BACKGROUND:The Xoft electronic brachytherapy source is commonly used to treat superficial lesions and tumors located at shallow depths. However, uncertainties in material composition and geometry, mainly arising due to the manual assembly of the x-ray tube components, contribute to inter-source variability in the tube output spectrum. In addition, aging of the x-ray tube may lead to intra-source variability in the tube spectrum. PURPOSE:To investigate the inter- and intra-source variability of the spectrum for the Xoft S7500 model experimentally and through simulations, as well as to study the impact of this variability on dosimetry. METHODS:The Amptek X123 CdTe x-ray spectrometer was used to measure the spectrum of the Xoft S7500 source model. First, the spectrometer was calibrated using 137Cs, 152Eu, and 57Co. Second, the source output spectrum was measured on the side and at the tip of the source at a distance of 15.5 cm from the source tip. Throughout the measurement, the source was fixed to the optical table using a 3D-printed holder and was aligned using a laser beam. The intra-source variability was studied by investigating the spectrum emitted by one single source measured in five trials. Similarly, the inter-source variability was investigated by measuring five different sources of the S7500 model at the tip and the side. The symmetry of the output was investigated by comparing the side and tip spectra. The measurements were then compared with the simulated spectra using a previously developed E-Brachy software package, taking into account the range of variation in material composition reported by the manufacturer. Finally, to determine whether or not the uncertainty in the material composition and the output spectrum affect the dosimetry by a clinically significant amount, we compared the depth dose curves created by the upper and lower limits of the range of uncertainty in the material composition. RESULTS:The calibration line was obtained to correspond the detector channels to the energy in keV using linear regression. Escape peak and background corrections were performed on the spectrum, and the counts in the K-edges of cadmium (26.7 keV) and tellurium (31.8 keV) were readjusted so that the silver peaks were more clearly resolved. Intra-source variability demonstrated consistent peak resolution for tungsten, yttrium, and silver, with a coefficient of variation (CV) ranging from 0.5% to 9.8%. Inter-source variability highlighted significant differences between tip and side measurements, with up to 13.5% variation. Simulated spectra revealed the impact of material composition on the characteristic peak intensities, with the intensity of the peaks in the measured spectra lying between simulated spectra in the case of higher and lower percentage limits of yttrium and silver present in the material composition. Depth-dose simulations showed minimal differences (<1.2%) between material compositions. CONCLUSIONS:This study comprehensively compared the measured and simulated spectra of the Xoft S7500 source model. The differences in the depth-dose curves are within 2% as recommended by the AAPM TG-568 requirements, and the variations in the spectra for the source model S7500 lie within the recommended range.

BACKGROUND:Radiochromic GafChromic film models are widely used in clinical settings for quality assurance during cancer treatment planning. Although these films are extensively studied in photon dosimetry, research on their application in α-particle dosimetry remains limited. With the growing use of α-particles in cancer therapy, it is important to establish film dosimetry protocols tailored to α-particles. Unlike photons, α-particles are charged, have a high linear energy transfer, and induce significantly greater biological damage, highlighting the need for specialized dosimetric approaches. PURPOSE:This study aimed to evaluate the response of various unlaminated GafChromic film models including EBT3, EBT-XD, and HD-V2, irradiated with an 241Am α-particle source, with combined experimental film irradiation and Monte Carlo (MC) simulations. METHODS:In this study, unlaminated EBT3, EBT-XD, and HD-V2 film pieces were irradiated with an 241Am disk source at various exposure times within a dark box. A detailed comparison was performed across the three film models, focusing on uncertainties and relative dose errors. Film analysis was conducted using a custom Python script, extracting normalized pixel values from the green channel. Additionally, a MC-based user code was developed using the Geant4 simulation toolkit to model the 241Am source and calculate the dose rates in the active layers of the films and in water. The mean dose rates were also calculated in a 1 mm diameter region of interest. These simulated dose rates were employed to convert film exposure times into absorbed doses for both the active layers and water, establishing a reference dosimetry protocol for α-particles across the three radiochromic GafChromic film models. RESULTS:The mean dose rates within a 1 mm diameter circular region of interest in the active layers of the three unlaminated GafChromic film models were determined to be 3.77 ± 0.002 Gy/min for EBT3, 4.04 ± 0.0022 Gy/min for EBT-XD, and 4.25 ± 0.0017 Gy/min for HD-V2. When the film material was changed to water, the dose rate was increased 14.3% for EBT3, 19.2% for EBT-XD, and 15.0% for HD-V2, with EBT3 showing the closest match to water-equivalence. Calibration curves for each film model were generated by fitting a power function to their responses. Refinements to the dose range were necessary to achieve an uncertainty below the 5% threshold. Among the models, HD-V2 required the most adjustments to its dose range and exhibited the highest levels of experimental, fit, and total uncertainties, along with the largest relative dose errors. CONCLUSIONS:This study investigated α-particle dosimetry protocols for unlaminated EBT3, EBT-XD, and HD-V2 GafChromic film models using experimental irradiations and MC simulations. Although EBT3 and EBT-XD demonstrate strong potential for α-particle quality assurance in treatment planning, the HD-V2 film model requires further investigation before it can be recommended for this application.

Introduction: The imaging modality kV CBCT on linear accelerators (linacs) is utilised to verify positioning and anatomy in cancer patients undergoing radiotherapy treatment. There is a need for optimisation of radiological protection in kV CBCT imaging protocols to avoid unnecessarily high exposures to normal tissues surrounding the target. Methods: A network of ICRP mentees from 23 countries were surveyed for available dosimetry equipment. Standardised measurements on CBCT linac imaging systems were conducted using a cone beam dose index (CBDI) devised as a straightforward measurement for wide beam doses. Measurements were made with (a) 100 mm ionisation chambers or (b) 0.6 cc Farmer ionisation chambers and cylindrical CT PMMA phantoms, and (c) an alternative setup of Farmer chambers and cubical phantoms comprised of slabs of water equivalent material readily available in radiotherapy centres. The measurements were compared with Monte Carlo (MC) simulations. Results: The survey showed limited availability for the reference setup using 100 mm chambers and CT phantoms. Correction factors were derived to convert normalised CBDI from alternative setups to the reference setup and are on average within 2% of MC simulations. Conclusion: The slab phantom in combination with a Farmer chamber provides an alternative to quantify CBCT radiation dose indices from linac-based image-guided radiotherapy using materials accessible in most centres worldwide. A method is presented to use correction factors for Varian Truebeam linacs if traditional 100 mm chambers and cylindrical CT phantoms are not available. This will enable most radiotherapy centres across the world to engage in meaningful imaging dose measurement and optimisation.

Background and study aims: Pancreatic cancer is a devastating disease with limited locoregional treatment options. Diffusing alpha-emitter radiation therapy (Alpha DaRT), a novel cancer treatment using alpha-particle interstitial radiotherapy, may help address this challenge. The aim of this study was to evaluate the feasibility and safety of endoscopic ultrasound (EUS)-guided Alpha DaRT for advanced pancreatic cancer. Patients and methods: Patients with inoperable locally advanced or metastatic pancreatic adenocarcinoma were treated with EUS-guided Alpha DaRT insertion. The Alpha DaRT sources were delivered into pancreatic tumors using a standard EUS needle with a novel proprietary applicator. Adverse events (AEs) were assessed based on the Common Terminology Criteria for Adverse Events version 5.0. Tumor response was evaluated by imaging 4 to 6 weeks post treatment. Results: The first five patients were treated between March and September 2023. The procedure was technically successful in all cases, with Alpha DaRT sources inserted into the target tumor. Estimated gross tumor volume coverage ranged from 8% to 44%. Fourteen AEs were reported among three patients. Four were serious AEs, none of which was associated with the treatment, but rather, with disease progression or medical assistance in dying. Only two AEs (mild) were deemed possibly related to the study device. At the 35-day visit, two patients had progressive disease and three had stable disease, with one of the latter showing partial response 2 months post procedure. Conclusions: Preliminary results from this first-in-human trial indicate that EUS-guided Alpha DaRT treatment for unresectable pancreatic cancer is feasible and safe, with no device-associated serious AEs. Further investigation of this promising novel modality is underway.

BackgroundLarge reported variability in the material composition and geometrical components of the Xoft electronic high-dose-rate brachytherapy Causes inter-source discrepancy in the source output. This variability is due to the manual manufacturing and assembly of the sources.PurposeThis study aimed to develop a dosimetry software tool called E-Brachy to characterize the Xoft source and quantify the discrepancies in its photon spectrum and dosimetric properties.MethodsE-Brachy is based on the Geant4 Monte Carlo toolkit and consists of two parts. In part one, the geometry and material composition for the source received in the computer-aided design format from the vendor were converted to the geometry description markup language format using the GUIMesh Python tool and integrated into the E-Brachy software. There was a large variation in material composition and thickness for some of the tube components. The simulation started from electrons and resulted in x-ray generations in the anode region. Multithreading, a track length estimation, and the uniform bremsstrahlung splitting variance reduction techniques were used to decrease the simulation time and increase the x-ray production. The photon energy, position, and momentum were saved into a phase space file as the photon exited the source, but before interacting with the external environment. The obtained x-ray energy spectrum was compared with measurements from the National Institute of Standards and Technology (NIST). In part two, by sampling from the generated photons, the dose rates and dosimetric parameters according to the TG-43 protocol were calculated for model S7500 and compared to the ones previously calculated for model S700 source, which were deemed identical by the manufacturer.ResultsThe material composition that resulted in the most similar spectrum as the measured NIST spectrum with Pearson's correlation coefficient of 0.99 and a calculated Euclidean difference of 0.061 +/- 0.001$0.061\,\pm \,0.001$ keV was chosen for further dosimetric analysis of the model S7500 source. Characteristic peaks showed the presence of tungsten, yttrium, and silver in the source components. Differences in dose rates between the two source models surpassed 20% for polar angles theta >= 150 degrees$\theta \,\ge \,150<^>\circ$, reaching a peak at r=3$r\,=\,3$ cm and theta=175 degrees$\theta \,=\,175<^>\circ$. The differences in the radial dose function values were within 5%. The relative difference in percentage between the anisotropy function values of the two models was closer to 0 for smaller theta$\theta$ values, but at higher polar angles, they increased to 300%.ConclusionsA software package called E-Brachy was successfully developed for the characterization and dosimetry of Xoft electronic brachytherapy sources. E-Brachy can be combined with spectral measurements to investigate the inter- and intra-source variability. The software package was tested by comparing the simulated spectra from the S7500 Xoft source model with NIST measurements and its TG-43 parameters with the S700 model. The TG-43 parameters between the two sources significantly exceed the recommendations of TG-56.

BACKGROUND:In radiotherapy, it is essential to deliver prescribed doses to tumors while minimizing damage to surrounding healthy tissue. Accurate measurements of absorbed dose are required for this purpose. Gafchromic® external beam therapy (EBT) radiochromic films have been widely used in radiotherapy. While the dosimetric characteristics of the EBT3 model film have been extensively studied for photon and charged particle beams (protons, electrons, and carbon ions), little research has been done on α $\alpha$ -particle dosimetry. α $\alpha$ -emitting radionuclides have gained popularity in cancer treatment due to their high linear energy transfer, short range in tissue, and ability to spare surrounding organs at risk, thereby delivering a more localized dose distribution to the tumor. Therefore, a dose-calibration film protocol for α $\alpha$ -particles is required. PURPOSE:This study aimed to develop a dose-calibration protocol for the α $\alpha$ -particle emitting radionuclide 241Am, using Monte Carlo (MC) simulations and measurements with unlaminated EBT3 films. METHODS:In this study, a MC-based user code was developed using the Geant4 simulation toolkit to model and simulate an 241Am source and an unlaminated EBT3 film. Two simulations were performed: one with voxelized geometries of the EBT3 active volume composition and the other using water. The dose rate was calculated within a region of interest in the voxelized geometries. Unlaminated EBT3 film pieces were irradiated with the 241Am source at various exposure times inside a black box. Film irradiations were compared to a 6-MV photon beam from a Varian TrueBeam machine. The simulated dose rate was used to convert the exposure times into absorbed doses to water, describing a radiochromic-film-based reference dosimetry protocol for α $\alpha$ -particles. The irradiated films were scanned and through an in-house Python script, the normalized pixel values from the green-color channel of scanned film images were analyzed. RESULTS:The 241Am energy spectra obtained from the simulations were in good agreement with IAEA and NIST databases, having differences < $&lt;$ 0.516% for the emitted γ $\gamma$ -rays and produced characteristic x-rays and < $&lt;$ 0.006% for the α $\alpha$ -particles. Due to the short range of α $\alpha$ -particles, there was no energy deposition in the voxels outside the active 241Am source region projected onto the film surface. Thus, the total dose rate within the voxels covering the source was 0.847 ± $\pm$ 0.003 Gy/min within the sensitive layer of the film (LiPCDA) and 0.847 ± $\pm$ 0.004 Gy/min in water, indicating that the active volume can be considered water equivalent for the 241Am beam quality. A novel approach was employed in α $\alpha$ -film dosimetry using an exponential fit for the green channel, which showed promising results by reducing the uncertainty in dose estimation within 5%. Although the statistical analysis did not reveal significant differences between the 6-MV photon beam and the α $\alpha$ calibration curves, the dose-response curves exhibited the expected behavior. CONCLUSIONS:The developed MC user code simulated the experimental setup for α $\alpha$ -dosimetry using radiochromic film with acceptable uncertainty. Unlaminated EBT3 film is suitable for the dosimetry of α $\alpha$ -radiation at low doses and can be used in conjunction with other unlaminated GafChromic® films for quality assurance and research purposes.

The purpose of this study was to investigate the dosimetric characteristics of the GAFCHROMIC® EBT3 film responding to alpha particle irradiation. Unlaminated GAFCHROMIC® EBT3 film pieces, were irradiated with a 30.055 kBq 241 Am alpha source, at eight different dose levels, between 0 and 509 Gy. The irradiations were performed inside an enclosed box. Epson Expression 10000 XL scanner in transmission mode was used to digitize irradiated films 24 hours post-irradiations as 16-bit RGB images in tagged image file format (TIFF). Optical density (OD) values were obtained by following the OD theorem. Raw and normalized pixel values (PV norm ) from the red, green, and blue colour channels were sampled from a 3 × 3 mm 2 region of interest. Calibration curves were created for both data sets (OD and PV norm ) and were fit accordingly. Monte Carlo simulations with the Geant4 toolkit were performed to establish a dose rate at the point within the sensitive layer of the film. An alpha dosimetry protocol for EBT3 films was obtained from the Monte Carlo calculated dose rate and dose calibration curves for alpha radiation were created. It is necessary to extend this study for different film types and compare to photon dosimetry calibration curves.

Purpose Intraoperative radiation therapy (IORT) using the INTRABEAM, a miniature x-ray source, has shown to be effective in treating breast cancer. However, recent investigations have suggested a significant deviation between the reported and delivered doses. In this work, the dose delivered by INTRABEAM in the TARGIT breast protocol was investigated, along with the dose from the Xoft Axxent, another source used in breast IORT. Methods and Materials The absorbed dose from the INTRABEAM was determined from ionization chamber measurements using: (a) the manufacturer-recommended formula (Zeiss V4.0 method), (b) a Monte Carlo calculated chamber conversion factor (CQ method), and (c) the formula consistent with the TARGIT breast protocol (TARGIT method). The dose from the Xoft Axxent was determined from ionization chamber measurements using the Zeiss V4.0 method and calculated using the American Association of Physicists in Medicine TG-43 formalism. Results For a nominal TARGIT prescription of 20 Gy, the dose at the INTRABEAM applicator surface ranged from 25.2 to 31.7 Gy according to the CQ method for the largest (5 cm) and smallest (1.5 cm) diameter applicator, respectively. The Zeiss V4.0 method results were 7% to 10% lower (23.2 to 28.6 Gy). At 1 cm depth, the CQ and Zeiss V4.0 absorbed doses were also larger than those predicted by the TARGIT method. The dose at 1 cm depth from the Xoft Axxent for a surface dose of 20 Gy was slightly less than INTRABEAM (3%-7% compared with CQ method). An exception was for the 3 cm applicator, where the Xoft dose was appreciably lower (31%). Conclusions The doses delivered in the TARGIT breast protocol with INTRABEAM were significantly greater than the prescribed 20 Gy and depended on the size of spherical applicator used. Breast IORT treatments with the Xoft Axxent received less dose compared with TARGIT INTRABEAM, which could have implications for studies comparing clinical outcomes between the 2 devices.

Purpose: We investigate the effect of the GafChromic (TM) film EBT3 model absorbed dose energy response when used for dose measurements around low-energy photon sources. Monte Carlo based correction procedure in synergy with appropriate calibration curves was shown to provide more accurate absorbed dose (either relative or absolute). An assessment was made of possible dose errors that might be encountered if such energy dependent response is ignored. Methods: We measured PDDs in water from a Xoft 50 kVp source using EBT3 film, and compared to PDD measurements acquired with a PTW-TN34013 parallel-plate ionization chamber. For the x-ray source, we simulated spectra using the EGSnrc (BEAMnrc) Monte Carlo code, and calculated Half Value Layer (HVL) at different distances from the source in water. Measurement strips of EBT3 film were positioned at distances of 2-6 cm from the Xoft source in a water phantom using a custom-made holder and irradiated simultaneously. Results: Our results show that film calibration curves obtained at beam qualities near the effective energy of the Xoft 50 kVp source in water lead to variation in absorbed dose energy dependence of the response of around 5%. However, if the calibration curve was established in an MV beam quality, the error in absorbed dose could be as large as 20%. Conclusion: Accurate dose measurements using radiochromic films at low photon energies require that the radiochromic film dosimetry system be calibrated at appropriate corresponding low energies, as large absorbed dose errors are expected when film calibration is performed in MV beam qualities.

Purpose: In this prospective phase II study, we investigated whether cone beam computed tomography scan was a superior method of image-guided radiotherapy relative to 2D orthogonal kilovoltage images in the post-radical prostatectomy setting. Methods: A total of 419 treatment fractions were included in this analysis. The shifts required to align the patient for each treatment were performed using 3D matching between cone beam computed tomography scans and the corresponding computed tomography images used for planning. This was compared with the shifts obtained from 2D orthogonal kilovoltage images, matching with the corresponding digitally reconstructed radiographs. Patients did not have fiducials inserted to assist with localization. Interfractional changes in the bladder and rectal volumes were subsequently measured on the cone beam computed tomography images for each fraction and compared to the shift differences between orthogonal kilovoltage and cone beam computed tomography scans. The proportion of treatment fractions with a shift difference exceeding the planning target volume of 7 mm, between orthogonal kilovoltage and cone beam computed tomography scans, was calculated. Results: The mean vertical, lateral, and longitudinal shifts resulted from 2D match between orthogonal kilovoltage images and corresponding digitally reconstructed radiographs were 0.353 cm (interquartile range: 0.1-0.5), 0.346 cm (interquartile range: 0.1-0.5), and 0.289 cm (interquartile range: 0.1-0.4), compared to 0.388 cm (interquartile range: 0.1-0.5), 0.342 cm (interquartile range: 0.1-0.5), and 0.291 cm (interquartile range: 0.1-0.4) obtained from 3D match between cone beam computed tomography and planning computed tomography scan, respectively. Our results show a significant difference between the kilovoltage and cone beam computed tomography shifts in the anterior–posterior direction ( P = .01). The proportion of treatment fractions in which the differences in kilovoltage and cone beam computed tomography shifts between exceeded the 7 mm planning target volume margin was 6%, 2%, and 3% in the anterior–posterior, lateral, and superior–inferior directions, respectively. Conclusion: We prospectively demonstrated that the daily use of volumetric cone beam computed tomography for treatment localization in post-radical prostatectomy patients demonstrated an increased need for a shift in patient position. This suggests that in post-radical prostatectomy patients the daily cone beam computed tomography imaging improved localization of the prostate bed and may have prevented a limited number of geographic misses, compared to daily kilovoltage imaging that was not assisted with fiducials.

Purpose: In this work we use Monte Carlo simulations to investigate change in Computed tomography (CT) X-ray energy spectra between exposures in air and within CT dose index (CTDI) phantom. While the results of these simulations will be relevant when measuring CTDI with any dosimeter, we apply the appropriate beam quality change correction for CTDI measurements using XR-QA2 model GafChromic (TM) film. Methods: Dose profiles were measured with film strips, sandwiched between acrylic rods cut in half, placed within CTDI phantoms and scanned before and after irradiation with document scanner in reflective mode. Reference dosimetry system was calibrated in terms of air kerma in air, which was converted into absorbed dose using ratio of mass-energy absorption coefficients water-to-air for a given beam quality, following the AAPM TG-61 protocol. Results: Beam qualifies for all film positions within CTDI phantom show beam softening for HVLs above 6 mm Al and beam hardening for HVLs bellow 6 mm Al. Calculated CTDI values using HVL in air for all CTDI positions, and those calculated using the appropriate calibration curves based on beam quality correction show for Head CTDI phantom differences ranging from 0.3% to 2.1% and for Body CTDI phantom from 2.5% to 5.7%. Conclusions: We describe method for CTDI measurements using radiochromic film dosimetry protocol corrected by the beam quality change within the phantom. Our results show differences in CTDI measurements of up to 5.7% when compared to using film calibration curves for beam quality in air.

In this prospective phase II study, we investigated how the change in the bladder and the rectal volumes could account for the difference in shifts between CBCT based IGRT and 2D KV based IGRT in post radical prostatectomy setting. We also assessed whether CBCT scan would be a better method of IGRT than kV imaging in the post-RP setting by comparing the shifts required to align the patient at the treatment. A total of 419 treatment fractions from 26 patients were included in this analysis. The bladder and rectum volumes were measured on the CBCT images in offline review for each fraction. These dimensions were then compared with the baseline bladder and rectum sizes measured on the CT simulation scan. The surrogate volume of the bladder was obtained by multiplying the vertical, lateral, and longitudinal bladder dimensions. The surrogate rectal volume was obtained by multiplying the vertical dimension and the most lateral extents. The correlation between the bladder and rectum sizes with the shifts was analyzed with Spearman’s correlation test. We also recorded the shifts required to align the patient during treatment fractions by performing a daily kV imaging and CBCT scans, the shift values were recorded in the vertical , lateral, and longitudinal directions. The absolute shift values from kV images and CBCT scans were then compared with Wilcoxon signed-rank test. Finally we investigated the proportion of treatment fractions in which the absolute value of the difference between the kV and CBCT shifts exceeded 0.7cm (our PTV margin). Our results showed that the vertical and longitudinal CBCT shifts were highly correlated with changes in the bladder (p < 0.001 and p = 0.001, respectively) and rectal volumes (p < 0.001 for both), but not for kV shifts. The p values for the correlation between the vertical and longitudinal shifts with the change in bladder size were 0.166 and 0.077 respectively, and 0.278 and 0.058 for the change in rectum size. There was no correlation between changes in the lateral kV and CBCT shifts with changes in bladder or rectum sizes . The mean anterior-posterior, lateral, and superior-inferior shifts in absolute value with kV imaging were 0.359 (interquartile range (IQR) 0.1-0.5), 0.348 (IQR 0.1-0.5), and 0.312 (IQR 0.1-0.5) cm, respectively, compared to 0.389 (IQR 0.1-0.5), 0.345 (IQR 0.1-0.5), and 0.300 (IQR 0.1-0.4) cm with CBCT scan. There was a significant difference for the anterior-posterior shifts (p = 0.046). Further analysis showed that the proportion of treatment fractions in which the absolute value of the difference between the kV and CBCT shifts exceeded 0.7cm were 21% in the anterior-posterior, 12% in the lateral, and 13% in the superior-inferior directions. CBCT improves localization of the prostate bed by addressing the interfractional changes of the bladder and rectal volumes and should be considered as the IGRT modality of choice in the daily monitoring of treatment for prostate cancer post RP.

PURPOSE: The Papillon technique using 50-kVp soft X-rays to treat rectal adenocarcinomas was developed and clinically implemented in the 1960s. We describe differences between accurate dosimetry and clinical implementation of this technique that is extending from its very inception to date. METHODS AND MATERIALS: A renaissance of the Papillon technique occurred with two recently introduced 50-kVp systems: Papillon+ by Ariane and a custom-made rectal applicator (consisting of a surface applicator inserted into a proctoscope) by iCAD's Xoft Axxent Electronic Brachytherapy (eBT) System (iCad, Inc., Sunnyvale, CA). In contrast to the initial design, we investigated the impact of introducing a plastic lid, which would provide more reproducible and more accurate dose delivery across the rectal adenocarcinoma patient population. We use both parallel-plate chamber and radiochromic film dosimeters to determine differences in basic dosimetry characteristics (beam half-value layers, outputs, percent depth doses, and profiles) between the Xoft Electronic Brachytherapy rectal applicator system with and without the plastic lid in place. RESULTS: Compared to the open-cone applicator, the proposed applicator with the plastic lid produces a slightly harder (more penetrating) beam quality (half-value layer of 1.4 vs. 1.3-mm Al), but with reduced output (by 33%), and a slightly broader beam with flatness not worse than 3% and symmetry not worse than 2%. CONCLUSIONS: In addition to characterizing beam properties modified by the possible introduction of the plastic cap, we also pointed out and addressed misconceptions in the use of radio chromic films for dose measurements at low-energy photon beams. (C) 2017 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.