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Brittany Bird
DOS 542 Quality Assurance
October 1, 2017

Tables

Table 1. Daily Quality Assurance (QA) for a linear accelerator1


Machine-type tolerance
Procedure Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray output constancy
(all energies)
Electron output constancy 3%
(weekly, except for machines
with unique e-monitoring
requiring daily)
Mechanical
Laser localization 2 mm 1.5 mm 1 mm
Distance indicator (ODI) @ iso 2 mm 2 mm 2 mm
Collimator size indicator 2 mm 2 mm 1 mm
Safety
Door interlock (beam off) Functional
Door closing safety Functional
Audiovisual monitor(s) Functional
Sterotactic interlocks (lockout) NA NA Functional
Radiation area monitor (if used) Functional
Beam on indicator Functional
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Table 2. Monthly QA for a linear accelerator1


Machine-type tolerance
Procedure Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray output constancy 2%
Electron output constancy 2%
Backup monitor chamber 2%
constancy
Typical dose rate output NA 2% (@ IMRT 2% (@ stereo dose
constancy dose rate) rate, MU)
Photon beam profile 1%
constancy
Electron beam profile 1%
constancy
Electron beam energy 2% / 2 mm
constancy
Mechanical
Light/radiation field 2 mm or 1% on a
coincidence side
Light/radiation field 1 mm or 1% on a
coincidence (asymmetric) side
Distance check device for 1 mm
lasers compared with front
pointer
Gantry/collimator angle 1.0
indicators (@cardinal angles)
(digital only)
Accessory trays (i.e., port film 2 mm
graticule tray)
Jaw position indicators 2 mm
(symmetric)
Jaw position indicators 1 mm
(asymmetric)
Cross-hair centering (walkout) 1 mm
Treatment couch position 2 mm / 1 2 mm / 1 1 mm / 0.5
indicators
Wedge placement accuracy 2 mm
Compensator placement 1 mm
accuracy
Latching of wedges, blocking Functional
tray
Localizing lasers 2 mm 1 mm < 1 mm
Safety
Laser-guard interlock test Functional
Respiratory gating
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Beam output constancy 2%


Phase, amplitude beam Functional
control
In-room respiratory Functional
monitoring system
Gating interlock Functional
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Table 3. Annual QA for a linear accelerator1


Machine-type tolerance
Procedure Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray flatness change from 1%
baseline
X-ray symmetry change from 1%
baseline
Electron flatness change from 1%
baseline
Electron symmetry change from 1%
baseline
SRS arc rotation mode NA NA Monitor units set vs.
(range: 0.5-10 MU/deg) delivered: 1.0 MU or
2% (whichever is
greater) Gantry arc set
vs delivered: 1.0 or
2% (whichever is
greater)
X-ray/electron output calibration 1% (absolute)
(TG 51)
Spot check of field size dependent 2% for field size
output factors for x-ray (2 or more < 4x4 cm2, 1% >
FSs) 4x4 cm2
Output factors for electron 2% from
applicators (spot check of one baseline
applicator/energy)
X-ray beam quality 1% from
baseline
Electron beam quality 1 mm
Physical wedge transmission 2%
factor constancy
X-ray monitor unit linearity 2% > 5 MU 5% (2-4 MU), 5% (2-4 MU),
(output constancy) 2% > 5 MU 2% > 5 MU
Electron monitor unit linearity 2% > 5 MU
(output constancy)
X-ray output constancy vs dose 2% from
rate baseline
X-ray output constancy vs gantry 1% from
angle baseline
Electron output constancy vs. 1% from
gantry angle baseline
Electron and x-ray off-axis factor 1% from
constancy vs. gantry angle baseline
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Arc mode (expected MU, 1% from


degrees) baseline
TBI/ TSET mode Functional
PDD or TMR and OAF constancy 1% (TBI) or 1
mm PDD shift
(TSET) from
baseline
TBI/ TSET output calibration 2% from
baseline
TBI/ TSET accessories 2% from
baseline
Mechanical
Collimator rotation isocenter 1% from
baseline
Gantry rotation isocenter 1% from
baseline
Couch rotation isocenter 1% from
baseline
Electron applicator interlocks Functional
Coincidence of radiation and 2% from 2% from 1% from baseline
mechanical isocenter baseline baseline
Table top sag 2% from
baseline
Table angle 1
Table travel maximum range 2 mm
movement in all directions
Stereotactic accessories, lockouts, NA NA Functional
etc.
Safety
Follow manufacturers test Functional
procedures
Respiratory Gating
Beam energy constancy 2%
Temporal accuracy of 100 ms of
phase/amplitude gate on expected
Calibration of surrogate for 100 ms of
respiratory phase/amplitude expected
Interlock testing Functional
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Table 4. Multi-leaf Collimation Quality Assurance2

Frequency Test Tolerance

Patient Specific Check of MLC-generated field vs. simulator film 2 mm


(or DRR) before each field treated

Double check of MLC field by therapists for each Expected field


fraction

On-line imaging verification for patient on each Physician discretion


infraction

Port film approval before second fraction Physician discretion

Quarterly Setting vs. light field vs. radiation field for two 1 mm
designated patterns

Testing of network system Expected fields over


network

Check of interlocks All must be


operational

Annually Setting vs. light vs. radiation field for patterns over 1 mm
range of gantry and collimator angles

Water scan of set parameters 50 % radiation edge


within 1 mm

Film scans to evaluate interleaf leakage and Interleaf leakage < 3


abutted leaf transmission %, abutted leakage <
25 %

Review of procedures and in-service with All operators must


therapists fully understand
operation and
procedures
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Table 5. Imaging QA1


Procedure Application-type tolerance
Non-SRS/SBRT SRS/SBRT
Daily
Planar kV and MV (EPID) imaging
Collision interlocks Functional Functional
Positioning/repositioning 2 mm 1 mm
Imaging and treatment 2 mm 1 mm
coordinate coincidence
CBCT (kV and MV)
Collision interlocks Functional Functional
Imaging and treatment 2 mm 1 mm
coordinate coincidence
Positioning/repositioning 1 mm 1 mm
Monthly
Planar MV imaging (EPID)
Imaging and treatment 2 mm 1 mm
coordinate coincidence
Scaling 2 mm 2 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline
Planar kV imaging
Imaging and treatment 2 mm 1 mm
coordinate coincidence
Scaling 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline
CBCT (kV and MV)
Geometric distortion 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
HU constancy Baseline Baseline
Uniformity and noise Baseline Baseline
Annual
Planar MV imaging (EPID)
Full range of travel SDD 5 mm 5 mm
Imaging Dose Baseline Baseline
Planar kV imaging
Beam quality/energy Baseline Baseline
Imaging dose Baseline Baseline
CBCT (kV and MV)
Imaging Dose Baseline Baseline
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Table 6. CT Simulator test specifications for electromechanical components3


Frequency Performance Test objective Tolerance limits
parameter
Daily Alignment of gantry lasers To verify proper 2 mm
with the center of imaging identification of scan plane
plane with gantry lasers
Monthly Orientation of gantry lasers To verify that the gantry 2 mm over the
with respect to the imaging lasers are parallel and length of laser
plane orthogonal with the projection
imaging plane over the full
length of laser projection
Spacing of lateral wall To verify that lateral wall 2 mm
lasers with respect to lateral lasers are accurately spaced
gantry lasers and scan plane from the scan plane. This
distance is used for patient
localization marking
Orientation of wall lasers To verify that the wall 2 mm over the
with respect to the imaging lasers are parallel and length of laser
plane orthogonal with the projection
imaging plane over the full
length of laser projection
Orientation of the ceiling To verify that the ceiling 2 mm over the
laser with respect to the laser is orthogonal with the length of laser
imaging plane imaging plane projection
Orientation of the CT- To verify that the CT- 2 mm over the
scanner tabletop with scanner tabletop is level length and width
respect to the imaging and orthogonal with the of the tabletop
plane imaging plane
Table vertical and To verify that the table 1 mm over the
longitudinal motion longitudinal motion range of table
according to digital motion
indicators is accurate and
reproducible
Annually Table indexing and position To verify table indexing 1 mm over the
and position accuracy scan range
under scanner control
Gantry tilt accuracy To verify accuracy 1 over the
of gantry tilt indicators gantry tilt range
Gantry tilt position To verify that the gantry 1 or 1 mm
accuracy accurately returns to from nominal
nominal position after position
tilting
Scan localization To verify accuracy of scan 1 mm of nominal
localization from pilot value 1 mm over
images the scan range
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Radiation profile width To verify that the radiation Manufacturer


profile width meets specifications
manufacturer specification
Semi- Sensitivity profile width To verify that the 1 mm of
annually sensitivity profile width nominal value
meets manufacturer
specification
After Generator tests To verify proper operation Manufacturer
replacement of the x-ray generator specifications or
of major Report No. 39
generator recommendations
component
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Table 7. CT Simulator test specifications for image performance evaluation3


Performance Frequency Tolerance limits
parameter
CT number accuracy DailyCT number for water For water, 0 5 HU
Monthly4 to 5 different materials
AnnuallyElectron density phantom
Image noise Daily Manufacturer
specifications
In plane spatial Dailyx or y direction 1 mm
integrity Monthlyboth directions
Field uniformity Monthlymost commonly used kVp Within 5 HU
Annuallyother used kVp settings
Electron density to Annuallyor after scanner calibration Consistent with
CT number commissioning results
conversion and test phantom
manufacturer specifications
Spatial resolution Annually Manufacturer specifications
Contrast resolution Annually Manufacturer specifications
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Table 8. CT-based IGRT systems3


Frequency Quality metric Quality check Tolerance
Daily Safety Collision and other Functional
interlocks
Warning lights Functional

System operation and Laser/ Image/ treatment 2 mm


accuracy isocenter coincidence
Phantom localization and 2 mm
repositioning with couch
shift
Monthly or Geometric Geometric calibration maps Replace/refresh
upon upgrade
kV/MV/laser alignment 1 mm
Couch shifts: accuracy of 1 mm
motions
Image quality Scale, distance, and Baseline
orientation accuracy
Uniformity, noise Baseline
High contrast spatial 2 mm
resolution (or 5 lp/cm)
Low contrast detectability Baseline
If used for Image quality CT number accuracy and Baseline
dose stability
calculation
Annually Dose Imaging dose Baseline

Imaging system performance X-ray generator performance Baseline


(kV systems only):
tube potential, mA, ms
accuracy, and linearity
Geometric Anteroposterior,
mediolateral, and
craniocaudal orientations are
maintained Accurate
(upon upgrade from CT to
IGRT system)
System operation Long and short term Support
planning of clinical use and
resources (disk space, current
manpower, etc.) imaging
policies and
procedures
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Table 9. Periodic Quality Assurance of Radiographic Simulators2


Frequency Procedure Tolerance
Daily Localizing lasers 2 mm
Distance indicator (ODI) 2 mm
Monthly Field size indicator 2 mm
Gantry/collimator angle indicators 1.0
Cross-hair centering 2 mm diameter
Focal spot-axis indicator 2 mm
Fluoroscopic image quality Baseline
Emergency/collision avoidance Functional
Light/radiation field coincidence 2 mm or 1%
Film processor sensitometry Baseline
Annually Mechanical checks
Collimator rotation isocenter 2 mm diameter
Gantry rotation isocenter 2 mm diameter
Couch rotation isocenter 2 mm diameter
Coincidence of collimator, gantry, couch axes, and 2 mm diameter
isocenter
Tabletop sag 2 mm
Vertical travel of couch 2 mm
Radiographic checks
Exposure rate Baseline
Tabletop exposure with fluoroscopy Baseline
kVp and mAs calibration Baseline
High- and low-contrast resolution Baseline
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Table 10. Treatment Planning System QA4


Daily
Error Log Review error messages and hardware malfunctions
Monthly
CT Data Input Review imported CT data to verify the geometrical accuracy, CT
number consistency and electron density
Annual
Dose Calculations Verify measured and calculated dose for each beam is in
agreement, then compare the data against the commissioned data
Critical Software Tools Review BEV/DRR images, CT geometry, density conversion,
DVH calculations and machine specific conversions
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Table 11. QA Tests for Brachytherapy Sources5


Type of Source Test Frequency Tolerance
Long half-life Physical/chemical form Initial purchase Documented
Description Source encapsulation Initial purchase Documented

Radionuclide distribution and source Initial purchase Documented


uniformity
Location of radionuclide Initial purchase 1 mm
Long half-life: Mean of batch Initial purchase 3%
Calibration Deviation from mean Initial purchase 5%, Documented
Calibration verification Every use Visual check
Short half-life: Physical/chemical form Initial purchase Documented
Description Source encapsulation Initial purchase Documented
Short half-life: Mean of batch Every use 3%
Calibration Deviation from mean Every use 5%
Radionuclide distribution and source Every use Visual check
uniformity

Table 12. Intracavitary source and applicator QA5


Procedure End point Frequency
Evaluate Source identity Physical length and diameter Initially
dimensions/serial number
Superposition of auto- Active source length and uniformity, capsule Initially
and transmission thickness accuracy of source construction
radiographs
Source leak test Capsule integrity NRC requires
leak testing,
generally 6 mo.
intervals
Source calibration Source strength Initially,
annually
Dosimetric evaluation of Magnitude and geometric characteristics of Initially
applicator shielding effect
Orthogonal radiographs Correct source position, mechanical integrity, Initially,
of applicators internal shielding positioning coincidence of annually
dummy and radioactive source
Measure applicator Correct diameter and length, correct diameter Initially,
dimensions of all colpostat caps and cylinder segments annually
Source inventory Correct source number Quarterly
Source preparation area Safety of brachytherapy personnel As needed
survey
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Table 13. Interstitial source and applicator QA5


Procedure End Point Frequency
Evaluate spacing and no. ribbon geometry and seed quantity initially
seeds/ribbon
Source calibration source strength initially, each
use
Strength per seed or strength source strength uniformity initially
per unit length
Applicator integrity varies: metal needles: sharpness and initially,
straightness templates: o-ring integrity annually
and hole locations
Evaluate dummy ribbon coincidence of dummy and radioactive initially,
geometry sources annually
Source leak test capsule integrity 6 mo. interval
Source inventory correct source number quarterly
Source preparation area safety or brachytherapy personnel quarterly
survey

Table 14. Remote Afterloader Acceptance Testing2


Functional Console Functionality: power, battery, source on/off
Performance Source control: dwell time accuracy, source retraction, unplanned
interruptions
Battery: ensure it is functioning properly in battery mode
Decay Correction: does the computer correctly calculate the decay
Multichannel indexer: dose it select the correct channel
Back-up system functionality
Radiation Area Detector Functionality
Facility Check Interlock Functionality: Door, warning lights, A/V monitors
Radiation Survey
Source Leak Testing
Calibration Determine Dose Anisotropy
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References

1. Klein E, Hanley J, Baymouth J. Task Group 142 report: Quality assurance of medical
accelerators. Med Phys. 2009;36(9):4197-4212. http://dx.doi.org/10.1118/1.3190392
2. Khan F. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams
and Wilkins; 2014.
3. Mutic S, Palta J, Butker EK, et al. Quality assurance for computed-tomography
simulators and the computed-tomography-simulation process: report of the AAPM
radiation therapy committee task group No. 66. Med Phys. 2003; 30(10):2762-2792.
http://dx. doi.org/10.1118/1.16092715
4. Fraass b, Doppke K, Hunt M, et al. Task Group 53 report: Quality assurance for clinical
radiotherapy treatment planning. Med Phys. 1998;25(10):1773-1829.
http://dx.doi.org/10.1118/1.598373
5. Nath R, Anderson L, Meli J, et al. Task group 56 report: Code of practice for
brachytherapy physics. Med Phys. 1997;24(10):1557-98.
http://dx.doi.org/10.1118/1:597966