Received: 12 December 1912 Revised: 12 December 1912 Accepted: 12 December 1912

DOI: 10.1002/mp.15987

RESEARCH ARTICLE

Tissue equivalence of 3D printing materials with respect to

attenuation and absorption of X-rays used for diagnostic
and interventional imaging

Patrizia Kunert1 Sebastian Trinkl1 Augusto Giussani1 Detlef Reichert2

Gunnar Brix1

1
Department of Medical and Occupational
Radiation Protection, Federal Office for
Radiation Protection, Oberschleissheim,
Germany
2
Department of Physics, Martin-Luther
University Halle-Wittenberg, Halle, Germany
Correspondence
Patrizia Kunert, Externe und interne
Dosimetrie, Biokinetik, Abteilung f ür
medizinischen und beruflichen
Strahlenschutz, Bundesamt f ür
Strahlenschutz, Ingolstädter Landstr. 1,
D-85764 Oberschleissheim, Germany.
Email: pkunert@bfs.de
Abstract
Introduction: Three-dimensional printing is a promising technology to produce
phantoms for quality assurance and dosimetry in X-ray imaging. Crucial to this,
however, is the use of tissue equivalent printing materials. It was thus the aim of
this study to evaluate the properties of a larger number of commercially avail-
able printing filaments with respect to their attenuation and absorption of X-rays.
Materials and methods: Apparent kerma attenuation coefficients (AKACs)
and absorbed doses for different X-ray spectra (tube voltages, 70–140 kV) were
measured and simulated by Monte-Carlo computations for a larger number
of fused-deposition-modeling (FDM) materials. The results were compared
with the respective values simulated for reference body tissues. In addition, the
properties of polylactide acid samples printed with reduced infill densities were
investigated.
Results: Measured and simulated AKACs and absorbed doses agreed well with
each other and in case of AKACs also with attenuation coefficients derived from
the reference database of the National Institute of Standards and Technology
(NIST). For lung, adipose, muscle, and bulk soft tissue as well as for spon-
giosa (cancellous bone), printed materials with equivalent attenuation as well
as absorption properties could be identified. In contrast, none of the considered
printed materials was equivalent to cortical bone.
Conclusion: Several FDM materials have been identified as well-suited sub-
stitutes for body tissues in terms of the investigated material characteristics.
They can therefore be used for in-house production of individualized and task-
specific phantoms for image quality assessment and dose measurements in
X-ray imaging.

KEYWORDS
3D printing materials, anthropomorphic phantoms, fused-deposition-modeling, Monte-Carlo
simulations, tissue equivalence

1 INTRODUCTION have been commonly used in wide areas of science as

well as product development and manufacturing for over
Technologies for 3D printing such as fused-deposition- a decade. For medical radiation physics, it is a promis-
modeling (FDM),stereo lithography,or multi-jet modeling ing technology for the production of individualized

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.

7766 wileyonlinelibrary.com/journal/mp Med Phys. 2022;49:7766–7778.


TISSUE EQUIVALENT 3D PRINTING MATERIALS
or task-specific phantoms for radiological imaging and
dosimetry.1–3 Since the variety and availability of com-
mercial anthropomorphic phantoms are limited not only
regarding their tailored size and stature of mimicked per-
sons but also because of their high acquisition costs, the
production of phantoms or add-ins to commercial phan-
toms using 3D printing offers great scientific potentials
with the advantage of a fast,cheap,and easy production.
The FDM method is one of the most common additive
manufacturing methods, where a plastic wire, called fila-
ment, is heated into a thermoplastic state and extruded
into a 3D shape. A decisive advantage compared to
other methods is the broad range of commercially
available filament materials and the ability to lower the
printed object density by increasing the amount of air
inside the object using a grid or honeycomb structure.4
Another advantage is the ability to process multiple
materials, which is offered by modern 3D printers with
more than one print head. This is especially of interest
for the production of heterogeneous anthropomorphic
phantoms.
A crucial prerequisite for producing tailored phan-
toms is the selection of materials that are equivalent to
tissues regarding X-ray interactions. Therefore, the char-
acterization of materials regarding their attenuation and
absorption properties is of great importance. In previ-
ous studies, various FDM materials were characterized
primarily with respect to their attenuation behavior only,
either by an analysis of CT densities given in Hounsfield
units (HU)4-9 or direct measurements of attenuation
coefficients.10–13
It was found that many thermoplastic FDM materials
have HU values between −80 and 340 HU, which make
them interesting as tissue substitutes.7 By decreasing
the infill density of printed objects, this range could be
expanded down to −800 HU5 offering the possibility to
approximate the CT density of lung tissue.4,9 In gen-
eral, there is a linear correlation between the infill and
CT density, depending on the infill structure and the
used material.4-6,14 On the other hand, the HU range
of printed materials can be expanded up to 7200 HU
using thermoplastic composite materials, often based
on polylactic acid (PLA) mixed with metal or stone
powders.8
The direct comparison of attenuation coefficients of
printed materials with reference values for body tissues,
like the ones given in the National Institute of Standards
and Technology (NIST) xcom database15 , indicated
that PLA and chlorinated polyethylene (PE) are suitable
muscle equivalents.Furthermore,acrylonitrile butadiene
styrene (ABS), Nylon, and polyvinyl alcohol (PVA) can
be used as adipose tissue substitutes in the diagnostic
energy range.11,12 Thermoplastic polyurethane (TPU)
and a wooden composite material proved suitable as
substitute for some soft tissue organs.10
A core problem of all mentioned studies was that
no suitable equivalent for cortical bone was found.6
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7767
To overcome this limitation, dedicated materials were
developed, in which either metal filaments were mixed
with PLA16 , or CaTiO3 or bismuth powder to ABS.17,18
However, these materials are not commercially available
(so far) and special equipment like multi-material printer
or filament-extruder are required for their processing.
Although many studies have already addressed the
issue of tissue equivalence of FDM materials, their
results can hardly be compared with each other due
to different measurement methods used and radiation
qualities studied. Moreover, to our knowledge, there are
no investigations of the tissue equivalence of FDM
materials regarding the energy deposition for diagnostic
X-rays, which is crucial for the production of dosimetry
phantoms. It was thus the aim of the present study to
characterize a larger number of commercially available
thermoplastic polymers and composite materials in
terms of their attenuation and absorption properties to
expand the spectrum of materials that are well suited
as substitutes for various body tissues. To this purpose,
measurements on FDM materials were accompanied
by Monte-Carlo (MC) simulations to characterize the
physical properties of body tissues under similar expo-
sure conditions. This is a novel approach that has not
been used in previous studies to quantify the tissue
equivalence of printed materials for photon energies
used in X-ray imaging.
2 MATERIALS AND METHODS
2.1 Sample production using FDM
In total, 20 different commercially available filament
types were investigated. They are summarized in
Table 1. For each material, six plates with dimen-
sions 40 × 30 × 3.5 mm3 were produced, as shown
in Figure 1a. For the metal composite filaments, e.g.,
stainless steel, and copperfil, the thickness of the slices
was reduced to 2 mm in view of their higher atten-
uation properties. Beside rigid materials, one flexible
material (Polyflex) was investigated. In contrast to other
TPU-based materials, this material can be processed
by any kind of FDM printer. For each material, plates
were printed with an infill density of 100%. To examine
the best infill density for the imitation of lung tissue,
an additional series of PLA samples was produced for
five different infill factors (25%, 30%, 35%, 40%, and
45%) using a grid infill structure. PLA was used, since
it has been proven as equivalent to skeletal muscle12 ,
which in turn is comparable in its atomic composition
to lung tissue.19 However, the boundary of the samples
with reduced densities must inevitably be printed in
full density (as shown in Figure 1b). To assess the
impact of the boundary on the attenuation behavior, two
blocks with different thicknesses (11 and 22 mm) were
produced for this sample series. The orientation during
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7768 TISSUE EQUIVALENT 3D PRINTING MATERIALS

TA B L E 1 Characterization of the fused-deposition-modeling (FDM) materials investigated in this study

Processing Mass density of

Sample Brand name, temperature Chemical the printed
name Material mixture manufacturer (◦ C) formula samples (g/cm3 )

ABS Acrylonitrile butadiene styrene ABS, Avistron 220–250 (C8 H8 C4 H6 C3 H3 N)n 1.01 ± 0.02
Carbonfil Polyethylentherepthalat + Cabronfil, FormFutura 230–265 1.16 ± 0.02
glycole + 20% carbon fibers
Copperfil PLA + high amount of copper Copperfil, ColorFabb 195–220 3.34 ± 0.02
powder
Easywood PLA + 40% wood particles Easywood, FormFutura 200–240 1.16 ± 0.02
HIPS High-impact polystyrene SSU00, 3ntr 220–260 (C8 H8 )n 0.95 ± 0.02
Laybrick Copolymers + chalk Laybrick, Polymaker 165–210 1.19 ± 0.02
Moldlay Unknown Moldlay, Layfilaments 170–180 1.10 ± 0.02
Nylon Nylon Nylon 230, Taulman 3D 225–235 (C12 H22 N2 O2 )n 1.05 ± 0.02
PC Max Polycarbonate PC-Max, Polymaker 250–270 1.16 ± 0.02
PETG Polyethylenterephthalat + PETG, Filamentworld 195–225 1.23 ± 0.02
glycole
PLA Polylactide PLA, Filamentworld 190–220 (C3 H4 O2 )n 1.21 ± 0.02
PMMA Polymethyl methacrylate PMMA, Material4Print 230–250 (C5 O2 H8 )n 1.12 ± 0.02
Polyflex Thermoplastic polyurethan Polyflex, Polymaker 220–235 1.17 ± 0.02
Pure PLA + 60% ecological fibers PURE, Aprinta Pro 190–220 1.21 ± 0.02
PVA Polyvinyl alcohol PVA, FormFutura 180–205 (C2 H4 O)n 1.17 ± 0.02
Concrete PLA + 50% concrete powder Stonefil, Concrete, FormFutura 200–240 1.57 ± 0.03
Potteryclay PLA + 50% clay powder Stonefil Pottery Clay, 200–240 1.51 ± 0.03
FormFutura
Granite PLA + 50% granite powder Stonefil, Granite, FormFutura 200–240 1.54 ± 0.03
Stainless PLA + high amount of steel Composite PLA, ProtoPasta 195–220 2.22 ± 0.06
steel powder
Terracotta PLA + 50% terracotta powder Stonefil, Terracotta, 200–240 1.53 ± 0.03
FormFutura

printing dictates the amount of material in each spatial
direction of the object since the chosen grid structure
exhibits air ducts as shown in Figure 1c. In this study, the
orientation of air ducts was chosen to be perpendicular
to the front surface that is perpendicular to the direction
of irradiation. However, samples printed with a parallel
orientation to the front surface were also examined
for comparison. For each material and infill density, an
additional plate was printed with dimensions 40 × 30
× 3.5 mm3 containing six 7 × 2 × 2 mm3 cavities to
accommodate thermoluminescent dosimeters (TLD) as
also shown in Figure 1a.
All samples were printed on an FDM printer (Ultimaker
2+; Ultimaker B.V., Geldermanser, Utrecht, Netherlands)
using a 0.6 mm nozzle. The geometric information
of objects given in the computer-aided design (CAD)
software (Rhinoceros 5; Robert McNeel & Associates,
Seattle, WA, USA) was translated into a numerical con-
trol language (g-code) using a slicing software (Cura
4.3.0; Ultimaker B.V.). The correct processing tempera-
ture for each material was found using a temperature
tower test20 , targeted on the temperature ranges given
in Table 1. The layer height was set to 0.1 mm. The
printing speeds were adapted to each material individ-
ually, with infill speeds ranging between 20 mm/s (e.g.,
for Polyflex and Nylon) and 40 mm/s (e.g., for ABS
and PLA). For a better adhesion during the printing
process, some materials [e.g., polymethyl methacrylate
(PMMA)] needed a heated print bed with temperatures
up to 100◦ C. The exact printing settings are given in
Supporting Information (Table S1).
The mass density of all 3D printed material samples
was determined by weighing with a precision balance
(Kern PCB; Kern & Sohn GmbH, Balingen, Germany;
precision, ±0.01 g) and measuring the dimensions with
a vernier calliper (uncertainty, ±0.01 mm). To avoid
systematic uncertainties, the dimensions were mea-
sured on three positions along the same direction and
averaged for volume calculation. The resulting densities
of the printed samples are summarized in Table 1. The
volume of 3D printed objects can slightly vary from
the CAD model depending on the filament materials
due to different material behaviors during the heating
and cooling processes. For samples with reduced infill

TISSUE EQUIVALENT 3D PRINTING MATERIALS
density, the mass density was determined only for the
inner structure, by assessing the contribution of the fully
printed boundaries on mass and volume measurements.
2.2 Experimental setup for the
measurement of attenuation properties
The experimental setup for the investigation of atten-
uation properties is presented in Figure 2a. For all
materials investigated, attenuation curves were deter-
mined by measuring the transmission of X-rays through
different numbers of plates using a X-ray tube with
tungsten anode (ISOVOLT 400/10; Seifert, Ahrensburg,
Germany).
Five radiation qualities were investigated, correspond-
ing to tube voltages of 70, 80, 100, 120, and 140 kV.
X-rays were filtered with 7 mm intrinsic beryllium (Be)
and additional 2.5 mm aluminium (Al), which corre-
sponds to first Al half value layers of 0.25, 0.28, 0.35,
0.43, and 0.51 cm. The used radiation qualities cover
approximately all RQR radiation qualities21 between
RQR 5 and RQR 9. A narrow beam geometry was
obtained putting a 2.4 mm wide circular collimator in
front of the opening window of the X-ray tube, between
the Be and Al filters. The collimator consisted of three
layers [2 mm lead (Pb), 1.8 mm copper (Cu), and 1.2 mm
Al]. For each investigated material type, printed plates
F I G U R E 1 (a) Computer-aided design (CAD) construction of
samples consisting of six fully printed plates and one additional plate
with cavities to accommodate thermoluminescent dosimeters (TLDs).
(b) Visualization of a sample block with a 35% infill density with grid
infill style in the slicing software (view from the top of the sample).
(c) Image of the printed sample block with a 35% infill density.
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7769
were stacked directly behind the Al filter to have samples
with increasing thickness. Backscattering of X-rays on
the floor was reduced by a lead shield. A calibrated stem
chamber (M2333; PTW-Freiburg, Freiburg, Germany),
connected to a UNIDOS E dosimeter (PTW-Freiburg),
was placed at a distance of 51 cm from the focal point of
the X-ray tube and 128 cm above the floor. An appropri-
ate distance between source and detector is essential
for the realization of a narrow-beam setup to mini-
mize the influence of multiple scattered photons on the
transmission. The chamber is characterized by a small
sensitive volume and is suitable for a wide range of
applications. It was calibrated for air kerma measure-
ments with radiation qualities of TH 140, 100, and 70.22
To adequately calibrate our measurement data, radia-
tion quality correction factors were interpolated for the
used radiation qualities.
The air kerma rate, Ka (d), was measured over an
exposure time of 3 min at a tube current of 10 mA.
A temperature and pressure correction of the cham-
ber was made before each measurement session, as
well as a zero-point correction to suppress background
noise. The mean values computed from three individual
measurements were used for the further evaluation.
Kerma transmission ratios Ka (d)∕Ka (0) were deter-
mined for different sample thicknesses, d. The resulting
data were approximated by mono-exponential functions,
according to the Lambert–Beer’s law:
E
Ka (d) ∫E max 𝜑 (d, E) ⋅ 𝛼 (E) dE
= 0
≅ exp (−AKAC ⋅ d) ,
Ka (0) Emax
∫E 𝜑 (0, E) ⋅ 𝛼 (E) dE
0
(1)
where 𝜑(d, E) is the photon fluence, 𝛼(E) the fluence-
to-kerma conversion coefficient, E the photon energy,
and AKAC being the apparent kerma attenuation coef-
ficients. This equation is valid to a good approximation,
since 𝛼(E) depends only slightly on the photon energy
in the considered energy range.23 Curve fitting was
performed by a least-squares algorithm using SciPy24 ,
weighting the values by their inverse standard devia-
tion. For samples with reduced infill density, the influence
of fully printed boundaries was considered and AKACs
were calculated for the infill structure only.
2.3 Experimental setup for the
measurement of absorption properties
Absorption properties of the different materials were
characterized by measuring the absorbed dose directly
inside a stack of all printed plates. The dose mea-
surements were performed with lithium fluoride (LiF)
TLD-rods of 1 × 1 × 6 mm3 (TLD-100; Bicron-Harshaw,
Cleveland, OH, USA) that were placed in the cavities of

7770
F I G U R E 2 Experimental setups: (a) Narrow-beam setup for the measurement of X-ray transmission through 3D printed samples of
different thickness d. The image excerpt shows the arrangement of filters used for the narrow-beam collimation. (b) Broad-beam setup for the
measurement of the dose absorbed in the printed material.
the designated plate, which was arranged in the middle
of the stack of the printed plates, as shown in Figure 2b.
The stack was placed in the center of the beam on a
low-density polystyrene plate at a distance of 127 cm
to the focal point of the X-ray tube. Irradiations were
performed with the ISOVOLT 400 X-ray tube, the expo-
sure time was 2 min for a tube current of 10 mA. A
broad-beam setup was used to ensure a homogeneous
irradiation of the material stack and the TLDs. The same
radiation qualities as for the attenuation measurements
were used.
For each measurement, a new set of six TLDs was
used, which were individually calibrated by irradiation
with the ISOVOLT 400 X-ray tube at the same radiation
qualities as used for the experiments. Calibration was
assessed with the above-mentioned stem chamber
and the dosimeter. The chamber was calibrated for
absorbed dose in water for radiation qualities of TH 140
and 100. The correction factors were interpolated for
the actual radiation qualities. The individual calibration,
annealing, and read-out of the TLDs were performed
with a TLD oven (TLDO 1321; PTW-Freiburg) and a
TLD reader (Harshaw TLD 5550; Thermo Fischer Sci-
entific, Waltham, MA, USA) according to a standardized
protocol.25 For further evaluations, the mean dose value,
D, of measured TLD doses was used.
2.4 Monte-Carlo-based computation of
tissue properties
Both experimental setups described above were sim-
ulated by MC computations (Geant4 10.5; Geant4
Collaboration26 ). In order to determine reference values
for different body tissues as characterized in Table 2,
simulations were run with the 3D sample materials
replaced by tissue samples of the same size.The energy
spectra were adjusted to the radiation qualities utilized
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TISSUE EQUIVALENT 3D PRINTING MATERIALS
in the measurements by using the spectral data of the
python-based program xpecgen.27 All simulations were
run on a Linux virtual machine with 40 CPUs (Intel Xeon
CPU E5-2687 W v3 at 3.10 GHz; Intel, Santa Clara, CA,
USA) using the low-energy electromagnetic package
of Geant4 with a cut-in-range of 0.1 mm.28 Coherent
scattering was neglected.
The simulations of transmission measurements were
done with 107 primary photons. For an uncertainty
analysis, the mean values and the standard deviation of
several simulation runs were calculated. The computing
time for one simulation was about 1 h. The AKACs
derived from the simulated attenuation curves were
computed by exponential fits of the simulated kerma
transmission ratios according to Equation (1).
Absorbed doses inside the reference tissues were
simulated in the middle of the tissue block with an
inserted LiF-crystal with a size of 12 × 6 × 1 mm3 . For
comparison with the measured dose in printed materi-
als, the thickness of the simulated tissue samples was
adjusted to the slightly varying thicknesses of the dif-
ferent kind of materials. To save computation time, the
opening angle of the broad-beam setup was set to 10◦ .
It could be shown that this did not affect the results.
Simulations were done with 109 primary photons, which
corresponds to a simulation time of 4 h per run. The
mean and standard deviation of independent runs was
used for further evaluations. The dose achieved by sim-
ulations was scaled using a calibration factor obtained
by comparing the experimentally measured dose in a set
of reference TLDs and the dose simulated for the same
geometrical setup.
To enable a cross-validation of measured and sim-
ulated AKACs and absorbed doses, simulations were
also performed for homogeneous PMMA samples with
the same dimensions as the printed samples and the
density and the atomic composition of PMMA given in
Table 1.
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TISSUE EQUIVALENT 3D PRINTING MATERIALS 7771

TA B L E 2 Reference tissues used for Monte-Carlo simulations as characterized by their mass densities and atomic compositions

Mass fraction (%)

Mass density
Tissue (g/cm3 ) H C N O Na Mg P S Cl K Ca

Lung tissue19,29 0.38 10.5 8.3 2.3 77.9 0.2 0.1 0.2 0.3 0.2 0.0 0.0
Adipose tissue19 0.95 11.4 59.8 0.7 27.8 0.1 0.0 0.0 0.1 0.1 0.0 0.0
Skeletal muscle19 1.05 10.2 14.3 3.4 71.0 0.1 0.0 0.2 0.3 0.1 0.4 0.0
Bulk soft tissue19 a 1.03 10.5 25.6 2.7 60.2 0.1 0.0 0.2 0.3 0.2 0.2 0.0
Cortical Bone19 1.92 3.4 15.5 4.2 43.5 0.1 0.2 10.3 0.3 0.0 0.0 22.5
Spongiosa29 1.31 7.8 24.8 3.9 52.5 0.1 0.2 3.4 0.3 0.0 0.1 6.8
a 19
Used as substitute for soft tissues, for example, glands, trachea, uterus in ICRP 89.

2.5 Validation of measurement and
simulation methods
To validate the methods for measurement and simula-
tion of AKACs and absorbed doses, both approaches
were compared in the case of PMMA at all tube voltages
considered. Additionally, the AKACs obtained by both
methodological approaches were compared with refer-
ence data derived from the energy-dependent fluence
attenuation coefficients given in the NIST database. For
this, the X-ray spectra were divided into small energy
bins for which the fluence attenuation coefficients can
be considered as constant. Using this approximation,
mean transmission ratios were computed for different
thicknesses, d, according to Equation (1) (replacing the
integrals by sums) and used to estimate NIST-based
AKACs by the mono-exponential fitting procedures
described above. To evaluate the effect of beam hard-
ening, simulated AKACs were also compared with NIST
data for cortical bone as a high-density tissue by using
the same approach as described above.
3 RESULTS
3.1 Validation of the used
measurement and simulation methods
All results for the validation processes are summarized
in Figure 3a–d. Figure 3a shows that the transmis-
sion ratios determined experimentally for PMMA can
be very well approximated by mono-exponential func-
tions in the considered energy range. This justified the
use of the Lambert–Beer law as in Equation (1) to
determine AKACs for the investigated materials and soft
tissues, although measurements were performed with
conventional X-ray spectra and not with mono-energetic
X-rays.
The linear relationship between both measured and
simulated AKACs and the respective NIST-based coef-
ficients is shown for PMMA in Figure 3b. Measured and
simulated AKACs were on average 1% lower and 2%
higher than the corresponding NIST data, respectively.
This verifies the high accuracy of the measurement
and simulation methods employed. The cross-validation
for simulated and NIST-based AKACs for cortical bone
is shown in Figure 3c. Again, there is a good linear
correlation between both data. Yet, the standard devi-
ations of the simulated AKACs are higher compared
to the data obtained for PMMA due to slight deviations
from the mono-exponential attenuation behavior due to
beam-hardening effects.
Absorbed doses measured in PMMA are plotted
against the corresponding simulated values in Figure 3d.
The differences were within the range of ±5%. On aver-
age, simulated dose values were 3% lower than the
measured values. This slight systematic deviation was
taken into account for a fine calibration of all simulation
results.
3.2 Physical properties of printed
materials as compared to tissues
Figure 4 summarizes the attenuation properties of
the investigated printed materials (measured AKACs)
in comparison with those of body tissues (simulated
AKACs) for a representative tube voltage of 100 kV. The
investigated printed materials cover a broad range of
attenuation values. Various materials are comparable
to adipose, bulk soft, and skeletal muscle tissue. Sam-
ples printed with a reduced infill density are in a range
comparable to lung tissue. Stone-containing filaments
show higher attenuation properties and are comparable
to spongiosa. In contrast, the attenuation behavior of
cortical bone cannot be adequately reproduced by the
printed materials considered, since stone-containing
materials have lower and metal-containing filaments
markedly higher attenuation coefficients. As high-
density materials are more effective in inducing beam
hardening, deviations from the Lambert–Beer law are
expected; this explains the slightly larger error bars of
the AKACs determined for the high-density material in
comparison to other materials
Absorbed doses measured in printed materials and
simulated for body tissues are summarized in Figure 5
for a representative tube voltage of 100 kV. Because
mass densities have per definition no direct impact
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7772 TISSUE EQUIVALENT 3D PRINTING MATERIALS

F I G U R E 3 General validation results for the considered X-ray spectra. (a) Measured transmission ratios for polymethyl methacrylate
(PMMA) samples of different thickness in log-scale. The fitted apparent kerma attenuation coefficients (AKACs) are given in the legend.
(b) Correlation of AKACs determined from attenuation measurements (light gray symbols) and simulations (dark gray symbols) with
NIST-based AKACs for PMMA. (c) Correlation of simulated and NIST-based AKACs for the example of cortical bone. (d) Correlation between
measured and simulated absorbed doses in a PMMA block. Error bars give standard deviations and the lines mono-exponential regressions (a)
and linear regressions through the origin (b–d). The shaded areas represent deviations of less than ±5% from the NIST-based AKACs (b and c)
and from the line of identity (d).

on the absorbed dose, the doses to most printed
non-composite materials and soft tissues are in a com-
parable range taking their uncertainties into account. In
contrast, the dose absorbed in spongiosa and cortical
bone is significantly lower due to the different elemental
composition of these tissues. While the absorbed dose
in Laybrick is very similar to that in spongiosa, the dose
in stone-containing materials is much higher than the
one in cortical bone.
The tissue equivalence of the investigated printed
materials was quantitatively assessed based on the
relative differences, δ, between measured AKACs and
absorbed doses and the corresponding simulated tissue
reference values. Materials were assumed to be tissue
equivalent if the δ values for both, AKACs and absorbed
doses, are less than ±5%.
The relative differences between AKACs measured
for selected printed materials and those simulated for
reference soft tissues, plotted in Figure 6a–d, show
only a slight energy dependence, with values increasing
at higher tube voltages. In contrast, the relative differ-
ences between stone filaments and spongiosa as well
as between stone/metal filaments and cortical bone
decrease with increasing tube voltages (Figure 6e,f ). For
lung tissue, PLA samples printed with 40% and 45% infill
densities are within their uncertainties in the range of
±5% difference (Figure 6a). The same holds for ABS
and Nylon for adipose tissue (Figure 6b). Easywood,
Moldlay, and PLA show very similar attenuation prop-
erties to each other and are within the range of tissue
equivalence over the whole investigated energy range
for bulk soft tissue and skeletal muscle (Figure 6c,d).
Additional materials fulfilling the condition for tissue
equivalence are PVA for bulk soft tissue, polyethy-
lenterephthalat + glycole (PETG) for skeletal muscle,
and with slight limitations Laybrick for spongiosa. With
the exception of Laybrick, the relative differences
are distinctly larger for stone/metal composites and
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TISSUE EQUIVALENT 3D PRINTING MATERIALS 7773

F I G U R E 4 Apparent kerma attenuation coefficients (AKACs) for a representative tube voltage of 100 kV for all printed materials
considered (light gray bars) and body tissues (dark gray bars) determined from measurements and simulations, respectively. The error bars give
the standard deviations.

F I G U R E 5 Absorbed doses for a representative tube voltage of 100 kV in the printed materials considered (light gray bars) and body
tissues (dark gray bars) determined from measurements and simulations, respectively. The error bars give the standard deviations. Doses were
measured in slightly different depths due to slight variations in sample thicknesses after the printing process; simulated tissue data refer to a
mean depth of 13 mm.

spongiosa/cortical bone as compared to polymers
and soft tissues due to the considerable differences
in their mass densities and elemental compositions
(Figure 6e,f ).
Figure 7 shows the measured mass densities and
AKACs for PLA samples printed with a reduced infill
density versus the nominal percent infill factors. There
is an excellent linear relation between measured mass
densities and infill factors. On the contrary, measured
AKACs are slightly lower than theoretically expected.It is
to be presumed that the attenuation behavior is not only
affected by the average mass density and the atomic
composition of the samples printed with a reduced infill
factor, but also by the inhomogeneous infill structure
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7774 TISSUE EQUIVALENT 3D PRINTING MATERIALS

F I G U R E 6 (a–f) Relative differences between apparent kerma attenuation coefficients (AKACs) measured for selected printed materials
and simulated for reference tissues for five tube voltages. The error bars were calculated by means of Gaussian error propagation of standard
deviations of measured/simulated values. Measured values are slightly shifted on the x-axis for better visualization. Reference simulations for
polymethyl methacrylate (PMMA), polylactide (PLA), and PLA35 with a mean density corresponding to that of the printed samples are
additionally plotted. The shaded areas represent the range of less than ±5% relative differences, for which tissue equivalence was assumed.

(cf. Figure 1c). This assumption is supported by the
fact that AKACs simulated for the PLA35 sample with a
homogeneous material distribution are about 5% higher
(averaged over all tube voltages) than the values mea-
sured in the printed sample with the corresponding mass
density (Figure 6a). Moreover, the direction of the air
ducts with respect to the X-ray beam affects the atten-
uation behavior. Irradiating the samples with the beam
parallel and not orthogonal to the air ducts resulted on
average in 10% lower AKACs.
As Figure 8a–e demonstrates, the relative differences
between absorbed doses measured in selected printed
materials and those simulated for soft tissues and spon-
giosa do not show a significant energy dependence.
In contrast, there is a distinct energy dependence for
cortical bone with larger differences for lower tube volt-
ages (Figure 8f ). Considering the uncertainties of the
relative differences, the doses inside all PLA samples
with reduced infill densities and fully printed PLA are
identical but do not strictly meet our equivalence cri-
terion for lung tissue over the examined energy range
(Figure 8a). Easywood, Moldlay, PETG, PLA, and PVA
are in good approximation within the equivalence range
for bulk soft tissue for all tube voltages (Figure 8c),

TISSUE EQUIVALENT 3D PRINTING MATERIALS
F I G U R E 7 Correlation of mass densities (light gray symbols, left
axis) and apparent kerma attenuation coefficients (AKACs) (dark
gray symbols, right axis) measured at 100 kV for polylactide (PLA)
samples printed with reduced infill factors. The error bars give the
standard deviations and the line the theoretically expected
relationship.
whereas the doses in these materials are more than 5%
higher than in skeletal muscle for tube voltages below
100 kV (Figure 8d). For adipose tissue, the dose inside
ABS, Nylon, and Polyflex is equivalent over the whole
investigated energy range (Figure 8b). The same holds
for Laybrick as a substitute for spongiosa (Figure 8e).
Comparable to the results reported for AKAC, neither
stone nor metal materials are suitable substitutes for
cortical bone (Figure 8f ).
The deviations between the physical properties
(AKAC, absorbed dose, physical density) of selected
printed materials and those of the reference soft tissues
and spongiosa are summarized in Table 3. The values
given here represent mean values over all tube voltages.
This approach was considered appropriate to charac-
terize the tissue equivalence of the printed materials
over the considered energy range due to the only weak
energy dependency of the transmission and absorption
properties observed.
4 DISCUSSION
In this study, the tissue equivalence of a large number
of commercially available thermoplastic polymers and
composite materials was investigated with respect to
both their attenuation and absorption of X-rays for tube
voltages between 70 and 140 kV typically used for X-ray
imaging. To this end, extensive measurements and MC
simulations were performed. The results were validated
with each other as well as to reference NIST data in
the case of attenuation measurements at the example
of PMMA. All measurements and simulations were
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7775
performed for X-ray spectra and not for monoenergetic
X-rays, which corresponds to the actual situation in
X-ray imaging. Due to the broad range of investigated
radiation qualities, the results of this study are transfer-
able to other radiation qualities typically used for X-ray
imaging.The fact that the transmission of X-rays through
printed samples was quantified by the kerma, and not by
the photon fluence, does not interfere with the objective
of our study, namely to compare the physical properties
of printed materials with those of body tissues.
Different tissue substitutes could be identified for
lung, adipose, bulk soft, skeletal muscle tissue as well
as for spongiosa. However, none of the investigated
commercial stone or metal filaments was similar to
cortical bone with respect to either their attenuation or
their absorption properties.
Materials which were already known to be appropriate
substitutes for skeletal muscle6,11,14 (PLA) or adipose
tissue11,13 (ABS, Nylon) with respect to their attenuation
behavior were found to be tissue equivalent also with
respect to their absorption properties. Additional materi-
als were identified to be suitable substitutes for skeletal
muscle (PETG, Moldlay), bulk soft tissue (PVA, Moldlay,
Easywood), and spongiosa (Laybrick) in both aspects.
With a decrease of the infill density of PLA to 45% or
40%, also lung tissue can be mimicked in both proper-
ties. For some materials the relative differences deter-
mined for specific tube voltages were slightly outside the
±5% range, for example, for absorbed doses in lung tis-
sue at 100 and 120 kV (Figure 8a) or skeletal muscle tis-
sue for tube voltages below 100 kV (Figure 8d). It should
be noted, however, that both the measured and simu-
lated values are subject to uncertainties, which results
in an increased relative uncertainty of their difference δ.
Our study thus succeeded not only in expanding the
number of 3D printing materials with tissue equivalent
transmission properties in the diagnostic energy range,
but also in identifying materials with tissue equivalent
absorption properties. To the best of our knowledge, the
latter aspect had not yet been systematically investi-
gated in previous studies for the energy range relevant
for X-ray imaging. Consequently, tissue equivalent fil-
ament materials can be used to print individualized or
task-specific tailored body phantoms to determine the
quality of images, for example, in terms of the noise
and contrast, as well as the dose distribution by inserted
TLDs.
Like in other studies, samples with different infill den-
sities were printed to simulate lung tissues.4,6 For the 3D
printer used in the present study, we could demonstrate
an excellent linear relation between infill factor and
the mass density of printed materials. Nevertheless,
measured AKACs slightly deviate from a linear relation
with the percent infill factor. This implies that the atten-
uation properties of samples printed with a reduced
infill density need to be investigated in detail, since they
cannot necessarily be derived from the nominal infill
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7776 TISSUE EQUIVALENT 3D PRINTING MATERIALS

F I G U R E 8 (a–f) Relative differences between absorbed doses measured for selected printed materials and for reference tissues, simulated
for each material (under consideration of individual material thicknesses), for five tube voltages. The error bars were calculated by means of
Gaussian error propagation of standard deviations of measured/simulated values. The curves show the results of reference simulations for
polymethyl methacrylate (PMMA) and polylactide (PLA), which were done with a sufficiently high number of initial particles. Measured values
are slightly shifted on the x-axis for better visualization. The shaded regions indicate the range of less than ±5% relative differences, for which
tissue equivalence was assumed.

factor itself. Moreover, the inhomogeneous structure of
printed samples, in particular the orientation of air ducts
with respect to the beam direction, has to be considered
as a relevant factor that may affect the measured atten-
uation in a narrow-beam setup. Other infill structures,
for example, a gyroid structure could be a solution for
this problem.30 As expected, the dose inside all printed
PLA samples was not considerably affected by the infill
density and structure.
The confirmation of PLA as substitute for skeletal
muscle and bulk soft tissue with respect to both X-ray
attenuation and absorption is especially beneficial since
PLA is easily available at low costs. Additionally, many
composite materials are based on PLA, which facilitates
their adhesion in the printing process of more complex
phantoms. The availability of other similar materials,
for example, Moldlay and Easywood, allows a certain
flexibility with respect to the processing temperature
and material adhesion, when using a multi-material
FDM printer. With PVA and PETG, there are additionally
bulk soft tissue and skeletal muscle equivalents with
slightly different attenuation properties than PLA. This
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TISSUE EQUIVALENT 3D PRINTING MATERIALS 7777

TA B L E 3 Percent differences (mean ± SD) between selected makes it possible to realize minor differences in imag-
printed materials (measured data) and soft tissues/spongiosa ing contrasts, for example, between different organs
(simulated data) with regard to their relevant material properties
[apparent kerma attenuation coefficient (AKAC), absorbed dose,
in anthropomorphic phantoms. On the other hand, it
mass density] averaged over the considered tube voltages should be noted that printed PMMA did not fulfil the
requirements for tissue equivalence neither for muscle
Relative differences (%)
nor for bulk soft tissue. The analysis of commercially
Adipose tissue AKAC D ρ
available composite filaments yielded that they are not
HIPS −8.9 ± 1.0 −4.5 ± 5.6 −0.1 ± 2.1 suited as substitutes for cortical bone due to the large
ABS −2.7 ± 1.6 0.8 ± 3.0 6.6 ± 1.8 differences in mass densities and atomic compositions.
Nylon 0.6 ± 2.0 0.2 ± 4.0 10.5 ± 1.8 The development of suitable filaments would therefore
Carbonfil 10.4 ± 2.6 −0.7 ± 3.1 22.1 ± 2.1
be very welcome.
There are some limitations to our study: We did not
PMMA 13.4 ± 2.2 −0.2 ± 2.4 17.9 ± 2.0
examine the variation between manufacturers for the
PLA 24.1 ± 3.4 −3.7 ± 2.4 27.4 ± 2.2 same kind of filament materials, nor the influence of
Polyflex 9.9 ± 0.6 −2.8 ± 3.0 22.6 ± 2.2 different types of printers and printing settings. The
Lung tissue AKAC D ρ adhesion between different tissue equivalent materials
was not aim of the present study, and will be inves-
PLA25 −41.6 ± 2.2 −7.8 ± 2.6 −26.3 ± 4.7
tigated in further work focusing on the production of
PLA30 −32.0 ± 1.3 −6.7 ± 3.1 −10.5 ± 4.8 complex structured phantoms by a multi-material FDM
PLA35 −16.8 ± 1.5 −7.7 ± 2.5 7.9 ± 4.7 printer. Finally, possible approaches to match mate-
PLA40 −3.3 ± 2.2 −6.8 ± 2.4 26.3 ± 4.5 rial properties to those of cortical bone, for example,
PLA45 4.0 ± 2.1 −5.8 ± 2.3 36.8 ± 4.5 by reducing the infill density or content of metal in
composite filaments, was not yet investigated.
Bulk soft tissue AKAC D ρ

Carbonfil −10.8 ± 1.8 6.4 ± 4.3 12.6 ± 1.9

PMMA −7.9 ± 1.1 6.3 ± 2.5 8.7 ± 1.8 5 CONCLUSION
PC Max −9.0 ± 1.3 4.9 ± 2.9 12.6 ± 1.8
PLA 0.5 ± 1.0 2.0 ± 2.9 17.5 ± 2.0 In this study, a large number of commercially available
PVA −3.8 ± 1.1 3.5 ± 2.4 13.5 ± 2.1
FDM materials was investigated as possible substitutes
for representative tissues for five different radiation qual-
Polyflex −19.5 ± 1.9 4.1 ± 4.2 13.1 ± 2.0
ities typically used for X-ray imaging. With respect to
Moldlay 0.0 ± 0.9 −0.6 ± 3.2 6.4 ± 1.8 both their attenuation and absorption properties, various
Easywood −1.4 ± 1.1 2.4 ± 1.5 12.6 ± 1.8 substitutes were found to be equivalent to soft tissues
PETG 9.7 ± 0.7 3.2 ± 2.3 19.4 ± 1.9 and spongiosa. These identified thermoplastic polymers
Pure 18.2 ± 4.1 −0.3 ± 2.2 17.5 ± 1.9 and composite materials can be used for in-house 3D
printing of patient- or task-specific phantoms aimed to
Spongiosa AKAC D ρ
improve image quality assessment and dosimetry in
Laybrick −3.7 ± 5.0 −0.9 ± 4.2 −9.1 ± 1.5 X-ray imaging.
Skeletal muscle AKAC D ρ
AC K N OW L E D G M E N T S
Carbonfil −15.6 ± 2.0 8.5 ± 4.9 10.5 ± 1.9
We would like to acknowledge Dr. Patrick Woidy (BfS,
PMMA −12. 9 ± 1.5 7.1 ± 3.2 6.7 ± 1.8
Department of Environmental Radioactivity) for the kind
PC Max −13.9 ± 1.6 7.3 ± 3.8 10.5 ± 1.8 introduction into the topic of FDM 3D printing, as well
PLA −4.8 ± 0.6 5.3 ± 4.8 15.2 ± 2.0 as the group of Oliver Meisenberg (BfS, Department of
PVA −9.1 ± 1.6 6.1 ± 3.4 11.3 ± 2.1 Medical and Occupational Radiation Protection) for the
Polyflex −15.9 ± 2.7 6.9 ± 4.1 11.0 ± 2.0 provision of their 3D printer and our colleague Dr.Helmut
Schlattl for his professional support.
Moldlay −5.5 ± 1.1 3.3 ± 3.8 4.4 ± 1.8
Open Access funding enabled and organized by
Easywood −6.7 ± 0.7 5.0 ± 4.6 10.5 ± 1.8
Projekt DEAL.
PETG 3.6 ± 1.2 6.1 ± 2.7 17.1 ± 1.9
Pure 11.6 ± 3.3 1.1 ± 2.4 15.2 ± 1.9 CONFLICT OF INTEREST
Note: The shaded materials meet or at least come very close to tissue The authors have no conflicts of interest to disclose.
equivalence in terms of both their attenuation and absorption properties.
Abbreviations: ABS, acrylonitrile butadiene styrene; HIPS, high impact
polystyrene; PC, polycarbonate; PETG, polyethylenterephthalat + glycole; PLA, F U N D I N G I N F O R M AT I O N
polylactide; PMMA, polymethyl methacrylate; PVA, polyvinyl alcohol The authors received no specific funding for this work.

7778
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are
available on request from the corresponding author.
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S U P P O R T I N G I N F O R M AT I O N
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.
How to cite this article: Kunert P, Trinkl S,
Giussani A, Reichert D, Brix G. Tissue
equivalence of 3D printing materials with respect
to attenuation and absorption of X-rays used for
diagnostic and interventional imaging. Med Phys.
2022;49:7766-7778.
https://doi.org/10.1002/mp.15987