An experimental extrapolation technique using the Gafchromic EBT3

film for relative output factor measurements in small x-ray fields

Johnny E. Moralesa)
Department of Radiation Oncology, Chris OBrien Lifehouse, 119-143 Missenden Road,
Camperdown, NSW 2050, Australia and School of Chemistry, Physics, and Mechanical Engineering,
Queensland University of Technology, Level 4 O Block, Gardens Point, QLD 4001, Australia

Martin Butson
Department of Radiation Oncology, Chris OBrien Lifehouse, 119-143 Missenden Road,
Camperdown, NSW 2050, Australia and Institute of Medical Physics, University of Sydney,
NSW 2006, Australia

Scott B. Crowe
School of Chemistry, Physics, and Mechanical Engineering, Queensland University of Technology,
Level 4 O Block, Gardens Point, QLD 4001, Australia and Cancer Care Services, Royal Brisbane
and Womens Hospital, Butterfield Street, Herston, QLD 4029, Australia

Robin Hill
Department of Radiation Oncology, Chris OBrien Lifehouse, 119-143 Missenden Road,
Camperdown, NSW 2050, Australia and Institute of Medical Physics, University of Sydney,
NSW 2006, Australia

J. V. Trapp
School of Chemistry, Physics, and Mechanical Engineering, Queensland University of Technology,
Level 4 O Block, Gardens Point, QLD 4001, Australia
(Received 17 February 2016; revised 27 June 2016; accepted for publication 29 June 2016;
published 19 July 2016)
Purpose: An experimental extrapolation technique is presented, which can be used to determine the
relative output factors for very small x-ray fields using the Gafchromic EBT3 film.
Methods: Relative output factors were measured for the Brainlab SRS cones ranging in diameters
from 4 to 30 mm2 on a Novalis Trilogy linear accelerator with 6 MV SRS x-rays. The relative output
factor was determined from an experimental reducing circular region of interest (ROI) extrapolation
technique developed to remove the effects of volume averaging. This was achieved by scanning the
EBT3 film measurements with a high scanning resolution of 1200 dpi. From the high resolution
scans, the size of the circular regions of interest was varied to produce a plot of relative output factors
versus area of analysis. The plot was then extrapolated to zero to determine the relative output factor
corresponding to zero volume.
Results: Results have shown that for a 4 mm field size, the extrapolated relative output factor was
measured as a value of 0.651 0.018 as compared to 0.639 0.019 and 0.633 0.021 for 0.5 and
1.0 mm diameter of analysis values, respectively. This showed a change in the relative output factors
of 1.8% and 2.8% at these comparative regions of interest sizes. In comparison, the 25 mm cone
had negligible differences in the measured output factor between zero extrapolation, 0.5 and 1.0 mm
diameter ROIs, respectively.
Conclusions: This work shows that for very small fields such as 4.0 mm cone sizes, a measureable
difference can be seen in the relative output factor based on the circular ROI and the size of the
area of analysis using radiochromic film dosimetry. The authors recommend to scan the Gafchromic
EBT3 film at a resolution of 1200 dpi for cone sizes less than 7.5 mm and to utilize an extrapolation
technique for the output factor measurements of very small field dosimetry. C 2016 American
Association of Physicists in Medicine. [http://dx.doi.org/10.1118/1.4958679]

Key words: small x-ray field dosimetry, Gafchromic EBT3 film, stereotactic radiosurgery, extrapola-
tion technique

1. INTRODUCTION nontissue equivalence of the detector active volume, and

Accurate small x-ray field dosimetry is crucial in the area
of stereotactic radiotherapy. There are a number of factors
that can influence the accuracy of dosimetry measurements
such as source occlusion, lack of charged particle equilibrium,
overlapping penumbra.1,2 Therefore, the selection of a suitable
detector is crucial and should have minimal corrections
for each of these factors where possible. A number of
commercially available detectors introduce volume averaging
effects in the field during measurements and a correction might

4687 Med. Phys. 43 (8), August 2016 0094-2405/2016/43(8)/4687/6/$30.00 2016 Am. Assoc. Phys. Med. 4687
4688 Morales et al.: An experimental extrapolation technique using Gafchromic EBT3 film 4688

be needed as shown by some studies.3,4 Volume averaging
effects are specifically due to the profile shape of the small
field beams and the influence of maximum dose deposition
that is averaged over a given area within the small field beams.3
Some methods have been proposed to deal with volume
averaging effects in small field dosimetry including using
film profiles to account for the shape of the small field3,4 or
by performing full geometry calculations using Monte Carlo
methods to obtain correction factors.5,6 However, Monte Carlo
simulations can be an arduous task requiring a full model of
the treatment machine, a process not readily available to many
radiation oncology departments.510
Previous studies have been performed using radiochromic
film for small field dosimetry such as the work by Gonzalez-
Lopez et al.1113 In this study, we introduce an experimental
extrapolation technique using the Gafchromic EBT3 film
(Ashland, NJ, USA), which can potentially eliminate the
volume effect in small field dosimetry. This technique consists
of varying the size of the region of interest (ROI) within the
scanned area of the film. A method is presented which uses a
zero area extrapolation technique utilizing the high resolution
scanning in order to determine the final relative output factors
for very small fields.
a PC desktop scanner and ImageJ (National Institutes of
Health, USA) software on a PC workstation at least 24 h
after irradiation to minimize effects from post-irradiation
coloration.21 The scanner was an Epson 10000XL dual lens
system desktop scanner (Epson, NSW, Australia) using a
scanning resolution of 1200 pixels/in. The images produced
were 48 bit RGB color images and analyzed with the red
component of the signal making the final pixel density values
16 bit information.22
A control film was scanned with every experimental film
in the same position for each measurement. The resulting
scans were then corrected for any interscan variations based
on the control films result compared to the average result in
a technique similar to that used by Lewis and Devic.23
The dose delivered to each experimental film was calcu-
lated by the creation of a calibration doseresponse curve for
the Gafchromic EBT3 film by using standard x-ray fields of
10 10 cm at given applied dose levels. This was performed
due to the known nonlinear relationship of net optical density
to doseresponse of the Gafchromic EBT3 film when scanned
using an Epson10000XL desktop scanner.

2. MATERIALS AND METHODS

All relative output factor measurements were performed on
the 6 MV SRS x-ray beam as produced by a Novalis Trilogy
linear accelerator (Varian Medical Systems, Palo Alto, USA),
which has a thin flattening filter in order to produce a dose
rate of 1000 MU/min.1416 Beam collimation for the SRS x-ray
beams was achieved by using the Brainlab circular applicators
(Brainlab, Germany) with diameters between 4 and 30 mm as
defined at the isocenter. The X and Y collimator jaws were
set to 5 cm for all measurements. The relative output factor
is defined as the measurement for a given cone at a depth
of 1.5 cm and SSD of 98.5 cm divided by the measurement
for the reference field size at a depth of 1.40 cm and SSD
of 100 cm as per the manufacturers recommendations. The
reference field size was 10 10 cm2. Monitor units delivered
to each film ranged between 180 and 350 MU depending on
the cone size in an attempt to deliver absorbed doses close to
200 cGy to each film. Nine experimental films were irradiated
separately for each cone size evaluated from which the average
output factor and uncertainties were calculated.

2.A. Film dosimetry technique

Gafchromic EBT3 film (lot number 09151402) was used
for all relative output factor measurements in this work.
All pieces of film were used and handled in the process
as outlined in the AAPM TG-55 report17 and the Medical
Radiation dosimetry with radiochromic film report series.18
It has been shown that the Gafchromic EBT3 film possesses
a minimal x-ray energy dependence19,20 and therefore should
have a minimal impact on output factor assessment at small
field sizes using 6 MV x-rays. All films were analyzed using
F. 1. (a) Measured and extrapolated output factor values for a 4 mm
Brainlab cone using the Gafchromic EBT3 film with varying sizes of analysis
area. As the area of analysis decreases, an increase in measured output
factor occurs due to the nonplateauing nature of the 4 mm cone profile. (b)
Measured net optical density profile for a 6 MV SRS x-ray beam, 4 mm cone
taken as the average of nine EBT3 film measurements. The inset in the figure
includes details of the center 1 mm of the profile.

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4689 Morales et al.: An experimental extrapolation technique using Gafchromic EBT3 film 4689

F. 3. Percentage difference in the relative output factor from the extrapo-

lated zero area value for the 4 and 25 mm diameter Brainlab cones. Variations
are seen using the 4 mm diameter cone, but negligible differences calculated
at larger cone sizes.

Relative output factor measurements determined with

a PTW 60019 microDiamond detector2428 (PTW, PTW-
Freiburg, Germany) have also been included for compar-
ison with the extrapolated Gafchromic EBT3 results. These
measurements were made under the same geometrical condi-
tions as the measurements for the Gafchromic EBT3 film.

F. 2. (a) Measured and extrapolated output factor values for a 25 mm diam-
eter Brainlab cone using the Gafchromic EBT3 film with varying diameters
of analysis area. As the area of analysis decreases, negligible differences in
the measured output factor occur due to the plateauing nature of the 25 mm
cone profile. (b) Measured net optical density profile for a 6 MV x-ray beam,
25 mm diameter Brainlab cone. Inset in the picture includes details of the
center 4 mm of the profile, for example, film showing the central plateau
effect at this field size.
The net optical densities were calculated for each film piece
using the circular regions of interest in ImageJ software. The
circular region of interest was centered on the cone produced
radiation field. The relative output factors versus diameter size
was plotted in a curve. A best fit extrapolation technique was
applied to the results to determine the zero area output factor
utilizing a second order polynomial or linear function based
on cone size and data requirements.
3. RESULTS
Figure 1(a) shows the measured values for the relative
output factor for a 4 mm cone when different size circular
regions of interest ranging from 1.8 to 0.1 mm were used for
the analysis in ImageJ. The figure also shows the extrapolation
estimate of the relative output factor for a zero volume or
area calculation, which was found to be 0.651 0.018 for the
4 mm Brainlab cone. The extrapolation was performed using
a second order polynomial line of best fit to provide the best
estimate at zero volume output factor. The variation in the
measured output factor with different regions of interest areas
is expected to change due to a number of reasons including the
profile shape of the beam and the light scattering properties
within the scanner and film. The uncertainty values quoted
in the figures and text are the standard deviation in measured
results comparing the nine experimental films assessed for
each cone size measured. These values combine both type A

T I. Measured and extrapolated relative output factors for the Gafchromic EBT3 film with different analysis
diameters and for the PTW 60019 microDiamond detector.

PTW
60019 Gafchromic EBT3 filmAnalysis diameter % Difference
Cone size (mm) Measured 0 mm Extrapolated 0.5 mm Measured 1 mm Measured 00.5 mm 01 mm

4 0.661 0.651 0.639 0.633 1.8 2.8

7.5 0.821 0.810 0.804 0.803 0.7 0.9
10 0.879 0.870 0.869 0.866 0.1 0.5
12.5 0.912 0.903 0.902 0.901 0.1 0.2
15 0.932 0.932 0.932 0.931 0.0 0.1
17.5 0.946 0.947 0.948 0.947 0.1 0.0
20 0.956 0.960 0.959 0.959 0.1 0.1
25 0.964 0.971 0.970 0.970 0.1 0.1
30 0.975 0.981 0.980 0.981 0.0 0.1

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4690 Morales et al.: An experimental extrapolation technique using Gafchromic EBT3 film 4690

and type B errors associated with the setup and dose delivery
uncertainty along with the experimental film analysis errors
combined. Results are quoted as 1 standard deviation of the
mean.
Figure 1(b) shows an example of net optical density profile
for one 4 mm cone as measured by the EBT3 film at a
resolution of 1200 dpi, which is the average of nine EBT3
film measurements. The central axis region of the profile is
also shown in more detail to highlight both the variation in
the net optical density and the uncertainty or noise level with
the film scan for this typical measurement. In terms of very
small region of interest analysis, the user should make multiple
measurements using different films to minimize the impact of
selecting a small region of interest for analysis around either
a noise peak or trough, thus skewing the measured dose level
either high or low by the magnitude of the noise which in our
case was found to be between 0.5% and 1.5%.
Figures 2(a) and 2(b) show similar results but for a 25 mm
cone size produced by the same 6 MV SRS beam. The
extrapolated relative output factor for this cone was calculated
to be 0.971 0.017. The 25 mm diameter cone, however,
has a negligible difference in the measured output factor
when the diameter of the circular ROI analysis ranges from
approximately 1.8 mm down to 0.1 mm. This is expected as
Fig. 2(a) shows that a percentage dose plateau does exist at
this field size. However, when the same comparison was made
for the very small 4 mm cone, the variation in the measured
output factor was 2.8%. These results highlight the necessity
of high spatial resolution scanning and analysis for very small
(4 mm) cone field measurements.
Figure 3 shows the variation in the measured output factor
for these two circular cones as a percentage decrease when
each measured point is compared to the extrapolated zero
area output factor value. As can be seen, over the range up to
2 mm diameter areas of analysis, an approximate percentage
difference for the 25 mm cone is negligible, whereas for the
4 mm cone the value rises to approximately 3%. These results
highlight the significance of the volume averaging effect and
effective detector size when dealing with very small fields like
a 4 mm cone.
Table I shows the relative output factor determination
when this extrapolation technique is applied to other cone
sizes available. The uncertainties in the film measurements
are not quoted to improve clarity in the table; however, the
F. 4. Exaggerated example of a small field. The average value of pixels in
ROI A will be greater than that of ROI B.
authors note that they are of similar size to those as shown
in Figs. 1 and 2. Shown are the measured values at 0.5 and
1 mm diameter circular ROI areas of analysis. Also shown are
the percentage differences or percentage under prediction in
relative output factors which would occur if the measurements
were performed at either 0.5 or 1 mm effective detector
diameter.
These results highlight that even for a 0.5 mm effective
detector size, the ROF for the 4 mm cone could be
underpredicted by approximately 2%. This effect is less than
1% for cone sizes of 7.5 mm or greater.
An analysis of effective detector size compared to scan-
ning resolution for the Epson 10000XL scanner and the
Gafchromic EBT3 film is shown in Table II.
From these results, we can see that using a scanning
resolution of 300 dpi and a 0.5 mm circular region of
interest, 27 pixels would be averaged to count toward net OD
calculation. Whereas, using a scanning resolution of 1200 dpi,
438 pixels would be used for the analysis. Similarly, for a
0.1 mm effective detector size, the values would be 1 pixel
and 17 pixels, respectively, for 300 dpi and 1200 dpi.
4. DISCUSSION
For small fields which are almost entirely penumbral and
thus nonflat at the center of the field, the selection of ROI
size in planar measurements can significantly impact the
measurement result. This is illustrated in Fig. 4, where two
different ROIs of the same field are selected; the average
value for net OD of pixels within ROI A will be greater
than in ROI B due to the greater number of pixels in ROI
B that are of lesser value. Therefore, obtaining a series of

T II. Analysis of detector effective size versus pixels measured for various resolutions.

Pixels per effective

Scan resolution Size of pixel Equivalent circle detector size (circle)
Dots/in. Dots/mm Square (mm) Diameter (mm) 0.1 mm 0.5 mm

75 2.95 0.339 0.382 0.07 1.71

100 3.93 0.254 0.287 0.12 3.04
150 5.91 0.169 0.191 0.27 6.84
200 7.87 0.127 0.143 0.49 12.20
300 11.81 0.085 0.096 1.10 27.40
600 23.62 0.042 0.048 4.38 109.00
1200 47.24 0.021 0.024 17.53 438.00

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4691 Morales et al.: An experimental extrapolation technique using Gafchromic EBT3 film
T III. The DPI scanning resolution used across studies for small field dosimetry.
Study Film type
Wilcox and Daskalov (Ref. 29) EBT
Garca-Garduo et al. (Ref. 30) EBT
Kairn et al. (Ref. 31) EBT2
Aland et al. (Ref. 32) EBT2
Huet et al. (Ref. 33) EBT2
Fiandra et al. (Ref. 34) EBT2 and EBT3
Huet et al. (Ref. 35) EBT3
Moignier et al. (Ref. 36) EBT3
Morales et al. (Ref. 13) EBT3
ROIs of different diameters will enable extrapolation to the
zero volume to obtain the true output factor.
Table II highlights the standard scanning resolutions found
on the Epson 10000XL flatbed scanner. In normal clinical
operations, a scanning resolution of 75300 dots/in. would
normally suffice. However, when dealing with very small fields,
the resolution plays a major role. In the table, the conversion to
dots per millimetre is shown along with the pixel square side
size and equivalent circular diameter per pixel. When these
values are applied to an area analysis using a circular region
of interest, the number of effective pixels which lie in the area
of analysis is shown for effective detector diameters of 0.1 and
0.5 mm. This means that if an equivalent detector size of 0.1 mm
is required, a scanning resolution of 300 dots/in. or below will
only give you one pixel or less information. At 1200 dpi reso-
lution, one would use approximately 1718 pixels for optical
density analysis. Using a high resolution provides substantially
more data for analysis and subsequently should provide a more
robust measurement to determine relative output factors and
uncertainty levels. For this reason, we recommend a scanning
resolution of at least 1200 dpi to perform the extrapolation of
the relative output factor measurements for very small cones
such as the 4 mm cone.
The importance of dosimetric accuracy for a very small
field relative output factor lies in both planning data and
experimental dose verification. While planning computer
grid sizes which are often larger than the sub-millimeter
measurement size in this work, they still require an accurate
relative maximum dose factor for each cone as their defined
value. For example, the Brainlab iPlan treatment system
utilizes an adaptive grid resolution down to 0.5 mm. By
utilizing the extrapolation technique, as shown in this work,
the peak relative output factor for the very small 4 mm cone
can be accurately measured and given for dose calculation in
the planning system.
Radiochromic film has been used more extensively for the
determination of the small field size relative output factors
and the data in Table III show the different DPI resolutions
used in various small field dosimetry studies.2936 None of
the studies shown in this table have been performed with
a resolution higher than 150 dpi and most of these studies
reported values based on a single scanning resolution. In
addition, no extrapolation technique was reported to have been
used in any of these studies.
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4691
Resolution DPI Year
75 2007
100 2010
72 2011
75 2011
150 2012
72 2013
150 2014
150 2014
150 2014
These resolutions are appropriate for cone sizes of 10 mm
and above; however, x-ray beams with dimensions less than
10 mm require greater resolution. Therefore, a high resolution
extrapolation technique is provided to best estimate the
relative output factors for these very small cone sizes.
The PTW 60019 microDiamond detector has been exten-
sively studied for small field dosimetry.2428,37,38 For the 4 mm
diameter cone used in this study, the ROF calculated using
the zero area extrapolation technique was in good agreement
to the ROF measured with the microDiamond detector. As
such, we believe this agreement shows the suitability of
using a zero area technique for these smaller fields in film
dosimetry.
5. CONCLUSIONS
The technique presented in this study is useful for the
analysis of the Gafchromic EBT3 film results in order to elimi-
nate volume averaging effects,3 to measure very small relative
output factors, and to correct for volume averaging effects,
which can be caused by insufficient scanning resolution.
It provides enough detail and guidance to be able to
reproduce the Gafchromic EBT3 film measurements with
high resolution. It has been shown that very small field
relative output factor measurements are dependent on the
effective detector size. When cones of size 4 mm are used, the
Gafchromic EBT3 film can be used to measure the relative
output factor. The measurement value is, however, affected
by the average volume or effective diameter size of the area
of analysis and up to 2.8% differences were measured when
using effective detector sizes ranging from 0.0 (extrapolated)
to 1 mm effective diameter sizes. Field sizes ranging from
7.5 to 30 mm produced negligible differences for the same
effective detector diameters.
CONFLICT OF INTEREST DISCLOSURE
The authors have no COI to report.
a)Author to whom correspondence should be addressed. Electronic mail:
johnny.morales@lh.org.au
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