Linear Accelerator Quality Assurance

Daily
Procedure Machine-type Tolerance
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray output constancy (all energies) 3%
Electron output constancy
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
Stereotactic interlocks (lockout) N/A N/A Functional
Radiation area monitor (if used) Functional
Beam on indicator Functional
Monthly
Procedure Machine-type Tolerance
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray output constancy 2%
Electron output constancy
Backup monitor chamber constancy
Typical dose rate output constancy N/A 2% (@ IMRT dose 2% (@ stereo dose rate, MU)
 rate)
Photon beam profile constancy 1%
Electron beam profile constancy 1%
Electron beam energy constancy 2%/2mm
Mechanical
Light/radiation field coincidence 2 mm or 1% on a side
Light/radiation field coincidence (asymmetric) 1 mm or 1% on a side
Distance check check device for lasers compared 1 mm
with front pointer
Gantry/collimator angle indicators @ cardinal angles 1.0 degree
(digital only)
Accessory trays 2 mm
Jaw position indicators (symmetric) 2 mm
Jaw position indicators (asymmetric) 1 mm
Cross-hair centering (walkout) 1 mm
Treatment cocuch position indicators 2 mm/1 2 mm/1 degree 1 mm/0.5 degree
degree
Wedge placement accuracy 2 mm
Compensator placement accuracy 1 mm
Latching of wedges, blocking tray Functional
Localizing lasers ± 2 mm ± 1 mm < 1 mm
Safety
Laser guard-interlock test Functional
Respiratory Gating
Beam output constancy 2%
Phase, amplitude beam control Functional
In-room respiratory monitoring system Functional
Gating interlock Functional
Annually
 Procedure Machine-type Tolerance
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray flatness change from baseline 1%
X-ray symmetry change from baseline ± 1%
Electron flatness change from baseline 1%
Electron symmetry change from baseline ± 1%
SRS arc rotation mode (range: 0.5-10 MU/deg) N/A N/A MU vs del: 1.0 MU or 2%, Gantr vs
del: 1.0 or 2%
X-ray/ electron output calibration (TG-51) ± 1% (absolute)
Spot check of field size dependent output factors for 2% for fields size < 4 × 4 cm , 1% ≥ 4 × 4 cm
x-ray
Output factors for electron applicators ± 2% from baseline
X-ray beam quality ± 1% from baseline
Electron beam quality ± 1 mm
Physical wedge transmission factor constancy ± 2%
X-ray monitor unit linearity (output constancy) ± 2% > 5 MU ± 5% (2-4 MU), ± ± 5% (2-4 MU), ± 2% > 5 MU
2% > 5 MU
Electron monitor unit linearity (output constancy) ± 2% > 5 MU
X-ray output constancy vs. dose rate ± 2% from baseline
X-ray output constancy vs. gantry angle ± 1% from baseline
Electron output constancy vs. gantry angle ± 1% from baseline
Electron and x-ray off-axis factor constancy vs. ± 1% from baseline
gantry angle
Arc mode (expected MU, degrees) ± 1% from 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 mm from baseline
Gantry rotation isocenter ± 1 mm from baseline
Couch rotation isocenter ± 1 mm from baseline
Electron applicator interlocks Functional
Coincidence of radiation and mechanical isocenter ± 2 mm from ± 2 mm from ± 1 mm from baseline
baseline baseline
Table top sag 2 mm from baseline
Table angle 1 degree
Table travel maximum range movement in all ± 2 mm
directions
Stereotactic accessories, lockouts, etc. N/A N/A Functional
Safety
Follow manufacturer's test procedures Functional
Respiratory Gating
Beam energy constancy 2%
Temporal accuracy of phase/amplitude gate on 100 ms of expected
Calibration of surrogate for respiratory 100 ms of expected
phase/amplitude
Interlock testing Functional

Computed Tomography (CT) Simulator QA

Daily
Procedure Tolerance
Electromechanical
Alignment of gantry lasers with the center imaging ± 2 mm
plane
Image Performance Evaluation
CT number accuracy For water, 0 ± 5 HU
Image noise Manufacturer specifications
In plane spatial integrity (X or Y direction) ± 1 mm
Monthly
Procedure Tolerance
Electromechanical
Orientation of gantry lasers with respect to the ± 2 mm over the length of laser projection
imaging plane
Spacing of lateral wall lasers with respect to lateral ± 2 mm
gantry lasers
Orientation of wall lasers with respect to the imaging ± 2 mm over the length of laser projection
plane
Orientation of the ceiling laser with respect to the ± 2 mm over the length of laser projection
imaging plane
Orientation of the CT scanner tabletop with respect to ± 2 mm over the length and width of the tabletop
imaging plane
Table vertical and longitudinal motion ± 1 mm over the range of table motion
Image Performance Evaluation
In plane spatial integrity (both directions ± 1 mm
Field uniformity (most commonly used kVp) within ± 5 HU
Annually
Procedure Tolerance
Electromechanical
Table indexing and position ± 1 mm over the scan range
Gantry tilt accuracy ± 1 degree over the gantry tilt range
Gantry tilt position and accuracy ± 1 degree or 1 mm from nominal position
Scan localization ± 1 mm over the scan range
Radiation profile width Manufacturer specifications
Sensitivity profile width (Semiannually) ± 1 mm of nominal value
Generator tests (After replacement of major generator Manufacturer specifications or Report No. 39
component)
Image Performance Evaluation
Field uniformity (other used kVp settings) within ± 5 HU
Electron density to CT number conversion Consistent with commissioning results and test phantom manufacturer
specifications
Spatial resolution Manufacturer specification
Contrast resolution Manufacturer specifications

Imaging
Procedure Application-type Tolerance
Non- SRS/SBRT
SRS/SBRT
Daily
Planar kV and MV (EPID) imaging
Collision interlocks Functional
Positioning/repositioning 2 mm 1 mm
Imaging and treatment coordinate coincidence (single 2 mm 1 mm
gantry angle)
Cone-beam CT (kV and MV)
Collision interlocks Functional
Imaging and treatment coordinate coincidence 2 mm 1 mm
Positioning/repositioning 1 mm
Monthly
Planar MV imaging (EPID)
Imaging and treatment coordinate coincidence (four 2 mm 1 mm
cardinal angles)
Scaling 2 mm 2 mm
Spatial resolution Baseline
Contrast Baseline
Uniformity and noise Baseline
Planar kV imaging
Imaging and treatment coordinate coincidence (four 2 mm 1 mm
cardinal angles)
Scaling 2 mm 1 mm
Spatial resolution Baseline
Contrast Baseline
Uniformity and noise Baseline
Cone-beam CT (kV and MV)
Geometric distortion 2 mm 1 mm
Spatial resolution Baseline
Contrast Baseline
HU constancy Baseline
Uniformity and noise Baseline
Annually
Planar MV imaging (EPID)
Full range of travel SDD ± 5 mm
Imaging dose Baseline
Planar kV imaging
Beam quality/energy Baseline
Imaging dose Baseline
Cone-beam CT (kV and MV)
Imaging dose Baseline

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
Annually
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

QA Tests for Brachytherapy Sources3

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

Intracavitary Source and Applicator QA3

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

Interstitial Source and Applicator QA3

Procedure End Point Frequency
Evaluate spacing and no. seeds/ribbons Ribbon geometry and seed quantity Initially
Source calibration Source strength Initially, each use
Strength per seed or strength per unit Source strength uniformity Initially
length
Evaluate dummy ribbon geometry Coincidence of dummy and radioactive Initially, annually
sources
Source leak test Capsule integrity 6 mo. Interval
Source inventory Correct source number Quarterly
Source preparation area survey Safety or brachytherapy personnel Quarterly

References:
1. Klein EE, Hanley J, Bayouth J, et al. Task Group 142 report: Quality assurance of medical accelerators. Med Phys. 2009;
36(9):4197-4212. https://dx.doi.org/10.1118/1.3190392
2. Khan F, Gibbons J. Quality Assurance In: Khan F, Gibbons, eds. Khan’s The Physics of Radiation Therapy. 5th ed.
Philadelphia, PA: Lippincott Williams and Wilkins; 2014: 371-403.
3. 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
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