The Billings Clinic radiation oncology department performs a variety of quality assurance (QA)

tasks on the image-guided radiation therapy (IGRT) equipment. QA procedures are performed on
a daily, monthly, and annual basis to ensure image and shifting accuracy. In attempts to stay
current with safe practices, all tasks performed in this department are based on recommendations
from both the TG-179 and TG-142 report.
Daily IGRT QA:
Each morning, the therapists will perform daily QA of our on-board imaging (OBI) and
electronic portal imaging device (EPID). For the OBI, both a KV orthog pair and a CBCT are
performed separately using a cube with specifically located fiducials (Figure 1). The cube is first
aligned to the main cross-hairs and shifts to these fiducials are verified for positioning accuracy.
The main goal of this task is to ensure that the necessary shifts being requested in the imaging
software are accurately shifted inside the treatment room.

Figure 1. Imaging cube with fiducials for CBCT and KV imaging

In addition, a set of orthog MV images are taken using the EPID with the cube aligned to the
main cross-hairs. The isocenter of the cube is then compared to the isocenter of imaging
software. Deviations of all 3 of these tasks should be within 2mm.

Figure 2. Isocenter comparison for MV image

Monthly IGRT QA:

The physicists will perform monthly QA of the IGRT equipment. A variety of phantoms and
equipment are used to evaluate both the EPID and OIB system including the Las Vegas
Phantom, the Leed Phantom, imaging cube, Catphan phantom, and a planar grid.

MV and KV Imaging and Treatment Coordinate System Isocenter Coincidence

(Tolerance 1mm)
o Radiation and imaging isocenter measured at 4 cardinal angles (0, 90, 180, 270)
as pictured in (A) below.
MV Contrast and Spatial Resolution (Tolerance = baseline)
o MV Images taken of the Las Vegas phantom (E) and number of visible circles are
recorded based on the image (F)
MV Planar Image Uniformity and Noise (Tolerance = baseline)
o Analyze acquired blank image measuring the standard deviation, mean, noise
values
MV and KV Scaling (Tolerance 2mm)
o Ensuring the actual size of an object is accurately displayed in correct size in the
imaging software. The Las Vegas image (F) is used for MV measurements and
the KV grid is used for KV measurements (D).
Planar KV Image Uniformity and Noise (Tolerance = baseline)
o Mean and standard deviation values collected based on measurements taken from
Leed phantom as pictured in (B)
Planar KV Image Low and High Contrast Sensitivity (Tolerance = 12 disks)
o Number of circular disks visible from Leed phantom as pictured in (B) are
recorded
CBCT Uniformity
o Mean measurements are taken throughout image (C)
CBCT Low and High Contrast Resolution (Tolerance 1mm)
o 2 scans are performed to assess high and low contrast and measurements are taken
based on what is seen as pictured in (C)
CBCT Linearity (Tolerance +/- 40 HU)
o Mean values are recorded for various substances located in the Catphan and
compared to expected values as pictured in image (C)
CBCT Spatial Linearity (Tolerance +/- 2mm or 1%)
o Distances are measured using the top left picture of image (C) and compared to
an expected value of 50 mm.

Figure 3. Equipment and images acquired in monthly QA. A: imaging cube used for
image/radiation isocenter. B: Leed phantom used in KV analysis. C: Catphan phantom used in
CBCT analysis. D: KV scaling grid. E: Las Vegas phantom used in MV imaging analysis. F: MV
portal of Las Vegas phantom.
Annual IGRT QA:
The physics staff will perform annual QA of the IGRT equipment, which is generally a little
more detailed than the monthly measurements. All IGRT tests performed during the monthly
QA are performed during the annual QA process as well. In addition, the EPID is tested for its
full range of travel SDD (Tolerance +/- 5mm). Finally, CBCT measurements will be acquired on
two different CBCT scans (standard dose head and pelvis) utilizing both the full and half fan
filters.