Abstract

Background: Low-energy x-ray beams used in electronic brachytherapy (eBT) present significant dosimetric challenges due to their high depth-dose gradients, the dependence of detector response on materials, and the lack of standardized dose-to-water references. These challenges have driven the need for Monte Carlo (MC) simulations to ensure accurate dosimetry. However, discrepancies in the physics models used by different MC systems have raised concerns about their dosimetric consistency, particularly in modeling bremsstrahlung interactions. Purpose: To assess the dosimetric impact of using different physics approaches in three state-of-the-art MC systems for eBT, focusing on the disagreements observed when different MC methods are used to evaluate bremsstrahlung interactions. Methods: The MC studies of the Axxent S700, the Esteya, and the INTRABEAM eBT systems were performed using two EGSnrc applications (egs_brachy and egs_kerma), TOPAS, and PENELOPE-2018 (PEN18). The fluence spectra and depth doses were compared for simplified x-ray tube models, which maintain the target mode (transmission or reflection), the target material and thickness, and the surface applicators’ source-to-surface distance. An extra simulation was made to evaluate the utility of the simplified models as proxies in predicting the most important characteristics of an accurate applicator's simulation (detailed model of INTRABEAM's 30 mm surface applicator). The EGSnrc applications and PEN18 utilized their default bremsstrahlung angular emission approaches. TOPAS used two physics lists: g4em-livermore (TOPASliv) and g4em-penelope (TOPASpen). Results: The most significant differences between MC codes were observed for the transmission target mode. The bremsstrahlung component of the fluence spectra differed by about 15% on average, comparing PEN18, EGSnrc applications, and TOPASliv, with PEN18's fluences consistently lower. EGSnrc and PEN18 agreed within 3% for their characteristic spectrum components. However, PEN18's characteristic lines overreached TOPASliv’s by 40%. Those spectral characteristics generated depth dose differences, where PEN18, on average, scored 9% lower than EGSnrc and TOPASliv. Considering TOPASpen in the transmission mode, PEN18's fluence spectrum presented a lower bremsstrahlung (5%) but a higher characteristic component (10%); these spectral differences compensated, generating depth dose differences within 1% average. In the reflection target mode, EGSnrc and PEN18 agreed within 4% for the bremsstrahlung and characteristic components of the fluence spectra. With TOPASpen in the reflection mode, PEN18 presents 12% lower fluences in the bremsstrahlung component but 6% higher characteristic lines. This spectral behavior diminished the depth dose differences up to 3%. Conclusion: This work found considerable disagreements between three state-of-the-art MC systems commonly used in medical applications when simulating bremsstrahlung in eBT. The differences arose when the bremsstrahlung angular distribution and the atomic relaxation processes in the target became relevant. More theoretical and experimental studies are necessary to evaluate the impact of these differences on related calculations. © 2025 The Author(s). Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.