A.J.

Kressin
Week 2 Discussion
At Gundersen Health System there are several machines that have daily quality assurance (QA) checks
that must be done each morning prior to the start of patient treatments and simulations. At Gundersen
there are 2 Varian 2100 EX linear accelerators, both with BrainLabs ExacTrac system and one with an
onboard imager (OBI), and 1 General Electric computed tomography (CT) simulator. Each morning, one
therapist arrives early in order to warm up each machine and complete the daily QA procedures.
The procedure for each linear accelerator is the same with the exception of extra procedures being
required for the OBI system on the one machine that has OBI capabilities. The first thing to check once
all the computers and machines have been turned on is the audio and visual system. The therapist
verifies that the video cameras in the room and the audio system from outside the room are working
properly. Next, the pendent is reset by hitting a series of buttons to make sure that it is functional and
ready to go for the day. The wall mounted lasers and the optical distance indicator (ODI) are checked to
ensure that both match at 100 source-to-surface distance (SSD). A QA meter is placed on the treatment
couch for this procedure and the horizontal lasers should just skim the top surface of the meter. The QA
meter is also used in order to check the field size versus light field. The jaws of the linear accelerator are
set to a 20 cm x 20 cm field. The light field projected from the head of the accelerator should match the
20 cm x 20 cm outline on the QA meter within 2 mm. For the next test, the graticule is placed in the
head of the machine to verify that the crosshairs from the graticule match the laser crosshairs. Another
check is done to verify the collision systems for the OBI and electronic portal imaging device (EPID) are
functional. The therapist brings out the device (either the EPID or OBI) and bumps the side of it to make
sure that a fault shows up on the computer screen. This ensures that if there is an obstruction upon
rotating the device the machine will freeze until the obstruction is removed. ExacTrac and the OBI must
also undergo daily QA. Five exposures are given at 70 kV and 10 mA in order to warm up the ExacTrac
system. A BrainLab iso phantom is placed on the treatment couch and lined up to the in-room lasers.
An isocenter is then set. A BrainLab x-ray calibration phantom is then used to calibrate the ExacTrac
system. The iso phantom is used again after calibration to ensure that the correct couch shifts are
made by the ExacTrac system to return the phantom to the designated isocenter. In our department
there is an unwritten tolerance of 1 mm for the accuracy of ExacTrac. For the OBI system, there are
markings on each of the arms of the device that must line up with the in-room lasers within 2 mm. This
is a simple visual check for the therapists during daily warm up. The water temperature and pressure
gauges are also checked each morning. The water pressure must fall between 40 and 95 psi, and the
water temperature must be between 37 and 41
o
C. A general department rule is that if any check falls
outside of tolerance by 3% physics must be notified. If the check falls outside of tolerance by greater
than or equal to 5%, then physics must measure and make corrections prior to any patients being
treated on the machine.
Daily QA is also needed for the CT simulator. After running a warm up program on the simulator, the
therapist lines up a water phantom with the in-room lasers and scans the phantom. In the phantom are
several points for which the Hounsfield units are known. The daily measured Hounsfield units for each
point must be within 3 Hounsfield units. Another phantom is then used to check the geometrical
accuracy between the in-room lasers and the internal CT lasers. The phantom is lined up with the in-
room lasers and the distance from the in-room lasers to the internal lasers is measured once the
phantom is scanned by the CT simulator. The distance must match the preset distance within 2 mm. If
any of the CT simulator QA measurements fall outside of tolerance, physics must be notified and the
physics team will go back and review the measurement that fell outside of tolerance.