initial kinetic energy converted into
in terms of the energy fluence Ψ: bremsstrahlung photons; this is equal to Etr(l − g), as we have
already seen.
æ m (hn ) ö Referring to Figure 5.7, the (net) kinetic energy leaving
K med = ç tr ÷ Y med (5.19) n
è r ø med the layer is E out , and the (net) kinetic energy entering the
layer on charged particles is E inn . The energy deposited in the
Up to this point, it has been assumed that the photons layer, ε, is given by:
crossing the elementary volume all have the same energy
e = E inn + Etrn - E out
n
(5.24)
hn. The equivalent expression for kerma for a photon spec-
trum is: where the scattered (Compton) photon and the bremsstrah-
lung photon are assumed to leave the layer without interact-
hn max
æ m (hn ) ö ing. If the electron track that leaves the layer is now
K med =
ò hn ´ (F hn )med ç tr
è r ø med
÷ dhn (5.20) compensated by an identical track entering the layer, i.e.
0
E inn = E out
n
in Equation 5.24, then it follows that:
where F hn is the photon fluence differential in energy e = E trn (5.25)
( F hn º dF /dhn ); Equation 5.20 is a fundamental relation-
ship in radiation dosimetry.

Additionally, we require the relationship between photon E nin

fluence and collision kerma, Kcol (see Section 5.3.2). Referring e– Bremsstrahlung
to Equations 5.19 and 5.20, the mass energy transfer coef-
ficient μtr/r is replaced by the mass energy absorption coeffi-
cient μen/r, as the energy absorbed excludes the fraction of the Incoming photons
e–
initial kinetic energy of charged particles that is converted to
bremsstrahlung photons (see Section 4.5.3 and ICRU 2011). E nout
For a single photon energy, we have: n
E tr

æ men (hn ) ö
( K col )med = ç ÷ hn F med (5.21) Scattered photon
è r ø med

and for a spectrum of photon energies: FIGURE 5.7 Schematic illustration of how secondary electrons lib-
hn max
erated by photons can transfer their kinetic energy E trn to a thin layer,
æ m (hn ) ö while some leave that layer and others enter the layer from outside. If the
( K col )med = ò 0
hn ´ (F hn )med ç en
è r ø med
÷ dhn (5.22) energy leaving the layer, E outn
, is exactly replaced by the energy entering,
E inn , then charged particle equilibrium is said to exist, and absorbed dose
The two types of kerma are related by: can be equated to collision kerma. This equality is represented sche-
matically in the figure: the section of the full length of the track of the
secondary electron starting outside the thin layer is exactly equal to the
(K col )med = K med (1 - g med ) (5.23) length of the two partial tracks of electrons (in bold) inside the layer.
 62
The equality between the kinetic energy of charged particles
leaving a volume and the kinetic energy of those entering
the same volume is known as charged particle equilibrium
(CPE); Equation 5.25 expresses the fact that under CPE, the
energy imparted to the volume, ε, is equal to the net energy
transferred to this same volume, Etrn.
Dividing both sides of Equation 5.25 by the mass of the
layer (or volume element), and changing from stochastic to
average quantities, we can write:
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CPE
D med = (K col )med
Equation 5.26 expresses the important result:
Under the special condition of charged-particle
equilibrium, the absorbed dose is equal to the colli-
sion kerma.
Replacing collision kerma by absorbed dose in Equation
5.21, for the case of monoenergetic photons we can there-
fore write:
CPE æ m (hn ) ö
D med = ç en
÷ hn F med
è r ømed
In the case of a spectrum of photon energies, (Φhv)med this
becomes:
hn max
CPE æ m (hn ) ö
D med =
ò
0
hn ´ (F hn )med ç en
è r ø med
÷ dhn
Equation 5.27 and Equation 5.28 are fundamental relation-
ships in radiation dosimetry; they will be exploited in Section
5.7.3.
Section 5.5 explains how CPE can be realised under cer-
tain conditions.
5.5 Charged-Particle Equilibrium
(CPE); Partial CPE
Charged-particle equilibrium (CPE), also known as elec-
tronic equilibrium* is said to exist in a volume V in an irradi-
ated medium:
if each charged particle of a given type and energy
leaving V is replaced by an identical particle of the
same energy entering V.
Figure 5.8 illustrates schematically how CPE can be achieved
in a photon-irradiated medium. Naturally, the figure is an
over-simplification, as in practice there will be a spectrum
of secondary-electron energies and directions. However, the
argument is not essentially altered by showing only one elec-
tron starting in each voxel (labelled A to G in the figure) and
travelling in a straight line.
* Other charged particles may be involved (e.g. positrons), but in
the photon beams employed in radiotherapy, (secondary) electrons
predominate.
Part A: Fundamentals
Range R
100 100 100 100
A B C D E F G
Kerma
Absorbed dose
Kerma
Build up Electronic
region equilibrium
(5.26)
Depth
FIGURE 5.8 Diagram showing the build-up to charged-particle equi-
librium for the idealised case of no attenuation of the photon beam
and one straight electron track generated in each voxel labelled A to
G. (Taken from Johns, H. E. and Cunningham, J. R., The Physics of
Radiology, 4th Ed., Charles, C., Ed., Thomas Publisher, Springfield,
IL, 1983. With permission.)
In each voxel, one electron is generated, and therefore the
kerma will be constant, as it is assumed that there is negligi-
ble photon attenuation. Only a small fraction of the electron’s
(5.27)
kinetic energy is deposited in voxel A; there is clearly no com-
pensation for the part of the track that leaves the volume, and
therefore the dose in voxel A is relatively low. In voxel B, a new
electron starts, but in addition, there is also part of the elec-
tron track that started upstream in voxel A. Hence, the dose in
(5.28) voxel B is higher than that in voxel A. In voxel C, the dose is
higher still. In voxel D, where the electron that started in voxel
A comes to rest, the sum of the sections of the separate electron
tracks is exactly equal to a complete electron track (which cor-
responds to the energy transferred, i.e. to kerma). Therefore,
CPE is first attained in voxel D. Subsequent voxels (E, F, G
etc.) will contain patterns of electron tracks identical to those in
D, and therefore CPE must also be present in these voxels. In
voxel D, the absorbed dose is equal to kerma (strictly, collision
kerma), and this will also be the case in the subsequent voxels
E, F, G etc., provided that photon attenuation is negligible.
In a real photon beam it is impossible to achieve true CPE;
photon attenuation reduces the photon fluence with depth,
and therefore the number of secondary particles (electrons)
starting at different depths will not be constant.
Even though in many situations strict CPE may not exist,
it can be well approximated, such as at depths beyond the
dose maximum in media irradiated by photons below around
1 MeV in energy. At higher energies, the equals sign in
Equation 5.26 can be replaced by the proportionality sym-
bol. This situation is termed partial charged particle equilib-
rium† or PCPE (see Chapter 4 in Andreo et al. 2017):
PCPE
D µ K col
See also Equation 5.30.
† Partial CPE was previously often termed transient CPE (e.g. Attix
1979, 1986) but in Chapter 4 of Andreo et al. (2017), it is argued that
transient is inappropriate, as it refers to time; the term quasi or partial
CPE is preferred.
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 63

TABLE 5.1 electrons give rise to an entirely negligible amount of (sec-

Approximate Thickness of Water Required to Establish Partial ondary) bremsstrahlung in water. Hence, the quantity g (see
Charged-Particle Equilibrium Equations 5.8 and 5.23) is very close to zero, and (total)
kerma and collision kerma cannot be separated. Even the
Maximum Approximate
highest-energy secondary electrons have extremely short
Energy of Thickness of Water for Approximate Photon
Photons (MeV) Equilibrium (mm) Attenuation (%) ranges; to show the build-up of dose from the surface (≈0–
0.017 cm), the depth scale in the figure only extends to
0.3 0.1 0.03 0.08 cm (equivalent to 0.08 g cm−2 for water), and over this
0.6 0.4 0.1 distance, photon attenuation is negligible. Summarising,
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1 0.8 0.3 the assumptions involved in the pedagogical Figure 5.8 are
2 2.5 0.8 amply fulfilled by the photon beams of Figure 5.9.
3 8 2 In Figure 5.10, the in-water depth dependence of absorbed
6 15 4 dose, total and collision kerma is shown for a much higher
8 25 6 photon beam energy (25 MeV). If radiative interactions
10 30 7 and scattered photons are ignored, it can be shown that
15 50 9 (Greening, 1981):
20 60 11
PCPE
30 80 13
D » K col ´ (1 + m x ) (5.29)
For bremsstrahlung beams of different maximum energies; the final column
gives approximately the attenuation of photons in that thickness of water. where
Source: From Greening, J. R., Fundamentals of Radiation Dosimetry, μ is the common slope of the D, K and Kcol curves
Adam Hilger, Bristol, 1981. With permission.
x is the mean distance the secondary charged particles
carry their energy in the direction of the primary rays
while depositing it as dose (see Chapter 4 in Andreo
et al. 2017).

The constant of proportionality between dose and colli-

sion kerma is conventionally denoted by β:

D med = b med ´ (K col )med (5.30)

FIGURE 5.9 Absorbed dose and kerma divided by the incident photon
fluence (Gy cm 2) versus depth in water for broad, parallel photon beams
of energy 250 keV and quality 250 kV, obtained from Monte-Carlo sim-
ulations.* (Reproduced from Kumar, S., Deshpande, D. D. and Nahum,
A. E., Phys. Med. Biol., 60 (2), 501–519, 2015. With permission.)

Table 5.1 shows the amount of photon attenuation over

the distance in water required to achieve partial electronic
equilibrium for photon beams of different energies. It can be
seen that the degree of CPE failure increases as the photon
energy increases.
Figure 5.9 shows the depth dependence (in water) of
kerma K and dose D in relatively low-energy mono- and
poly-energetic photon beams. At these relatively low pho-
ton energies the even lower energies of the secondary
* It is usual to refer to the ‘quality’ (related to penetration) of a polyen-
ergetic photon beam obtained via the bremsstrahlung interaction pro-
cess, by stating the ‘voltage’ (e.g. kV or MV) that would produce such
a beam, i.e. of the maximum energy of the spectrum (see Sections
22.2 and 23.2.1); using keV or MeV as unit indicates that the beam
is monoenergetic. Monte-Carlo simulation of radiation transport is
covered in Chapter 30.
FIGURE 5.10 Monte-Carlo calculations of the variation with depth
of dose D, kerma K and collision kerma K col along the central axis
for a broad, monoenergetic 25 MeV photon beam incident on water.
The partial CPE region beyond the depth of maximum secondary
electron range, R max = 11.2 cm, is emphasised; the displacement
x between the collision kerma and dose curves is also indicated.
Note that the scale on the ordinate is logarithmic, and therefore
the values where D ≈ 0, cannot be shown. Data from Kumar et al.
(2015a). (Reproduced from Chapter 4 in Andreo, P., Burns, D.
T., Nahum, E. E., Seuntjens, J. and Attix, F. H., Fundamentals of
Ionizing Radiation Dosimetry, Wiley-VCH, Weinheim, 2017. With
permission.)
 64 Part A: Fundamentals

Figure 5.10 identifies the distance x and the PCPE region, The depth x1 at which kerma and dose are equal is therefore:
where the D, K and Kcol curves first become parallel to each
other. At this high photon energy, g is appreciable, resulting ln ( me /m p )
in a clear separation between kerma and collision kerma. x1 = (5.35)
me - m p
When integrated out to large depth, the area under the
collision kerma curve is closely equal to the area under the
Greening also showed that the maximum value of the dose
absorbed dose curve. However, it is clear from Figure 5.10
occurred at depth x1.
that the area under the kerma curve exceeds that under the
These features can be seen in Figure 5.10, although the
collision kerma curve, and therefore kerma violates energy
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high energy, 25 MeV, of the photons gives rise to appreciable

conservation. This issue has been explored in depth in Kumar
secondary bremsstrahlung, causing the collision kerma to
and Nahum (2016).
cross the dose curve at a depth slightly less than that of Dmax.
Kumar et al. (2015a) propose the following approximate
For photon beams of very small cross section (‘small
expression for (D/Kcol):
fields’, see Section 5.8), there can be major departures from
(partial) CPE, causing the dose to differ significantly from
æ D ö the collision kerma at all depths. Figure 5.11 shows the
çK ÷ = b med ratio of the absorbed dose D to the kerma K for spectra
è col ø med (5.31) (for point sources) of 6 MV, 10 MV and 15 MV obtained
æ m (hn ) é ù ÷ö by Monte-Carlo simulation (see Chapter 30);* it can be
» çç 1 + eff
r
{
êë0.5 ´ Rcsda (E 0)hn } û ÷ø
med ú seen that D/K decreases rapidly for field sizes less than
è
~3 cm × 3 cm. This decrease is due to the onset of (lateral)
electronic disequilibrium as the field width drops below
where that required to encompass the lateral excursions of the
µeff is an effective attenuation coefficient that takes higher-energy secondary electrons (see Section 5.8; Scott
account of the build-up due to scattered photons et al. 2009; IPEM 2010).
and is therefore smaller than the narrow-beam Dutreix et al. (1965) contains an excellent, pedagogical
attenuation coefficient µ (see Section 4.5.1) discussion of the concept of charged-particle equilibrium.
hn is the kerma-weighted mean energy over the pho-
ton-fluence spectrum (the term in the square brack-
ets corresponds to the x of Equation 5.29)
E 0 is the mean initial energy of the (secondary) elec-
trons set in motion by these photons
Rcsda is the continuous-slowing-down-approximation
(CSDA) range of these electrons expressed as mass
per unit area (e.g. g cm–2) (see Section 3.5.3).

Greening (1981) has given an instructive analytical treat-

ment of the depth dependence of kerma and dose. A parallel
beam of high-energy photons of energy fluence Y 0 at the
surface of the medium is assumed with an effective linear
attenuation coefficient µp. The secondary electron energy flu-
ence decreases in the beam direction with an effective lin-
ear attenuation coefficient µe, and secondary bremsstrahlung
can be ignored. Greening showed that the absorbed dose at
depth x1 is given by:
x1
m tr me FIGURE 5.11 Monte-Carlo-derived ratios of absorbed dose to kerma
Dx1 = Y 0
r ò exp(-m x)exp éë-m (x
0
p e 1 - x )ùûdx (5.32) (D/K) on the central axis at 10 cm depth in a large cylindrical water
phantom for megavoltage beam qualities versus field size defined at 100
cm source-to-phantom surface distance; the sides of the square fields
yielding: are 0.25 cm, 0.5 cm, 0.75 cm, 1 cm, 1.5 cm, 2 cm, 3 cm and 10 cm,
respectively; the error bars are ±2 standard deviations (k=2) and corre-
m tr me spond to statistical (type A) uncertainties. (Reproduced from Kumar, S.,
Dx1 = Y 0 éexp(- m p x 1) - exp(- me x 1)ùû (5.33)
r (me - m p ) ë Deshpande, D. D. and Nahum, A. E., Phys. Med. Biol., 60 (2), 501–519,
2015. With permission.)

Now the kerma at depth x1 is given by:

m tr * The quantity shown in Figure 5.11 is D/K rather than D/Kcol, and
K x1 =Y 0 exp(- m p x 1) (5.34) therefore, the ratio at large field sizes and high energies is slightly below
r unity, as kerma includes secondary bremsstrahlung (cf. Figure 5.10).
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry
5.6 Relation between Fluence and
Dose for Charged Particles
5.6.1 Stopping Power and CEMA
The previous two sections have concerned uncharged par-
ticles, i.e. photons.* In this section, equivalent relationships
are derived between the fluence of charged particles (assumed
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here to be electrons) and absorbed dose.
Figure 5.12 shows, schematically, a number of electron
tracks crossing a small volume ΔV of medium ‘med’, density
r = r med and mass Δm. In contrast to photons, for charged
particles the relevant quantity is stopping power, the energy
lost (quasi-continuously) per unit track length (see Section
3.2.2); we denote this type of local energy loss by dE ℓ to
distinguish it from dEtr employed for photons. We are pri-
marily interested in energy deposited locally in the volume,
so the appropriate quantity is the electronic stopping power,
Sel, rather than the total stopping power, as the latter includes
energy lost in the form of bremsstrahlung photons, and these
would escape the volume of interest† (this is analogous to the
difference between collision kerma and kerma).
For any of the electron tracks in ΔV, we can write
dEl = S el dl (5.36)
FIGURE 5.12 A schematic representation of electron tracks crossing an
elementary volume ΔV of material ‘med’ with density r; it is assumed
that the mean chord length across the volume is much smaller than the
ranges of the electrons (represented as straight lines). Bremsstrahlung
photons (labelled k i) are emitted from electron tracks 2, 5 and 6.
(Adapted from Andreo, P., Burns, D. T., Nahum, E. E., Seuntjens,
J. and Attix, F. H., Fundamentals of Ionizing Radiation Dosimetry,
Wiley-VCH, Weinheim, 2017.)
* Neutron interactions are covered in Chapter 4. Neutron dosimetry has
some similarities with photon dosimetry (e.g. the use of the kerma con-
cept). However, it is of limited interest in current radiotherapy and is
therefore not covered in this book (see Chapter 19 in Andreo et al. 2017).
† Note that the secondary electrons liberated within the elementary
volume by bremsstrahlung photons are included in the total electron
fluence; some of the incident electrons may also originate from brems-
strahlung losses elsewhere in the medium.
65
The total local energy transfer to an elementary volume dV
is therefore:
S dEl ,i = S el S dli
i i
Dividing both sides by the mass of the elementary volume
and replacing dm by r dV on the right-hand side of the
equation:
S dEl ,i S el S dli æ S ö é S dl i ù
i
= i
= ç el ÷ ê i ú (5.37)
dm r dV è r ø med êë dV úû
The term in the square brackets is the total tracklength per
unit volume, i.e. the average electron fluence‡ in the elemen-
tary volume (Equation 5.14), which we can write as Φmed.
Thus:
S dE ,i æS ö
i
= ç el ÷ Fmed (5.38a)
dm è r ø med
The quantity cema§ for charged particles was proposed by
Kellerer et al. (1992) as an equivalent to kerma for uncharged
particles. ICRU (2011) defines cema as:
‘the quotient of the mean energy lost in electronic
interactions in a mass dm of a material by dm,
except secondary electrons incident on dm.’
‘Secondary electrons’ refers here to the knock-on electrons
(or delta-rays) generated by the incident primary electrons
(see Section 3.2) – their kinetic energies are automatically
included in dEl through the use of the unrestricted elec-
tronic stopping power ¶ in Equation 5.38a. Cema is given by
ΣdEl/dm and is therefore equal to the product of electron
fluence and mass electronic stopping power:
æS ö
C med = F med ç el ÷ (5.38b)
è r ø med
Cema is not necessarily equal to absorbed dose, as some of
the delta-rays can leave ΔV, in an analagous way to second-
ary electrons when photons constitute the primary radiation.
For cema to equal absorbed dose, we require that charged-
particle kinetic energy leaving the elementary volume is
replaced by an exactly equal amount entering this volume
and being deposited in it or imparted to it (cf. Figure 5.7).
This is known as delta-ray (or knock-on electron) equilibrium.
If this form of equilibrium is present, then absorbed dose can
be equated to cema, and we can write, for a medium ‘med’,
d - eqm
æS ö
D med = F ç el ÷ (5.39)
è r ø med
‡ If the photon spectrum includes energies above the threshold for pair
production (1.022 MeV, see Section 4.3.3) the particle fluence will
include positrons as well as electrons.
§ The name ‘cema’ is the acronym for ‘converted energy per unit mass’.
¶ The term ‘unrestricted’ indicates that there is no restriction on the
magnitude of the energy transfer, via kinetic energy of delta-rays or
atomic excitation, to the medium (see Sections 3.2.4, 3.2.5 and 5.7.5).
 66
or, in the case of a spectrum of electron energies:
E max
d - eqm
æ S el (E ) ö
D med =
òF E ç
è r ø med
÷ dE (5.40)
0 f Q =  med 
where ΦE is the electron fluence, differential in energy (see
Section 5.3.3).
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5.6.2 Delta-Ray Equilibrium
Naturally, delta-ray equilibrium must always exist if charged-
particle equilibrium exists. However, if the primary radia-
tion consists of charged particles, CPE can never be achieved
except in the rather special case of uniformly distributed β
sources in a large medium. For the beams of high-energy
electrons used in radiotherapy, the energy of the primary
electrons decreases continuously with depth, and hence there
can never be CPE. However, the ranges of most delta-rays are
extremely short (see Section 3.2), and almost all the energy is
transferred through electronic losses; i.e. the cema is mostly
deposited locally. This is demonstrated by the closeness
of L D S el to unity even for very small values of the cut-off
energy Δ (see Figure 3.8).* Consequently, delta-ray equilib-
rium is generally present to a high degree in an electron-
irradiated medium.
One situation where delta-ray equilibrium is definitely
not a good approximation is very close to the surface in a
medium irradiated by an electron beam. The appreciable
range, in the forward direction, of the most energetic delta-
rays results in a small but discernible delta-ray build-up (see
Figure 3.16).†
5.7 Cavity Theory
5.7.1 Introduction
When a measurement is made with a detector, the detector
material will in general differ from that of the medium into
which it is introduced. As stated in Section 5.1, the signal
from a radiation detector used as a dosimeter is proportional
to the energy absorbed in its sensitive material and thus, to
the absorbed dose in this material, Ddet. The step from the
raw detector signal to Ddet at some reference radiation quality,
generally known as calibration, is dealt with in Chapter 19.
The detector can be thought of as a cavity introduced
into the (uniform or ‘undisturbed’) medium under irradia-
tion; the name ‘cavity’ stems from the fact that gas-filled
ionisation chambers dominated the early development of the
subject (Greening 1981; Whyte 1959), and the associated
* See Section 3.2.5 for definition of L Δ .
† As illustrated in Figure 3.16 and Figure 5.5, the increase in the pri-
mary electron fluence with depth, due to the increasing obliquity of
the electron tracks, remains the prominent phenomenon to explain
the increase of dose with depth in a medium irradiated by a ‘broad’
electron beam.
Part A: Fundamentals
theory, which relates Ddet to Dmed, is known as cavity theory.
The principal aim of cavity theory is to determine the factor
f Q, given by:
D 
(5.41)
 Ddet  Q
for an arbitrary detector ‘det’, in an arbitrary medium ‘med’,
irradiated by radiation of quality Q (here, photons or elec-
trons). Figure 5.13 illustrates the situation schematically.
This section contains the key ideas and expressions involved
in applying cavity theory to practical radiotherapy dosimetry.
Extensive use is made of some of the results obtained in the
previous sections of this chapter – in particular, the concept
of particle fluence and its relationship to absorbed dose. A
more detailed treatment is given in Chapter 9 of Andreo et
al. (2017). Burlin (1968) is also worth consulting.
The ‘Fano theorem’ is arguably the most fundamental
form of cavity theory and is covered first (see Section 5.7.2).
This is followed by the two most important situations
where it is possible to derive an exact expression for f Q.
The first of these is that of a so-called ‘large detector’ in
a photon-irradiated medium (see Section 5.7.3); ‘large’
refers to its size in relation to the ranges of the second-
ary particles, i.e. electrons. The Bragg–Gray cavity theory,
for ‘small’ detectors, is covered in Section 5.7.4, and the
more exact Spencer–Attix cavity theory in Section 5.7.5
Ion-chamber correction factors or perturbations to the
Bragg–Gray-based dose ratio are described in Section
5.7.6. The approximate Burlin or ‘general’ cavity theory,
for intermediate-size detectors, is described in Section
5.7.7. A Monte-Carlo-based example of the response of a
‘fictitious’ detector, involving all three cavity theories, is
given in Section 5.7.8. The final, separate Section 5.8 is
devoted to the dosimetry of ‘small’, sub-equilibrium mega-
voltage photon beams.
5.7.2 The Fano Theorem
Fano (1954) proved in a formal, mathematical way that:
In a medium of given composition exposed to a
uniform fluence of primary radiation (such as x-rays
or neutrons) the fluence of secondary radiation is
also uniform and independent of the density of the
medium as well as of the density variations from
point to point.
Figure 5.14 illustrates schematically the situation to which
the Fano theorem applies. A medium large enough for CPE
to be established is irradiated by indirectly ionising radiation,
giving rise to secondary-particle tracks (shown as straight
lines for simplicity). The central region has a higher density
but with its atomic composition identical to the region sur-
rounding it. More electron tracks per unit volume are started
in this central region, but each track is correspondingly
shorter due to the higher stopping power. Fano’s theorem
predicts that the electron fluence (i.e. total track length per
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry
Quality Q
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Ddet µ signal
(a)
FIGURE 5.13 The general situation of a detector introduced into a medium (a), yielding the dose averaged over the sensitive volume of the detec-
tor, Ddet , for a given exposure to radiation of quality Q and then (b) being converted into the dose Dmed at ×, in the absence of the detector, by
multiplying by the cavity-theory factor f Q.
Electron tracks in medium with density variation
High density
Low density
FIGURE 5.14 Schematic illustration of the situation to which the Fano
theorem applies: the total track length of secondary electrons per unit
volume, i.e. the electron fluence, remains the same, although the den-
sity of the photon-irradiated medium may vary. The electron tracks are
shown as straight lines for simplicity.
unit volume) in the central region will be exactly the same as
that in the outer region, irrespective of the size or density of
the central region. Greening (1981) and Chapter 9 in Andreo
et al. (2017) contain more detailed treatments of the Fano
theorem.
An example of the application of the Fano theorem is
in the dosimetry of low-energy x-ray beams, where it is
not possible to make a gas cavity small enough to fulfil
the Bragg–Gray condition (see Section 5.7.4, especially
Table 5.2). If the low-density (gas) cavity had the same
atomic condition as the surrounding medium (including
that of the chamber wall), then there would be no limita-
tion on the size of the cavity (e.g. water vapour surrounded
by water-equivalent chamber walls in a water phantom).
Of course, in practice, corrections would be required for
67
Quality Q
Dmed = fQDdet
(b)
beam attenuation. Reference is made to the Fano theo-
rem in Section 5.7.4.3 and in particular, in explaining
ion-chamber ‘Bragg–Gray breakdown’ in small, sub-
equilibrium megavoltage photon fields (see Section 5.8.3;
Figure 5.35).
The Fano theorem implicitly assumes that the mass
stopping power of a medium is independent of its density.
At relativistic energies (i.e. above around 0.5 MeV for
electrons), this is no longer the case due to the density
(or polarisation) effect (see Section 3.2.3). However, this
‘ violation’ of the Fano-theorem preconditions probably
­
has no practical importance. Fortunately, Bragg–Gray cav-
ity theory (Section 5.7.4) can be applied to the response
of a low-density cavity (e.g. air) in megavoltage photon
beams.
5.7.3 Cavity Theory for ‘Large’ Photon Detectors
Imagine a uniform medium irradiated by a beam of monoen-
ergetic photons with energy fluence Y med,z at depth z.
Provided that this depth is sufficient for partial CPE to be
established, by combining Equations 5.21 and 5.30, the dose
in the uniform medium at depth z can be written as:
PCPE æm ö
D med,z = b med Y med,z ç en ÷ (5.42)
è r ø med
Suppose now that a detector is placed with its centre at
depth z and that the volume of the sensitive material of the
detector, ‘det’, is large enough for there to be PCPE in this
volume; i.e. its dimensions are greater than the maximum
range of the secondary electrons generated in this material.
Figure 5.15 illustrates the situation schematically.
The photons interact with the detector material, giving
rise to secondary electron tracks. Within a narrow ‘rind’
region on either side of the detector edge there cannot be
(partial) CPE as the electrons in this region are generated
 68
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FIGURE 5.15 The deposition of energy by photon-liberated second-
ary electrons in a (wall-less) detector that is ‘large’ compared with the
secondary electron ranges (for simplicity represented by straight lines).
(Reproduced from Andreo, P., Burns, D. T., Nahum, E. E., Seuntjens,
J. and Attix, F. H., Fundamentals of Ionizing Radiation Dosimetry,
Wiley-VCH, Weinheim, 2017. With permission.)
partly in the surrounding medium and partly in the detector.
Away from the detector edge PCPE will exist in the detector
material. The absorbed dose in the detector, with the bar
indicating that this is an average over the detector volume,
will therefore be given by:
PCPE æm ö
Ddet = b det Y det ç en ÷ (5.43)
è r ødet
where the energy fluence is that in the detector material
(strictly an average over the detector volume) and the mass–
energy absorption coefficient applies to the detector mate-
rial ‘det’. The ‘large detector’ condition is essentially fulfilled
when the volume of the no-CPE ‘rind’ region is only a small
fraction of the total volume of the sensitive material of the
detector.
Combining Equations 5.42 and 5.43, we arrive at:
D med,z æ b med öY med,z (men r)med
=ç ÷ (5.44)
Ddet è b det ø Y det (men r)det
If it is assumed that the photon (energy) fluence in the detec-
tor differs negligibly from the photon (energy) fluence exist-
ing in the undisturbed medium, then we can set Ψdet equal to
Ψmed,z; this is justified for detector dimensions much smaller
than the photon mean path, 1/µdet, or if the detector and the
medium have very similar density and atomic composition. If
additionally the ratio of βs is negligibly different from unity,
then the ratio of the absorbed doses, or the cavity theory fac-
tor f Q , can be simplified to:
D (m r)med
fQ = med,z = en (5.45)
Ddet (men r)det
In all real situations, there will be a spectrum of photon ener-
gies. This will be the case even for a monoenergetic photon
source, as Compton-scattered photons of lower energy will
always be present at a depth in the medium. From Equations
5.28 and 5.45, the full expression becomes:
Part A: Fundamentals
med
D med,z æ men ö
= çç ÷÷
Ddet è r ødet
hn max (5.46)
=
ò0
hn max
hn ´ (F hn )med,z ( men (hn )/r )med dhn
ò0
hn ´ (F hn )med,z ( men (hn )/r )det dhn
This expression, often written simply as (men r)med, det , is
known as the mass–energy absorption coefficient ratio. The
photon fluence spectrum at a depth in the medium can
generally only be obtained by Monte-Carlo simulation (see
Chapter 30).
As has already been noted, the detector should be small
with respect to the attenuation of photons within it, i.e. to
the photon mean free path s = 1/μ; otherwise, it is difficult to
fulfil the requirement that the energy fluence in the detector
is negligibly different from that in the medium. It may be
necessary to add a perturbation correction factor to correct
for the differences between photon attenuation in the detec-
tor and that in the medium it replaces. Mobit et al. (2000)
have made a detailed Monte-Carlo-based study of this issue.
The use of small thermoluminescent dosimeters (TLDs)
(see Section 17.2) in kilovoltage photon fields is an example of
a large-detector situation; the maximum secondary electron
range for kV x-rays in the common TLD material lithium
fluoride is of the order of 0.5 mm (i.e. less than the dosimeter
thickness). Figure 5.16 shows how the mass–energy absorp-
tion coefficient ratio (Equations 5.45 or 5.46) varies with
photon energy for three different thermoluminescent materi-
als. The rapid variation below 100 keV is due to the strong
dependence of the photoelectric effect on atomic number
(see Section 4.3.1). The virtually flat portion of the curves
corresponds to the energy region where the Compton effect
dominates, and therefore, the interaction coefficients depend
only on electron density (see Section 4.3.2), their ratio being
independent of photon energy.
1.2
1.1 A
(men /r) TLD / (men /r)H O
2
1.0
C
0.9
B
0.8
0.01 0.1 1 10
Photon energy (MeV)
FIGURE 5.16 Variation of the mass–energy absorption coefficient ratio
relative to water for different thermoluminescent materials as a func-
tion of photon energy. A: Lithium fluoride, B: lithium tetraborate
Li 2B 4O7, C: Li 2B 4O7 + 0.3% Mn. (From Greening, J. R., Fundamentals
of Radiation Dosimetry, Adam Hilger, Bristol, 1981. With permission.)
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry
Tissue Bone
Dose
or Kerma
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FIGURE 5.17 Variation of absorbed dose at an interface between soft
tissue and bone, irradiated by kilovoltage photons but assuming neg-
ligible photon attenuation. There is charged particle equilibrium in
both media except very close to the interface, where electron-scattering
effects will occur. The dashed lines indicate kerma where it differs from
absorbed dose.
The large photon cavity result can be exploited to calculate
the change in the absorbed dose close to an interface, e.g.
going from tissue to bone in a patient irradiated by a low-
energy x-ray beam. Figure 5.17 is only schematic; the effect
of photon attenuation, which is appreciable at low ener-
gies, has been assumed to be negligible. The equilibrium-
dose levels in the tissue and the bone will be proportional
to (men /r)tissue and (men /r)bone, respectively (evaluated over
the photon energy-fluence spectrum). Extremely close to
the interface (i.e. within the range of the maximum energy
secondary electrons), there cannot be PCPE; the increased
electron backscattering from the bone, due to its higher
effective atomic number (see Section 3.6), produces the com-
plex behaviour indicated by the dose curves on either side of
the interface. Kerma, which, by definition, is unaffected by
Photon
beam
Uniform medium
(a)
FIGURE 5.18 A (megavoltage) photon beam is incident on a uniform medium (a). The tracks of the secondary electrons liberated in the medium
are indicated schematically. A low-density detector is inserted into the medium (b). If the electron-fluence in the detector is negligibly different (in
energy distribution and magnitude) from that in the undisturbed medium at the same position, then the cavity can be said to behave in a ‘Bragg–
Gray’ manner. (Reproduced from Andreo, P., Burns, D. T., Nahum, E. E., Seuntjens, J. and Attix, F. H., Fundamentals of Ionizing Radiation
Dosimetry, Wiley-VCH, Weinheim, 2017. With permission.)
69
electron transport, is also shown. The reader will understand
after studying Section 5.7.4 that the ratio of the doses exactly
on either side of the interface will be given by the (mass)
electronic stopping-power ratio, as the electron fluences must
be equal. Johns and Cunningham (1983) discuss in detail
interface effects in photon-irradiated media.
In the megavoltage energy range, the appreciable ranges
of the secondary electrons make it impossible for radiation
detectors to fulfil the large photon detector condition without
becoming impractically large. We shall see that the (μen/r)
ratio appears as a component in the (approximate) expression
for the perturbation factor that corrects for the non-water-
equivalence of ionisation chamber walls (Section 19.4.2.3)
and more significantly, in the formalism for absorbed dose
determination in kilovoltage x-ray beams (Section 19.8).
5.7.4 Bragg–Gray Cavity Theory
5.7.4.1 Introduction
We will now focus on a different class of detector, one that
is small compared with the ranges of the electrons.* In
Figure 5.18a, a uniform medium is irradiated by a photon
beam; the tracks of the secondary electrons are shown sche-
matically. In Figure 5.18b, a detector has been introduced that
is ‘small’ in the sense that the majority of the electrons lose only
a tiny fraction of their energy in passing through this detector.
In the situation depicted in the figure, the size and compo-
sition of the detector are such that, in any direction, the path
through the detector corresponds to an entirely negligible
fraction of the build-up depth required for the establishment
of (partial) CPE. Therefore, the absorbed dose in this small
detector is definitely not given by the product of photon
Photon
beam
(b)
* The primary radiation can be either electrons or photons; in the latter
case, the electrons are termed secondary.
 70 Part A: Fundamentals

energy fluence and (μen/r)det. Instead, the absorbed dose in
the detector material and in the medium can be derived from
the respective electron fluences present in these materials.
5.7.4.2 Theory
From Equation 5.39, the ratio of doses, medium to detector,
at the depth z in the medium is given by
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ought to negligibly modify the number, energy and direc-
tion of electrons present in a photon-irradiated medium
(there were no electron beams at the time). Gray showed
that the ratio of energy lost per unit mass in the medium
to the energy lost per unit mass in the gas was equal to the
ratio of the mass electronic stopping powers, medium to
gas, smed,gas, and then made the assumption that the ratio of
energy absorbed in the respective media was also equal to
smed,gas. This is equivalent to assuming delta-ray equilibrium

D med,z F med,z ´ (S el r)med (see Sections 5.6.1 and 5.6.2) and is discussed further in
= (5.47)
Ddet F det ´ (S el r)det Section 5.7.5.
In radiotherapy, we also deal with beams of electrons and
If it is assumed that the electron fluence in the (sensitive vol- heavy charged particles. In these cases, the primary particles
ume of the) detector is identical to the electron fluence exist- are electrons (or protons or carbon ions), and there are no
ing in the ‘undisturbed’ medium, i.e. photon-generated secondary electrons (except for the small
bremsstrahlung contribution). The Bragg–Gray idea can also
F det = F med,z (5.48) be applied to detectors in these charged-particle beams.

then Equation 5.47 can be simplified to

5.7.4.3 When Does a Detector Behave
D med (S el (E ) r)med in a Bragg–Gray Manner?
= º s med,det (5.49)
Ddet (S el (E ) r)det For a detector to respond as a Bragg–Gray (BG) cavity:
This expression is known as the (mass) stopping-power ratio, The charged-particle fluence in the sensitive vol-
med
generally written as smed,det or alternatively as [S el (E )/r]det . ume of the detector (or cavity) must be identical in
In all practical cases, there will be a spectrum of electron magnitude and energy distribution to that in the
energies, and the full expression for the stopping-power ratio uniform medium at the reference point.
becomes
We will now consider the requirements for a ‘cavity’ (i.e. a
E max detector) to behave in a Bragg–Gray manner in a charged-
ò
pr
(F E )med ,z ´ (S el (E ) r )med dE particle or photon field.
D med
= 0
E max
º s BG
med ,det (5.50)
Ddet
ò
pr
(F )
E med ,z ´ (S el (E ) r)det dE I. The cavity must be small compared with the ranges of
0
the charged particles crossing it.
where the energy dependence of the electronic stopping
power has been made explicit, and it is understood that This is equivalent to requiring that the energy losses of the
(ΦE)med,z refers to the medium in the absence of the detector in charged particles crossing the cavity are a very small fraction
both the numerator and the denominator. It is emphasised of the kinetic energies of the charged particles, i.e. DE  E .
that this is the fluence of primary electrons only* – no delta- It is difficult to convert this into concrete numbers, but we
rays are involved; hence the superscript ‘pr’. For reasons that will assume that DE £ 0.01E , i.e. a maximum 1% energy loss
will become apparent in Section 5.7.5, the stopping-power in traversing the detector.
ratio evaluated according to Equation 5.50 is convention- For a 1 MeV electron, with (dE/ds)tot = 1.86 MeV cm 2 g−1 in
ally denoted by s med, water (see Tables L2 at the end of the book), this translates
det (Nahum 1978; ICRU 1984b; Andreo
BG

et al. 2017). into a detector thickness <5.5 × 10 −3 g cm−2; this becomes

Detectors that behave in this fashion in photon-irra-
diated media, i.e. that respond to, but do not ‘disturb’,
the electron fluence that exists at some reference point in
the irradiated medium in the absence of any detector, are
known as Bragg–Gray cavities, after the pioneering work
of Bragg (1912) and Gray (1929, 1936). As we have seen
in the introduction to this chapter, gas-filled detectors
dominated all the early radiation measurement techniques.
Bragg presented qualitative arguments and Gray reasoned
in a more quantitative way that a small gas-filled cavity
* Although the electrons liberated in photon interactions with matter
(e.g. Compton scattering) are conventionally termed secondary, in this
context it is useful to label these (e.g. Compton) electrons as primary
to distinguish them from the delta-rays (or knock-on electrons) liber-
ated by these primary electrons while slowing down.
<4.7 × 10 −2 g cm−2 for a 10 MeV electron, i.e. still imprac-
ticably thin for detector sensitive material of unit density or
greater (but see Figure 5.20). For a 4 MV x-ray beam, the
average secondary electron energy is of the order of 0.5 MeV,
and the ‘Bragg–Gray’ detector would have to be even thinner.
If the primary particles are photons, then there is an addi-
tional requirement:
II. The absorbed dose in the cavity must originate from
the charged particles incident on it.
This means that any contribution to the dose in the cavity
due to photon interactions in the cavity must be negligible. It
is essentially a corollary to the first requirement. If the cav-
ity is small enough to fulfil requirement I, then the build-up
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry
of dose due to interactions in the cavity material itself will
also be very small. If, however, this build-up is appreciable,
then the charged-particle fluence in the cavity will differ
from that in the undisturbed medium, thereby violating
Bragg–Gray behaviour (except when the detector material
and the medium are perfectly matched – a Fano-theorem-
like situation).
At this point, it is useful to distinguish between solid-state
detectors – see Chapter 17 (e.g. diamond, diode, TLD, liquid
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ionisation chambers) and gas-filled detectors – see Chapter
16 (i.e. air-filled ionisation chambers). In the former case, the
fulfilment of the requirements means that the dimensions of
any such detector must be extremely small, especially in the
beam direction (e.g. single-crystal diamond) – any variation
in dose either across the detector or across the volume of
medium replaced by the detector will therefore be negligible.
In the case of a photon field, there is therefore no need for
(partial) CPE; such an extremely small detector will behave
in a Bragg–Gray manner even in the build-up region of a
high-energy photon beam.
Consider now a gas-filled detector (with a medium-equivalent
wall for simplicity), e.g. ionisation chambers with volumes
of practical dimensions of a few millimetres (see Tables 16.2
and 16.4). The volume of medium ‘replaced’ by such a detec-
tor will in general no longer be extremely small, but due to
the extremely low density of the gas (e.g. air), there is no
problem meeting requirement II at megavoltage qualities
(see Table 5.2 and Figure 5.22). However, dose variations
across the ‘displaced medium’ can be appreciable (especially
in the build-up region in any beam and at any depth in very
small fields – see Section 5.8.3). Therefore, in this important
special case of a (very) low-density detector, CPE is required*
in order to make dose variation across the ‘replaced’ medium
manageably small† (see Sections 5.7.6 and 19.4.2). An alter-
native way of arriving at the necessity for (partial) CPE is to
invoke the Fano theorem (see Section 5.7.2).
Summarising, for a gas-filled detector when the primary
particles are photons there is the additional requirement:
III. (Partial) Charged-particle equilibrium should be
present in the medium at the position of the detector
The fact that in real megavoltage beams the equilibrium can
only ever be ‘partial’ due to photon attenuation (see Section
5.5, especially Figure 5.10) gives rise to minor departures
from perfect Bragg–Gray behaviour, corrected by ‘perturba-
tion’ correction factors – see Sections 5.7.6 and 19.4.2.
If the primary radiation is a charged-particle beam, then
there can never be CPE; variations in the charged-particle
* Greening (1981) emphasised that Gray’s original theory required
CPE.
† In real photon beams, there will only ever be partial CPE due to pho-
ton attenuation – see Section 5.5. This minor departure from ‘perfect’
CPE causes the response of small air cavities to deviate from ‘perfect’
Bragg–Gray behaviour; this is generally corrected by either a displace-
ment perturbation factor or a shift in the effective point of measure-
ment (see Section 19.4.2.2).
71
fluence in the medium ‘displaced’ by the gaseous detector
result in deviations from Bragg–Gray behaviour. However,
these ‘perturbations’ can be minimised by intelligent ionisa-
tion chamber design – see Section 5.7.6.
It should be noted that the atomic composition and/or
density of the detector cavity (i.e. the part of the detector giv-
ing rise to the signal) is implicitly assumed to differ from that
of the medium. If this is not the case, then rather obviously,
there will be no difference in the respective electron-fluence
spectra under any circumstances; consequently, a (real or
imagined) perfectly medium-equivalent detector will always
fulfil Bragg–Gray conditions, as Bouchard et al. (2015) have
emphasised.
An air-filled ionisation chamber of the dimensions used
in radiotherapy (see Chapter 16), irradiated by a megavolt-
age photon beam of a ‘standard’ (i.e. not ‘small’) field size,
is a clear case of a Bragg–Gray cavity. Figure 5.19 compares
the (secondary) electron-fluence spectrum in a small water
voxel to that in a small air cavity at the same position in a
water phantom irradiated by a 6 MV x-ray beam of field size
3 cm × 3 cm; the two curves lie on top of one another.
Figure 5.20 compares (total) electron-fluence spectra in
a (synthetic) diamond detector of 2.20 mm diameter and
0.001 mm height/thickness with that in a small volume of
water in a water phantom irradiated by a 6 MV x-ray beam.
For the 10 cm × 10 cm field, the spectra match ‘perfectly’, and
the water-to-detector electron-fluence ratio, integrated over
the spectrum, is within 0.2% of unity. Thus, this extremely
thin ‘solid-state’ detector also behaves as a quasi-perfect
Bragg–Gray detector at this field size and beam quality.‡
FIGURE 5.19 Monte-Carlo-derived electron-fluence spectra (all gen-
erations of secondary electrons) scored in a ‘point like’ water ‘voxel’
(0.5 mm diameter, 0.5 mm thickness) and in a ‘PinPoint’ air cavity
(2.3 mm diameter, 2.6 mm length) both at 5 cm depth on the beam
central axis in a large water phantom irradiated by a 6 MV photon beam
of field size 3 cm × 3 cm. (Reproduced from Kumar, S., Fenwick, J. D.,
Underwood, T. S., Deshpande, D. D., Scott, A. J. and Nahum, A. E.,
Phys. Med. Biol., 60 (20), 8187–8212, 2015. With permission.)
‡ The Bragg–Gray-like response of this diamond detector is to be expected,
given that its thickness in the beam ­d irection (3.51 × 10 −4 g cm−2)
easily fulfils the detector thickness ≤5.5 × 10 −3 g cm−2 requirement
derived earlier.
 72
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FIGURE 5.20 Monte-Carlo-calculated electron-fluence spectra (all
generations of secondary electrons) at 10 cm depth in water irradiated
by a 6 MV beam in 10 cm × 10 cm and 0.5 cm × 0.5 cm fields. The
red (wavy) lines represent the spectrum in the extremely thin diamond
detector (see text), the black lines represent the spectrum at the same
depth in a small volume of water. (Reproduced from Benmakhlouf, H.
and Andreo, P., Med. Phys., 44 (2), 713–724, 2017. With permission.)
The figure also shows the corresponding data for a ‘small’
0.5 cm × 0.5 cm field – in such a field, PCPE will not be
present (see Section 5.8.2). The small difference between the
electron fluence in the very thin diamond detector and that
in the undisturbed medium indicates at most a minor depar-
ture from Bragg–Gray behaviour. This is an example of how a
very small (non-gaseous) detector can exhibit a Bragg–Gray-
like response in the absence of CPE, as discussed previously.
What is the situation for a high-energy electron beam? The
(primary) electrons will easily cross the small air cavity of a
typical ionisation chamber and photon interactions in the sen-
sitive volume of the detector (including any bremsstrahlung-
induced interactions) will clearly not be a problem. However,
CPE is never present in a medium irradiated by an electron
beam (see Section 5.5). To summarise a moderately complex
situation, Bragg–Gray conditions are well approximated by
certain designs of ionisation chamber, particularly adequately
guarded ‘plane-parallel’ designs with an appropriate choice
of the effective point of measurement (see Section 5.7.6).
For Farmer-type cylindrical designs, the change in the angu-
lar distribution of electrons with depth (in-scattering – see
Section 19.4.2.4) gives rise to medium-to-air-cavity electron-
fluence differences (or ‘perturbation’) that require correction
via an appropriate factor (see Section 5.7.6).
5.7.4.4 Bragg-Gray (Unrestricted) Stopping-Power
Ratios, Water-to-Detector
Values of the water-to-medium unrestricted mass elec-
tronic stopping-power ratio s w,air, as a function of electron
energy, for a variety of media including air are shown in
Figure 5.21. Several features can be noted. First, for all
the materials, except aluminium and air, this ratio varies
very little with electron energy, especially above ~1 MeV.
The major exception is air. The strong decrease of s w,air
with increasing electron energy, starting at ~0.5 MeV, is
Part A: Fundamentals
FIGURE 5.21 Variation of the unrestricted mass electronic stopping-
power ratio, water to medium, as a function of electron energy, evaluated
from Equation 5.49 for materials of dosimetric interest. (Reproduced
from Andreo, P., Burns, D. T., Nahum, E. E., Seuntjens, J. and Attix,
F. H., Fundamentals of Ionizing Radiation Dosimetry, Wiley-VCH,
Weinheim, 2017. With permission.)
due to the reduction in electronic stopping power brought
about by the density or polarisation effect in condensed
media (i.e. water compared with air) at relativistic ener-
gies – see Section 3.2.3 and especially Figure 3.6. Values
of smed,air for other media ‘med’ would have shown a sim-
ilar strong dependence on electron energy. The marked
dependence of s w,air on electron energy translates into the
strong depth dependence of air-filled ionisation chamber
response (essentially D w/D air) in a water phantom irradi-
ated by a megavoltage electron beam (see Figure 19.9).
By contrast, in a megavoltage photon beam, s w,air exhibits
an entirely negligible depth dependence (except possibly
in the build-up region), as partial CPE ensures that the
secondary ­ electron energy distribution remains essen-
tially unchanged with depth (Andreo and Nahum 1985;
Andreo 1988).
5.7.4.5 Is a Low-density Cavity in a
Medium Irradiated by Kilovoltage
X-Rays a Bragg–Gray Cavity?
Should we expect that an air-filled ionisation chamber will
act as a Bragg–Gray cavity in a medium irradiated by a kilo-
voltage x-ray beam? (see also Section 19.8 and Chapter 22).
The energies of the secondary electrons will be significantly
lower than for megavoltage photons, and the build-up depth
(in water) is only a fraction of that in a megavoltage beam
(see Figure 5.9). Will the signal produced by an ionisation
chamber still be overwhelmingly due to secondary electrons
incident from the surrounding medium, as opposed to elec-
trons liberated by photon interactions with the air molecules?
Table 5.2 gives values of ( Dair )tot , the ratio of the dose
cav
to a small air cavity, as defined in the table caption, due to
photon interactions in the air to the dose corresponding to
full build-up in air, calculated by Monte-Carlo simulation
(Ma and Nahum 1991).
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 73

TABLE 5.2
tot for an Air Cavity
Calculated Dose Ratio (Dair )cav
Exposed to Different Photon Beam Qualities
Incident Beam
(Dair )cav
tot
Tube HVL (Dair )cav
tot (5 cm depth
Potential (mm Al) (in vacuum) in water)
50 kV 1.62 0.26 0.18
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150 kV 5.01 0.27 0.29

240 kV 7.30 0.27 0.27
240 kV 17.4 0.18 0.23
60Co 0.0037 0.0060
  4 MV 0.0014 0.0098
The calculated ratio (Dair)cav
tot is the dose due to direct photon
interactions with the air of the cavity divided by the total
absorbed dose in the cavity. The air cavity is a 6 mm diameter
and 6 mm thick cylinder, located either in vacuum or at a
depth of 5 cm in water. (Dair )cav
tot is expected to be very small in FIGURE 5.22 Ratio of the dose from photon interactions in the air
a Bragg–Gray cavity. cavity to the total dose, (Dair )cav / (Dair )tot , (in water at 5 cm depth)
Source: From Ma, C.-M. and Nahum, A. E., Phys. Med. Biol., for air cavities of typical ion-chamber dimensions and for a Farmer
36, 413–428, 1991. With permission. chamber, for low-energy photons. The radiation quality is expressed
in terms of the half-value layer (HVL) of Cu (lower axis) and Al (upper
axis). The data points are for a cylindrical air cavity of 6 mm thick-
In a Bragg–Gray cavity, ( Dair )tot ought to be very close
cav
ness and diameter with monoenergetic photons (open circles, dashed
to zero. It can be seen in the table that this is the case line), following the Monte-Carlo (MC) calculations of Ma and Nahum
(1991), and for a Farmer chamber as described in Figure 16.6 (trian-
for the 60Co γ-ray and 4 MV x-ray qualities but not for
gles, solid line: monoenergetic photons; filled circles, kV spectra: MC
any of the kilovoltage x-ray qualities. These results dem- work by J.Wulff and P. Andreo, private communication). (Reproduced
onstrate that air-filled ionisation chambers do not fulfil from Andreo, P., Burns, D. T., Nahum, E. E., Seuntjens, J. and Attix,
Bragg–Gray assumptions at any kilovoltage x-ray quality. F. H., Fundamentals of Ionizing Radiation Dosimetry, Wiley-VCH,
Figure 5.22 shows essentially the same dose ratio but over Weinheim, 2017. With permission.)
a much wider range of kilovoltage beam qualities, specifi-
cally for an air volume with the dimensions of a Farmer
chamber (see also Chapter 9 in Andreo et al. 2017). The 5.7.5 The Spencer–Attix Modification
absorbed dose fraction reaches a value of 0.6 at a half-value of Bragg–Gray Theory
layer (HVL) of 0.3 mm Al - i.e. the response of the air
cavity is approaching that of a ‘large photon detector’ (see 5.7.5.1 Introduction
Section 5.7.3). In the previous section, delta-ray equilibrium was implic-
What is the explanation for the shape of the curves in itly assumed – it is a pre-requisite for the strict validity of
Figure 5.22? Basically, the value of ( Dair )tot is critically
cav
the stopping-power ratio as evaluated in Equations 5.49
dependent on the mean range of the secondary electrons. and 5.50. Bragg and Gray effectively assumed that all the
If the electron ranges are long, the cavity will tend towards delta-rays energy arising from electronic losses in the cav-
ity was deposited in the cavity. Expressed alternatively,
Bragg–Gray behaviour, i.e. ( Dair )tot  1 (cf. Table 5.2); if
cav

the charged particles lose all their energy by continuous

the electron ranges are (very) short, ( Dair )tot will approach
cav
unity, and the cavity will exhibit ‘large photon’ behaviour.
At high photon energies (i.e. high kV), Compton inter-
actions dominate, and the mean initial energies of the
Compton electrons are a much lower than that of the pho-
ton energy (see Figure 4.5 and Section 4.3.2), with cor-
respondingly short ranges. As the photon energy decreases,
the photoelectric-effect begins to take over, and the result-
ing photo-electrons have kinetic energies essentially equal
to those of the photons that give rise to them (see Section
4.3.1); paradoxically, therefore there is an increase in the
initial kinetic energy of the secondary electrons. Hence,
as the photon energy decreases, Figure 5.22 shows an ini-
tial increase in ( Dair )tot followed by a decrease before a final
cav
increase at very low photon energies.
slowing down, i.e. in a large number of extremely small
energy-transfer events. Greening (1981) emphasised that
this was one of the pre-conditions for Gray’s cavity theory
(Gray 1929).
Experiments by Attix et al. (1958) employing a series
of flat, air-filled ionisation chambers with walls made of
C, Al, Cu, Sn and Pb respectively, i.e. ranging from low
and air-like (C) to high (Cu–Pb) atomic numbers, showed
clearly that in a 412 keV γ-ray field (from 198Au), the
charge collected per unit mass of gas (or ‘mass ionisation’)
depended on the wall separation (which varied from tenths
of a millimetre to 10 mm). However, if the instrument
were responding strictly as a Bragg–Gray cavity, the mass
ionisation should be constant. Attix et al. suggested that
delta-ray transport might explain this dependence on wall
separation.
 74 Part A: Fundamentals

5.7.5.2 Theory E max

Spencer and Attix (1955) proposed an extension of Bragg–

D med =
ò (F )
2D
tot
E
med
(L D (E ) r)med dE
Gray theory to take account of, in an approximate manner, (5.51)
the effect of the finite ranges of delta-rays. In their cavity the- 2D

ory, all the electrons above a cutoff energy Δ, whether ‘pri-

mary’ electrons or delta-rays, were considered to be part of
+
ò (F )
D
tot
E
med
(S S- A (E ) r)med dE

the (total) electron-fluence spectrum incident on the cavity.

All electrons liberated in the cavity (or in the same volume in where the term SS-A(E) is explained in the next paragraph.
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the uniform medium) with energies below Δ were assumed to
deposit 100% of their (kinetic) energy locally, i.e. inside the
cavity; Figure 5.23 illustrates this schematically.
Spencer and Attix suggested that Δ be set equal to the
energy of electrons that have a range (in the cavity mate-
rial) just sufficient to traverse the cavity. The energy trans-
ferred to the cavity was therefore derived from the electronic
stopping power restricted to losses less than Δ, conventionally
denoted by L Δ (see Section 3.2.5). The dose local to the ‘cav-
ity’, in the case of the uniform medium, was given by:
E max
ò (F ) tot
E (L D (E ) r)med dE
med
D the evaluation of Equation 5.51, and hence that of the stop-
(
where F Etot )med
is the total electron fluence, differential in
energy, present in the volume of medium corresponding
to the (detector) cavity. However, this expression did not
include the contribution to the dose from ‘primary’ electrons
whose energies had dropped below Δ after the interaction. To
account for these contributions, Spencer and Attix modified
their ‘cavity integral’ to:
As the lower integration limit of the first integral is 2Δ, no
electron can fall below Δ in energy after a (single) electronic
interaction; this is possible, however, for losses described
by the second integral. Therefore, the electronic stopping
power was modified to include not only the energy of the
delta-rays (which by convention cannot exceed half that of
the ‘primary’ electrons – see Section 3.2.2) but also that of
the ‘primary’ electrons if it is below Δ after the interaction –
this ‘special stopping power’ is denoted by SS–A in Equation
5.51. The two integrals on the right-hand side of Equation
5.51 account for all the energy transferred to the medium in
electronic interactions.*
The presence of the ‘special’ stopping power, SS–A , makes
ping-power ratio, problematic. Nahum (1976, 1978) showed
that the contribution to the dose to the medium from elec-
trons as they fell below Δ in energy, which he termed the
dose due to the ‘track ends’, D med
TE , was approximated by:
TE
Dmed = éëF Etot ( D ) ùû éëS el ( D ) /r ùû D (5.52)
med med
where
F Etot ( D ) is the electron fluence (all generations), differen-
tial in energy, at energy Δ.

The product of the first two terms in Equation 5.52 yields

the number of electrons slowing down past Δ per unit mass,
and multiplying this by Δ yields the dose due to these track
ends (Nahum 1976, 1978; Chapter 9 in Andreo et al. 2017).†
Therefore, the cavity integral for the dose to the uniform
medium becomes:

E max
SA
D med,D =
ò (F )
D
tot
E
med
(L D (E )/r)med dE
(5.53)
+ éëF tot
E (D )ùû éëS el (D )/r ùû med D
med

FIGURE 5.23 Schematic illustration of energy deposition in a volume

(‘cavity’) in the medium according to the Spencer–Attix two-group
local-energy-deposition scheme. Photons are represented as straight
green lines. All generations of electrons are included in the fluence Φtot,
down to energy Δ. The electrons deposit energy in the cavity ‘continu-
ously’ according to the restricted electronic stopping power L Δ; these
transfers are shown schematically as very short blue dotted lines. The
three ‘track ends’ of energy Δ (----) are accounted for explicitly. ①:
Compton electron falls below Δ. ②: Electron crosses the cavity, pro-
ducing a bremsstrahlung photon that leaves the cavity. ③: Electron
The ‘track-end term’ constitutes between 5% and 10% of the
total dose, depending on the value of Δ.
Figure 5.24 shows the excellent agreement (at the 0.5%
level or better) between the dose computed from Equation
* In the corresponding expression for the dose to the detector material, the
two stopping powers in Equation 5.51 naturally pertain to this material.
† Bouchard (2012) arrived at an identical expression for the track-end

slows down below Δ. ④: Photon crosses cavity without interacting. ⑤: dose in a more rigorous and elegant fashion. His paper contains a deri-
Electron crosses cavity, producing bremsstrahlung photon and delta-ray vation of the Spencer–Attix dose ratio starting from the Boltzmann
above Δ in energy. ⑥: Delta-ray drops below Δ in energy. Transport Equation (see Section 30.4.1).
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 75

The Spencer–Attix ratio, s med,det, D , predicts reasonably well the

variation of chamber response with gas pressure for chamber
walls of high-atomic-number materials irradiated by gamma
rays of energies high enough to fulfil Bragg–Gray conditions
(Greening 1957; Attix et al. 1958; Burlin 1962). It is empha-
sised that the simpler unrestricted or ‘Bragg–Gray’ stopping-
BG
power ratio, s med,det , predicts that chamber response should
be completely independent of gas pressure.
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5.7.5.3 Practical Implications of
Spencer–Attix Theory
If the atomic composition and hence the effective atomic
number, Z, of the cavity and the medium are quite simi-
lar (e.g. air and water), the difference between s med,det, D and
FIGURE 5.24 Ratio of the Spencer–Attix dose to the Monte-Carlo BG
dose, (DS-A(Δ)/DMC), as a function of the Spencer–Attix Δ, for a water s med,det may be only of the order of 0.5% to 1.0% (Spencer and
volume (20 mm diameter, 6 mm thickness) along the beam central Attix, 1955; Chapter 9 in Andreo et al. 2017). For example,
axis in a cylindrical water phantom (30 cm diameter, thickness 30 cm), for Δ = 10 keV, Nahum (1978) showed that s water,air,D =10 keV was
at 2.5 cm depth for a 10 MeV electron beam, 5 cm depth for Co-60 BG
generally about 1% higher than s water,air for megavoltage pho-
γ-rays and 6 MV, 10 MV and 15 MV x-rays, and 10 cm depth for a
10 MeV monoenergetic photon beam. (Reproduced from Kumar, S.,
ton and electron beams. The SA−BG difference depends crit-
Deshpande, D. D. and Nahum, A. E., Phys. Med. Biol., 61 (7), 2680– ically on the degree of atomic-number ‘mismatch’ between
2704, 2016. With permission.) the detector and the medium, or more specifically, on the
difference between the respective I-values (see Section 3.2.2
5.53, for small values of Δ, and that scored in a Monte-Carlo and also Spencer and Attix 1955 and Chapter 9 in Andreo
simulation in a small volume of water at a depth in a large et al. 2017). As an example, Figure 5.27 indicates a differ-
water phantom irradiated by a range of radiation qualities.* ence between Spencer–Attix and Bragg–Gray formalism of
This agreement (at small Δ) is a demonstration of the validity ≈2.5% for the water-to-silicon ratio for a (simulated) gaseous
of Equations 5.52 and 5.53. Si detector in water irradiated by 6 MV photons.
The corresponding expression for the dose to the detector The value of Δ is difficult to define uniquely for any shape
cavity with a size corresponding to electron energy Δ is: of cavity given the quasi-isotropic directions of the electrons
E max as they enter the detector volume. Fortunately, s water,air,D varies

ò (F ) only slowly with Δ, which is conventionally set to 10 keV for

SA tot
Ddet,D = E (L D (E )/r)det dE
D
med
(5.54) the ionisation chambers employed in radiotherapy. Buckley
et al. (2003) found that Δ = 16 keV corresponded to the mean
+ éëF Etot (D)ùû éëS el (D) / r ùû det D chord length for a cylindrical ionisation chamber of Farmer
med
dimensions (air cavity 6.3 mm in diameter and 2 cm in
It is emphasised that the implicit assumption in Equation length) and that this value, rather than Δ = 10 keV, resulted
5.54 is that the electron-fluence spectrum (down to energy in better agreement between the Spencer–Attix stopping-
Δ) in the detector cavity is identical to that in the equivalent power ratio and the Monte-Carlo-derived dose ratio. Borg
volume of the (undisturbed) medium, cf. Equation 5.53; i.e. et al. (2000) concluded from their Monte-Carlo study that
the detector is acting in a Bragg–Gray manner. Spencer–Attix cavity theory with Δ = 10 keV was acceptable
Accordingly, the full expression for the Spencer–Attix within 0.5% for photon energies at 300 keV or above.
­stopping-power ratio (ICRU 1984b; Nahum 2009; Chapter 9 The use of the Spencer–Attix expression inherently
in Andreo et al. 2017) becomes: assumes that the electron-fluence spectra in the cavity and in
the medium are identical only down to energy Δ. This is less
med demanding than the original Bragg–Gray requirement that
æL ö D SA D
s med,det, D º ç D ÷÷ = med, the cavity and medium electron fluences be identical down
ç r SA
Ddet,
è ødet D
to the lowest electron energies present in the fluence spec-
trum. At energies below Δ, the electron fluence in the cavity
( )
E max

=
ò (F )
D
tot
E
med
(L D (E ) r)med dE + éëF Etot ( D ) ùû éëS el ( D ) r ùû D
med med material must consist overwhelmingly of (knock-on or delta)
dE + ( éëF D)
E max
electrons liberated in the cavity and the number and energy
ò (F ) ( D )ùû med éëSel ( D ) r ùû
tot tot
E (L D (E ) r)det E
D med det distribution of these electrons will inevitably be characteris-
tic of the detector material.
(5.55) BG
Should we expect smed,det, D to tend towards s med,det as the
cavity becomes larger (i.e. as Δ increases) or as it becomes
smaller (as Δ decreases)? Although it may initially seem coun-
* The reason for the decrease in D S-A(Δ)/D MC at relatively large values of ter-intuitive, it is large cavities that most closely correspond
Δ is discussed in Section 5.7.5.3. to the simpler unrestricted Bragg–Gray ratio (Nahum 1976;
 76 Part A: Fundamentals

Chapter 9 in Andreo et al. 2017). The ranges of the majority

of delta-rays will be small compared with the dimensions of a
large cavity, which is consistent with the implicit Bragg–Gray
assumption of negligible delta-ray range. Conversely, if the
cavity is very small, then delta-rays generated in the medium
will be responsible for a much greater proportion of the cav-
ity dose.
However, if the cavity size is large, it may violate the
Bragg–Gray condition that a negligible fraction of the dose
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arises from photon interactions in the cavity (see Section

5.7.4.3, requirement II). Referring to Figure 5.24, for all the
photon qualities, there is a value of Δ beyond which this ratio FIGURE 5.25 An ‘imaginary’ ionisation chamber illustrating the vari-
starts to fall significantly below unity. This is because in the ous potential sources of perturbation. (From Nahum, A. E., Phys. Med.
Spencer–Attix formalism (Equation 5.53), the integral over Biol., 41, 1531–1580, 1996. With permission.)
the electron-fluence spectrum only extends down to energy Δ;
any contributions due to photon-liberated electrons with However, as illustrated schematically in Figure 5.25, a
­initial energies below Δ are consequently not accounted for. practical ionisation chamber consists of more than a ‘bare’
This ‘missing’ dose corresponds to the second term of the air cavity. The effects of the various components of chamber
dose ratio given by Burlin cavity theory (Section 5.7.7). Note construction, indicated schematically in Figure 5.25, are gen-
that for 10 MeV electrons DS−A(Δ)/DMC remains essentially erally dealt with by introducing one or more perturbation cor-
at unity for all Δ, as the contribution due to photon-liberated rection factors into the expression for the absorbed dose, via
electrons is negligible. the composite factor ( pQ )ch in Equation 5.56. This factor cor-
Codes of Practice for reference dosimetry in megavoltage rects the ionisation chamber response for any deviations from
photon and electron beams (see Chapter 19) give values of perfect Bragg–Gray behaviour and is therefore defined by:
s w,air, D =10 keV evaluated according to Equation 5.55; these are
required to convert D air derived from the ionisation chamber D med,z = Dair,ch s med,air,D ( pQ )ch (5.56)
reading to absorbed dose to water.
where
Dair,ch  is the dose to air recorded by the ion chamber,
5.7.6 Departures from ‘Perfect’ Bragg–Gray i.e. by the instrument.
Behaviour For Ionisation Chambers
5.7.6.1 Introduction It is emphasised that the (Spencer–Attix) stopping-power
ratio s med,air,D (Equation 5.55) is derived on the assumption
As emphasised in Section 5.7.4, for a detector to behave as a of identical electron (and positron) fluence spectra in the
‘perfect’ Bragg–Gray cavity, the electron fluence in the sensi- medium and the air cavity, i.e. the Bragg–Gray condition.
tive medium of the detector must be identical (in magnitude The subscripts ‘ch’ and ‘Q’ emphasise that the perturbation
and energy distribution) to that at the position of interest factor depends on both the details of the chamber design and
in the uniform medium, i.e. in the absence of the detector. the radiation quality.
Consequently, a perfect Bragg–Gray detector would have to Denoting the fluence, differential in energy (of all genera-
be completely medium-equivalent (in composition and den- tions of electrons and positrons) in the medium, at depth z, by
sity). Under certain conditions, an air-filled ionisation cham-
ber, which can be likened to a small ‘gas bubble’, behaves as a
tot
(F Etot )med,z and that averaged over the air cavity by F E
air,ch
, ( )
good approximation to a Bragg–Gray cavity: for broad-beam and recalling the Spencer–Attix expression for absorbed dose
megavoltage photon and electron radiation, the basic Bragg– for a finite-size cavity (Equation 5.53), but without assuming
Gray conditions are adequately fulfilled by the ionisation that electron-fluence spectra in the air are identical to that in
chamber designs in common use in radiotherapy (see Section the medium, we can write:
16.3.2); in particular, the ranges in air of the vast majority
( )
E max
of ‘secondary’ electrons* set in motion by megavoltage pho- ò (F ) (L D (E ) r)med dE + éëF Etot ( D ) ùû éS el ( D ) r ù D
tot
D med, z med .z ë û med
E
med , z
= D
tons are much greater than the cavity dimensions† (Ma and
ò (F )
D air,ch E max
æ é tot ö
(L D (E ) r)air dE + ç F E ( D ) ù
úû air,ch ë el ( ) û air ÷ø
tot
éS D r ù D
Nahum 1991; Chapter 9 in Andreo et al. 2017). D
E
air,ch è êë

(5.57)
* The electrons (and positrons) set in motion by photons (through pair
production, Compton scattering and the photoelectric effect) are con- Since the absorbed dose to air predicted by Spencer–Attix
ventionally denoted as ‘secondary’, but here we wish to distinguish cavity theory, (Dair )SA , multiplied by the stopping-power
these photon-generated electrons from the delta-rays they in turn set ratio medium to air gives the dose to the medium, we can
in motion.
† The case of sub-equilibrium, small-field photon beams (see Section
derive (pQ)ch from equation 5.56 as:
5.8) demonstrates that the condition regarding the secondary elec-
tron ranges in air is not sufficient (see also Kumar et al. 2015b); CPE (Dair )SA
( pQ )ch = (5.58)
is also required (see Sections 5.5 and 5.7.4). (Dair )ch
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 77

Taking in Equation 5.57 the medium ‘med’ as ‘air’, we The topic of perturbation correction factors for (air-filled)
arrive at the following expression for the chamber perturba- ionisation chambers in radiotherapy has received a great deal
tion factor (Nahum 1996; Bouchard 2012): of attention due to the high demands placed on dosimetric
accuracy; Section 19.4.2 deals with it in more detail.
{ }
E max

ò (F ) (L D (E ) r)air dE + éëF Etot ( D ) ùû éS el ( D ) r ù D

tot
med.z ë û air
E
(pQ )ch = D med,z 5.7.7 General or ‘Burlin’ Cavity Theory
ò (F )
E max
ì ü
(L D (E ) r)air dE + í éF Etot ( D ) ù
úû air,ch ë el ( ) û air ýþ
tot
éS D r ù D Up to this point, two ‘extreme’ cases have been covered:
î êë
E
D air,ch
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(5.59) 1. Detectors that are small compared with the elec-

tron ranges and that do not disturb the electron flu-
The electron fluence in the numerator is that in the medium ence present in the medium (Bragg–Gray cavities;
at the depth of interest, z; in the denominator it is the elec- Section 5.7.4)
tron fluence averaged over the air cavity of the ionisation 2. Detectors that are large compared with the second-
chamber. In principle, these two spectra can have different ary electron ranges and in which, therefore, par-
shapes – see Figure 5.35b. tial CPE is established (‘large photon detectors’;
Section 5.7.3).
5.7.6.2 The Various Sources of Ion-
Chamber Perturbation Many situations involve measuring the dose from photon (or
neutron) radiation using detectors that fall into neither of
As indicated in Figure 5.25 (see also Figures 16.6 and 16.7), these categories (Figure 5.26). In such cases, there is no exact
practical designs of ionisation chambers inevitably give rise expression for the dose ratio, Dmed/Ddet. ‘General’ cavity theory
to a number of different sources of perturbation, expressed was developed by Burlin (1966); the detector-to-medium dose
through various factors: ratio was approximated by a weighted mean of the stopping-
power ratio and the mass–energy absorption coefficient ratio:
pdis accounts for the displacement* of a certain volume of
det
medium by the air of the cavity; alternatively, this effect Ddet æ men ö
can be handled by assigning the chamber signal to an = ( f Q )det
med = wBG s det, med,D + (1 - wBG ) ç
ç r ÷÷ (5.61)
D med è ø med
effective point of measurement, Peff, displaced with
respect to the centre of the cavity. This effect applies to
where ωBG is a weighting factor that varies between unity for
high-energy photon and electron beams.
small (or Bragg–Gray) cavities and zero for large cavities (or
pwall accounts for the fact that the nature and composition of
photon detectors).
the chamber wall, which is responsible for a significant
Burlin estimated ωBG from the exponential attenuation of
proportion of the secondary electrons contributing to
the electron fluence entering the cavity through the wall,
the chamber signal, is different from that of the medium
balanced by the exponential build-up of the cavity-generated
(generally water). In the case of electron beams, this
electron fluence:
effect is generally assumed to be negligible (but see
Nahum 1996 for a theoretical analysis that challenged 

ò F e dx = 1 - e
eqm - me x
this). Buckley and Rogers (2006a, 2006b) found dif- F med med - me 
ferences up to 1.7% for plane-parallel chambers and wBG = eqm
= 0
(5.62)
F med 
m 
ò F dx
eqm e
0.6% for thimble chambers at the reference depth (with med
greater differences at other depths). 0

pcel accounts for the lack of air equivalence of the central where
electrode of cylindrical chambers. eqm
F med is the equilibrium electron fluence present in the
pcav accounts for the perturbation of the electron fluence in medium
the air of the cavity due to in-scattering; this effect is µe is the attenuation coefficient of the secondary elec-
important for electron beams but is negligible for pho- trons in the detector material
ton beams, as Harder (1974) demonstrated by reference  is the mean chord length in the detector.
to the Fano theorem (see Section 5.7.2).
The overall or ‘global’ perturbation correction factor, pQ, When applying his theory to air-filled cavities, Burlin used
is given approximately by the product of these perturbation the following expression, due to Loevinger (1956), for the
factors: attenuation of electrons from β-emitting radionuclides:

( pQ )ch = pdis pwall pcel pcav (5.60) 16 r

me = (5.63)
( E max - 0.036 )
1.4

where
* The word ‘displacement’ is somewhat ambiguous. It refers both to a
replacement of the medium (i.e. water) with air and to the shift of the r is the density (of air)
effective point of measurement (EPOM) according to the shape of the Emax is the maximum initial energy (in MeV) of the elec-
cavity and the direction of the ionising particles. trons in the β-ray spectrum (see Section 2.2.4).
 78 Part A: Fundamentals

5.7.8 The Response of a Detector as it Varies

FIGURE 5.26 A schematic illustration of an ‘intermediate’ or ‘Burlin’
detector in a photon-irradiated medium; the secondary electron ranges
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from ‘Bragg–Gray’ to ‘Large Photon’
Figure 5.27 shows how the response of a (fictitious) silicon
detector, D water/DSi, in water irradiated by a 6 MV x-ray
beam, computed by the Monte-Carlo usercode CAVnrc,
would vary as the detector density increased from that
of a gas (r = 0.005 g cm−3) past its real physical density
(rSi = 2.33 g cm−3) to r = 10 g cm−3 (Kumar et al. 2016). The

are neither exclusively much greater (Bragg–Gray detector) nor much
smaller (large photon detector) than the detector dimensions. (Adapted
from Chapter 9 in Andreo, P., Burns, D. T., Nahum, E. E., Seuntjens,
J. and Attix, F. H., Fundamentals of Ionizing Radiation Dosimetry,
Wiley-VCH, Weinheim, 2017.)
Burlin and Chan (1969) suggested that e - met max = 0.01
yielded a better estimation of µe, where t max is the maximum
thickness of electron penetration, beyond which only 1% of
electrons reach. Janssens et al. (1974) found that 0.04 rather
than 0.01 yielded improved agreement with experiment.
A more detailed treatment of the Burlin cavity is given in
Chapter 9 in Andreo et al. (2017), including a brief discus-
sion of the more complicated, but not necessarily more accu-
rate, theories of Horowitz and Dubi (1982), Janssens (1983)
and Kearsley (1984). Andreo et al. concluded that analytical
theories would never be able to compete in accuracy with
Monte-Carlo simulation (Mobit et al. 1997). However,
Figure 5.27 in the next section demonstrates that the dose
ratio (Equation 5.61) given by Burlin theory can agree quite
well with the Monte-Carlo-derived value.
Burlin cavity theory has recently been employed to esti-
mate dose deposition in cellular (micrometre-sized) targets
irradiated by kilovoltage photons (Oliver and Thomson
2017).
silicon detector was modelled as a cylinder of (constant)
diameter 2.3 mm and thickness 2 mm situated at 5.0 cm
depth in a large water phantom. The electron and photon
fluence spectra required to evaluate the Spencer–Attix,
Bragg–Gray and Burlin dose ratios were computed with
usercode FLURZnrc. For each value of the detector density
a value of the Spencer–Attix Δ was estimated which satisfied:
éëRcsda (D)ùû Si
=
( Rcsda /R50 )
where
 is the mean chord length in the detector.
Rcsda is the CSDA range in the detector material
R50 is the depth at which the dose is 50% of the maxi-
mum dose for a broad parallel electron beam inci-
dent on the detector material.
The ratio Rcsda/R50 was used to correct for the vast num-
ber of changes in direction when the electrons slow down. It
was found to be around 1.95, almost independent of energy
below 1 MeV.
At the lowest density, 0.005 g cm−3, i.e. a gaseous detector,
Δ = 15 keV, the Monte-Carlo and Spencer–Attix dose ratios
BG
are in excellent agreement, while the Bragg–Gray ratio, s w,Si ,

FIGURE 5.27 Left-hand axis: i) the variation of the Monte-Carlo dose ratio, (D w/DSi)MC (..□ ..), ii) the Spencer–Attix stopping power ratio,
water-to-silicon, sw,Si,Δ (--△--) and iii) the Burlin cavity ratio (--▽--), with the pseudo-density of a silicon cavity (0.23 cm diameter, 0.2 cm height)
located at 5 cm depth in a large water phantom irradiated by a 6 MV photon beam of radius 5.55 cm. Right-hand axis: the fraction of dose to the
silicon cavity due to direct photon interactions, (1 − ωBG), i) derived from Monte-Carlo (-.-o-.-) and ii) from the Burlin–Janssens formula (..△..).
BG
An arrow indicates the (density-independent) value of the unrestricted stopping-power ratio, s w,Si . A second arrow indicates the value of the ‘large

( ) ´(p )
w
ph
photon cavity’ dose ratio, corrected for photon fluence perturbation, men / r w,Si . (Adapted from Kumar, S., Deshpande, D. D. and
Si r =10 g cm -3
Nahum, A. E., Phys. Med. Biol., 61 (7), 2680–2704, 2016.)
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry
is ≈2.5% lower. As the detector density is increased, the
ranges of the secondary electrons in the silicon decrease, and
the response of the detector moves into the ‘intermediate’
or Burlin region. At a density of 0.5 g cm−3 the Burlin-theory
factor (1 − ωBG) – see Equation 5.62 – has risen to ≈0.1; thus
≈10% of the detector dose comes from photon interactions in
the detector material. At the (true) silicon density of 2.33 g cm−3
this has increased to 40% and the Burlin ratio now lies signifi-
cantly below the Spencer–Attix ratio.
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The ‘large photon detector’ ratio is approximately 1.114,
which is ≈12% lower than the Spencer–Attix dose ratio at
a typical gas density. The Monte-Carlo dose ratio begins
to approach 1.114 at the highest silicon pseudo-density,
10 g cm−3, where the Burlin-theory weighting factor (1 − ωBG)
has reached ≈0.8, meaning that 80% of the detector dose is
due to photon interactions in the detector material.
5.8 The Special Case of Small, Non-
equilibrium, Megavoltage Photon Fields
5.8.1 Introduction
As a result of the treatment of small target volumes with corre-
spondingly small field sizes (see Chapter 40), narrow or ‘small’
beams (often known as ‘small fields’) are being increasingly
employed and are deserving more attention (e.g. Alfonso et
al. 2008; Das et al. 2008; IPEM 2010; Bouchard et al. 2015;
ICRU 2017; IAEA 2017). In such ‘small’ megavoltage photon
fields, the distance from the beam central axis to the field edge is
often less than the maximum lateral excursions of the secondary
electrons, and therefore CPE is never established at any depth.
FIGURE 5.28 Schematic illustration of the effect of decreasing the field size to the point where the collimators obscure the ‘view’ of the extended
source (taking the FWHM of a 3D Gaussian distribution) even on the central axis. (Reproduced from Aspradakis, M. M., Byrne, J. P., Palmans,
H., Duane, S., Conway, J., Warrington, A. P. et al. IPEM Report 103. York: IPEM, 2010 with permission.)
79
Field sizes at which CPE is violated can serve as a definition of
‘small fields’ (see Section 19.5.2.3 and especially Table 19.3).
This lack of electronic equilibrium, together with the ‘geo-
metrical’ phenomenon of ‘source occlusion’ due to the finite
size of the effective x-ray source, requires special consideration
regarding firstly, the distribution of absorbed dose in a uni-
form medium such as water (Section 5.8.2) and secondly, the
response of detectors employed to determine the absorbed
dose (McKerracher and Thwaites 1999; Sanchez-Doblado et
al. 2007; Francescon et al. 2011; Scott et al. 2012; Bouchard et
al. 2015; Kumar et al. 2015b; Benmakhlouf and Andreo 2017).
5.8.2 Absorbed Dose in a Uniform Medium
Irradiated by a Small Photon Field
Megavoltage photon beams are created by electrons acceler-
ated in the section of a linear accelerator, reaching an energy of
several MeV and ‘hitting’ a thick tungsten target (see Section
11.2.12). The photon beam is the result of the bremsstrahlung
interaction process (see Section 3.4). The effective source of the
bremsstrahlung radiation has a finite extent. Figure 5.28 illus-
trates how this extended source is partially blocked or occluded
when the opening of the collimator jaws is very narrow.
Scott et al. (2009) found that a 0.7 mm full width at half
maximum (FWHM) electron ‘pencil’ produced the best match
with measured output factors at a field width of 0.5 cm for a 15
MV Varian 2100C linear accelerator (linac). This translated into
a 2.5 mm ‘spot width’ of the photon fluence at the exit surface
of the target; the extra broadening is due to the strong electron
scattering in the high-Z tungsten target (see Section 3.6).
The effect of ‘source occlusion’ is demonstrated explicitly
by the variation of water kerma as a function of the field
 80
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FIGURE 5.29 Monte-Carlo derived output factors (OFs) for a 6 MV
photon beam with full linac-head geometry and point-source geometry
in terms of kerma ‘OF(kerma)’, and absorbed dose ‘OF(dose)’, on the
beam central axis at 10 cm depth in a cylindrical water phantom, versus
field size defined at 100 cm source–surface distance. The side lengths
of the square fields are 0.25 cm, 0.5 cm, 0.75 cm, 1 cm, 1.5 cm, 2 cm
and 3 cm, respectively. The error bars (masked by the symbols) are ±2
standard deviations (k=2) and correspond to statistical (Type A) uncer-
tainties. (Reproduced from Kumar, S., Fenwick, J. D., Underwood, T.
S., Deshpande, D. D., Scott, A. J. and Nahum, A. E., Phys. Med. Biol.,
60 (20), 8187–8212, 2015. With permission).
size (‘output factor’ OF) corresponding to ‘full linac geom-
etry’ (i.e. extended focal spot) of Figure 5.29 – there is a
dramatic decrease below a field size of ≈0.7 cm. In contrast,
the ‘OF(kerma) – point source’ curve decreases gradually
with decreasing field size. The reader is reminded that kerma
relates directly to photon (energy) fluence – secondary elec-
trons are not involved.
Figure 5.30 explains schematically how there cannot be
(partial) CPE (see Section 5.5) on the beam axis if the field
width is insufficient to encompass the lateral displacement of
secondary electrons. Electrons labelled ‘𝟣’ leave the volume
defined by the edges of the narrow beam (the dashed diver-
gent lines) but are not replaced by electrons labelled ‘2’, as the
source of these virtual electrons lies outside the edges of the
narrow beam, and therefore these electron tracks are never
created. The effect of this loss of CPE* is clearly demon-
strated by the two curves labelled ‘OF(dose)’ in Figure 5.29.
The ‘full linac geometry’ curve shows the combined effect of
loss of CPE and source occlusion.
It follows that the absorbed dose on the central axis of a
(very) narrow megavoltage photon beam from a linear accel-
erator falls off rapidly with field size due to the combined
effect of source occlusion and lack of CPE, as demonstrated
by the ‘Monte-Carlo’ curve of Figure 5.31. The challenge
is to determine accurately this strong decrease of absorbed
dose at sub-equilibrium field sizes.
* This loss of CPE is sometimes described as lateral electronic disequi-
librium, although strictly either CPE exists or it does not, i.e. it is not
a ‘directional’ concept.
Part A: Fundamentals
FIGURE 5.30 Schematic illustration of loss of charged particle equi-
librium in a narrow field. Electrons labelled ‘𝟣’ leave the volume defined
by the edges of the narrow beam (the dashed divergent lines) but are
not replaced by electrons labelled ‘2’ as it would be if the field size were
larger (e.g. extending to the solid divergent lines). (Reproduced from
Gagliardi, G., Nahum, A. E. and Muren, L., ESTRO Newsletter Physics
Corner, 80, 2011. With permission.)
5.8.3 Detector Response in Small Photon Fields
5.8.3.1 General
For a non-small megavoltage photon beam of a given quality,
dosimeter response, expressed as Dmed/Ddet, exhibits a negli-
gible dependence on field size (Ding and Ding 2012; Taylor
et al. 2012). Figure 5.31 shows the variation of (uncorrected)
detector response as the field size becomes ‘small’. The quan-
tity on the y-axis is the response M f clin of the detector for a
small ‘clinical’ field size f clin , decreasing from 3.0 cm × 3.0 cm
to 0.5 cm × 0.5 cm, normalised to a (wide) ‘reference’ field
f ref (typically 10 cm × 10 cm).†
The figure shows that all the ionisation chambers ‘under-
read’; i.e. their response relative to a wide field decreases
faster than the absorbed dose to the medium (the ‘Monte-
Carlo’ curve), and the degree of ‘under-reading’ increases as
the field size decreases. Note in particular that at the smallest
field size, 0.5 cm, the reading of the commonly employed
Farmer chamber appears to be a factor ~5 below the ‘Monte-
Carlo’ curve.
The dose in water at the measurement point, Dw-point, in a
field fclin of quality Q clin, can be expressed as:
(D w-point )Qfclin = M Qfclin N Qfrefref
((D f clin
)
w-point Q clin /M Qfclin
clin ) (5.64)
clin clin
((D f ref f ref
w-point )Q ref /M Q ref )
where
M is the reading of the detector, with the centre of its
sensitive volume at the measurement point
N  is the absorbed-dose-to-water calibration coefficient
for this detector in machine-specific reference field fmsr
of quality Q msr (see Section 19.5.2).
† The subscript Q clin refers to the ‘clinical’ beam quality, which can be
different from the reference quality Q.
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry
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FIGURE 5.31 Measured detector response at field size, fclin, normalised to that at the reference field size, as a function of fclin for three different
ionisation chamber types, for a diamond detector and for a diode in a 6 MV beam; the Monte-Carlo curve is assumed to represent the true ratio
of doses. (Adapted from Sanchez-Doblado, F., Hartmann, G. H., Pena, J., Rosello, J. V., Russiello, G. and Gonzalez-Castano, D. M., Phys. Med.,
23 (2), 58–66, 2007. by S. Duane [private communication].)
The final term is a field-specific correction factor, often written
as k, accounting for the difference in response between the
clinical and reference fields (see Section 19.5.3)
The variation of the ratio D/M as the field size decreases
is usually obtained from Monte-Carlo simulations (e.g.
Francescon et al. 2011 – see later; see also Section 19.5.4).
Bouchard et al. (2009) have given the following expression
for the ratio of dose at a point in water to the mean dose in
the sensitive volume of the detector:
{ }
f
{D } it takes full account of differences in the electron spectra
f w
w-point / Ddet = PZ Pr Pvol éëL D /r ùû
Qf det
Qf
This expression, derived from Equation 5.56, contains the
following perturbation correction factors, which are needed
because the electron fluence in the detector differs from that
at the point in water, i.e. deviates from perfect Bragg–Gray
behaviour (Fenwick et al. 2013):
PZ accounts for the effect of detector material of atomic
number Z (denoted as Pfl in Bouchard et al. (2009)
and in Fenwick et al. (2013);
Pr accounts for the effect of detector material of density r;
P vol accounts for the averaging of the fluence across the
sensitive volume of the detector.
Figure 5.32 is a schematic description of the different sources
of perturbation that contribute to the overall detector
81
response in a small field;* the separate factors are defined
such that they act sequentially.
It should be noted that the changes in the stopping-power
ratio for water to air, silicon or diamond, between field sizes
of 4 cm × 4 cm and 0.5 cm × 0.5 cm, are in the region of 0.2%
to 0.6% (Ding and Ding 2012; Czarnecki and Zink 2013).
The stopping-power ratio in Equation 5.65 could imply
that the secondary electron fluence (spectrum) in the detec-
tor is negligibly different from that in the uniform medium;
i.e. the detector behaves substantially as a Bragg–Gray cav-
ity. However, this ratio can in principle be evaluated so that
(5.65)
between the medium (water) and the detector.
5.8.3.2 Response as a Function of Detector Type
Francescon et al. (2011) computed the response of a range
of detector types (‘micro’ ionisation chambers, diodes and
a liquid ionisation chamber) as a function of field sizes from
3.0 cm down to 0.5 cm using the Monte-Carlo egs_cham-
ber usercode. Figure 5.33 shows their results expressed in
terms of the correction factor, i.e. the change in D/M with
field size (cf. Equation 5.64). Some clear trends can be seen
in the figure – the diodes ‘over-read’, therefore requiring
* It should be noted that Figure 5.32 is cast in the framework of Bragg–
Gray cavity theory. However, non-gaseous detectors do not generally
fulfill B–G conditions (see Section 5.7.4.3) even in large fields; in small
fields neither non-gaseous nor gaseous detectors do so. Consequently,
small-field perturbation factors may correct for relatively large perturba-
tions of the electron fluence (spectrum) existing in the uniform medium.
 82 Part A: Fundamentals
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FIGURE 5.32 Factors for the sequential conversion of mean dose in the sensitive volume of the detector, Ddet , to dose at a point in water, D w-point,
via the electron fluences, Φ, in the sensitive volume and intermediate structures. (Reproduced from Fenwick, J. D., Georgiou, G., Rowbottom, C.
G., Underwood, T. S. A., Kumar, S. and Nahum, A. E., Phys. Med. Biol., 63 (12), 125003, 2018. With permission.)

corrections factors less than unity, but the ‘under-reading’

of the ionisation chambers is clearly greater; the PinPoint
chamber requires a correction factor of ≈1.13 at the smallest
field size. Referring to Equation 5.60, the value of ( pQ )ch
must be close to 1.13. A departure from unity of this magni-
tude is far larger than that of the ion-chamber perturbation
correction factors encountered in non-small megavoltage
photon beams (see Sections 5.7.6 and 19.4.2).
Scott et al. (2012) carried out Monte-Carlo computations
of the response of ionisation chambers and of diamond and
diode solid-state detectors in a 15 MV Varian linac beam
(modelled as in Scott et al. 2008) as a function of field
size, from 10 cm × 10 cm (reference) all the way down to
0.25 cm × 0.25 cm. Their results were expressed in terms
of Fdetector = D water/Ddetector evaluated at 5 cm depth in water.
Figure 5.34 from Scott et al. (2012) confirmed the trend
with detector type which was found by Francescon et al.
(2011): strong under-reading by a PinPoint-chamber-like air
volume, moderate over-reading by the diode and the dia-
mond detector, as shown by the light-grey data points in FIGURE 5.33 This figure represents the correction factor
Figure 5.34 and curves in Figure 5.33. ((D w-point )Qfclin
clin ) (
/M Qfclin
clin )
/ (D w-point )Qf1010××1010 /M Qf1010××1010 for five detectors as
In an attempt to shed more light on the role played by the a function of the field size, for the 6 MV beams of Siemens (dotted
various detector characteristics (principally atomic number curve) and Elekta (full curve) linear accelerators. (Reproduced from
and density relative to those of water) in the variation of Francescon, P., Cora, S. and Satariano, N., Med. Phys., 38 (12), 6513–
6527, 2011. With permission.)
overall detector response with field size, Scott et al. (2012)
also simulated the response of detectors made of ‘water’
but with the physical densities of air, diamond and silicon, the PinPoint air cavity, this is sw,air,Δ ≈ 1.10 (cf. Figure 5.21),
respectively.* These variable-density-water-detector results and for the diamond and diode detectors, the values (≈1.15)
are shown as the black curves and data points in Figure 5.34. correspond to D water/Ddetector predicted by Burlin theory (see
Several features should be noted. At the largest (reference) Section 5.7.7), as neither detector acts in a 100% Bragg–
field size, the ‘water-detector’ curves all have an Fdetector of Gray manner.
unity, as expected. By contrast, the reference-field-size, real- By a careful examination of Figure 5.34, one can see that
detector values (light-grey) are given by the dose ratios, for each detector type, the water-detector (black) curve
D water/Ddetector, predicted by cavity theory (Section 5.7); for is displaced vertically (i.e. along the Fdetector axis) from the
‘true-detector’ (light-grey) curve by an amount that is almost
totally independent of the field size; i.e. the black/light-grey
* The (PEGS4) data files for the Monte-Carlo simulations of the arti-
ficial (water) substances corresponded to the densities of silicon,
pairs of curves remain parallel to each other. Expressed
diamond and air, but their mass stopping powers and mass energy another way, the relative change in detector response with
absorption coefficients were set equal to those of unit-density water. field size is virtually unaffected by replacing the true atomic
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 83
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FIGURE 5.34 Monte-Carlo calculated dose-to-water to dose-to-detector-in-water ratios, Fdetector, obtained for diamond, diode and PinPoint
detector voxels (light grey data points and curves) and the detector-voxels filled with detector-density water (data points and curves in black). All
detectors were positioned on-axis at 5 cm depth in a water phantom and the results displayed with k=2 error bars, reflecting the statistical uncer-
tainties of the MC calculations. The field sizes were 0.25, 0.5, 0.75, 1.0, 1.5, 2.0, 3.0 and 10.0 cm. (Reproduced from Scott, A. J., Kumar, S.,
Nahum, A. E. and Fenwick, J. D., Phys. Med. Biol., 57 (14), 4461–4476, 2012. With permission.)

composition of each detector by water while keeping its physi-
cal density equal to the true value.
The findings illustrated in Figure 5.34 suggest very
strongly, at least for a 15 MV x-ray beam, that the physi-
cal density of the detector material is the main driver of the
change in its response with field size, with the atomic com-
position playing at most a very minor role. However, the dose
ratio at non-small field sizes is driven by medium-to-detector
differences in atomic composition (Andreo and Benmakhlouf
2017) consistent with cavity theory. In a subsequent Monte-
Carlo-based analysis of the response of a PTW 60017 diode
detector at both 6 MV and 15 MV, Fenwick et al. (2018)
confirmed the pivotal role of detector density in small-field
dosimeter response. They also showed that the electron flu-
ence in the detector’s sensitive volume was perturbed more
by differences in atomic composition than by differences
in density; however, this Z-dependent perturbation was
independent of field size, in marked contrast to the density-
dependent perturbation.
Values of field-specific correction factors for a wide range
of commercially available detectors can be found in Figures
19.18 to 19.23; these show essentially the same trends as
Figures 5.33 and 5.34 – values below unity for solid-state
detectors and above unity for (air) ionisation chambers.
5.8.3.3 Small-Field Perturbation Factor for
Air-filled Ionisation Chambers
Kumar et al. (2015b) employed the EGSnrc Monte-Carlo
code with the aim of gaining insight into the large devia-
tions from Bragg–Gray behaviour exhibited by air-filled
ionisation chambers in very small fields. Figures 5.35a and
b show the dramatic difference in electron-fluence spectra
between a ‘PinPoint’ air cavity and a small water voxel at the
0.25 cm × 0.25 cm field size in the 6 MV and 15 MV beams,
respectively. As discussed in Section 5.7.4, small air cavities
in megavoltage photon beams might be expected to behave
in a Bragg–Gray manner irrespective of the field size, as the
contribution to the detector signal due to photon interac-
tions in the air cavity is negligible, and the ranges (in air)
of the photon-liberated electrons are much greater than the
cavity dimensions.* Yet Figure 5.35 clearly indicates major
differences between electron-fluence spectra in the air and
water volumes: Bragg–Gray behaviour can be said to have
‘broken down’.
The electron-fluence spectra of Figure 5.35a can be com-
pared with the ‘perfect’ B–G behaviour of an air volume (of
the same dimensions), but now in a 3 cm × 3 cm field, shown
in Figure 5.19, i.e. negligible perturbation. Furthermore, the
15 MV electron-fluence spectra in Figure 5.35b indicate that
the shape of the electron-fluence spectra in the air cavity dif-
fers significantly from that in water; i.e. the two distributions
cannot be brought into coincidence by applying a single,
energy-independent perturbation correction factor.
The Monte-Carlo computations of Kumar et al. (2015b)
yielded perturbation factors of 1.323 and 2.139 (=Φwater/Φair
integrated over energy) for the 6 MV and 15 MV beams,
respectively. Table 5.3 compares, for a PinPoint air cav-
ity, the EGSnrc-based Kumar et al. results with those of
Benmakhlouf et al. (2014) obtained with the PENELOPE
Monte-Carlo code (see Chapter 30).
* The very short ranges of the lowest-energy delta-rays are accounted
for implicitly by employing the Spencer–Attix stopping-power ratio –
see Section 5.7.5.
 84 Part A: Fundamentals

TABLE 5.3
'Total' electron fluence differential in energy
per incident photon fluence (cm-2 MeV-1)
1.0x10-7 '0.25 x 0.25 cm2' 6 MV Comparison of Monte-Carlo-Derived Dose Ratios, Water-to-
Water voxel
Air, as a Function of Field Size for the PinPoint 3D Air Cavity
8.0x10-8 Pinpoint air cavity × 1.323 with Monte-Carlo-Calculated Output Correction Factor
Pinpoint air cavity
kQf clin , f msr
clin , Q msr
from Benmakhlouf et al. (2014).
6.0x10-8 é(Dw /Ddet )MC ù
kQfclin , fmsr ë û Qclin
clin , Qmsr
é(Dw /Ddet )MC ù
Beam Field Size (Benmakhlouf ë û Qmsr
4.0x10-8 Quality (cm × cm) et al. 2014) (Kumar et al. 2015b)
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6 MV, FLG 0.5 × 0.5 1.147 1.144 ± 0.006

2.0x10-8
1×1 1.010 1.024 ± 0.007
2×2 1.000 1.000 ± 0.005
0.0
0.001 0.01 0.1 1 6 The uncertainties are ±2s (k = 2).
Energy (MeV) FLG: full linac geometry.
(a) The field size was defined at 100 cm source surface distance.
(Adapted from Kumar, S, Fenwick, J. D., Underwood, T. S. A.,
Deshpande, D. D., Scott, J. S. and Nahum, A. E., Phys. Med. Biol., 60
(20), 8187–8212, 2015. With permission.)
1.4x10-6
'Total' electron fluence differential in energy

'0.25 x 0.25 cm2' 15 MV

per incident photon fluence (cm-2 MeV-1)

1.2x10-6 The absorbed dose in either the medium or the detector can
Water voxel be approximated by the product of the electron fluence, F e,
1.0x10-6
(at ‘×’ or averaged over the detector) and the electronic stop-
Pinpoint air cavity × 2.139
Pinpoint air cavity
8.0x10-7 ping power, S el /r , averaged over the fluence (see e.g. Kumar
et al. 2015b):
6.0x10-7

4.0x10-7 { int
D w-point » éëF e (´)ùû ´ éëS el /r ùû
w w
int
}
{ }
-7
2.0x10 ext ext
+ éëF e (´)ùû ´ éëS el /r ùû (5.67)
w w
0.0
0.001 0.01 0.1 1 10 int
= éëD (´)ùû w + éëD (´)ùû w
ext
Energy (MeV)
(b)
and:

{ }
FIGURE 5.35 Monte-Carlo-derived electron-fluence spectra (all int int
generations of secondary electrons) scored in a ‘point-like’ water Ddet » éëF e (cav)ùû ´ éëS el /r ùû
det det
‘voxel’ (0.5 mm diameter, 0.5 mm thickness) and in a ‘PinPoint’ air
cavity (2.3 mm diameter, 2.6 mm length) both at 5 cm depth, in a
0.25 cm × 0.25 cm field, on the beam central axis in a large water phan-
tom irradiated by (a) 6 MV and (b) 15 MV photon beams. (Reproduced
{ ext
+ éëF e (cav)ùû ´ éëS el /r ùû
det det
ext
} (5.68)

int ext
from Kumar, S., Fenwick, J. D., Underwood, T. S., Deshpande, D. D., = éëD (cav)ùû det + éëD (cav)ùû det
Scott, A. J. and Nahum, A. E., Phys. Med. Biol., 60 (20), 8187–8212,
2015. With permission.)
where
5.8.3.4 The Physics of ‘Bragg–Gray ‘int’ signifies that this component of the electron fluence
Breakdown’ in Small Fields is generated internally, i.e. by photon interactions in
the equivalent water volume (w) or detector (det),
The signal generated by an arbitrary detector in water (for
respectively
simplicity) irradiated by a photon field can be analysed in
‘ext’ signifies that the electron fluence is generated exter-
terms of the electron fluence present in the detector, irrespec-
nally, i.e. by photon interactions in the water volume
tive of the origin(s) of this fluence. Referring to Figure 5.36,
external to the equivalent water volume (w) or detec-
the field on the left is denoted by fqCPE, indicating that this
tor (det), respectively.
field is wide enough for quasi-CPE to be present at ‘×’; the
sub-equilibrium field on the right is denoted by fsmall. Combining Equations 5.66 through 5.68 yields:
Taking Equation 5.64 as our starting point, and simplify-
ing the notation, we can write: éD wint + D wext ù é int ext
ù
kqCPE = ë int
small û small / ëDdet + Ddet û small
(5.69)
( ) éD w + D w ù é ù
ext int ext

small
D w-point / Ddet ë û qCPE / ëD det + D det û qCPE
kqCPE = small
(5.66)
(D w-point / Ddet )
qCPE
where, for simplicity, the bar over Ddet has been omitted and
‘w-point’ has been replaced by ‘w’.
 Chapter 5: Principles and Basic Concepts in Radiation Dosimetry 85

(i) Uniform medium

fqCPE fsmall
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(ii) Detector in medium

fqCPE fsmall

FIGURE 5.36 Schematic illustration of the response of a detector of arbitrary physical density in a narrow, sub-equilibrium megavoltage photon
e−
field; the measurement position, marked by ‘×’, lies at a depth greater than that of Dmax, and rmax is the maximum lateral distance any electron can
travel. (Adapted from Kumar, S., Fenwick, J. D., Underwood, T. S., Deshpande, D. D., Scott, A. J. and Nahum, A. E., Phys. Med. Biol., 60 (20),
8187–8212, 2015.)

• Case I – detector with density lower than water, e.g.
air ionisation chamber
int
For such a detector, it can be assumed that Ddet ext
 Ddet – this
is usually sufficient for Bragg–Gray behaviour; the denomi-
nator, the dose ratio in a non-small beam, is the conventional
water-to-detector stopping-power ratio. Consequently:
Figure 5.36. First, the contribution from the external elec-
trons to the electron fluence in the air cavity and in the
water volume will be substantially equal. However, the dose
at × in the water volume is augmented by the ‘internal’
electron fluence generated by photon interactions in this
water volume. In the air volume, this ‘internal’ component
is negligible.

éD wint + D wext ù é ext ù

û small / ëDdet û small • Case II – detector with density higher than water e.g.
(ksmall
)
qCPE low-density ȑ
éD wtot ù é tot ù diamond or diode detector
ë û qCPE / ëDdet û qCPE
(5.70)
For a detector with a density greater than that of the medium
éD wint + D wext ù é ext ù
»ë û small / ëDdet û small (water), we must start from the full Equation 5.69, but we
éës w ,det ùû qCPE can replace the denominator, for the qCPE field, by the cav-
ity-theory ratio, which we will write as f w,det to emphasise that
It is clear that this quantity is greater than unity, consistent this is not necessarily a Bragg–Gray detector:
with Figures 5.33 and 5.34. Therefore, there is now a signifi-
cant imbalance between the electron fluence in the undisturbed
éD wint + D wext ù é int ext
ù
û small / ëDdet + Ddet û small
medium and that in the gas cavity – one can say that Bragg–
Gray conditions have broken down.* Consequently, an (air-
(ksmall
)
qCPE high-density =ë
éë f w,det ùû qCPE
filled) ionisation chamber in a small, sub-equilibrium field will
‘under-read’, requiring a correction factor greater than unity. (5.71)
The significant under-reading of an air cavity in a small
int
field can also be understood from the right-hand side of The Ddet and D wint components are negligibly influenced
by field size, as in Case I. Therefore, it is the change in the
* The conversion of electron-fluence to absorbed dose is naturally taken Dext component that drives the variation in k with field size.
care of by cavity integrals (e.g. Equations 5.65 and 5.66) involving the Given that the detector now has a higher density than the
mass electronic stopping power of the detector material, in which the ext
water it replaces, Ddet must constitute a smaller fraction of
natural logarithm of the I-value (I increases with Z) plays a key role.
 86
the total dose than D wext i.e. the detector is more ‘Burlin-like’
than the water it replaces. As the field size becomes smaller,
D wint + D wext will therefore decrease faster than Ddet
int ext
+ Ddet , and
consequently, k will drop below unity, as Figure 5.33 dem-
onstrates. Thus detectors with density greater than water will
‘over-read’ in small, sub-equilibrium fields.
In the case of a 100% photon detector (i.e. small with a very
high density), the ‘ext’ terms will, by definition, be zero (elec-
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trons from the medium make a negligible contribution to the
detector signal – see Section 5.7.3), and the detector signal
(∝ Ddet ) will therefore, to first order, be independent of field
size. Consequently, the k-factor will be entirely determined by
the decrease in the ‘external’ electron fluence entering the equiv-
alent volume of the medium (water) as the field width decreases
from ‘equilibrium’ (or reference) to ‘small’. For a given detector
volume and (small) field size, this corresponds to the lower limit
of k, just as the air ionisation chamber corresponds to an upper
limit for a detector of that volume. It is worth pointing out that
in the hypothetical case of a high-density detector with a vol-
ume so small that there is negligible build-up in it and therefore,
negligible build-up in the (unit density) medium it displaces,
Bragg–Gray behaviour would be ‘restored’, as the electron flu-
ence in the detector and in the displaced medium would be
overwhelmingly due to ‘external’ secondary electrons.
The description of small-field detector response given
here is complemented by the comprehensive small-field cav-
ity-theory review by Bouchard et al. (2015). These authors
emphasised that the lack of CPE alone does not give rise to
significant detector correction factors (i.e. departures from
‘classical’ cavity theory): a perfectly water-equivalent detec-
tor never requires corrections whether CPE is present or not.
Rather, it is the combination of lack of CPE in the small field
itself and the difference between the density of the detector
cavity and the density of the medium that gives rise to the large
correction or perturbation factors. Bouchard et al. (2015) also
emphasise the major role played by volume averaging in small
fields (see P vol in Section 5.8.3.1 and k vol in Section 19.6.2).
FIGURE 5.38 For 6 MV beams: the impact of the modifications to the diode detector on the correction factor kQf clin
by the linac jaws. Error bars correspond to k = 1 statistical uncertainties. (a) Monte-Carlo simulations, (b) experiments using radiochromic EBT3
film (see Section 18.3). (Reproduced from Underwood, T. S., Thompson, J., Bird, L., Scott, A. J., Patmore, P., Winter, H. C. et al., Phys. Med.
Biol., 60 (7), 2939–2953, 2015. With permission.)
Part A: Fundamentals
5.8.4 Mass-density Compensation to Improve
Small-field Detector Response
It was shown in Section 5.8.3.2 that the physical density of
the sensitive detector material, relative to that of the medium
(water), plays the dominant role in detector response, as
the field is reduced below the minimum width required for
quasi-CPE in the uniform medium. This finding suggests
that by surrounding a low-density detector with high-density
material (e.g. a dense ion-chamber wall), or alternatively by
adding a low-density material to a high-density detector, it
might be possible to reduce or even eliminate the dependence
of response on (sub-equilibrium) field size (Underwood
et al. 2012). This mass-density compensation concept was
demonstrated in simulation-based studies (Charles et al.
2013; Underwood et al. 2013) and subsequently validated
experimentally by Charles et al. (2014), who modified two
unshielded diode detectors.
Figure 5.37 shows the design of the DiodeAir detector
proposed by Underwood et al. (2015). Monte-Carlo simu-
lation of the response of the detector as a function of field
size together with an experimental confirmation are shown
in Figure 5.38; it can be seen that an air gap of 1 mm results
in almost perfect field-size independence of the ‘DiodeAir’
response.
FIGURE 5.37 Schematic representation of the DiodeAir detector
design, with an air-gap thickness t. Prototypes with t = 0.5 mm, 1.0 mm,
1.2 mm and 1.55 mm were studied. (Reproduced from Underwood, T.
S., Thompson, J., Bird, L., Scott, A. J., Patmore, P., Winter, H. C. et al.,
Phys. Med. Biol., 60 (7), 2939–2953, 2015. With permission.)
, f10×10
clin , Q 10 ×10
for square fields defined
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