Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Radiotherapy Quality Assurance Program

These document is originated from the South African Standards for Quality Assurance in
Radiotherapy. The purpose of this document is to list mandatory Quality control tests to be
performed by medical physicists at the radiotherapy department of Black Lion Hospital in order
to ensure patient safety. The test frequencies and tolerance are set to be the same as that
specified on the original document.
The frequency of the tests can be revised based on future experience with the available RT
equipment performance stability. If an equipment shows historical stability beyond the
frequency of testing stipulated in this initial version of this document then the medical physicist
should allow for a reduction in the test frequency. In contrast, where equipment is known to
have inherent instability below ‘normal’ standards, the medical physicist should perform tests
at shorter intervals than suggested in this document.

The techniques employed to establish the compliance of a particular test to the tolerances
specified in this document is based on internationally recognized technique

If a tolerance cannot be reached due to economic, mechanical or electronic constraints, there

should be documentation to show how the clinical procedures are adapted to accommodate
these anomalies, without impacting upon patient safety.

These tests should be conducted by a qualified medical physicist, or radiotherapy personnel

trained by a qualified medical physicist. Any test exceeding tolerance should be reported to a
qualified medical physicist to determine the course of action.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

The format of this document specifies tests which need to be performed within certain time periods.
These time periods are as follows:

D Daily (Routine QC)

M Monthly (Routine QC) A
Annually (Routine QC)
P Per Patient (Patient Specific Tests) C
Commissioning (Once-off QC)

The tests performed during commissioning may be repeated during the routine quality control
intervals.

For quantities that can be measured, the “Performance” of a test is compared to an action and tolerance
level. If the difference between the measured and expected value is at or below the tolerance level, no
action is required. If the difference is larger than the “action” level, immediate action is required.

These document is adapted from the South African Standards for Quality Assurance Program
Canadian Association of Provincial Cancer Agencies (CAPCA) gave permission for us to use their
Standards for Quality Control as a basis for this documentation. Whilst ensuring patient safety. The
assistance and information sharing of CAPCA is appreciated but they are not in any way responsible
for the final SASQART documentation.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

QA program for CT Simulators

Performance
Designator Test
Tolerance Action Value
Daily
DCS1 Door interlock Functional
DCS2 Beam status indicators Functional
Monthly
MCS1 Door interlock Functional
MCS2 Beam status indicators Functional
MCS3 Emergency off buttons Functional
MCS4 CT number accuracy of water (mean) 0 ± 3 HU 0 ± 5 HU
MCS5 Image noise 5 HU 10 HU
MCS6 Field uniformity of water 5 HU 10 HU
MCS7 Simulated planning 1 2
MCS8 Lasers: parallel to scan plane 1º 2º
MCS9 Lasers: orthogonality 1º 2º
MCS10 Lasers: position from scan plane 1 2
MCS11 Lasers: linearity of translatable lasers 1 2
MCS12 Couch Level: lateral & longitudinal 0.5º 1º
MCS13 Couch motions: vertical & longitudinal 1 2
MCS14 Gantry tilt (where used) 1º 2º
MCS15 Records Complete
Annually
ACS1 Slice localization from pilot 0.5 1
ACS2 CT number accuracy of water (mean) 0 ± 3 HU 0±5 HU
ACS3 CT number accuracy of other material (mean)
ACS4 Field uniformity of water (std deviation) 5 HU 10 HU
ACS5 Low contrast resolution 10 @ 0.3%
ACS6 High contrast resolution (5% MTF) 5 lp/cm
ACS7 Slice thickness (sensitivity profile) 0.5 1
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Bi-Ennial (Every Two Years)

BCS1 X-ray Generation : kV and HVL 2 kV 5 kV
BCS2 X-ray Generation: mAs linearity 5% 10%
BCS3 Radiation Dose (CTDI) 5% 10%
BCS4 Independent quality control review Complete
Commissioning
CCS1 Manufacturer’s Acceptance Testing Complete
CCS2 MCS1-14, ACS1-7, BCS1-3 As Above
CCS3 Demographic Data Transfer Correct
CCS4 Image Orientation Transfer Correct

Tolerances and Action Levels are specified in millimetres unless otherwise stated
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes

Monthly Tests

MCS5 Standard deviation of water in ROI at image centre using a typical CT-simulation protocol
and a cylindrical water phantom.
MCS6 Maximum deviation of the mean CT# in any ROI from the mean CT# in an ROI at the
centre of a cylindrical water phantom.
MCS7 A phantom with various markers can be scanned with a CT-simulation protocol, the images
transferred and virtually simulated, and marked with the lasers according to the laser/couch
output data.
MCS8-11 Alignment of lasers should match minimally the tolerance set for those in the treatment delivery
rooms. Laser lines should also be parallel to three principal axes of the images.
MCS12-13 The couch motions should be in directions parallel to the principal axes of the images.
MCS14 Digital gantry angle readouts must be verified using a spirit level for gantry 0º.
MCS15 Documentation relating to the quality control checks, preventive maintenance, service calls
and subsequent checks must be complete, legible and the operator identified.

Annual Tests

ACS1 Slice localization from pilot should be checked over the total scannable length of the couch.
ACS2-7 CT image performance is highly dependent on the scan technique used. A standard QA
protocol should be established and used for all image performance checks. Tolerances
should be established at acceptance testing.
ACS3 Tolerances for other materials should be established at acceptance testing
ACS5 Low contrast resolution scan protocol and tolerances should be set at acceptance testing.
Vendors quote 3-5mm at this contrast level but this is seldom achieved with large FOV
simulation protocols. 10mm visible at 0.3% density difference
ACS6 High contrast resolution scan protocol and tolerances should be set at acceptance testing

Bi-Ennial Test

BCS1-2 CT image performance is highly dependent on the scan technique used. A standard QA
protocol should be established and used for all image performance checks. Tolerances
should be established at acceptance testing.
BCS3 CTDI should be measured bi-ennially or when there is a change in the tube model that may
affect x-ray output. CTDI is measured in units of dose and the tolerance and action levels
refer to deviations from the manufacturer’s specification.
BCS4 A second qualified medical physicist must independently verify the implementation,
analysis and interpretation of the quality control tests at least bi-ennially.

Commissioning

CCS1 Manufacturer’s acceptance testing protocol should be followed where available

CCS2 All monthly, annual and bi-ennial tests should be conducted during acceptance testing and
tolerances levels established
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Program for Medical Linear

Accelerators

Performance
Designator Test
Tolerance Action Value
Daily
DL1 Door interlock/last person out Functional
DL2 Beam status indicators Functional
DL3 Patient audio-visual monitors Functional
DL4 Output constancy - photons 2.00% 3.00%
DL5 Output constancy - electrons 2.00% 3.00%
Monthly
ML1 Motion interlock Functional
ML2 Couch brakes Functional
ML3 Room radiation monitors (where available) Functional
ML4 Beam interrupt/ counters Functional
ML5 Emergency off (alternate monthly) Functional
ML6 Lasers/crosswires 1 2
ML7 Optical distance indicator 1 2
ML8 Optical back pointer (where available) 2 3
ML9 Field size indicator 1 2
ML10 Wedge factors (dynamic or virtual) 1.00% 2.00%
ML11 Gantry angle readouts 0.5° 1°
ML 12 Collimator angle readouts 0.5° 1°
ML13 Couch position readouts 1 2
ML14 Couch isocentre 1 2
ML15 Couch angle 0.5° 1°
ML16 Crosswire centering 1 2
ML17 Light/radiation coincidence 1 2
ML18 Central axis depth dose reproducibility 1%/2mm 2%/3mm
ML19 Beam flatness 4.00% 5.00%
ML20 Beam symmetry 2.00% 3.00%
ML21 Records Complete
Annually
AL1 Accessories: integrity and centering Functional
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

AL2 Accessories: latching and interlocks Functional

AL3 Optical distance indicator 1 2
AL4 Light/radiation coincidence 1 2
AL5 Field size indicator with gantry angle 1 2
AL6 Reference dosimetry – TRS398 1.00% 2.00%
AL7 Relative output factor reproducibility 1.00% 2.00%
AL8 Wedge transmission factor reproducibility 1.00% 2.00%
AL9 Accessory transmission factor reproducibility 1.00% 2.00%
AL10 Output reproducibility vs. gantry angle 1.00% 2.00%
AL11 Beam symmetry reproducibility vs. gantry angle 2.00% 3.00%
AL12 Monitor chamber linearity 1.00% 2.00%
AL13 End monitor effect 0.1 MU 0.2 MU
AL14 Collimator rotation isocentre 1 2
AL15 Gantry rotation isocentre 1 2
AL16 Couch rotation isocentre 1 2
AL17 Coincidence of collimator, gantry, couch axes 1 2
AL18 Coincidence of isocentres 1 2
AL19 Couch deflection 3 5
AL20 Independent quality control review Complete

Tolerances and action levels are specified in millimetres unless otherwise stated
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes
Daily:
DL1-3 The configuration of these tests will depend on the design of the facility and equipment. Safety
is the concern and tests should be designed accordingly. As a minimum, manufacturer’s
recommendations and applicable regulations must be followed.
DL4-5 All energies in use on the particular treatment day. Standard local geometry.

Monthly:
ML1-4 The configuration of these tests will depend on the design of the facility and equipment. Safety
is the concern and tests should be designed accordingly. As a minimum, manufacturer’s
recommendations and applicable regulations must be followed.
ML5 Proper functioning of the emergency stop buttons, indicators and emergency circuits.
ML6 Alignment of crosswires and appropriate lasers for collimator angle 0°, gantry angles 0°, 90° and
270° at an SSD of SAD-10 cm
ML7 Gantry angle 0° and at the isocentre and at SSD of SSD-10cm, or similar range ML8
Gantry angle 0° and at the isocentre
ML9 Gantry angle 0°, 100cm SAD, field sizes of 5x5, 10x10, 20x20, max cm2
ML10 Virtual or dynamic wedge factors for at least one wedge angle to be verified, relative to open
beam outputs, for each photon energy.
ML11 Mechanical and digital gantry angle readouts must be verified using a spirit level, or other
appropriate levelling device, for at least 0°, 90°, 180° and 270°.
ML12 Mechanical and digital collimator angle readouts must be verified using a spirit level, or
other appropriate levelling device, for at least 0°, 90° and 270°.
ML13 Mechanical and digital couch position readouts must be verified over an appropriate clinical
range in the directions of the three cardinal axes.
ML14 Rotation of the couch about the optical collimator rotation axis must be verified.
ML15 The couch rotation angle must be verified over an appropriate clinical range.
ML16 The trajectory of the optical image of the crosswires is measured at the appropriate SSD for
collimator angles of 0°, 90° and 270°. Tolerances and Action Levels refer to the optical isocentre
so measured.
ML17 Geometric alignment of the radiation and optical field edges must be established at a clinically
relevant field size at a gantry angles 0°. The field size and energy employed should be varied
monthly.
ML18 Measurements at two depths in an appropriate phantom serve to confirm that depth dose has not
changed since commissioning the unit. Tolerances and Action Levels are specified in % for
photon beams and mm for electron beams. Clinically relevant depths are used for these
measurements
ML19-20 Flatness and symmetry are compared with those measured at acceptance. A single, convenient
gantry angle may be chosen.
ML21 Documentation relating to the daily quality control checks, preventive maintenance, service calls
and subsequent checks must be complete, legible and the operator identified.

Annual:
AL1 Physical integrity and centering of accessories, including physical wedges, trays and cones.
AL2 Latching and interlocks of accessories, including physical wedges, trays and cones.
AL3 The optical distance indicator should be checked over a clinically relevant range of SSD and gantry
angle. The tolerance and action level may be twice as large (i.e. 2 and 4mm) at the clinical limits
of the optical distance indicator’s range.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

AL4 Geometric alignment of the radiation and optical field edges must be established over
a range of field sizes at gantry angles 0°, 90° and 270°. Representative half blocked
fields must be included if available. A minimum of six field sizes will be required
for this test. Tolerances and Action Levels apply to each edge of a rectangular field.
AL5 Compliance of the radiation and optical field sizes with the indicated dimensions must be
established over a range of field sizes at gantry angles 0°, 90° and 270°. Jaw sizes
at six representative sizes, e.g. 0,5,10,20,30,max cm.
AL6 A full TRS-398 calibration is performed annually using a local primary standard. The
output of all available beams is then measured using the local secondary standard,
to provide a reference for daily readings.
AL7-9 These tests confirm that essential parameters used for treatment time calculations have
not changed. All accessories available in the treatment room must be checked.
AL8 Wedge factors to be checked for all dynamic, virtual and physical wedges, for all photon
energies. For non-physical wedges, this should be measured for at least four wedge
angles
AL10 An ion chamber with build-up cap may be used in air for these measurements. The
chamber may be positioned at the isocentre or may be mounted on the head of the
unit. In the latter case, effects due to head sag will not be observed.
AL11 Gantry angles of 0°, 90° and 270°, should be used.
AL12-13 From a series of radiation measurements with different monitor units the linearity
and the end monitor effect are determined.
AL14-16 Using film, star or spoke patterns are produced and the three radiation axes of
rotation are determined. Tolerances and Action Levels refer to the diameters so
measured.
AL17 By referencing the films in 14-16 above to the laser system the relative locations
of the three axes of rotation at the isocentre may be determined.
AL18 The radiation, optical and mechanical isocentres are determined with reference to
the laser system and their degree of coincidence determined.
AL19 Couch deflection is measured with 70 kg at the end with the couch extended to
the isocentre. AL20 To ensure redundancy and adequate monitoring, a second qualified
medical physicist must independently verify the implementation, analysis and interpretation
of the quality control
tests at least annually.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Program for Treatment Planning Systems

Designator Test Tolerance Action

Level
Patient-specific
PTPS1 Patient related data Data verified
PTPS2 Beam geometry Data verified
PTPS3 Dose distribution Data verified
PTPS4 MU/time per beam 2MU/2% 3MU/3%
PTPS5 Plan data transfer Data verified
Quarterly
QTPS1 CPU Functional
QTPS2 Digitizer (if it is used clinically) 2 mm 3 mm
QTPS3 Electronic plan transfer Data verified
QTPS4 Plan details Data verified
QTPS5 Plotter/Printer 2 mm 3 mm
QTPS6 Back up recovery Functional
QTPS7 Revalidation 2% 3%
Semi-Annual (Every 6 months)
STPS1 CT geometry/density 2 mm/.02 3 mm/.03
Commissioning
CTPS1 Independent quality control Complete
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes
PTPS1 Anatomical and contour data are current and for the correct patient; correct
orientation; target and OAR contours look reasonable.
PTPS2 Wedges correctly oriented; compensators and bolus included
as appropriate; tertiary blocking/MLC correctly oriented; plan normalization point
in an appropriate position.
PTPS3 Dose distribution looks reasonable for the beam geometry;
beam configuration achievable; plan objectives and constraints met as closely as
possible. Clearly the plan has to be consistent with the prescription and receive
approval by the Radiation Oncologist.
PTPS4 Independent check of MU or time per beam either manually or by an
independent computer program. Local tolerance and action levels may need to be
developed for complex geometries such as IMRT, thoracic and tangential breast
irradiation.
PTPS5 Prior to the first treatment, the treatment machine settings must be
compared with those used to generate the dose distribution.

Quarterly Tests

QTPS1 On rebooting the system on-screen messages must be checked for indications of
possible system malfunction. The system should be checked if error message is displayed during
routing rebooting process. Document the error message and fix.
QTPS2 Using the on-screen ruler check that a known contour has been digitized accurately.
QTPS3 Using a standard set of at least 3 clinical plans covering a range of treatment
configurations (e.g., photons, electrons, brachytherapy), confirm that the data are accurately transferred
from the TPS to the therapy machine.
QTPS4 Using a standard set of at least 3 clinical plans covering a range of treatment
configurations, confirm that the data are accurately transferred from the TPS to hard copy, or digital
copy for paperless environments.
QTPS5 Check the dimensions on the print out against the inputted contour and previous plots.
QTPS6 Check the integrity of data restored from recently backed up files.
QTPS7 Check the constancy of external beam dose calculations using a standard set of at
least 4 clinical plans covering a range of geometries. Evaluate using mu per field, maximum dose and
dose to isocentre

Semi-Annual Tests
STPS1 Check that the CT geometry and the relationship between CT number and density has
not changed. Tolerances and Action Levels are specified in mm/relative electron density. Under some
circumstances, for example volumes in close proximity to the optic nerve, tighter performance criteria
may be necessary.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

CommissioningTests

CTPS1 To ensure redundancy and adequate monitoring, a second qualified medical physicist
must independently verify the implementation, analysis and interpretation of the quality control tests.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Tests for Electronic Portal

Imaging Devices

Performance
Designator Test
Tolerance Action Value
Daily
DE1 Mechanical integrity Functional
DE2 Electrical integrity Functional
Monthly
ME1 Collision interlocks Functional
ME2 Positioning in the imaging plane 1 2
ME3 Image quality Reproducibility
ME4 Artifacts Reproducibility
ME5 Spatial distortion 1 2
ME6 Monitor controls Reproducibility
ME7 Records Complete
Annually
Positioning perpendicular to the imaging
AE1 10 20
plane
AE2 Spatial resolution Reproducibility
AE3 Noise Reproducibility
AE4 On screen measurement tools 0.5 1
AE5 Set-up verification tools 0.5, 0.5º 1, 1º
AE6 Independent quality control review Complete
Commissioning
CE1 Manufacturer’s Acceptance Testing Complete
CE2 DE1-2, ME1-6, AE1-5 As Above
CE3 Recall of archived data Functional

Tolerances and Action Levels are specified in millimetres unless otherwise stated
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes
Daily tests
DE1 The imager must be visually inspected for loose or damaged components.
DE2 The imager must be inspected for loose connectors, frayed cables or potential electrical hazard.

Monthly Tests

ME1 All collision prevention devices must be tested for correct operation.
ME3 A contrast detail phantom must be imaged at available x-ray energies and the most commonly
used acquisition mode. Visibility of the holes is compared with that at acceptance testing.
ME2 Alignment of the mechanical centre of the imager with the axis of collimator rotation must be
established at the four cardinal gantry angles.
ME4 Artefacts should be absent.
ME5 Spatial distortion across the imager is determined using a large grid.
ME6 The monitor must be checked for optimum focus, brightness and
contrast
ME7 Documentation relating to the daily quality control checks, preventive maintenance, service calls
and subsequent checks must be complete and legible.

Annual Tests

AE1 The distance of the imager from the X-ray source (or isocentre) must agree with that set or
indicated.
AE2 Using a high contrast bar pattern, or some similar device, the spatial resolution of the imager is
measured at least three representative positions and the values compared with those measured
at acceptance (for video based systems only).
AE3 An image of a uniform thickness attenuator is obtained under a standard exposure condition.
Using the imager’s software, the standard deviations of pixel values in three or more predefined
regions of interest are compared with the values measured at acceptance.
AE4 A geometrically accurate phantom is used to compare the system’s estimate of distance with the
true distance. The comparison should be made in orthogonal directions and at several locations
in the imaging plane. The Tolerance and Action Levels may need to be modified to
accommodate the actual pixel size of the unit of interest
AE5 Software tools which report spatial discrepancies between images should be checked.
AE6 A second qualified medical physicist must independently verify the implementation, analysis and
interpretation of the quality control tests at least annually.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Commissioning

CE1 Manufacturer’s acceptance testing protocol should be followed where available

CE2 All daily, monthly and annual tests should be conducted during acceptance testing and
tolerances levels established
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Tests for Multileaf

Collimators

Performance
Designator Test
Tolerance Action Value
Patient-specific
Verification of transferred data vs planned
PM1 1 2
field shape
PM2 Daily verification of correct data Reproducibility
Verification of record & verify
PM3 Reproducibility
programming
Monthly
MM1 Electron field interlocks Functional
Bi-Monthly (Every Two Months)
BM1 Light and radiation field coincidence 1 2
BM2 Leaf positions for standard field template 1 2
Annual
AM1 Leaf transmission (all energies) Reproducibility
AM2 Leakage between leaves (all energies) Reproducibility
AM3* Transmission through abutting leaves Reproducibility
AM4 Stability with gantry rotation Reproducibility
AM5 Alignment with jaws 1
AM6 Records Complete
AM7 Independent quality control review Complete

* May not apply to all MLC designs.

Tolerances and Action Levels are specified in millimetres unless otherwise stated
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes
Daily Tests

PM1 Comparison of the optical projection of the MLC field with a template, usually an
appropriately-scaled printout of a DRR or a BEV.
PM2 Daily comparison of a template with corresponding field on MLC monitor.
PM3 Verification of the programming of record-and-verify systems prior to first treatment.

Monthly Tests
MM1 Verify that electron beams cannot be turned on unless leaves are retracted

Bi-Monthly Tests
BM1 For MLCs with rounded leaf edges, the optical field may be smaller than the radiation
field.
A standard irregular shaped field may be verified.
BM2 Light projection of an irregular MLC shaped field involving all leafs onto a standard
template. The displayed leaf positions should match those of the x- ray field.
.

Yearly tests
AM1,2,3 Best achieved with film. Average and maximal transmission should be reported.
AM4 With the gantry at 90 or 270 degrees, irradiate film placed at isocentre with long, narrow
field defined by MLC. Exposures should be made with the leaves vertical and the collimator
rotated ± 60 degrees.
AM5 Use a large field with one leaf from each leaf bank protruding well into the field. The
parallelism with the collimator edge is checked on film.
AM6 Documentation relating to the daily quality control checks, preventive maintenance, service
calls and subsequent checks must be complete, legible and the operator identified.
AM7 To ensure redundancy and adequate monitoring, a second qualified medical physicist must
independently verify the implementation, analysis and interpretation of the quality control
tests at least annually.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Program for Intensity

Modulated Radiotherapy

Performance
Designator Test
Tolerance Action Value
Commissioning
CIM1 Leaf position transfer per segment Correct 1
CIM2 Mu per segment transfer Correct 0.1 mu
CIM3 Back-up diaphragm transfer where present Correct 1
Non-coplanar gantry, diaphragm and couch
CIM4 Correct 1º
transfer
CIM5 Interleaf transmission model 2% 5%
Fluence map relative reproduction
CIM6 2% / 1 mm 3% / 3mm
(dose or distance) in uniform phantom
Composite relative dose reproduction
CIM7 2% / 1 mm 3% / 2mm
(dose or distance) in uniform phantom
Composite absolute dose reproduction
CIM8 2% 3%
(dose or distance) in uniform phantom
Composite absolute dose reproduction
CIM9 2% 3%
(dose or distance) in non-uniform phantom
CIM10 Small field output model 2% 3%
CIM11 Records Complete
Patient Specific
Fluence map relative reproduction
PIM1 3% / 2 mm 5% / 3mm
(dose or distance)
Absolute dosimetry at a clinically relevant
PIM2 point 3% / 2 mm 5% / 3mm
PIM3 Records Complete

Tolerances and Action Levels are specified in millimetres unless otherwise stated
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes

Commissionin

g Tests
CIM1 Numerical value of each leaf for each segment is transferred to linac
correctly CIM2 Numerical value of monitor units for each segment is transferred to
linac correctly
CIM3 Numerical value of backup diaphragms transferred to linac correctly, where
available CIM4 Numerical value of gantry, collimator and couch position is transferred to
linac correctly CIM5 Interleaf transmission agrees with TPS model
CIM6 Fluence maps for all fields are reproduced in a uniform phantom, with a distance
or dose to agreement not more than tolerances shown
CIM7 The total summed dose distribution, from all fields of an IMRT plan, , is
reproduced in a uniform scanned phantom, and compared to the planned summed
dose distribution. Can be measured using relative dosimetry techniques such as
EPID, film or diode/ion chamber arrays
CIM8 The total absolute dose, of all summed fields treated, is reproduced in a uniform
scanned phantom, at a point in a region of low dose gradient. Must be measured
using absolute dosimetry techniques such as a temperature pressure corrected ion
chamber reading
CIM9 As for CIM8, in a phantom with non-uniform density, such as lung inserts.
CIM1-9 Test compliance should be established for at least 10 patients before
commissioning can be considered complete.
CIM10 Small field output model agrees with measurement down to smallest segment
employed

Patient Specific Tests

PIM1 As for CIM6
PIM2 Dose measurement may be performed using ion chamber arrays, a single ion
chamber measurement or any other device suitable for absolute dosimetry
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Program for Dosimetry devices

Major Dosimetry
Devices for Absolute Dosimetry
Secondary Standard (Chamber and Electrometer Combination)
Designator Test Tolerance Measurement Initial
Before Initial Use and following Chamber Repair
ISS1 Extra–cameral signal 0.5% 1.0%
(Stem effect)
ISS2 Linearity 0.5% 1.0%
ISS3 Leakage 0.1% 0.2%
At each use
ESS1 Reproducibility 0.2% 0.5%
Bi-ennial (every two years)
BSS1 Calibration at STD lab Every two years

Field Standard (Chamber and Electrometer Combination)

Designator Test Tolerance Measurement Initial
Before Initial Use and following Chamber Repair
IFS1 Extra –cameral signal 0.5% 1.0%
(Stem effect)
IFS2 Linearity 0.5% 1.0%
IFS3 Leakage 0.1% 0.2%
Semi-Annual
SFS1 Signal Reproducibility 0.2% 0.5%
Annual
AFS1 Cross calibration Characterize & document

Devices for Relative Dosimetry

TLD systems
Designator Test Tolerance Measurement Initial
Initial Use or following malfunction and repair
IRD1 Linearity or supralinearity Characterize and document
At each use
ERD1 Individual calibration Characterize and document

Film dosimetry systems

Initial Use or following malfunction and repair
Designator Test Tolerance Measurement Initial
IRD2 Dose response curve Characterize and document
IRD3 Film reader linearity Characterize and document
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT
Diode Systems
Initial Use or following malfunction and repair
Designator Test Tolerance Measurement Initial
IRD4 Linearity Characterize and document
IRD5 Energy Dependence Characterize and document
IRD6 Angular dependence Characterize and document
Monthly
MRD1 Calibration 2% 3%

Automated beam scanning devices and detector arrays

Initial Use or following malfunction and repair
Designator Test Tolerance Measurement Initial
IBS1 Alignment Characterize and document
IBS2 Hysteresis Characterize and document
IBS3 Orthogonality Characterize and document
Annual
ABS1 Positional accuracy 1 mm 2 mm
Detectors
Initial Use or following malfunction and repair
IBS4 Extra –cameral signal (Stem 0.5% 1.0%
effect)
Annual
ABS3 Collection Potential 0.5% 1.0%
Reproducibility
ABS4 Leakage 0.5% 1.0%
ABS5 Linearity 0.5% 1.0%
Data acquisition / analysis
Initial Use or following malfunction and repair
IBS5 Scan speed insensitivity Characterize and document
IBS6 Agreement with static 1.0% 2.0%
measurements
IBS7 Symmetry / Flatness 1.0% 2.0%
calculations
IBS8 Energy / Bremsstrahlung 1.0% 2.0%
calculations.
IBS9 Ionization-to-dose 1.0% 2.0%
calculations.
IBS10 Accuracy of output 1 mm 2 mm
(soft and hardcopy)
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Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Devices

Diode Arrays
Initial Use or following malfunction and repair
Designator Test Tolerance Measurement Initial
IQD1 Accuracy 1 mm 2 mm
IQD2 Linearity (Dose & Dose rate) Characterize and document
IQD3 Agreement with static 1.0 % 2.0 %
measurements.
IQD4 Symmetry / Flatness 1.0 % 2.0 %
calculations
IQD5 Accuracy of output 1 mm 2 mm
(soft and hardcopy)
Annual
AQD1 Energy Dependence Characterize and document
AQD2 Energy Dependence Characterize and document
calibration

Phantom materials
Initial Use
Designator Test Tolerance Measurement Initial
IPM1 Physical density, composition, Characterize and document
electron density, homogeneity
IPM2 Dimensions of slabs of pieces Characterize and document
IPM3 Homogeneity, internal defects Characterize and document
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes
General: Where two tolerance levels are given, the first is the tolerance and the second the action
level.
ISS1-ISS3: Tolerances based on AAPM TG-40. Action levels are suggested and may be modified
based on experience. Suggested methods for measurement may be found in AAPM
TG-51.
ESS1: Based on AAPM TG-40.
BSS1: Based on AAPM TG-40.
IFS1-IFS3: Tolerances based on TG-40. Action levels are suggested and may be modified based on
experience. Suggested methods for measurement may be found in AAPM TG-51.
IFS6: Based on local experience.
SFS1 / 2: Based on local experience and AAPM TG-40.
AFS1: Modified frequency from AAPM TG-40 based on local experience.
IRD1&ERD1: Based on AAPM TG-40.
IRD2-IRD3: Can be established using classic H&D curve at initial use. Each batch film changed
should be remeasured
ARD1 Based on AAPM TG-40.
ARD2: Based loosely on AAPM TG-40 and local experience.
IRD4-IRD6: Based on AAPM TG-40.
IBM1: Certificates are retained for reference devices.
IBM2: Field devices are compared to reference devices prior to initial use.
IBM3&ABM1Field devices are checked against reference devices every year except for barometers.
Barometers are checked every 3 months (see AAPM TG-40).
IBS1-IBS3: Based on clinical experience. Tolerances on the order of 0.5 mm are probably
acceptable. Acceptance test criteria may be provided by the vendor as a guideline.
ABS1: Based on local experience. Users may adapt and document criterion to local needs.
IBS4: Based on IFS1 with looser criteria.
ABS3: Based on similar criteria for IFS5.
ABS4 & 5: Based on similar criteria for IFS4 and IFS3.
IBS5-IBS10: Tests based on clinical experience and may be modified to meet the user criteria. Tests
may also be modified to follow the vendors’ acceptance test criteria.
IQD1-IQD5: Based loosely on IBS5 to IBS10 and AAPM TG-40. In addition the manufacturers’
acceptance test procedures may be used to modify the users’ criteria.
AQD1&2 If devices are used across a range of beam energies, care must be taken to ensure the
correct calibration factors are applied. Verification and inspection once a year based
loosely on AAPM TG-40.
IPM1-IPM3 Inspection and radiographic verification prior to use is recommended. The tolerance
depends on the intended use of the material and may be appropriately chosen by the
user.
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Program for Record and

Verify Systems

Performance
Designator Test
Tolerance Action Value
Commissioning
Enter site details, assign user rights to users
CRV1
and groups
CRV2 Verification of treatment parameters Correct
CRV3 Lightfield tests Correct
Patient Specific
PRV1 Verification of treatment parameters Correct
PRV2 Verification of dose recording Correct
Weekly
WRV1 Back-ups

Tolerances and Action Levels are specified in millimetres unless otherwise stated

Notes

Commissioning

Tests

CRV1 For safety purposes, assign appropriate user rights

CRV2 Export treatment plans to R&V system and to treatment system to check correct
transport of treatment parameters, at least for MU, couch angle, gantry angle,
collimator angle, position of X and Y jaws, energy, start and stop angles for arcs (if
applicable)
CRV3 The lightfield test needs to be performed by sending fields/collimator files via an R&V
system to the linac testing the complete treatment transfer chain. Test for conformal
beam, conformal arc, dynamic conformal arc, IMRT beam. Test orientation.

Patient Specific Tests

PRV1 Export treatment plans to R&V system and to treatment system to check correct
transport of treatment parameters, at least for MU, couch angle, gantry angle,
collimator angle, position of X and Y jaws, energy, start and stop angles for arcs (if
applicable)
PRV2 Check that dose records for every field treated

Weekly Tests

WRV1 System back-up

 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Quality Assurance Program for Cobalt-60 Units

Performance
Designator Test
Tolerance Action Value
Daily
DCO1 Door interlock/last person out Functional
DCO2 Beam status indicators Functional
DCO3 Patient audio-visual monitors Functional
DCO4 Lasers/cross-wires 1 2
DCO5 Optical distance indicator 1 2
DCO6 Optical back pointer 2 3
DCO7 Field size indicator 1 2
Monthly
MCO1 Motion interlock Functional
MCO2 Couch brakes Functional
MCO3 Room radiation monitors Functional
MCO4 Emergency off Functional
MCO5 Beam interrupt/ counters Functional
MCO6 Head swivel lock Functional
MCO7 Wedge, tray interlocks Functional
MCO8 Gantry angle readouts 0.5° 1°
MCO9 Collimator angle readouts 0.5° 1°
MCO10 Couch position readouts 1 2
MCO11 Couch rotation isocentre 2 3
MCO12 Couch angle 0.5° 1°
MCO13 Optical distance indicator 1 2
MCO14 Crosswire centering 1 2
MCO15 Light/Radiation coincidence 2 3
MCO16 Field size indicator 1 2
MCO17 Relative Dosimetry 1% 2%
MCO18 Records Complete
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Annually
ACO1 Accessories integrity and centering Functional
ACO2 Reference dosimetry 1% 2%
ACO3 Relative output factor reproducibility 1% 2%
ACO4 Central axis depth dose reproducibility 1% 2%
ACO5 Wedge transmission factor reproducibility 1% 2%
Accessory transmission factor
ACO6 1% 2%
reproducibility
Light/Radiation coincidence vs. gantry
ACO7 2 3
angle
ACO8 Field size indicator vs. gantry angle 1 2
ACO9 Output reproducibility vs. gantry angle 1% 2%
Beam symmetry reproducibility vs gantry
ACO10 2% 3%
angle
ACO11 Timer linearity 1% 2%
ACO12 Shutter error 0.03 min 0.05 min
ACO13 Collimator rotation isocentre 2 3
ACO14 Gantry rotation isocentre 2 3
ACO15 Couch rotation isocentre 2 3
Coincidence of collimator, gantry, couch
ACO16 2 3
axes
ACO17 Coincidence of isocentres 2 3
ACO18 Couch deflection 3 5
ACO19 Independent quality control review Complete

Tolerances and Action Levels are specified in millimetres unless otherwise stated
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes

Daily Tests

DCO1-3 The configuration of these tests will depend on the design of the facility and equipment.
Safety is the concern and tests should be designed accordingly. As a minimum,
manufacturer’s recommendations and applicable regulations must be followed.
DCO4 Alignment of cross-wires and appropriate lasers for collimator angle 0º, gantry angles 0º,
90º and 270º at an SSD of SAD – 10cm.
DCO5 Gantry angle 0º and an SSD of SAD – 10cm.
DCO6 Gantry angle 0º and an SSD of SAD+10cm
DCO7 Gantry angle 0º, nominal SAD, field sizes of 10x10 and 20x20 cm

Monthly Tests

MCO1-6 The configuration of these tests will depend on the design of the facility and equipment.
Safety is the concern and tests should be designed accordingly. As a minimum,
manufacturer’s recommendations and applicable regulations must be followed.
MCO7 Proper functioning of the accessories and indicators
MCO8 Mechanical and digital gantry angle readouts must be verified using a spirit level, or
other appropriate levelling device, for at least 0º, 90º, 180º and 270º
MCO9 Mechanical and digital collimator angle readouts must be verified using a spirit level, or
other appropriate levelling device, for at least 0º, 90º and 270º.
MCO10 Mechanical and digital couch position readouts must be verified over an appropriate
clinical range in the directions of the three cardinal axes.
MCO11 Rotation of the couch about the optical collimator rotation axis must be verified
MCO12 The couch rotation angle must be verified over an appropriate clinical range.
MCO13 A mechanical device, calibrated against the true radiation isocentre, is used to provide
the base reading for the check of the optical distance indicator. The standards stated in
the Table apply at the isocentre. The optical distance indicator should be checked over a
clinically relevant range of SSD and gantry angle. The tolerance and action level may be
twice as large (i.e. 2 and 4 mm) at the clinical limits of the optical distance indicator’s
range.
MCO14 The trajectory of the optical image of the cross-wires is measured at the appropriate SSD
for collimator angles of 0º, 90º and 270º. Tolerances and Action Levels refer to the
diameter of the optical isocentre so measured.
MCO15 Geometric alignment of the radiation and optical field edges must be established over a
clinically relevant range of field sizes at gantry angle 0º.
MCO16 Compliance of the radiation and optical field sizes with the indicated dimensions must
be established over a clinically relevant range of field sizes at gantry angle 0º.
MCO17 Although the radiation output (cGy/min) from a Co-60 unit should decay at a known
rate, it is necessary to confirm this regularly to ensure that no unexpected changes have
occurred (e.g. malfunction of shutter or source transport mechanism).
MCO18 Documentation relating to the daily quality control checks, preventive maintenance,
service calls and subsequent checks must be complete, legible and the operator identified
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

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RADIOTHERAPY DEPARTMENT
Annual Tests

AC01 Proper functioning of accessories and indicators

ACO2 A full TRS398 calibration is performed annually.
ACO3-6 These tests confirm that essential parameters used for treatment time calculations have
not changed due to, for example, a wedge being remounted. All accessories available in
the treatment room must be checked.
ACO7 Geometric alignment of the radiation and optical field edges must be established over a
range of field sizes at gantry angles 0º, 90º and 270º. Representative half blocked fields
must be included if available. A minimum of six field sizes will be required for this test.
ACO8 Compliance of the radiation and optical field sizes with the indicated dimensions must
be established over a range of field sizes at gantry angles 0º, 90º and 270º.
Representative half blocked fields must be included if available. A minimum of six field
sizes will be required for this test. Different field sizes may be examined at different
gantry angles if appropriate and efficient.
ACO9 An ion chamber with build-up cap may be used in air for these measurements. The
chamber may be positioned at the isocentre or may be mounted on the head of the unit.
In the latter case, effects due to head sag will not be observed.
AC10 Film and optical densitometry is used to confirm symmetry of the radiation output and
hence proper centering of the source with respect to the primary collimator. A large field,
e.g. 30x30cm2, and gantry angles of 0º, 90º and 270º should be used.
ACO11, 12 From a series of radiation measurements with different set times the timer linearity and
the timer offset or shutter errors are determined.
ACO13-15 Using film, star or spoke patterns are produced and the three radiation axes of rotation
are determined. Tolerances and Action Levels refer to the diameters so measured.
ACO16 By referencing the films in 13-15 above to the laser system the relative locations of the
three axes of rotation at the isocentre may be determined
ACO17 The radiation, optical and mechanical isocentres are determined with reference to the
laser system and their degree of coincidence determined.
ACO18 Couch deflection is measured with 70kg at the end with the couch extended to the
isocentre.
ACO19 To ensure redundancy and adequate monitoring, a second qualified medical physicist
must independently verify the implementation, analysis and interpretation of the quality
control tests at least annually.

Main References:

- IPEM Report 81: “Physics Aspects of Quality Control in Radiotherapy”

- AAPM Report 46: “Comprehensive QA for Radiation Oncology”
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Radiation Protection

Performance
Designator Test
Tolerance Action Value
Annual Linac
ARP1 Skyshine DoH Licensing Limits*
ARP2 Wall penetration DoH Licensing Limits*
ARP3 Roof penetration DoH Licensing Limits*
ARP4 Door/maze penetration (neutron) DoH Licensing Limits*
ARP5 Door/maze penetration (x-rays) DoH Licensing Limits*
Annual Cobalt / CT / Simulator / Contact / HDR
ARP6 Wall penetration DoH Licensing Limits*

ARP7 Roof penetration DoH Licensing Limits*

ARP8 Door/maze penetration DoH Licensing Limits*
Daily
DRP1 Room area monitor (where required) Functional
DRP2 Radiation ON lights Functional
Weekly
Pregnant personnel monitored with direct
WRP1 DoH Licensing Limits
read digital dosimeter
Monthly
MRP1 Radiation worker monitoring DoH Licensing Limits
MRP2 Radiation warning signs in place Functional
Annually
ARP1 Survey meter calibration Performed
ARP2 Lead apron (where required) in tact Physical
ARP3 Lead apron (where required) image X Ray
Magnitude equal to local
ARP4 Swipe test of all radionuclides
background
ARP5 Documentation Complete
Bi-Ennially (Every Two Years)
BRP1 Room area monitor calibration Performed
BRP2 Digital dosimeter Performed
Commissioning
CRP1 ARP1-8, DRP1-2, MRP2, ARP1-4, BRP1-2
 Document: Quality assurance program for RT equipment

Source: South African Standards for QA in RT

Version: 1.0
RADIOTHERAPY DEPARTMENT

Notes:

ARP1-8 Department of Health Directorate of Radiation Control Licensing Conditions

and Dose Limits. Calculated based on room usage, beam output, classification
of individuals at risk of exposure etc
ARP1 Calibration performed by SSDL or through documented cross calibration
with meter calibrated by SSDL
ARP3 Lead apron should be imaged using kV X rays to check integrity upon
failure of a physical check
ARP5 Documentation should include radiation survey readings, radiation worker
medical reports, monthly radiation worker readings, pregnant worker monitoring
and swipe test results
BRP1-2 Calibration performed by SSDL or through documented cross calibration
with meter calibrated by SSDL
CRP1 Tests performed as relevant to equipment being commissioned