Draft MPPG Therapy #1 TG-226 - IGRT Commissioning & QA 1 of 15

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1
The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose
primary purposes are to advance the science, education and professional practice of medical physics.
The AAPM has more than 7,500 members and is the principal organization of medical physicists in the
United States.

The AAPM will periodically define new practice guidelines for medical physics practice to help
advance the science of medical physics and to improve the quality of service to patients throughout the
United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision
or renewal, as appropriate, on their fifth anniversary or sooner.

Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a
thorough consensus process in which it has been subjected to extensive review, and requires the
approval of the Professional Council. The medical physics practice guidelines recognize that the safe
and effective use of diagnostic and therapeutic radiology requires specific training, skills, and
techniques, as described in each document. Reproduction or modification of the published practice
guidelines and technical standards by those entities not providing these services is not authorized.
2 Approved [insert date]*
3
4
5 COMMISSIONING AND QUALITY ASSURANCE OF X-RAY BASED IMAGE GUIDED
6 RADIOTHERAPY SYSTEMS
7
8
9 1. Introduction
10
11 Image-guided radiation therapy (IGRT), in its many forms, is an important tool in improving the
12 effectiveness of clinical radiation oncology. IGRT involves the use of patient images to localize
13 and reposition the patient or delivery system prior to treatment to ensure that the therapeutic
14 beam is correctly directed toward the tumor. IGRT imaging strategies have utilized x-rays,
15 ultrasound, and other means. In particular, IGRT has been most commonly facilitated using x-
16 rays, beginning with use of megavoltage (MV) portal and/or orthogonal setup images some
17 decades ago. These images provide a means of evaluating the position of the treatment isocenter
18 and field edges relative to the patient position. Because of the poor low-contrast resolution of
19 MV images, bony anatomy may be taken as a surrogate of the target volume, which is
20 frequently soft-tissue-equivalent and not clearly visible within the image. However, as many
21 studies have shown, the target volume can exhibit different patterns of motion relative to bony
22 anatomy; therefore, daily localization using bony anatomy alone may lead to increased
23 uncertainty in target positioning. One solution to clinical scenarios in which improved soft-
24 tissue targeting was desired was the introduction of in-room kilovoltage (kV) imaging systems.
25 Such systems have included computed tomography (CT) scanners located within the treatment
26 room (e.g., “CT-on-rails”) and kV imaging systems affixed to the floor/ceiling or to the linear
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27 accelerator gantry itself. These systems have provided improved low-contrast localization of
28 soft tissue targets and – in the case of in-room CT scanners and gantry-mounted imaging
29 systems – allowed for acquisition of pre-treatment volumetric images.
30
31 The specific choice and application of IGRT strategy depends on the complexity and
32 requirements of the treatment in question. It may serve as an enhancement to an established
33 technique (as in the case of three-dimensional conformal radiation therapy or intensity
34 modulated radiation therapy) or as a necessary and critical component of the treatment process
35 (as in the case of stereotactic body radiation therapy). Whatever its application, it is
36 undoubtedly true that (1) IGRT strategies are being used more now than ever before, and (2)
37 various forms of IGRT have been, are, and will continue to be important tools in radiation
38 therapy.
39
40 As the clinical treatment process continues to rely more heavily on IGRT strategies, the
41 Qualified Medical Physicist (QMP) is under increasing pressure to maintain patient safety and
42 treatment quality through quality assurance programs that are in step with the rapid pace of
43 technological development. Many clinical practice environments now utilize treatment delivery
44 systems with one or more IGRT systems that fall under the responsibility of the QMP. A variety
45 of guidance documents and task groups reports have been issued that include additional
46 recommendations for commissioning and quality assurance of IGRT systems [1-8]. However,
47 these reports do not clearly delineate best practice from minimum practice standards.
48
49 a. Goals and rationale
50
51 This document is part of a series of medical physics practice guidelines commissioned
52 by the American Association of Physicists in Medicine (AAPM) intended to succinctly
53 state the minimum acceptable standards for various aspects of clinical medical physics.
54 While implementation of robust and comprehensive quality assurance programs
55 recommended in other reports from the AAPM is encouraged, the purpose of this
56 particular report is to describe the minimum acceptable practice standards for the
57 commissioning and quality assurance of x-ray based image-guidance systems utilized in
58 radiotherapy. This document is not intended to replace or revise previous AAPM Task
59 Group Reports, but to assist the QMP in establishing and maintaining a safe and
60 effective IGRT program by providing an overview of the minimum requirements and
61 needs of x-ray based IGRT systems. Indeed, the reader is referred to the appropriate
62 technical reference documents or task group reports in instances when additional
63 recommendations beyond minimum practice guidelines are desired [1-8]. Finally, the
64 standards and procedures described in this document are applicable to the imaging
65 guidance system insofar as its resulting images are used to position the patient and/or
66 localize the target volume. Use of IGRT system hardware and software for other
67 purposes, such as dose calculation, are beyond the scope of this report. Technologies
68 covered by these guidelines include:
69
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70 • Gantry-mounted two dimensional MV imaging systems

71 • Gantry-mounted three dimensional MV imaging systems
72 • Gantry-mounted two dimensional kV imaging systems
73 • Gantry-mounted three dimensional kV imaging systems
74 • Room-mounted two dimensional kV imaging systems
75 • Room-mounted three dimensional kV imaging systems
76
77 In this context, “gantry-mounted” imaging systems are those in which the mechanical
78 movement of the imaging hardware is coupled with mechanical movement of the
79 treatment delivery device (e.g., Varian/Elekta/Siemens on-board kV imaging systems,
80 electronic portal MV imaging systems, TomoTherapy megavoltage CT, etc.). “Room-
81 mounted” systems include all imaging systems not coupled with the treatment delivery
82 device (e.g., ExacTrac, CyberKnife, in-room CT, etc.). For room-mounted and gantry-
83 mounted two-dimensional kV imaging systems, fluoroscopy modes are also within the
84 scope of this report.
85
86 b. Intended users
87
88 The intended users of this report are QMPs who seek to understand the technical
89 requirements of clinical implementation and quality assurance of a safe IGRT practice,
90 and administrators interested in the resources required for IGRT.
91
92 2. Definitions and Abbreviations
93
94 • CBCT - cone beam computed tomography
95 • IGRT - image guided radiotherapy
96 • kV - kilovoltage
97 • MV - megavoltage
98 • OIS - oncology information system
99 • QA - quality assurance
100 • TPS - treatment planning system
101
102 3. Staff qualifications and responsibilities
103
104 Implementation of a successful IGRT program requires contributions from each member of the
105 treatment team. Recommendations for staff qualifications and responsibilities are consistent
106 with those described by the ACR-ASTRO practice guideline for clinical use of IGRT [9].
107
108 a. Radiation Oncologist - the radiation oncologist should meet qualifications outlined in
109 the ACR-ASTRO practice guideline for clinical use of IGRT [9]. In short, the
110 responsibilities of the radiation oncologist in an IGRT program include:
111 • Managing patient positioning procedures
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112 • Specifying imaging modalities and frequencies

113 • Identifying registration targets and re-positioning thresholds
114 • Timely review of clinical IGRT images
115 • Conducting regular reviews of the IGRT program
116
117 b. Medical Physicist - the QMP must be competent to practice independently in the
118 subfield of therapeutic radiological physics. The individual must be certified either by
119 the American Board of Radiology, American Board of Medical Physicists, or the
120 Canadian College of Medical Physicists. Responsibilities of the QMP in an IGRT
121 program include:
122 • Acceptance testing and commissioning
123 • Implementing and managing of a quality assurance program
124 • Developing and implementing standard operating procedures (including
125 imaging protocols and repositioning thresholds)
126
127 c. Medical Dosimetrist - responsibilities of the medical dosimetrist or treatment planner in
128 an IGRT program include:
129 • Creating and transferring to the OIS all patient-specific data necessary for IGRT
130 implementation
131
132 d. Radiation Therapist - responsibilities of the radiation therapist in an IGRT program
133 include:
134 • Understanding the use of positioning devices in IGRT
135 • Preparing the IGRT system for acquisition of patient-specific positioning
136 verification images
137 • Implementing the IGRT treatment protocol under the supervision of the radiation
138 oncologist and medical physicist
139 • Acquiring positioning verification images for review by the radiation oncologist
140 • Assisting in periodic review of the stability of the IGRT system (e.g., daily QA)
141
142 e. Information Technologist - It is important that each facility identify an individual that is
143 responsible for providing and maintaining resources necessary for storing, archiving and
144 retrieving images generated during IGRT. This may be accomplished by a dedicated
145 Information Specialist or duties assigned to another team member.
146
147 4. Implementation Guidelines
148
149 a. Minimum required resources and equipment
150
151 i. Staffing
152
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153 Approximate time requirements needed for implementation, maintenance and

154 quality assurance of each IGRT program type (per each IGRT system) are
155 provided below. Estimates are provided as general reference values only, and
156 are not intended to justify site-specific staffing models or physics time for
157 specific billing codes. "Acceptance/commissioning" includes all activities
158 needed for IGRT program implementation, including documentation (e.g.,
159 drafting of a commissioning report and creation of policies and procedures
160 describing the routine IGRT QA program). "Documentation" refers to
161 creation of a formal commissioning report and drafting of policies and
162 procedures specific to clinical use and routine quality assurance of IGRT
163 (including creating QA forms and templates). "Ongoing support" includes all
164 activities needed for maintenance of an established IGRT program (e.g.,
165 routine quality assurance, troubleshooting, upgrades, service/repairs).
166 1. Two dimensional MV imaging systems
167 • Acceptance/Commissioning/Documentation: 18-36 hours
168 • Ongoing support: 25-50 hours annually
169 2. Two dimensional kV imaging systems
170 • Acceptance/Commissioning/Documentation: 18-36 hours
171 • Ongoing support: 25-50 hours annually
172 3. Three dimensional MV imaging systems
173 • Acceptance/Commissioning/Documentation: 18-36 hours
174 • Ongoing support: 100-125 hours annually
175 4. Three dimensional kV imaging systems
176 • Acceptance/Commissioning/Documentation: 18-36 hours
177 • Ongoing support: 100-125 hours annually
178
179 ii. Equipment
180
181 Quality assurance phantoms and tools must provide reliable values of the
182 measured parameters and can be used to judge whether tolerance criteria
183 have been achieved. In many cases, manufacturers of IGRT systems provide
184 quality assurance phantoms which can be used for quality assurance
185 purposes. In-house and commercial phantoms specifically designed for IGRT
186 are also available and, when coupled with automated image analysis tools,
187 may improve efficiency. At a minimum, quality assurance tools must be
188 capable of assessing the following IGRT characteristics:
189 • Image quality
190 • Spatial accuracy (scaling)
191 • Congruence of imaging and treatment isocenters
192 • Accuracy of registration/couch movements
193 • Imaging dose
194
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195 b. Staff training

196
197 Training for the operation of the IGRT system must be provided. The IGRT system
198 vendor typically provides onsite training to the physicist and therapists for use of the
199 equipment. Prior to initial use of IGRT, the treatment team should meet to discuss
200 staff responsibilities, clinical goals and process workflows. The physicist should
201 also review the image acquisition procedures with the therapists and radiation
202 oncologists.
203
204 c. Process descriptions
205
206 Example procedures for each of the tests recommended in Table 1 are described
207 below. The approximate time needed to complete each procedure is noted in
208 parenthesis following the process description. In some cases, customer acceptance
209 procedures provided by the equipment vendor satisfactorily meet the stated practice
210 standards; however, it is the responsibility of the QMP to judge the adequacy and
211 completeness of all measurements needed for use of a particular IGRT system. It is
212 important to note that these are only example procedures, and a variety of methods
213 may be used to complete the recommended tests.
214
215 i. Customer acceptance procedures (all systems)
216
217 The QMP must be present during acceptance testing. Customer acceptance
218 tests procedures are intended to ensure that the imaging equipment satisfies
219 the performance requirements stated in the purchase agreement. In some
220 cases, measurements completed as part of the acceptance procedures may
221 also serve as components in establishing the routine quality assurance
222 program. The vendor must demonstrate acceptable system performance.
223 (Time: 8-16 hours).
224
225 ii. TPS configuration and connectivity (2D systems)
226
227 Digitally reconstructed radiographs (DRR) of test objects in various
228 orientations are created with the treatment planning system and transferred
229 (typically via DICOM interface) to the image guidance system. Proper
230 display of the DRR image within the image guidance software must be
231 ensured. (Time: 3-4 hours)
232
233 iii. TPS configuration and connectivity (3D systems)
234
235 Reference CT image sets of test objects in various orientations are imported
236 into the treatment planning system. Contours are added and the images and
237 structures are transferred (typically via DICOM interface) to the image
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238 guidance system. Proper display of the reference CT images and structures
239 within the image guidance software must be ensured. (Time: 3-4 hours)
240
241 iv. OIS integration and connectivity (2D systems)
242
243 Setup fields created for a test patient within the oncology information system
244 are properly recognized by the imaging hardware and software when loaded.
245 Acquired images are then assigned to the correct patient, if applicable.
246 (Time: 2-3 hours)
247
248 v. OIS integration and connectivity (3D systems)
249
250 Volumetric IGRT image fields (CBCT, MVCT, CT-on-rails) created for a
251 test patient within the oncology information system are properly loaded and
252 recognized by the imaging hardware and software. Acquired images are
253 assigned to the correct patient, if applicable. (Time: 2-3 hours)
254
255 vi. Routine QA baselines (all systems)
256
257 Measurements taken at the time of IGRT system commissioning which
258 characterize IGRT system performance will serve as reference values for the
259 routine QA program. See Table I for recommended QA tests requiring
260 reference measurements. (Time: 2-3 hours).
261
262 vii. Documentation (all systems)
263
264 All acceptance and commissioning procedures and results must be contained
265 within a formal report. Furthermore, a formal policy for routine IGRT QA
266 program and procedures for performing routine QA measurements must be
267 developed. (Time: 4-8 hours)
268
269 viii. Safety/interlocks (all systems)
270
271 With image acquisition initiated, ensure beam termination occurs when the
272 treatment room door is opened and when any termination keys are depressed.
273 Also ensure that gantry rotation is terminated when touch guards are
274 depressed. Verify that indicator lamps are illuminated during image
275 acquisition (Time: 5 minutes)
276
277 ix. Contrast (2D kV systems)
278
279 A phantom with low contrast objects (such as the Leeds phantom) is placed
280 on the treatment couch at isocenter, typically with a 1 mm copper plate on
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281 top of phantom. A planar kV image is acquired using a reference technique

282 determined at the time of acceptance testing. The window and level are
283 adjusted to reference values determined at the time of acceptance testing. The
284 number of visible disks is recorded, with more indicating better low contrast
285 visibility. (Time: 15 minutes).
286
287 x. Contrast (2D MV systems)
288
289 A phantom with low contrast targets (such as the Las Vegas phantom) is
290 placed on the treatment couch. A planar MV image is acquired using a
291 reference technique determined at the time of acceptance testing. The
292 window and level are adjusted to a reference value determined at the time of
293 acceptance testing. The number of visible disks of largest diameter or
294 frequency groups is recorded, with more indicating better low contrast
295 visibility. (Time: 15 minutes).
296
297 xi. Contrast (3D systems)
298
299 An appropriate volumetric image quality phantom (such as a CT phantom) is
300 positioned on the treatment table using the room lasers. A volumetric image
301 is acquired using a reference technique determined at the time of acceptance
302 testing. Either the difference in CT number of different materials within the
303 phantom, or the number of visible low contrast objects is recorded. (Time: 15
304 minutes)
305
306 xii. Spatial resolution (2D kV systems)
307
308 A phantom with high contrast objects (such as the Leeds phantom) is placed
309 on the treatment couch, typically with 1 mm copper plate on top of phantom.
310 A planar kV image is acquired using a reference technique determined at the
311 time of acceptance testing. The number of frequency groups that are clearly
312 distinguished is recorded; with more frequency groups indicating better
313 spatial resolution. (Time: 15 minutes)
314
315 xiii. Spatial resolution (2D MV systems)
316
317 A high contrast phantom (such as the Las Vegas phantom) is placed on the
318 treatment couch. A planar MV image is acquired using a reference technique
319 determined at the time of acceptance testing. The number of visible disks of
320 greatest contrast is recorded, with more disks indicating better spatial
321 resolution. (Time: 15 minutes)
322
323 xiv. Spatial resolution (3D systems)
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324
325 An appropriate volumetric image quality phantom (such as the Catphan) is
326 positioned on the treatment table using the room lasers. A volumetric image
327 is acquired using a reference technique determined at the time of acceptance
328 testing. The number of frequency groups that are clearly distinguished is
329 recorded; with more frequency groups indicating better spatial resolution.
330 (Time: 15 minutes)
331
332 xv. Scaling (all systems)
333
334 A phantom of known dimensions is placed on the treatment table using the
335 room lasers. A planar or volumetric image is acquired. Window and level are
336 adjusted such that phantom is clearly visible. The distance between two
337 objects of known separation in the horizontal and vertical axes is recorded
338 and compared with the known distance. For 3D imaging systems, scaling
339 must be measured in all 3 dimensions. (Time: 10 minutes)
340
341 xvi. Uniformity (3D systems)
342
343 An appropriate volumetric image quality phantom (such as the Catphan) is
344 positioned on the treatment table using the room lasers. A volumetric image
345 is recorded. The average pixel value over a region of interest at multiple
346 locations (e.g., center, 12 o’clock, and 3 o’clock) is recorded and compared.
347 (Time: 15 minutes)
348
349 xvii. Imaging-treatment isocenter coincidence (2D systems)
350
351 A variety of methods may be used to verify congruence of imaging and
352 treatment isocenters. Most of these techniques require alignment of a
353 radiopaque marker (e.g., ball bearing, fiducial, or commercial device) to
354 treatment isocenter via room lasers. Orthogonal or oblique images are then
355 acquired. Congruence of imaging and treatment isocenters is verified by
356 comparing the position of the markers with the center of the
357 orthogonal/oblique images. (Time: 10-15 minutes)
358
359 xviii. Imaging-treatment isocenter coincidence (3D systems)
360
361 A variety of methods may be used to verify congruence of imaging and
362 treatment isocenters. Most of these techniques are usually coupled with the
363 “positioning/repositioning” test and begin with positioning of a radiopaque
364 marker (ballbearing, fiducial, or commercial device) on the treatment table
365 with known offsets from isocenter. Volumetric IGRT images are then
366 acquired and registered with reference images. The recommended couch
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367 shifts from the image registration software are recorded and applied, and
368 coincidence of the imaging and treatment isocenters is assessed by (1)
369 comparing the position of the marker with the room lasers or (2) comparing
370 the coincidence of the marker with the center position of an acquired MV
371 portal image, if available. (Time: 10-15 minutes)
372
373 xix. Positioning/Repositioning (all systems)
374
375 A radiopaque marker is positioned on the treatment table with known offsets
376 from isocenter. Images are acquired and registered with reference images.
377 The recommended couch shifts from the image registration software are
378 recorded and applied. Proper functioning of the image registration software is
379 verified by comparing the recommended couch shifts with the known offsets,
380 while correct application of the shifts is assessed by comparing the position
381 of the marker with the room lasers. (Time: 10-15 minutes)
382
383 xx. Imaging dose (3D systems)
384
385 Several different methods are currently used to characterize the dose from 3D
386 IGRT systems. The traditional metric for dose from CT imaging, the
387 computed tomography dose index (CTDI), has been applied to IGRT
388 imaging. More recently, the AAPM Task Group 111 [8] report has
389 introduced a new metric, the cumulative dose. These two different metrics
390 use different measurement equipment and irradiation geometries to
391 characterize the dose.
392
393 Measurement equipment used to measure CTDI includes a calibrated 100
394 mm long pencil ionization chamber and acrylic CTDI phantoms, one
395 resembling a head and the other a pelvis. For each imaging mode, the
396 phantom that matches the mode’s target anatomy is used. The phantom is
397 centered at isocenter and the pencil chamber is centered in the phantom. The
398 radiation field length is constrained to be less than the active length of the
399 pencil ionization chamber. For each imaging mode, measurements are
400 repeated for the central and peripheral phantom locations.
401
402 Measurement equipment used to measure the cumulative dose includes a
403 farmer chamber calibrated in the appropriate energy range and several acrylic
404 CTDI phantoms. For each imaging mode, the phantoms that match the
405 modes’ target anatomy are used. The CTDI phantoms are abutted until their
406 length exceeds the length of the radiation field. The phantom is centered at
407 isocenter and the farmer chamber is centered in the phantom. For each
408 imaging mode, measurements are repeated for the central and peripheral
409 phantom locations.
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410
411 Measured imaging dose must be documented and its management should be
412 approached with the goal of keeping it as low as necessary to achieve
413 clinically useful images. (Time: 15-60 minutes, depending on the number of
414 techniques measured.)
415
416 xxi. Imaging dose (2D systems)
417
418 Imaging dose from 2D kV systems is most typically characterized using
419 entrance skin exposure. Measurement equipment used to measure the
420 entrance exposure includes a calibrated ionization chamber and a phantom.
421 The ionization chamber is placed in the phantom at a shallow depth on the
422 tube side of the x-ray beam. The field size is set to cover the detector. A
423 clinically relevant beam is delivered, and the exposure rate is calculated.
424
425 Measured imaging dose should be documented and its management should
426 be approached with the goal of keeping it as low as necessary to achieve
427 clinically useful images. (Time: 15-60 minutes, depending on the number of
428 techniques measured)
429
430 d. Continuing quality improvement
431
432 Ongoing review and audit of the IGRT program should occur at regular intervals. In
433 particular, use of appropriate imaging techniques/frequencies, adherence to stated
434 QA programs, and revision of IGRT strategies based on pertinent changes in clinical
435 practices should be assessed.
436
437 5. Recommendations
438
439 Recommended minimum practices for commissioning and QA of an IGRT system are shown in
440 Table I. Test frequencies and tolerance values were developed based on relevant AAPM Task
441 Group reports and the experience of the MPPG members in relation to the stability and
442 importance of each parameter to the IGRT process. Sample process descriptions are included in
443 Section 5.c. The “acceptance value” shown in the table refers to the IGRT system
444 manufacturer’s minimum performance standard stated in the customer acceptance procedure
445 documentation. If unavailable or not specified, then “acceptance value” can be taken as the
446 value measured at the time of commissioning. For example, most IGRT system manufacturers
447 have stated performance specifications for image quality and, in such cases; those may serve as
448 the tolerance values for routine QA measurements of image quality. However, most IGRT
449 system manufacturers do not have stated performance specifications for imaging dose and, in
450 such cases, the imaging dose measured at the time of commissioning may serve as the baseline
451 value to which future measurements are compared.
452
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453 Table I. Recommended minimum practices for commissioning and QA of an IGRT system.
454
Procedure Tolerance

Acceptance/Commissioning

Customer acceptance procedures -

TPS integration -
OIS integration -
Establish routine QA baselines -
Documentation -

Daily

Safety/interlocks Functional
Imaging-treatment isocenter coincidence (SRS only) 1 mm
Positioning/repositioning (SRS only) 1 mm
Imaging-treatment isocenter coincidence (SBRT only) 2 mm
Positioning/repositioning (SBRT only) 2 mm

Weekly

Imaging-treatment isocenter coincidence (non-SRS/SBRT) 2 mm

Positioning/repositioning (non-SRS/SBRT) 2 mm

Semi-Annually

Image scaling 2 mm

Annually

Imaging dose
2D MV and all 3D imaging modes ± 1 cGy of acceptance value
2D kV (static imaging mode) ± 25 mR of acceptance value
2D kV (fluoroscopy mode) ± 1 R/min of acceptance value
Image quality
2D (spatial resolution, contrast) Acceptance value
3D (uniformity, spatial resolution, contrast)

Upgrade/Repair/Service

Verify / Re-establish QA baselines (as appropriate) -

455 Abbreviations: SRS = stereotactic radiosurgery, SBRT = stereotactic body radiation therapy
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456
457 In general, the frequency of routine QA tests is proportional to the importance of their
458 performance for the purpose of patient alignment. As such, evaluation of imaging-treatment
459 isocenter coincidence and positioning/repositioning is considered critical. While daily checks of
460 these parameters are preferred, weekly checks are considered acceptable for IGRT systems used
461 with standard fractionation schemes. For IGRT systems used for SRS/SBRT, daily QA testing
462 frequency is required on days when procedures are scheduled.
463
464 The imaging dose from an IGRT system must be measured for at least one acquisition
465 technique of each mode of clinical operation. For example, a gantry-mounted kV system used to
466 acquire both 2D and 3D clinical images must have documented imaging doses for both 2D and
467 3D modes. If imaging dose is only measured for one acquisition technique, then the chosen
468 technique should serve to provide the most conservative value (e.g., choose the acquisition
469 technique that results in the greatest imaging dose). For 2D kV systems operated in fluoroscopy
470 mode, the entrance exposure rate should be measured for the technique expected to produce the
471 highest value.
472
473 These recommendations must be also augmented with procedures required by state regulations
474 (such as measurement of x-ray tube voltage accuracy, where applicable). Furthermore, IGRT
475 systems with known recurring problems should be subjected to more frequent QA at the
476 discretion of the QMP.
477
478 6. Conclusions
479
480 IGRT is a powerful and increasingly essential component of clinical radiation oncology practice.
481 Proper use and quality assurance of clinical IGRT systems are of critical importance to maximizing
482 the benefits and minimizing the risks of the technology. The minimum technical requirements for
483 managing a clinical IGRT program stated in this document will help to achieve a more uniform
484 standard of practice that improves the safety and quality of care of patients for whom IGRT is
485 needed.
486
487 Acknowledgements
488
489 This guideline was developed according to the process described under the heading The Process for
490 Developing AAPM Medical Practice Guidelines AAPM web site [insert link] by the Medical
491 Physics Practice Guideline Task Group-225 of the Professional Council of the AAPM.
492
493 TG-226 MPPG Therapy #1 Members:
494 Jonas D. Fontenot, PhD, Chair
495 Hassaan Alkhatib, PhD
496 Jeffrey A. Garrett, MS
497 Andrew R Jensen, MS
498 Steven P. McCullough, PhD
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499 Arthur J. Olch, PhD, FAAPM

500 Brent C. Parker, PhD
501 Ching-Chong Jack Yang, PhD
502 Lynne A. Fairobent, AAPM Staff
503
504 AAPM Subcommittee on Practice Guidelines – AAPM Committee responsible for sponsoring the
505 draft through the process.
506 Maria F. Chan, Chair, PhD
507 Jessica B. Clements, MS
508 Dianna D. Cody, PhD, FAAPM
509 Indra J. Das, PhD, FAAPM
510 Nicholas A. Detorie, PhD, FAAPM
511 Vladimir Feygelman, PhD
512 Jonas D Fontenot, PhD
513 David P Gierga, PhD
514 Kristina E. Huffman, MMSc
515 Ingrid R. Marshall, PhD
516 Yildirim D Mutaf, PhD
517 Arthur J. Olch, PhD, FAAPM
518 Nikos Papanikolaou, PhD, FAAPM
519 Joann I Prisciandaro, PhD
520 Narayan Sahoo, PhD, FAAPM
521 S. Jeff Shepard, MS, FAAPM
522 George W. Sherouse, PhD, FAAPM
523 James J VanDamme, MS
524 Gerald A. White Jr., MS, FAAPM
525 Ning J. Yue, PhD, FAAPM
526 Lynne A. Fairobent, AAPM Staff
527
528
529 References
530
531 1. AAPM TG-179: Quality assurance for image-guided therapy utilizing CT-based
532 technologies
533 2. AAPM TG-75: The management of imaging dose during image-guided radiotherapy
534 3. AAPM TG-104: The role of in-room kV X-ray imaging for patient setup and target
535 localization
536 4. AAPM TG-148: QA for helical tomotherapy
537 5. AAPM TG-58: Clinical use of electronic portal imaging
538 6. AAPM TG-135: Quality assurance for robotic radiosurgery
539 7. AAPM TG-142: Quality assurance of medical accelerators
540 8. AAPM TG-111: Comprehensive methodology for the evaluation of radiation dose in x-ray
541 computed tomography
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542 9. ACR-ASTRO Practice guideline for image-guided radiation therapy

543