Medical Physics - 2021 - Hanley

Received: 9 February 2021 | Revised: 16 March 2021 | Accepted: 28 April 2021
DOI: 10.1002/mp.14992
AAPM SCIENTIFIC REPORT
AAPM Task Group 198 Report: An implementation guide

for TG 142 quality assurance of medical accelerators
Joseph Hanley1 | Sean Dresser2 | William Simon3 | Ryan Flynn4 |

Eric E. Klein5 | Daniel Letourneau6 | Chihray Liu7 | Fang- Fang Yin8 |
Bijan Arjomandy9 | Lijun Ma10 | Francisco Aguirre11 | Jimmy Jones12 |
John Bayouth13 | Todd Holmes14
1
Princeton Radiation Oncology, Monroe, Abstract
New Jersey 08831, USA
2
Winship Cancer Institute, Radiation
The charges on this task group (TG) were as follows: (a) provide specific proce-
Oncology, Emory University, Atlanta, dural guidelines for performing the tests recommended in TG 142; (b) provide es-
Georgia 30322, USA
3
Sun Nuclear Corp, Melbourne, Florida
timate of the range of time, appropriate personnel, and qualifications necessary
32940, USA to complete the tests in TG 142; and (c) provide sample daily, weekly, monthly,
4
Department of Radiation Oncology,
University of Iowa, Iowa City, Iowa, 52242,
or annual quality assurance (QA) forms. Many of the guidelines in this report are
USA drawn from the literature and are included in the references. When literature was
5
Brown university, Rhode Island Hospital,
Providence, Rhode Island 02905, USA
not available, specific test methods reflect the experiences of the TG members
6
Princess Margaret Cancer Centre, (e.g., a test method for door interlock is self- evident with no literature necessary).
Toronto, M5G 2M9, Canada
7
In other cases, the technology is so new that no literature for test methods was
University of Florida, Gainesville, Florida
32610- 0385, USA available. Given broad clinical adaptation of volumetric modulated arc therapy
8
Department of Radiation Oncology, Duke (VMAT), which is not a specific topic of TG 142, several tests and criteria specific
University Medical Center, Durham, North
Carolina 27710, USA to VMAT were added.
9
Karmanos Cancer Institute at McLaren-
Flint, Flint, Michigan 48532, USA KEYWORDS
10
Department of Radiation Oncology, accelerator, QA, quality assurance, radiotherapy
University of California San Francisco,
San Francisco, 94143- 0226, USA
11
MD Anderson Cancer Center, Mansfield,
OH 44907, USA
12
Department of Radiation Oncology, The
University of Colorado Health— Poudre
Valley, Fort Collins, Colorado 80525, USA
13
Department of Human Oncology, School
of Medicine and Public Health, University
of Wisconsin— Madison, Madison,
Wisconsin 53792- 0600, USA
14
Varian Medical Systems, Palo Alto,
California 94304, USA
Author to whom correspondence should

be addressed. Electronic mail: joseph.
hanley@asterahealthcare.org; Telephone:
609- 655- 5755.
Consultants: Carlos Sandin (Elekta)

TG 198 was constituted by the AAPM, Science Council, Therapy Physics Committee, and Quality Assurance and Outcome Improvement Subcommittee.
© 2021 American Association of Physicists in Medicine
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Medical Physics. 2021;00:1–56. |
Medical Physics. 2021;48:e830–e885.
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REPORT OF AAPM TASK
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2 |
TASK GROUP 198 REPORT 2 TASK GROUP 198 REPORT
e831
Table of Contents 1 Contents

| STATE M ENT O F TH E PRO BLE M verifica
Contents A ND TG CH A RG ES jority
2.C.4.1. Beam output constancy
proxim
1 INTRODUCTION An2.C.4.2. Phase, displacement
independent magnitude beamunits
check of dose/monitor controlhas been verifica
1.A. Purpose and continue
2.C.4.3. In-room torespiratory
be an important
monitoringpart
systemof quality assur- time. T
1.B. Background ance (QA)
2.C.4.4. for interlock
Gating patient treatment plans. AAPM Report in the
2 QA OF MEDICAL ACCELERATORS Task
2.C.5. volumetric reports
Group 71 modulatedon arcthe formalism
therapy (VMAT) for calculat- most c
1
2.A. General ing2.C.5.1.
monitor units. AAPM Task
Test patient-specific VMAT QA
Group 114 reports on ported
methods and requirements for verification of data for CA). T
2.A.1. Clarifications and deviations from TG 142 2.D. Annual
conformal external beam plans.2 The need for mon- of the
2.A.1.1. Test frequency
itor2.D.1.
unitDosimetry
verification programs was identified early in criteria
2.A.1.2. Daily or weekly QA the2.D.1.1. Photonofflatness
adoption IMRTand symmetryplanning and delivery
treatment IMRT (
3
2.A.1.3. Monthly QA techniques.
2.D.1.2. Electron Several
flatnessdifferent types of programs were
and symmetry though
2.A.1.4. Annual QA developed
2.D.1.3. Photon or electron output calibrationof dose at a sin-
ranging from confirmation rate. M
2.A.2. Documentation gle2.D.1.4.
pointOutput
in a simple
factors phantom geometry to calculation their ca
2.B. Daily
of dose at a single point while taking patient anatomy (3D) v
2.D.1.5. Photon beam quality
and geometry into consideration. While these programs measu
2.B.1. Dosimetry 2.D.1.6. Electron beam quality
have been in use for some time, guidance was lacking (DLG)
2.B.1.1. Photon and electron output constancy
in 2.D.1.7.
how toPhysical
commissionwedge transmission factor
such technologies as well as their missio
2.B.2. Mechanical role as part
2.D.1.8. MU of an IMRT QA program as was noted in the
linearity cation
2.B.2.1. Laser localization ASTRO
2.D.1.9. white
Photonpaper entitled
output versus “Safety
dose rate Considerations for in use
4,5
2.B.2.2. Optical distance indicator (ODI) IMRT”.
2.D.1.10. Output constancy versus gantry angle gorithm
2.B.2.3. Collimator size indicator This task group was charged with: (a) Reviewing
2.D.1.11. Off-axis factor constancy versus gantry angle
with m
2.B.3. Safety
and evaluating the algorithms for “independent/second troduc
2.D.1.12. Arc mode
check” of monitor unit calculations for IMRT; (b) Making as 3D
2.B.3.1. Door interlock 2.D.1.13. TBI/TSET mode
recommendations on the clinical implementation of cal- users
2.B.3.2. Door closing safety 2.D.1.14.programs
culation TBI/TSET TMR/PDD and OAFof
(e.g., number constancy
points, locations, when i
2.B.3.3. Audiovisual monitor accuracy, evaluation
2.D.1.15. TBI/TSET methods,
output and heterogeneities); (3)
calibration
2.B.3.4. Stereotactic interlocks Describing commissioning
2.D.1.16. TBI/TSET accessoriesand benchmark QA of sec-
2.B.3.5. Radiation area monitor (if used) ondary MU calculation
2.D.2. Mechanical programs, proposing additional 2 |
2.B.3.6. Beam- on indicator measurements, if necessary;
2.D.2.1. Collimator rotation isocenter
and (4) Describing clini- MU V
2.C. Monthly
cal testing and periodic QA of secondary MU calcula- CO M
2.D.2.2. Gantry rotation isocenter
tion programs and recommendations on test tolerance.
2.C.1. Dosimetry 2.D.2.3. Treatment couch
The terminology rotation
used in isocenter
this report follows that 2.1 |
2.C.1.1. Photon and electron output constancy used in other
2.D.2.4. Electron AAPM Task
applicator Group reports including in
interlocks
2.C.1.2. Backup monitor chamber constancy particular:
2.D.2.5. Coincidence of radiation and mechanical isocenter The im
2.C.1.3. Typical dose rate output constancy 2.D.2.6. Treatment couch top flex as IMR
2.C.1.4. Photon and electron beam profile constancy 1. 2.D.2.7. indicatescouch
Shall Treatment a procedure
angle that is essential for the com
2.C.1.5. Electron beam energy constancy
either (a) establishment of uniform practices, or potenti
2.D.2.8. Treatment couch maximum range
(b) the most safe and effective result and/or main- of radi
2.C.2. Mechanical 2.D.2.9. Stereotactic accessories or lockouts
taining established standards of practice to ensure therefo
2.C.2.1. Light or radiation field coincidence (symmetric and 2.D.3. Safety
the accuracy of dose/MU determination. verifica
asymmetric)
2. 2.D.3.1. indicates
ShouldFollow an advisory
manufacturer’s recommendation that
test procedures rors b
2.C.2.2. Lasers is to be applied when practicable. The task group measu
2.D.4. Respiratory gating
2.C.2.3. Gantry or collimator angle favors the indicated procedure but understands that deliver
2.D.4.1. Beam energy constancy
2.C.2.4. Accessory trays there are other procedures which can
2.D.4.2. Temporal accuracy of phase or displacement
accomplish tion ch
2.C.2.5. Jaw position indicators the same goal.
magnitude gate onDeviations from the recommended rays. E
2.C.2.6. Crosshair centering procedure should only be carried out after careful
2.D.4.3. Calibration of surrogate for respiratory phase or
advanc
analysis
displacement magnitude that an equivalent result will
demonstrates in both
2.C.2.7. Treatment couch position indicators
be produced.
2.D.4.4. Interlock testing
shown
2.C.2.8. Wedge placement accuracy
3. May indicates a statement that is likely (or probably) plans.6
2.C.2.9. Compensator placement accuracy 2.D.5. volumetric modulated arc therapy (VMAT)
to be correct but the task group does not make any ity of o
2.D.5.1. Test patient-specific VMAT QA constancy
2.C.2.10. Latching of wedges, blocking tray recommendations. pretrea
2.C.3. Safety 2.D.5.2. Interruption test ment p
2.C.3.1. LaserGuard or touch guard— interlock test As Dynamic,
2.E. part of virtual,
this work, the wedges
or universal AAPM community was of pati
2.C.4. Respiratory gating
surveyed
2.E.1. Enhanced dynamic wedges the type of software
in 2012 regarding niques
being used. According to the responses, a dose/MU cation
REPORT OF AAPM TASK GROUP 219 ON INDEPENDENT CALCULATION- BASED DOSE/
|
2 GROUP 198 REPORT
TASK
e832 MU VERIFICATION FOR IMRT
3
TASK GROUP 198 REPORT |
1 | STATE M ENT O F TH E PRO BLE M
Contents verification
Contents program was generally used for the ma-
A N D TG CH A RG ES jority of IMRT/VMAT treatment plans although ap-
2.E.1.1. Daily checks 2.G.5.2. Spatial resolution, contrast, Hounsfield unit constancy,
proximately 31% of responders did not use dose/MU
2.E.1.2. Monthly checks uniformity, and noise
An independent check of dose/monitor units has been verification software for VMAT treatment plans at that
2.G.6. Annual— MV imaging (EPID)
and continue
2.E.1.3. to be
Annual checks an important part of quality assur- time. The most common commercial system reported
anceUniversal
2.E.2. (QA) for wedgepatient treatment plans. AAPM Report 2.G.6.1.
in theFull range ofwas
survey travelRadCalc
SDD (Lifeline, Tyler, TX). The
2.E.2.1. Daily checks reports on the formalism for calculat-
Task Group 71 most Imaging
2.G.6.2. common dosetreatment planning system (TPS) re-
ing monitor units.1 AAPM Task Group 114 reports on
2.E.2.2. Monthly checks
ported
2.G.7. in the
Annual— survey was Eclipse (Varian, Palo Alto,
kV imaging
methods and requirements for verification of data for CA). This is not
2.G.7.1. Beam quality or toenergy
be considered as an endorsement
2.E.2.3. Annual checks
conformal external beam plans.2 The need for mon- of these products.
2.G.7.2. Imaging dose
The most common passing rate
2.E.3.
itor Siemens virtual wedge
unit verification programs was identified early in criteria for dose/MU verification software was 5% for
2.E.3.1. Daily checks 2.G.8. Annual— CBCT (kV and MV)
the adoption of IMRT treatment planning and delivery IMRT (51%) and “None Specified” for VMAT (34%), al-
3 2.G.8.1. Imaging dose
techniques.
2.E.3.2. Several different types of programs were
Monthly checks though 30% of VMAT responders used 5% as passing
2.E.3.3. Annual checks from confirmation of dose at a sin-
developed ranging 3.rate.
SUMMARYMoreOF RECOMMENDATIONS
than 50% of users used OR a single point for
IMPLEMENTATION SCHEME
gleMultileaf
2.F. point collimators
in a simple phantom geometry to calculation
(MLCs) their calculations and only 6% used three- dimensional
of dose at a single point while taking patient anatomy (3D) volumetric dose in the 2012 survey. Additional
2.F.1. Weekly
and geometry into consideration. While these programs measurements (typically the MLC dosimetric leaf gap
2.F.1.1. Qualitative test (Picket Fence)
have been in use for some time, guidance was lacking 1 (DLG)
| I NTROmeasurements)DUCTIwere O N also required during com-
2.F.2. Monthly
in how to commission such technologies as well as their missioning. The most common IMRT dose/MU verifi-
role as
2.F.2.1. part
Leaf of anaccuracy
position IMRT QA (non-program
IMRT) as was noted in the 1.A cation calculation algorithm represented by software
| Purpose
ASTRO
2.F.2.2. white
Backup paper entitled
diaphragm settings “Safety Considerations for in use at the time was a “factor- based calculation al-
4,5
IMRT”.
2.F.2.3. Leaf travel speed Thegorithm.”
American Note that the clinical
Association practiceinhas
of Physicists changed,
Medicine
This task group was charged with: (a) Reviewing
2.F.2.4. Leaf position accuracy (IMRT)
with more widespread use
(AAPM) Task Group (TG) 142 report, “Quality of VMAT as well
1 as the in-
and evaluating the algorithms for “independent/second troduction and adoption of new
Assurance of Medical Accelerators,” published in 2009, software tools (such
2.F.3. Annual
check” of monitor unit calculations for IMRT; (b) Making updated table II of TG 40 with respect to frequency so
as 3D volumetric calculation
2 systems) since 2012,
2.F.3.1. MLC transmission
recommendations on the clinical implementation of cal- andusers should of
tolerances consider
existingthe age and context
procedures. It alsoofadded
the data
2.F.3.2. Leaf programs
culation position repeatability
(e.g., number of points, locations, when interpreting the survey.
recommendations for quality assurance (QA) of an-
accuracy,
2.F.3.3. evaluation
MLC spoke shot methods, and heterogeneities); (3) cillary devices [asymmetric jaws, multileaf collimators
Describing
2.F.3.4. commissioning
Coincidence and
of light- radiation benchmark QA of sec-
fields (MLCs), dynamic or virtual wedges] that were not cov-
ondary MU calculation
2.F.3.5. Moving window IMRT programs, proposing additional ered2 in|TGRO 40. LE O F DOSE / made in TG 142
The recommendations
measurements,
2.G. Radiographic imaging
if necessary; and (4) Describing clini- M U V ER I FI
were dependent on the types CATI O NS IN A
of procedures performed
cal testing and periodic QA of secondary MU calcula- CO M PR EH ENSI V
on the linear accelerator (linac). Separate E Q A PROGtests R AM and
2.G.1. Daily— kV and MV (EPID) imaging
tion programs and recommendations on test tolerance. tolerances were recommended based on whether spe-
cial2.1 | Review such asof the problem
2.G.1.1.
TheCollision interlocks used in this report follows that
terminology programs stereotactic radiosurgery (SRS),
used Positioning
2.G.1.2. in other AAPM Task Group reports including in
or repositioning
stereotactic body radiotherapy (SBRT), total body irra-
particular:
2.G.1.3. Imaging and treatment coordinate coincidence The (TBI)/total
diation implementation of new therapy
skin electron treatment techniques
(TSET), respira-such
2.G.2. Daily— CBCT (kV and MV) as IMRT/VMAT in a radiotherapy
tory gating, or intensity-modulated radiotherapy (IMRT) department increases
1. Shall
2.G.2.1. indicates
Collision a
interlocks procedure that is essential for weretheperformed
complexities oninthe planning
linac. The and delivery and thus, the
tightest tolerances
either (a) establishment of uniform practices, or potential for serious errors
are reserved for SRS/SBRT treatments, as they in the planning andaredelivery
ex-
2.G.2.2. Positioning or repositioning
(b) the most safe and effective result and/or main- of radiotherapy. An effective
quisitely sensitive to treatment machine errors. set of QA procedures
3– 5
For is
2.G.2.3. Imaging and treatment coordinate coincidence
taining established standards of practice to ensure therefore essential.
clarification, if no IMRTThe goal of are
treatments a routine
delivered pretreatment
on the
2.G.3.the
Monthly— Planarof
accuracy MVdose/MU
imaging (EPID)
determination. linac, the machine falls into the non-IMRT category.any er-
verification procedure is to identify and resolve
2. Should
2.G.3.1. Imagingindicates an advisory
and treatment coordinate recommendation
coincidence that rors report,
This before as patient treatment.of For
an extension IMRT,mainly
TG 142, verification
fo-
is to be
2.G.3.2. Scaling applied when practicable. The task group measurements are commonly
cuses on C-arm type medical accelerators. However, used to verify correct
favors
2.G.3.3. theresolution
Spatial indicated procedure but understands that manydelivery
of theofrecommendations
treatment plans, are for example with ioniza-
directly applicable
there are
2.G.3.4. Contrast
other procedures which can accomplish tion chambers, films, or multidimensional
to other types of accelerators, for example, ring- detector
based ar-
the same goal. Deviations from the recommended rays. Experimental methods for
gantries or robotic mounted. The reader is also referredpatient- specific QA in
2.G.3.5. Uniformity and noise
procedure should only be carried out after careful advanced radiotherapy are,
to the AAPM guidance documents for the other typeshowever, time- consuming
2.G.4.analysis
Monthly—demonstrates
Planar kV imagingthat an equivalent result will in both manpower 6,7 and accelerator time and have been
of accelerators.
be Imaging
2.G.4.1. produced.
and treatment coordinate coincidence shown to be unable
Many 6-of11 these recommended to detect testssome
are new unacceptable
to the
3. May
2.G.4.2. indicates a statement that is likely (or probably)
Scaling plans. Recent studies have
medical physics community and, as with TG 40, demonstrated a sensitiv-
there
to be correct
2.G.4.3. Spatial but the task group does not make any
resolution ity of only
is more than 5% onetoway detect IMRT plan
to perform the errors using IMRT
recommended
12,13
recommendations.
2.G.4.4. Contrast pretreatment
tests. In addition,measurements.
because of the increasing Moreover, as treat-
complexity
ment planning becomes more efficient
of radiation therapy delivery and patient setup verifica- and the number
2.G.4.5. Uniformity and noise
As part of this work, the AAPM community was of patients treated with advanced
tion, there are significantly more tests that need to be radiotherapy tech-
2.G.5. Monthly— CBCT (kV and MV)
surveyed in 2012 regarding the type of software niques steadily increases, measurement-
performed. The TG has endeavored to align with pre- based verifi-
2.G.5.1.
beingGeometric distortion to the responses, a dose/MU
used. According cationpublished
may resultAAPM in a continued
viously reports, increase
especially in “Medical
workload.
REPORT OF AAPM TASK
|
4 |
e833
Physics Practice Guideline 2.a”8 and “Medical Physics 1this|TGSTATE

replaced M
allENT O F to
references TH“x-Eray”
PROwithBLE M
“photon” verifica
Practice Guideline 8.a.”9 Since the formation of this Aand
NDupdated
TG CH A RG ES
the tolerances for a few of the tests rec- jority
TG, the AAPM has published TG 100,10 which uses risk ommended in TG 142. Furthermore, in the gating sec- proxim
analysis to develop institution-specific quality manage- An independent
tions, all references checktoofamplitude
dose/monitor haveunits beenhas been
replaced verifica
ment programs. The TG feels that there is a synergy and continue to be an important
with displacement or displacement magnitude to align part of quality assur- time. T
between this report and TG 100 and that this report ance
with TG (QA) 76,for
13 patient treatment plans. AAPM Report
the management of respiratory motion in in the
will help fill the gap as physicists adopt TG 100 into Task Group
radiation oncology. 71 reports on the formalism
Volumetric modulatedfor arccalculat-
therapy most c
1
their clinical practice. As part of a TG 100 quality man- ing monitor units. AAPM Task
(VMAT) QA has also been included in this report. Group 114 reports on ported
agement program, there will still be QA that needs to methods
As with and TGrequirements
40, the goal of foraverification
QA program of for
data for
linacs CA). T
2
be performed on the linacs. This report will serve as a conformal external beam plans.
is to ensure that the machine characteristics do not de- The need for mon- of the
reference of how to perform those tests. itor
viateunit verificationfrom
significantly programs was identified
their baseline early in
values acquired criteria
As in TG 142, the TG would also like to reiterate that the adoption of IMRT treatment
at the time 3of acceptance and commissioning. As rec- planning and delivery IMRT (
institutional deviations from some of the recommenda- techniques.
ommended in Several
TG 106, different
14 types ofvalues
the baseline programs should werebe though
tions in this report are expected based upon that insti- developed ranging from confirmation
of the highest quality to avoid the transfer of systematic of dose at a sin- rate. M
tution’s policies and procedures. The institution must gle point
errors intoin the
a simple phantom
QA process. Theregeometry to calculation
are several publica- their ca
understand and follow local regulations, both on the of dose at a single point while
tions that describe procedures and conditions taking patient anatomy
for ac- (3D) v
QA tests themselves and on the training/qualifications and geometry
ceptance into consideration.
testing and commissioning, While these and the programs
reader measu
necessary for performing them. Should the institution have been intouse
is referred thesefor bysome thetime, guidance
following: was lacking
the International (DLG)
decide to decrease the frequency of a particular test, inElectrotechnical
how to commission such technologies
Commission (IEC),15,16as AAPM,well as14,17,18
their missio
the decision should be validated with an appreciable role as part of an IMRT QA program
and American College of Medical Physics. Many as was noted 19 in the cation
history of that test, and it should be based on sound sta- ASTRO
of these white papervalues
baseline entitledare “Safety Considerations
entered into treatment for in use
4,5
tistical principles. In addition, the TG reiterates that the IMRT”.
planning systems to characterize and/or model the gorithm
QA program should be flexible enough to consider such This taskmachine
treatment group was and charged
thereforewith: can (a) Reviewing
directly affect with m
things as institutional needs, costs, and available test and evaluating the algorithms for
treatment plans calculated for every patient treated “independent/second troduc
equipment. However, as in TG 142, we do recommend check”
on thatofmachine.
monitor unit calculations
Deviation from for theIMRT;
baseline(b) Making
values as 3D
using the tests and frequencies outlined in this report recommendations on the clinical
could thus result in suboptimal treatment of patients.implementation of cal- users
until such time as the institution transitions to TG 100. culation
Machineprograms parameters (e.g., cannumber
deviateoffrom points,
theirlocations,
baseline when i
The purpose of this report is to provide specific ex- accuracy, evaluation
values because of many reasons. methods, and heterogeneities);
20– 22
There could(3) be
amples of how to perform the tests recommended in Describing
unexpectedcommissioning
changes in machine and benchmark performance QA ofdue sec-to
TG 142, to provide estimates of the range of time and ondary
machine MUmalfunction,
calculation programs,
mechanicalproposing breakdown, additional
physi- 2 |
personnel resources necessary to complete the tests. measurements,
cal accidents, orif component necessary; failure. and (4) Major Describingcomponent clini- MU V
Sample QA forms will also be provided. cal testing and periodic QA of
replacement (waveguide, accelerator structure, bend-secondary MU calcula- CO M
The recommendations of this TG are not intended to tion
ing programs
magnet, etc.) andmay recommendations
also alter machine on test tolerance.
performance
be used as regulations. These recommendations are The terminology used in this
from the original parameters. In addition, there could report follows that 2.1 |
guidelines for qualified medical physicists (QMPs) to used in other AAPM Task Group
be gradual changes because of aging of the machine reports including in
use and appropriately interpret for their individual in- particular:
components. These patterns of failure need to be con- The im
stitution and clinical setting. Each institution may have sidered when establishing a periodic QA program. as IMR
site-specific needs and requirements which may mod- 1. Shall indicates in
The advances a procedure
medical accelerator that is essentialdesign that for the com
ify their usage of these recommendations. either (a) establishment of
have enabled both the delivery of complex treatments uniform practices, or potenti
(b) the most safe and effective
and more sophisticated setup verification necessitate result and/or main- of radi
a taining
more extensiveestablished QA standards
program. While of practiceTG 142 to ensure
itself is therefo
1.B | Background the accuracy of dose/MU
considered a comprehensive report that covers the determination. verifica
2. Should indicatesfor
recommendations anlinac
advisory
QA inrecommendation
detail, an implemen- that rors b
The underlying principle behind TG 40 and TG 142 is to be applied when practicable.
tation guide to its test procedures is needed to ensure The task group measu
was the International Commission on Radiation Units favors the implementation
appropriate indicated procedure but understands
in routine clinical settings. that deliver
and Measurements’ (ICRU)11 recommendation that there are other procedures
While there are several publications that recommend which can accomplish tion ch
the dose delivered to the patient be within ±5% of the same
many aspects goal.of QADeviations
procedures from for thespecific
recommended compo- rays. E
the prescribed dose.12 Taking into consideration the procedure should only be
nents of the tests in TG 142, we feel that the carried out after careful
community advanc
many steps involved in delivering dose to a target vol- analysis demonstrates that an
would be better served by integrating these guidelines equivalent result will in both
ume in a patient, each step must be performed with be produced.
into one updated document. The TG has analyzed the shown
accuracy significantly better than 5% to achieve this 3. May indicates
various published a statement
techniquesthat to ismake
likelyrecommenda-
(or probably) plans.6
recommendation. to be correct but the task
tions as to which procedure(s) should be used group does not makewher- any ity of o
The report of the TG 142 considerably expanded the recommendations.
ever the literature differs on procedure for a given test. pretrea
tests of TG 40. In addition, the report recommended It should be noted that continuing advances in radio- ment p
tolerances that accommodated differences in the in- As part
therapy makeof thiseven work, recentthe reports
AAPM community
incomplete. was It is of pati
tended use of the machine functionality: non-IMRT, surveyed in 2012 regarding
therefore incumbent upon the QMP to stay the type of abreast
software of niques
IMRT, and stereotactic delivery. It should be noted that being used. According
QA methodologies on new to the responses,
advances as they a dose/MU
appear in cation
|
2 MU VERIFICATION FOR IMRT
e834
TASK GROUP 198 REPORT TASK GROUP 198 REPORT
5|
1 | STATE M ENT O F TH E PRO BLE M verification program was generally used for the ma-
the literature as well as improvements on conventional Throughout the report, we reference gantry, collima-
topics covered in this report. To this end, the TG feels tor, and table angles. The convention used to describe
that, as VMAT has been widely adopted in clinical prac- these angles is the IEC 6121727 coordinate system. For
tice, guidelines for the routine QA of VMAT programs example, gantry zero is defined by the gantry head/
and continue to be an important part of quality assur- time. The most common commercial system reported
should be included in this report. The report does not radiation beam pointing vertically down. The terms
ance (QA) for patient treatment plans. AAPM Report in the survey was RadCalc (Lifeline, Tyler, TX). The
cover commissioning of VMAT programs as they have for AAPM accredited dosimetry calibration laboratory
Task Group 71 reports on the formalism for calculat- most common treatment planning system (TPS) re-
already been covered in the literature.23–25 (ADCL) and secondary standard dosimetry laboratory
ing monitor units.1 AAPM Task Group 114 reports on ported in the survey was Eclipse (Varian, Palo Alto,
This report addresses the extra time that is neces- (SSDL) are used in reference to the calibration of ion-
methods and requirements for verification of data for CA). This is not to be considered as an endorsement
sary to perform the increased number of tests, with the ization chambers and electrometers. Both ADCL and
conformal external beam plans.2 The need for mon- of these products. The most common passing rate
aim of educating oncology administrators on the addi- SSDL are traceable to their corresponding national
itor unit verification programs was identified early in criteria for dose/MU verification software was 5% for
tional demands and time that it could take for medical standards. Throughout the document, we use the term
physicists to perform such tasks. We recommend the ADCL which can be equivalently interpreted as SSDL.
techniques.3 Several different types of programs were though 30% of VMAT responders used 5% as passing
appropriate qualified personnel to perform the tests The daily QA tests are typically performed by an
developed ranging from confirmation of dose at a sin- rate. More than 50% of users used a single point for
and provide ranges of time that the test could require. RTT. The TG recommends a detailed policy and pro-
gle point in a simple phantom geometry to calculation their calculations and only 6% used three- dimensional
The time ranges were estimated from an internal sur- cedure for daily QA checks to be used as a guide for
vey of TG members and cover all accelerator manufac- the RTTs. The competency of the RTTs to perform the
turers and a variety of test techniques. This document tests should be documented. The procedures should
have been in use for some time, guidance was lacking (DLG) measurements) were also required during com-
contains illustrative pictures of QA devices from various indicate how the tests are performed, the tolerance of
device manufacturers. These images are intended only each test, and what corrective action is necessary if
role as part of an IMRT QA program as was noted in the cation calculation algorithm represented by software
as aids to understanding the tests and as examples any test should fall out of tolerance. An example cor-
ASTRO white paper entitled “Safety Considerations for in use at the time was a “factor- based calculation al-
of possible tools for performing those tests; they are rective action for daily output constancy of photons and
IMRT”.4,5 gorithm.” Note that the clinical practice has changed,
not intended as an endorsement of any manufacturer. electrons is given here:
This task group was charged with: (a) Reviewing with more widespread use of VMAT as well as the in-
Ultimately, it is the responsibility of the QMP to deter- If the output measurement performed by the RTT is
and evaluating the algorithms for “independent/second troduction and adoption of new software tools (such
mine the method for performing the test. As additional outside the ±5% tolerance range, do not treat. We rec-
check” of monitor unit calculations for IMRT; (b) Making as 3D volumetric calculation systems) since 2012, so
guidance, this report will provide sample QA forms for ommend a second person should first repeat the mea-
recommendations on the clinical implementation of cal- users should consider the age and context of the data
daily, monthly, and annual QA checks. surement, and if the measurement is still out of the ±5%
culation programs (e.g., number of points, locations, when interpreting the survey.
This report has several recommendations that de- tolerance range, a QMP must repeat the measurement
accuracy, evaluation methods, and heterogeneities); (3)
viate from TG 142. These deviations are discussed in as soon as possible.
Describing commissioning and benchmark QA of sec-
detail in the appropriate sections. If the output measurement performed by the RTT is
ondary MU calculation programs, proposing additional 2 | RO LE O F DOSE /
outside the ±3% tolerance range but within ±5%, treat-
measurements, if necessary; and (4) Describing clini- M U V ER I FI CATI O NS I N A
ment may continue, but a second person should repeat
cal testing and periodic QA of secondary MU calcula- CO M PR EH ENSI V E Q A PROG R A M
2 tion Q A O Fand recommendations on test tolerance.
| programs the measurement. If the repeated measurement still in-
M EDThe I CAterminology
L ACCELE R ATO RS
used in this report follows that
dicates out of ±3% tolerance, the cause of the discrep-
2.1 | Review of the problem
ancy should be investigated at the first opportunity by the
used in other AAPM Task Group reports including in
2.A | General
particular:
QMP.
The implementation of new treatment techniques such
The procedure should also clearly state that any out-
as IMRT/VMAT in a radiotherapy department increases
Each section begins with the objective, tolerance, and of-tolerance test should be brought to the attention of
1. Shall indicates a procedure that is essential for the complexities in planning and delivery and thus, the
methods and equipment to perform the test and ends the QMP as soon as possible. The QMP should review
either (a) establishment of uniform practices, or potential for serious errors in the planning and delivery
with a summary table documenting the appropriate per- and sign off on the daily QA tests, preferably daily but
(b) the most safe and effective result and/or main- of radiotherapy. An effective set of QA procedures is
sonnel needed to perform each test and the required at a minimum of once per week. This frequency has
taining established standards of practice to ensure therefore essential. The goal of a routine pretreatment
time. As local regulations regarding physicist qualifica- increased since TG 142, which had recommended a
the accuracy of dose/MU determination. verification procedure is to identify and resolve any er-
tions and supervision vary, the institution may need to minimum of once per month. More recently, QA man-
2. Should indicates an advisory recommendation that rors before patient treatment. For IMRT, verification
modify the appropriate personnel for the tests. The per- agement systems are being used. These systems can
is to be applied when practicable. The task group measurements are commonly used to verify correct
sonnel fall into three categories: Registered Radiation be configured to automatically alert the QMP should a
favors the indicated procedure but understands that delivery of treatment plans, for example with ioniza-
Therapy Technologist (RTT) working under the super- daily QA result exceed tolerance, and the daily sign off
there are other procedures which can accomplish tion chambers, films, or multidimensional detector ar-
vision of a Qualified Medical Physicist (QMP), an indi- is therefore inherent in the system.
the same goal. Deviations from the recommended rays. Experimental methods for patient-specific QA in
vidual designated by the QMP and working under the The monthly QA tests are typically performed by the
procedure should only be carried out after careful advanced radiotherapy are, however, time-consuming
supervision of the QMP, and a QMP. In this context, we QMP, a medical physicist, or physics assistant working
analysis demonstrates that an equivalent result will in both manpower and accelerator time and have been
use the AAPM definition of a QMP.26 under the supervision of a QMP. These tests can also be
be produced. shown to be unable to detect some unacceptable
Linacs have several modes of operation. The two performed by medical physics trainees, such as students
3. May indicates a statement that is likely (or probably) plans.6-11 Recent studies have demonstrated a sensitiv-
used most are treatment and service. All patients are or residents, working under the supervision of a QMP. If
to be correct but the task group does not make any ity of only 5% to detect IMRT plan errors using IMRT
treated in treatment mode. Many of the QA tasks rec- an individual other than the QMP12,13 performs these tests,
recommendations. pretreatment measurements. Moreover, as treat-
ommended in TG 142 can be accomplished in either competency of the individual should be documented,
ment planning becomes more efficient and the number
mode. If any of the tests are performed in service including whether he or she can correctly assess and
As part of this work, the AAPM community was of patients treated with advanced radiotherapy tech-
mode, it is the responsibility of the QMP to ensure that investigate the cause of discrepancies and make proper
surveyed in 2012 regarding the type of software niques steadily increases, measurement-based verifi-
the result of any test run in service mode is equivalent adjustments to bring the system into tolerance. The de-
being used. According to the responses, a dose/MU cation may result in a continued increase in workload.
to the result from treatment mode. tailed procedures to perform the tests and the methods
REPORT OF AAPM TASK
|
6 |
e835
to make necessary corrective actions should be avail- 12.A.1.3

| STATE M ENT
| Monthly QA O F TH E PRO BLE M verifica
able. In addition, any out-of-tolerance test should be A1.ND TG CH A RG ES radiation coincidence for
The tolerance for light jority
brought to the attention of the QMP as soon as possi- both asymmetric and symmetric fields was changed proxim
ble. The QMP should sign off on the monthly QA tests An to independent
±2 mm per check jaw oftodose/monitor
align with “AAPM units has been
Medical verifica
every month, preferably within 15 days of completion of andPhysics
continuePractice to be anGuidelineimportant8.a.” part9 of quality assur- time. T
the tests. ance
2. The (QA)
tolerancefor patient
for jawtreatment plans. AAPM
position indicators Report
was changed in the
The annual QA tests are typically performed by the Task Group
to ±2 mm per jaw 71 reports on the formalism
for symmetric mode and ±1 mm per for calculat- most c
QMP.28 The annual tests are usually more complex and ing jawmonitor units.1 AAPM
for asymmetric mode Taskwhen Group
used114 reports
for field match-on ported
require a greater understanding of the tests, test equip- methods and requirements for verification
ing at the central axis to align2 with “AAPM Medical of data for CA). T
ment, and all components of the linac. The annual re- conformal
Physicsexternal Practice beam Guidelineplans. 8.a.”The
9 need for mon- of the
port should include a summary section that details the itor unit verification programs
3. An absolute couch position test was added was identified early
to thein criteria
findings of the annual QA. Upon completion, the report the relative
adoption of
couch IMRT treatment planning
tests in TG 142 to align with “AAPM and delivery IMRT (
3
should be checked, signed, and dated by the responsi- techniques.
Medical Physics SeveralPractice
differentGuideline
types of 8.a.” programs
9 were though
ble QMP and should be kept as a record for inspection developed
4. For clarity, the monthly setting vs radiation sin-
ranging from confirmation of dose at a field rate. M
for as long as the machine is used for patient treatment. gle (non-
pointIMRT)in a simple was phantom
renamed geometryleaf position to calculation
accuracy their ca
As recommended in TG 142, this report reiterates of dose
(non-at IMRT).a single point while taking patient anatomy (3D) v
that, although the QA program for linacs is a group ef- and geometry
5. Test patient- intospecific
consideration.
VMAT While constancythese programs
QA was measu
fort, the overall responsibility for administering the linac have been
added. in use for some time, guidance was lacking (DLG)
QA program should be assigned to one individual, the in how to commission such technologies as well as their missio
designated QMP. role
2.A.1.4as part| ofAnnual an IMRT QA QA program as was noted in the cation
ASTRO
1. For 4,5efficiency, the SRS“Safety
white paper entitled Considerations
arc rotation mode and for in use
IMRT”.the arc mode tests were combined into one arc gorithm
2.A.1 | Clarifications and deviations from This
modetask test.group was charged with: (a) Reviewing with m
TG 142 and
2. Monitor unitthe
evaluating (MU) algorithms
linearityforfor “independent/second
photons should be troduc
check” of monitor unit calculations
tested for both static (nonsegmented) for IMRT; and (b) dynamic
Making as 3D
2.A.1.1 | Test frequency recommendations on the clinical
(segmented) beams as the beam control systems implementation of cal-
can users
This report adopts the test frequencies from TG 142. culation programs (e.g., number
differ. This was added to align with “AAPM Medical of points, locations, when i
There is only one frequency change: “The QMP should accuracy,
Physicsevaluation methods, 8.a.”
Practice Guideline and heterogeneities);
9 (3)
review and sign off on the daily QA tests, preferably daily Describing commissioning and benchmark
3. For clarification, the photon or electron output con- QA of sec-
but at a minimum of once per week.” This frequency ondarystancy MUand calculation
off-axis factorprograms, proposing
constancy additional
vs gantry angle 2 |
has increased since TG 142, which had recommended measurements, if necessary;
tolerance was reworded to “The measured output and (4) Describing clini- MU V
a minimum of once per month. This change is based cal should
testing be andwithin
periodic QA of secondary
1% of the value acquired at gantry MU calcula- CO M
upon the recommendations of the American College tion0°.”programs and recommendations on test tolerance.
of Radiology (ACR)—“ACR Technical Standard for the 4. The
TBI/TSETterminologymeasurements used inspecificthis report follows
for energy andthatpro- 2.1 |
Performance of Radiation Oncology Physics for External used in other AAPM Task Group
files were made optional at the extended treatment reports including in
Beam Therapy”29 —who state that “the medical physi- particular:
distance. The tolerances for measurements taken at The im
cist must review, as soon as possible, all dosimetric and the extended distance were adjusted as follows: TBI as IMR
physics activities that occurred during his/her absence.” 1. Shall
TMR/PDD indicates ±5% afrom procedure
baseline,that TSET is essential
±3 mm PDD for the com
either (a) establishment of
shift, OAF constancy ±5% from baseline, TBI/TSET uniform practices, or potenti
2.A.1.2 | Daily or weekly QA (b) the most safe and
output calibration ±3% from baseline. effective result and/or main- of radi
1. The tests for positioning or repositioning and im- 5. taining
The toleranceestablished standards and
for mechanical of practice
radiationtoisocenter
ensure therefo
aging and treatment coordinate coincidence for the accuracy of dose/MU determination.
coincidence was changed to absolute values as op- verifica
SRS/SBRT machines were increased to ≤2 from 2. Should
posed to indicates
reference an to advisory
baselinerecommendation
to align with “AAPM that rors b
≤1 mm. The one exception to this increase is for isMedical
to be Physicsapplied when practicable.
Practice Guideline 8.a.” The 9task group measu
the clinical situation where image- guided radiation 6. favors the indicated
For clarification andprocedure
consistency, but understands
the tabletop that sag deliver
therapy (IGRT) is to be used with SRS. Under there are other procedures
test was renamed treatment couch top which canflex.accomplish tion ch
that circumstance, it is the recommendation of this 7. the
For same
VMATgoal. QA, test Deviations from theVMAT
patient-specific recommended
constancy rays. E
TG that the QMP must validate the IGRT imaging procedure
QA and an interruption test were added.after careful
should only be carried out advanc
tests to ≤1 mm on the day of SRS treatment. The analysis demonstrates that an equivalent result will in both
change was made to align with TG 179.30 be produced. shown
2. For efficiency purposes, the weekly picket fence test 3. May indicates
2.A.2 a statement that is likely (or probably)
| Documentation plans.6
for the MLC was reworded so that the test is to be to be correct but the task group does not make any ity of o
performed at a different cardinal gantry angle each recommendations.
Documentation of all the tests performed is critical. All pretrea
week. results should be documented in either a permanent ment p
3. The QMP should review and sign off on the daily QA As part or
electronic of this
hardcopywork, format
the AAPM community
and should was
be read- of pati
tests, preferably daily but at a minimum of once per surveyed in 2012 regarding
ily available for inspection purposes. For daily QA, itthe type of software niques
week, as described above. being used. According
is recommended that the to QMP
the responses,
review andasign dose/MU
off on cation
|
e836
7|
the reports, preferably daily but at a minimum of once to indicate whether respiratory gating is being used on
per week. For monthly QA, the QMP should review and the linac. There is a similar selection process on the
sign off on the reports within 15 days of completion. MLC sheet to indicate usage as non-IMRT or IMRT.
Upon completion of the annual measurements, it is rec- The imaging sheet has selection areas for linac usage,
ommended that a comprehensive annual QA report be which will determine tolerances and imaging usage.
generated. The report should contain a summary sec- For example, a machine might only have megavoltage
tion that states significant findings based on the recom- (MV) imaging. The imaging tests also contain the base-
mended table tolerance values. The QA report should line values for each test. The monthly summary sheet
be signed and reviewed by the QMP2 and filed for future uses the same format as the daily summary sheet with
conformal external beam plans. The need for mon- of these products. The most common passing rate
machine maintenance and inspection needs. an extra column for the personnel performing the test.
This TG has provided sample daily, monthly and an- Unlike the daily QA, several personnel may perform the
nual QA forms3 (supplementary Materials). The forms monthly tests for one machine. Similarly, there is also a
techniques. Several different types of programs were though 30% of VMAT responders used 5% as passing
were developed in Microsoft Excel but are distributed free text area where comments pertaining to the tests
as PDF printouts. The original forms use logical tests, can be entered. There is also a signature area that is to
dropdown lists, and other form controls to facilitate data be completed by the QMP who reviews the tests.
entry. A common theme between all the forms is that The annual QA form is based on an Excel work-
data were entered only in the areas highlighted in yel- book with the same six tabs at the monthly form: do-
low. We suggest that the forms be stored electronically simetry, mechanical safety, respiratory gating, MLC,
on a departmental network drive. Once the QMP has imaging, and annual summary. While we recommend
reviewed the forms, they should be locked and stored that the QMP continues to use his or her TG 51 forms,
as secure4,5 PDFs. If hardcopies are preferred over elec- the dosimetry sheet has a section to record the TG
IMRT”. gorithm.” Note that the clinical practice has changed,
tronic, it is suggested that the hardcopies be scanned 51 results. In addition, there are sections for all the
and stored in digital format for redundancy purposes. photon and electron dosimetry tests, TBI/TSET tests,
The daily QA form is a single summary sheet. It con- and wedge tests. It contains the list of tests to be per-
tains the list of tests to be performed and the tolerances formed and the tolerances based on machine type.
based on machine type. It has sections to record the It has sections to record the results of the dosimetry,
results of the dosimetry, mechanical, safety, wedges, mechanical, safety, wedges, MLCs, and imaging tests.
MLCs, and imaging tests. There is also a free text area The mechanical and safety sheet has an area to docu-
where comments pertaining to the tests can be en- ment the QMP’s review of the manufacturer’s user and
tered. There is a signature area that is to be completed technical manuals, safety guides, safety notices, and
by the therapist performing the tests and the QMP who technical bulletins. There is also an area to document
reviews the tests. the linac QA program annual review. The respiratory
The monthly QA form is based on an Excel work- gating, MLC, and imaging sheets have sections for all
The terminology used in this report follows that 2.1 | Review of the problem
book with six tabs: dosimetry, mechanical safety, re- the annual respiratory gating, MLC, and imaging tests.
spiratory gating, MLC, imaging, and monthly summary. The imaging sheet has selection areas for linac usage
particular: The implementation of new treatment techniques such
The dosimetry sheet has sections to record: photon which will determine tolerances and imaging usage.
and electron output; EDW, Virtual, or Universal Wedge For example, a machine might only have MV imaging.
output; electron energy constancy; photon and electron The annual summary sheet uses the same format as
beam profile constancy; and respiratory gating beam the monthly summary sheet. Similarly, there is also a
output constancy. It contains the list of tests to be per- free text area where comments pertaining to the tests
formed and the tolerances based on machine type. can be entered. There is one additional section on the
It has sections to record the results of the dosimetry, annual summary sheet, summary of findings, where
mechanical, safety, wedges, MLCs, and imaging tests. any items that are out of tolerance on the annual tests
The dosimetry sheet can be customized to populate can be documented if necessary. Below that section is
photon and electron energies, dosimetry equipment, a signature area that is to be completed by the QMP
calibration dates, and personnel into the dropdown who reviews the tests.
lists. On the mechanical and safety sheet where tol-
erances depend upon the linac usage, for example,
treatment couch position indicators, the usage can be
be produced.
2.B | Daily
shown to be unable to detect some unacceptable
picked from the dropdown list, and the tolerances are
adjusted accordingly. In addition, there are selection
to be correct but the task group does not make any
2.B.1 | Dosimetry
ity of only 5% to detect IMRT plan errors using IMRT
boxes to allow users to indicate that certain tests may
recommendations. pretreatment measurements.12,13 Moreover, as treat-
not be applicable to their linac, for example, graticule The baseline for the daily dose measurement system
trays. The mechanical and safety sheet also has an should be established by performing an intercompari-
area to document the QMP’s review of the daily QA, the son with the primary dose measurement system on at
machine logbook, and the service reports. The respira- least an annual basis.9 Primary measurement systems
tory gating sheet has a selection box to allow the QMP are typically performed in a water tank; a secondary
REPORT OF AAPM TASK
|
8 |
e837
measurement system may be used for monthly QA and 11. The

| STATE M ENT and
setup geometry O F the
TH E PRO
beam BLE M
parameters verifica
a tertiary system for daily QA. Intercomparisons can be A ND TG CH A RG ES
must be clearly stated in written instructions. These jority
quick and easy and provide high confidence in stabil- would include beam energy; dose rate; MU; field proxim
ity when all available devices are compared during a An size
independent
and beam check of dose/monitor
limiters; source-to-surface units has been
distance verifica
single session. and(SSD);
continue to be an important part
collimator, gantry, or couch angles; posi- of quality assur- time. T
ance tion(QA)
on for patient
couch; treatment
buildup; and the plans. AAPM Report
orientation of the in the
2.B.1.1 | Photon and electron output constancy: Task Group 71
measurement 1device.reports on the formalism for calculat- most c
2.B.1.1.1 | Objective. Daily verification of photon ing monitor
2. The units. AAPM
repeatability of Task Group 114
measuring reports
device on
setup ported
and electron output is essential for overall confidence methods and requirements
should be such that it can satisfy for verification of data
the statements in for CA). T
2
that the patient’s dose during that day’s treatment conformal
Section external
2.C.4. of beam TG 142. plans. The need forthat
It is recommended mon- the of the
fraction is constant and nominally accurate to the itor measurement
unit verification programs was identified
system and procedure repeatability be early in criteria
expected prescribed dose. These measurements are the such
adoption of IMRT treatment planning
that3 two standard deviations for three or more and delivery IMRT (
not a calibration of the beam’s output but serve as techniques. Several different
repeated consecutive types of programs
measurements are lesswere than though
confirmation that the outputs have not changed within developed ranging from confirmation
the tolerance value. This will generally require of dose at an
a sin-
ion- rate. M
a reasonable tolerance. gle ization
point inchamber-
a simplebased phantom system geometry
that may tobecalculation
equipped their ca
of dose at a single
with sensors point while
to correct taking patient
for temperature anatomy
and pressure. (3D) v
2.B.1.1.2 | Tolerance. The measured output andAlternatively,
geometry into consideration. While
diode and metal– oxide–semiconductor these programs measu
should be within 3% of the established baseline. have been
field- in use
effect for some (MOSFET)
transistor time, guidance was lacking
systems could (DLG)
An institution may choose a smaller tolerance limit in how
be used if their calibration is carefully well
to commission such technologies as as their
established. missio
to respond more quickly to a change in output. In roleTemperature
as part of an IMRT QA program
measurements, if as was noted
required, must in theal- cation
addition, an institution can have operational guidelines ASTROways white
be paper
made in entitled
the “Safety
treatment Considerations
room. for in use
4,5
such that, if the output measurement performed by IMRT”.
3. Data and beam parameters should be recorded in gorithm
the RTT is outside the ±3% tolerance range but within This
a log,task group
either physicalwas or charged
digital. Thesewith: (a) Reviewing
include all the with m
±5%, treatment may continue, but a second person andmeasurement
evaluating theresults algorithms for “independent/second
such as offset, final readings, troduc
should repeat the measurement. If the repeated check” of monitorand
temperature, unitpressure.
calculations Some for devices
IMRT; (b) Making
with dedi- as 3D
measurement still indicates out of ±3% tolerance, the recommendations on the clinical implementation
cated software may record all the data in a database. of cal- users
cause of the discrepancy should be investigated at the culation
4. Analysis programs
should (e.g.,
include number of points, of
the comparison locations,
the final when i
first opportunity by the QMP. accuracy,
measurement results with the baseline and an (3)
evaluation methods, and heterogeneities); in-
Describing
dication commissioning
of a pass (within and benchmark
tolerance) or aQA failof(out
sec- of
2.B.1.1.3 | Methods and equipment. Ideally, ondary MU calculation programs, proposing additional
tolerance). 2 |
each treatment vault will have its own dedicated daily measurements, if necessary; and (4) Describing clini- MU V
measurement system; however, it is not uncommon to cal Ittesting
shouldand periodic
be noted thatQA someof secondary
daily QA devicesMU calcula- could CO M
share devices between treatment vaults. The system tion
measure other QA items at the same timetolerance.
programs and recommendations on test as when
used to measure daily dose output constancy normally, The constancy
output terminology used in For
is checked. this example,
report followsbeam sym- that 2.1 |
although not always, consists of a phantom embedded used in other AAPM Task Group
metry, flatness, and field size may be measured simul- reports including in
with at least five or more ionization chambers or particular:
taneously with output with one of these devices. The im
diodes and electrometers. These devices typically as IMR
contain sensitive electronics. Radiation damage to 1. Shall indicates a procedure that is essential for the com
these electronics could cause drifts in the readings; either |(a) Mechanical
2.B.2 establishment of uniform practices, or potenti
therefore, it is important that the setup avoids irradiating (b) the most safe and effective result and/or main- of radi
electronics during measurements. Another common taining established
2.B.2.1 standards of practice to ensure
| Laser localization therefo
mistake is to irradiate the electronics during morning the accuracy of dose/MU
2.B.2.1.1 | Objective. At the determination.
time of installation and verifica
warmups; therefore, it is recommended that the device 2.
acceptance, the laser systems onrecommendation
Should indicates an advisory that
the linac are aligned rors b
not be placed on the couch the night before. The is to be applied when practicable. The
to the radiation or mechanical isocenter of the machine. task group measu
important features of the measurement procedures favors
There arethe indicated
typically fourprocedure
lasers units:but two
understands that
on the lateral deliver
are the reproducibility in the setup geometry, proper there are other procedures which can
walls, one on the ceiling, and one sagittal at the foot accomplish tion ch
measuring system functionality, data recording, and of the
the same
treatmentgoal.couch.
Deviations from the
The lasers on recommended
the side walls rays. E
analysis. In addition, for electron output, the inherent and the ceiling laser have orthogonal out
procedure should only be carried after careful
fan beams, while advanc
buildup of the device used for measurements should not analysis demonstrates that an equivalent
the laser facing the foot of the treatment couch result only
will in both
be positioned in the steep distal falloff of the depth dose, be produced.
has a vertical fan beam. Lasers may be used for the shown
a particular problem for low electron energies. Slight 3. indicates
Maysetup
initial a statement
of patients thattreatment
before is likely (or
or probably)
acquiring plans.6
variations in electron energy may cause a false dose to be correct but the task group
images using in-room imaging systems. Lasers does not make used
any ity of o
constancy error relative to the dose at depth of clinical recommendations.
in radiation oncology have electronic control systems pretrea
interest. Some linacs are designed with independent that can be subject to drift with time. If the lasers are ment p
photon and electron monitor chambers (e.g., Siemens). theAsonlypartmeans
of thisto work,
setup thethe AAPM
patientscommunity wasit
for treatment, of pati
It is recommended that each independent monitor surveyed in 2012 regarding the type
is crucial to ensure that the positional errors are as of software niques
chamber system should be checked daily. being
small used. According
as possible to the
to deliver theresponses,
clinical plana accurately
dose/MU cation
|
e838
9 |
to the intended target and to avoid critical structures. 2.B.2.3.2 | Tolerance. The tolerance for non-IMRT
In the case of initial positioning followed by imaging, is ±2 mm per jaw; for IMRT, ±2 mm per jaw; for SRS/
while the imaging is used for final patient setup, it is SBRT, ±1 mm per jaw.
still desirable for the errors in the laser system to be
as small as possible so that the patient shifts can be 2.B.2.3.3 | Methods and equipment. The equipment
tracked against a stable baseline. required to perform this test could be as simple as a piece
of graph paper, a template with predefined rectangular
2.B.2.1.2 | Tolerance. The tolerance for non-IMRT shapes, or the flat surface of the QA device used to
is ±2 mm; for IMRT, ±1.5 mm; for SRS/SBRT, ±1 mm. measure output constancy. The test equipment can be
illuminated by the light field for visual inspection against
2.B.2.1.3 | Methods and equipment. A variety of the collimator indicator and should be positioned at
commercial test devices are available to verify laser isocenter where the collimator setting is defined. In this
accuracy, such as a cube with markings on the sides method, the light field is a surrogate of the radiation field.
which is positioned at isocenter, typically using the Alternatively, the QA device that is used to measure the
crosshairs and the light field as a reference point, to output constancy can often measure radiation field size,
determine the accuracy of coincidence of lasers at and this can be compared with the collimator settings. If
isocenter. Setting up the cube is very quick but less the device is used for this purpose, care should be taken
rigorous than other methods. For example, the front to set the surface of the device and not the detector plane
pointer linac accessory provides an independent at isocenter, which would cause an error in the indicated
reference point for the mechanical isocenter of the light field on the equipment surface.
machine, 4,5but it is more time consuming and more fragile
than the cube. The choice of the method is dependent
upon the institution’s goals.
and evaluating the algorithms for “independent/second
2.B.3 | Safety
troduction and adoption of new software tools (such
2.B.2.2 | Optical distance indicator (ODI) 2.B.3.1 | Door interlock
2.B.2.2.1 | Objective. The ODI has been a 2.B.3.1.1 | Objective. It is important for the safety
traditional method for setting up SSD for phantom of personnel to make sure that the beam is turned off
dosimetry measurements and patient treatment. The when the door is opened and beam on is prevented
purpose and method of using ODI varies from institution when the door is not closed.
to institution. The ODI is an important redundancy to
the coronal lasers and the only setup reference for 2.B.3.1.2 | Tolerance. The tolerance is functional.
when the surface is located away from the machine
isocenter. This redundancy may have an important 2.B.3.1.3 | Methods and equipment. There are
impact during an SSD setup technique where errors two tests that could be executed to check both failure
are magnified by an inverse square factor. modes: (a) While the beam is on, open the treatment
room door. The beam should turn off as soon as the
2.B.2.2.2 | Tolerance. The tolerance is ±2 mm. door starts to open. This test should be run during the
beam warmup. (b) While the door is open, attempt to
2.B.2.2.3 | Methods and equipment. The most turn the beam on. The beam should remain off. Beam
expedient method is to set the ODI coinciding with off is indicated on the accelerator console and via the
crosshairs on a surface at the machine isocenter radiation area monitor. This test can also be used as
(100 cm SAD in most machines) and check that the the test for the beam- on indicator (see Section 2.B.3.6).
coronal lasers “graze” the surface illuminated by the
ODI field light. This test assumes that the lasers have 2.B.3.2 | Door closing safety
already been tested and coincide with machine or 2.B.3.2.1 | Objective. The treatment room door
radiation isocenter. can weigh as much as 15 tons and may use a large
force to close, with the potential to cause injury. This
2.B.2.3 | Collimator size indicator test should verify that, if the door has emergency stop
2.B.2.3.1 | Objective. Collimators on the linac equipment, the door will stop closing if personnel are
are used in conjunction with MLCs or blocks to define accidentally caught in the path.
the treatment field edges. The collimator positions
are set either through a hand pendant inside the 2.B.3.2.2 | Tolerance. The tolerance is functional.
treatment room, the console, or by the record and
verify (R&V) system. The objective is to verify that 2.B.3.2.3 | Methods and equipment. With the
the collimator indicators are consistent with the treatment room door in the open position, press the
desired setting. control to close the door. Stand in a safe position away
REPORT OF AAPM TASK
|
|
10 GROUP 198 REPORT
TASK 2 TASK GROUP 198 REPORT
e839
from the door closing path and when the door is halfway 1 | STATE M ENT O F TH E PRO BLE M verifica
closed, activate the emergency stop equipment. This A ND TG CH A RG ES jority
could be a push bar, proximity sensor, or motion- proxim
detection system, for example. The door should stop An independent check of dose/monitor units has been verifica
closing if the emergency stop is functioning properly. and continue to be an important part of quality assur- time. T
ance (QA) for patient treatment plans. AAPM Report in the
2.B.3.3 | Audiovisual monitor Task Group 71 reports on the formalism for calculat- most c
2.B.3.3.1 | Objective. The RTTs need to be in ing monitor units.1 AAPM Task Group 114 reports on ported
constant audio and visual communication with the methods and requirements for verification of data for CA). T
patient to ensure safe patient treatments. This is conformal external beam plans.2 The need for mon- of the
accomplished by installing at least two cameras and a itor unit verification programs was identified early in criteria
two-way audio communication system in the treatment the adoption of IMRT treatment planning and delivery IMRT (
room. Systems are tested daily to ensure that they are techniques.3 Several different types of programs were though
functional. developed ranging from confirmation of dose at a sin- rate. M
gle point in a simple phantom geometry to calculation their ca
2.B.3.3.2 | Tolerance. The tolerance is functional. of dose at a single point while taking patient anatomy (3D) v
F I G geometry
and . 1 Beam-into consideration.
on indicator and x- ray-While these
in- use lights programs
outside a measu
treatment
have been vault. [Colorfor
in use figure
some can time,
be viewed at wileyonlinelibrary.
guidance was lacking (DLG)
2.B.3.3.3 | Methods and equipment. Turn on the com]
music system, place a sound-producing device on the in how to commission such technologies as well as their missio
treatment couch or have a second person stand near the role as part of an IMRT QA program as was noted in the cation
treatment couch and speak. Exit the treatment room and ASTRO
to prevent white paper entitled
personnel “Safety the
from entering Considerations
treatment room for in use
4,5
verify that the device or person is visually observable on IMRT”.
while the beam is on. Verify that the area monitor is gorithm
the monitor at the console and sound can be heard. Next, This task group was charged with: (a) Reviewing
functional. with m
enable the console side of the two-way communication and evaluating the algorithms for “independent/second troduc
device and talk into the microphone. Have a second check”
2.B.3.5.2 of monitor unit calculations
| Tolerance. for IMRT;
The tolerance is (b) Making
functional. as 3D
person or a recording device such as a smartphone recommendations on the clinical implementation of cal- users
verify that sound can be heard or the communication culation
2.B.3.5.3programs | Methods (e.g.,and number of points,
equipment. Whilelocations,
outside when i
recorded. Alternatively, listen to the communication accuracy, evaluation methods, and
the treatment room entrance and with the treatment heterogeneities); (3)
sounds coming out of the open treatment room door. Describing commissioning and
room door closed, verify that the remote radiation benchmark QA of sec-
ondary
area monitorMU calculation
indicatesprograms,
no radiation proposing
when additional
the beam 2 |
2.B.3.4 | Stereotactic interlocks measurements, if necessary; and
is off. With the beam turned on, the radiation monitor (4) Describing clini- MU V
2.B.3.4.1 | Objective. Stereotactic interlocks cal testing and periodic QA of secondary
should illuminate to indicate radiation is present in the MU calcula- CO M
ensure that the devices to be used are interlocked, and tion programs
treatment room.and recommendations on test tolerance.
the dose rate for a given modality is only allowed under The terminology used in this report follows that 2.1 |
this condition. used
2.B.3.6 in other AAPMon
| Beam- Task Group reports including in
indicator
particular:
2.B.3.6.1 | Objective. The entrance to the The im
2.B.3.4.2 | Tolerance. The tolerance is functional. treatment room has indicators for beam off and beam as IMR
1.onShall
located indicates
close to atheprocedure
treatment door.that is Theseessential for
indicators the com
2.B.3.4.3 | Methods and equipment. Attach either (a) establishment of uniform
are controlled by the linac to indicate if a radiation beam practices, or potenti
the stereotactic device to the head of the linac while a (b) the most safe and effective result
is on or off (see Fig. 1). Verify that these indicators are and/or main- of radi
nonstereo beam is programmed for delivery. The linac taining established
functioning properly. There standards
may be of practice
separateto ensure
indicators therefo
should indicate an interlock related to this attachment the accuracy of dose/MU
for the MV and kilovoltage (kV) systems. determination. verifica
and prevent the operator from beam delivery. Based on 2. Should indicates an advisory recommendation that rors b
the manufacturer, take the recommended steps to clear is to be applied
2.B.3.6.2 | Tolerance.when practicable.
The tolerance Theistask group
functional. measu
the interlock. Program a stereotactic beam. Deliver a favors the indicated procedure but understands that deliver
set dose that is designated for QA purposes. Remove there are| other
2.B.3.6.3 Methodsprocedures which can accomplish
and equipment. Close the tion ch
the device and attempt to deliver the same dose. The treatment room door. Visually verifythe
the same goal. Deviations from thatrecommended
the beam- on rays. E
linac should not be able to deliver the dose when the procedureisshould
indicator(s) on when onlythebe beamcarried
is onoutandafter
thencareful
beam- advanc
interlock is activated. At the QMP’s discretion, the on indicator(s) is off when the beam is off. result will
analysis demonstrates that an equivalent in both
stereotactic interlocks could only be performed on days be
The produced.
time required to perform the daily QA ranges shown
with stereotactic procedures. 3.
from 20indicates
May to 30 min. a statement
This will that is likely
typically (or probably)
include the daily plans.6
to be correct but the task
check of the dynamic, virtual, or universal group does not make any
wedge. ity of o
2.B.3.5 | Radiation area monitor (if used) recommendations.
Additional time is necessary for the radiographic im- pretrea
2.B.3.5.1 | Objective. The treatment room aging daily QA (see Table VII) which can add another ment p
radiation area monitor is connected to a remote 20As partmin.
to 30 of Times
this work, on the thelower
AAPM end community
of the rangewas use of pati
indicator located outside of the treatment room. This is surveyed in 2012 regarding
commercial systems to combine many of the the type of tests.
software
Note niques
a visual safety check as a backup to the door interlock being
these used. According
times include the totimethetoresponses,
document the a dose/MU
tests. cation
|
e840
11 |
2.C
A N|D Monthly
TG CH A RG ES jority of IMRT/VMAT treatment plans although ap-
2.C.1 | Dosimetry
2.C.1.1 | Photon and electron output constancy
2.C.1.1.1 | Objective. The output of a linac is
expected to be stable over time. However, changes
in output can have occurred for multiple reasons.31
It is important to verify the output 2constancy monthly
for photon and electron beams with a calibrated
ionization chamber and electrometer under standard
testing conditions. The output constancy check is not
an absolute calibration of the machine. The test is to
verify that dose per MU obtained at the time of absolute
calibration and those measured at the time of the test,
corrected for temperature and pressure, are within
and geometry into consideration. While these programs F I Gmeasurements (typically
. 2 Solid water setup the MLC
for monthly output dosimetric leaf gap
measurements.
a specific tolerance limit. All available photon and
[Color figuremeasurements) were also required during com-
can be viewed at wileyonlinelibrary.com]
electron beams should be checked monthly.
2.C.1.1.2 | Tolerance. The tolerance for output linac at all times to stay in a state of equilibrium
constancy4,5should be ±2% from the baseline under with the ambient temperature in the room. If this is
standard conditions (e.g., baseline is 1.000 cGy/MU not possible, the phantom and chamber should be
at dmax, 10 × 10 cm field size, 100.0 cm SSD). As in placed in the treatment room for a sufficient period to
the tolerance set by the daily output constancy checks, allow the equipment to reach room temperature. The
the institution may choose a different tolerance. If the temperature of the chamber cavity in the phantom
tolerance is exceeded, an adjustment should be made and the barometric pressure should be monitored
to restore the machine to within the tolerance limit. periodically throughout the measurements, and ap-
Note that the need for large adjustments (e.g., >3%) propriate changes should be made to correct the
is uncommon.32,33 If a large adjustment is indicated by temperature or pressure factor if necessary. If the
initial measurements, a careful review of the measure- electrometer requires a long warmup period—that
ment setup, all calculations, and the history of daily should be confirmed from the user manual but is
output constancy checks should be conducted to verify typically 10 to 15 min37—it should be turned on with
that the indicated adjustment is necessary. the appropriate voltage before any measurements.
2. The phantom should be placed on the treatment couch
2.C.1.1.3 | Methods and equipment. Institutions or other supportive device at conditions like those at
may have several options for measuring the output the time of annual calibration (see Fig. 2) per TG 5138
constancy of the treatment beams. It is in the best interest calibration (SSD, SAD, gantry settings, etc.). If cross-
of the facility to use the simplest setup to reduce the calibrations are performed from water to a solid phan-
time required. One may use either solid materials (e.g., tom, measurement depths should be close to those
solid water, plastic water) or small water phantoms for depths used for TG 51 calibration.
the measurements. It is also suggested to consolidate 3. For statistical purposes, three measurements should
the depths of measurement to minimize time spent be obtained for each energy to allow for any drift that
entering the treatment room. The ionization chamber could occur with the linac or electrometer or ionization
and electrometer should have a national standards chamber. Variation between each reading should not
traceable calibration, usually obtained from an ADCL exceed ±0.5%.1
or SSDL, within the last 2 yr or be cross-calibrated with 4. Perform all appropriate corrections to the measure-
the institution’s traceable equipment. In addition, the ments following the protocol used for the initial cali-
calibration of the barometer and thermometer should bration (e.g., TG 51) or alternately using the previously
be checked annually. Measurements are made at the established cross-calibration. Calculate the result in
standard clinical dose rate. Physicists should be aware cGy/MU at the depth indicated by the protocol (e.g.,
that there may be limitations to their electrometer in dmax, d = 10 cm, etc.).
accumulating charge when the beam is rapidly delivered 5. Adjustments should be made 12,13 if the measured output
recommendations. pretreatment measurements. Moreover, as treat-
at a high dose rate.34–36 The following procedures may be exceeds ±2%. At the discretion of the facility, adjust-
used for either a solid or water phantom setup: ments could be made for smaller deviations from ex-
pected values. Repeated measurements should be
1. Ideally, the solid phantom and ionization chamber made after any adjustments to ensure the correct out-
should be stored in the treatment room with the put adjustment was made.
REPORT OF AAPM TASK
|
|
12 GROUP 198 REPORT
e841
6. If adjustments are made to the outputs, any devices 12. Once

| STATE M ENT
the primary O Fchamber
monitor TH E PRO BLE Mto
is calibrated verifica
used for daily QA should be checked. Any deviation A ND TG CH A RG ES
within tolerance, the secondary backup monitor jority
from the new monthly readings should be investigated chamber is adjusted to give the same reading as the proxim
to determine the cause, and appropriate action should An primary.
independent This check of dose/monitor
will bring the backup monitor units has been
chamber verifica
be taken. Possible causes of a discrepancy are that andwithin
continue to be an
the tolerance of ±2%. important part of quality assur- time. T
the output adjustment was performed incorrectly or ance
3. The (QA)
backup for patient
MU countertreatment plans.
is visually AAPM for
inspected Report
con- in the
that the daily QA device has drifted. Note that, if the Task Group
sistency with the 71 reports
primaryon the formalism
monitor chamber for calculat-
reading. most c
output adjustment is done correctly and the daily QA ing monitor units.1 AAPM Task Group 114 reports on ported
device is stable, then the adjustment of the output back methods
2.C.1.3 and requirements
| Typical dose rate for output
verification of data for
constancy CA). T
2
to nominal should result in the readings of the daily QA conformal external
2.C.1.3.1 | Objective. Dose beam plans. The
rates need canfor mon-vary of the
device also moving back toward the reference (base- itor
significantly with treatment type, especially early
unit verification programs was identified with the in criteria
line) values.39,40 the adoption
variety of options of IMRT treatment planning
available on most modern machines. and delivery IMRT (
3
7. All photon and electron beams should be tested at techniques.
Even within Several the same different
treatment typesfield, of programs
the dosewere rate though
least monthly for output constancy. developed ranging from confirmation
can vary from one end of the range to the other of dose at a sin-
(i.e., rate. M
8. The time requirements for monthly output checks can gle
IMRT, point in a simple
dynamic wedges).phantom geometrytoto
It is important calculation
verify that the their ca
be minimized if the measurements are compiled to sim- of dose at a single point while
machine is operating correctly at all dose rates taking patient anatomy
used (3D) v
ilar settings. This time would increase if recalibration of and geometry
clinically and into that consideration.
the dose per MU While these programs
is consistent for all measu
beam(s) and daily QA device would be necessary. have
dosebeen rates.in use for some time, guidance was lacking (DLG)
in how to commission such technologies as well as their missio
role as part of
2.C.1.3.2 | an IMRT QA program
Tolerance. For non- asIMRT
was noted in the
machines, cation
2.C.1.2 | Backup monitor chamber constancy ASTRO
dose rate white dependence may not be an issue since for
paper entitled “Safety Considerations the in use
4,5
2.C.1.2.1 | Objective. All modern linacs are IMRT”.
dose rate is not meant to change during treatment. The gorithm
required to have a secondary monitor. The backup This taskwould
exception groupbewas for charged
enhanced with: (a) Reviewing
dynamic wedges with m
monitor is intended to monitor radiation output, flatness, and evaluating the algorithms for
where the dose rate is modulated with jaw movement to “independent/second troduc
and symmetry in the event of a failure of the primary check”
deliverof the monitor
desired unit calculations
wedge- shapedfor IMRT; distribution.
isodose (b) Making as 3D
radiation monitor chamber. Due to the possibility of such recommendations on the clinical
For IMRT and stereotactic machines, the dose implementation of cal-
rate users
an event, the backup monitor chamber will need to be culation programs (e.g., number
intentionally fluctuates for certain IMRT deliveries. The of points, locations, when i
calibrated with the same expectations as the primary accuracy,
tolerance evaluation methods, and
for output constancy shouldheterogeneities);
be ±2% from (3) the
monitor chamber. Absolute calibrations are applied to Describing commissioning and
baseline under standard conditions for all measurable benchmark QA of sec-
the primary monitor chamber. The backup chamber ondary
dose rates. MU calculation
The QMP may programs,
implement proposing additional
tighter tolerances 2 |
is either cross- calibrated to the primary or calibrated measurements,
at his or her discretion. if necessary; and (4) Describing clini- MU V
simultaneously and independently. In addition to the cal testing and periodic QA of secondary MU calcula- CO M
secondary monitor chamber, some machines may tion programs
2.C.1.3.3 | and recommendations
Methods and equipment. on test tolerance.
have an independent MU counter located at the control The terminology used
1. The typical dose rate output constancy in this report follows canthat be 2.1 |
console. The purpose of this counter is to display the used in other AAPM Task Group
checked at the time that the output calibration of the reports including in
MUs delivered in the event of a power failure during particular:
machine is being checked using the same setup. The im
treatment. The delivered MUs will be displayed until the 2. Measurements are made at the standard dose as IMR
machine is reset. The backup MU counter should be 1. Shall
rate indicates
that is used a procedure
clinically.thatAdditionalis essential outputfor the com
checked for accuracy during this test. either (a) establishment
measurements are made at dose rates typicallyof uniform practices, or potenti
used with the types of treatments delivered on result and/or main- of radi
2.C.1.2.2 | Tolerance. The tolerance for the backup taining
the machine established (SRS,standards
IMRT delivery, of practice to ensure
enhanced dy- therefo
monitor chamber should be the same as the primary the accuracy of dose/MU determination.
namic wedges, etc.). For example, if the typical verifica
monitor chamber ±2%. The tolerance can be more 2. Should
standard indicates
dose rate an advisory
is 400 MU/min recommendation
and stereotac- that rors b
stringent as deemed by the QMP. It should be noted istictodose
be applied when practicable.
rate is 600 MU/min, then the output at The task group measu
that this tolerance is insufficient for fields requiring favors
either the dose indicated procedure
rate setting should but understands
be checked that and deliver
large MU delivery. For example, an Elekta machine there are other procedures
compared with the typical or standard which can doseaccomplish
rate. If tion ch
may be limited to fields not exceeding 999 MU yet the same goal.
unflattened beamsDeviations
are used fromclinically,
the recommendedphysicists rays. E
will be interrupted if the monitor chamber discrepancy procedure
should be aware that there may out
should only be carried after careful
be limitations to advanc
exceeds 10 MU, which is 1%. The backup MU counter analysis demonstrates
their electrometer in that an equivalent
accumulating chargeresultwhenwill in both
should have an identical reading to the primary monitor betheproduced.
beam is rapidly delivered with extremely high shown
chamber. 3. Maydoseindicates
rates. 34–a36statement that is likely (or probably) plans.6
to be correct but the task group does not make any ity of o
2.C.1.2.3 | Methods and equipment. recommendations.
2.C.1.4 | Photon and electron beam profile pretrea
1. The secondary monitor chamber constancy should constancy ment p
be checked at the same time as the primary monitor As part |of Objective.
2.C.1.4.1 this work, the AAPM
Photon andcommunity was
electron beam of pati
chamber, using the same setup (see Section 2.C.1.1.). surveyed in 2012 regarding the type of software
profile constancy is intended to measure any change in niques
being used. According to the responses, a dose/MU cation
|
e842
TASK GROUP 198 REPORT
13
flatness or symmetry that could occur with a machine value, subsequent routine measurements should be
due to a change in energy, steering failure, or drift in performed with the same setup and device.
servos used to direct the beam. Changes in flatness 4. Perform measurements at multiple points along the
and/or symmetry could result in underdose or overdose beam profile in both radial (in-plane) and transverse
of the patient. (cross-plane) directions. At a minimum, measure a
Beam profiles vary with machine type and energy. point at the central axis and four points at the cardinal
The baseline values1 for photon and electron beam axes at 80% of the field width defined by the primary
ing monitor units. AAPM Task Group 114 reports on ported in the survey was Eclipse (Varian, Palo Alto,
profiles are determined during acceptance testing and jaws.
commissioning and are verified annually. Flattening 5. Apply corrections to all readings that are appropriate
filter-free (FFF) beams are handled in the same manner for the measurement device (e.g., temperature and
as flattened beams.41 While there is much discussion in pressure corrections for ionization chambers, density
the literature on the properties of FFF beams,34,36,41,42 vs. dose corrections for film, dark field and flood field
the measured profile is compared with the baseline corrections for EPIDs, etc.).
profile established for the beams during commission- 6. At each individual measurement point, calculate the
ing. As stated in TG 142, the beam profile constancy percent deviation from the baseline off-axis ratio at
test includes flatness and symmetry and is meant to be that point. For full profiles, such as those from film
a measurement of deviation from baseline values, not scans or EPIDs, calculate a percent difference from
an absolute measurement. the baseline profile.
All photon and electron beams should be tested for 7. Repeat for all photon and electron energies.
beam profile constancy monthly.43 The photon profiles
should be4,5inspected closely, as deviations could indi- A simple calculation for the central axis and four
cate a change in energy.44,45 points is shown here in Table II.
2.C.1.4.2 | Tolerance. The tolerance for photon 2.C.1.5 | Electron beam energy constancy
and electron beam profile constancy is ±1% for all 2.C.1.5.1 | Objective. The objective is to determine
machine types. This value is a deviation from baseline, if the electron beam energy has changed from original
not an absolute value. baseline values. This is done by calculating the ratio of
measured ionizations at two depths, usually within the
2.C.1.4.3 | Methods and equipment. practical range of electron beam.
1. The device used for daily output monitoring often has
the additional ability to measure flatness or symme- 2.C.1.5.2 | Tolerance. The tolerance is ±2% of the
try. The QMP may review the daily measurements expected ionization ratio or ±2.0 mm of the expected
made during the daily QA for any changes in flat- depth.
ness and symmetry. It is up to the QMP if additional
monthly measurements are required. However, it is 2.C.1.5.3 | Methods and equipment. It is most
not specified in TG 142 to measure flatness and sym- efficient to perform this test at the same time as the
metry daily. electron output constancy test. Using the methods and
2. Equipment used during acceptance testing and com- equipment used in Section 2.C.1.1.:
missioning is not always conducive to routine use. At
the time of these measurements, simpler test equip- 1. Repeat a series of three measurements at a sec-
ment may be implemented to measure flatness and ond known depth.
symmetry with reference to values obtained at com- 2. Calculate the ratio of the reading at the second depth
missioning. This equipment should be stable over to the reading at the depth of calibration.
time and has sensitivity that is less than the tolerance 3. Compare the result with the baseline values and
limit for profile constancy. It should be noted that flat- compare with tolerance values.
ness and symmetry will be unique to the measuring
device, and if a new device is introduced for QA, new Alternatively, one could use an array detector with
baselines must be established. built-in filters order to discriminate electron energy.
3. The specific test equipment used and depth of meas-
urement are the choice of the individual performing
the measurements. There are a variety of array type
2.C.2 | Mechanical
ity of only 5% to detect IMRT plan errors using IMRT
detectors46 available that can be used to acquire
data for multiple tests at one time. These devices 2.C.2.1 | Light or radiation field coincidence
can either be placed on the couch top or mounted (symmetric and asymmetric)
on the gantry. Electronic portal imaging devices 2.C.2.1.1 | Objective. The radiation light field
(EPIDs) have also been used.33 Whatever meas- coincidence is established at acceptance testing
urement geometry is used to establish the baseline and should remain relatively stable for the life of the
REPORT OF AAPM TASK
|
|
14 GROUP 198 REPORT
e843
machine. Major changes or repairs to devices in the 1rely|lessSTATE M ENT

on the use Oand
of lasers F TH E on
more PRO BLE M
the alignment verifica
beam path (e.g., mirror, field light assembly) may result AofND TG CH A RG ES
internal anatomy or fiducials. However, the lasers can jority
in changes in radiation or light field coincidence.47 form the basis of many of the QA tests described in this proxim
This is a concern for treatment instances where An independent
report. The tolerance checkon of the
dose/monitor
degree of units accuracy has of been
the verifica
clinical setups are performed using the light field. and continue to be an important
lasers will depend on the use of the machine. Machines part of quality assur- time. T
The result would be erroneous treatments due to the ance
that are (QA) notforusedpatient treatment
for IMRT may plans.have aAAPM Report
less stringent in the
misconception of treated area to proposed area if Task Group 71
tolerance than machines reports on the formalism
used for IMRT or stereotacticfor calculat- most c
1
radiation or light fields do not coincide. In contrast to ing monitor units.
treatments. Also, the AAPM processTaskofGroup 114 reports
determining on
the laser ported
TG 142, while we acknowledge that asymmetric jaws methods and requirements
alignment as it correlates to the mechanical for verification of data
or radiationfor CA). T
2
can be used for beam matching and dynamic or virtual conformal
isocenter may external beamtheplans.
vary with machine The useneed
(i.e.,for mon-
Winston- of the
wedge delivery, this TG believes that the tolerances itor unit verification programs was
Lutz test vs. mechanical testing). It should be noted that identified early in criteria
should be the same for both symmetric and asymmetric the adoption of IMRT treatment
the QMP can determine which method to use. planning and delivery IMRT (
jaws. This also aligns with “AAPM Medical Physics techniques.3 Several different types of programs were though
Practice Guideline 8.a.”9 The coincidence of the light developed
2.C.2.2.2 ranging from confirmation
| Tolerance. The tolerance of dose at a sin-
will vary with rate. M
fields for all photon energies used for clinical setups gle point in a simple phantom
machine use. Non-IMRT machine laser tolerance is geometry to calculation their ca
should be tested against the radiation field. of dose
±2.0 mm, at a single
IMRT point while
machines taking
is ±1.0 mm, patient anatomy
and machines (3D) v
and geometry into consideration.
used for SRS/SBRT treatments is <1.0 mm deviation. While these programs measu
2.C.2.1.2 | Tolerance. The tolerance is ±2 mm per have been incan
Tolerances usebefor
madesome more time, guidance
stringent was
at the lacking
discretion (DLG)
jaw. (Note: This is adjusted from TG 142 to align with inofhow to
the QMP. commission such technologies as well as their missio
“AAPM Medical Physics Practice Guideline 8.a.”9). role as part of an IMRT QA program as was noted in the cation
ASTRO
2.C.2.2.3 white | paper
Methods entitled
and “Safety
equipment. Considerations for in use
4,5
2.C.2.1.3 | Methods and equipment. IMRT”.
1. The methods and equipment will depend on the use gorithm
1. Film has long been the choice for this type of meas- This
of thetask group Less
machine. was precise
chargedmethods with: (a)can Reviewing
be used with m
urement, but with the age of digital radiography, film andfor evaluating the algorithms for “independent/second
non-IMRT machines. The highest level of preci- troduc
processors may no longer be available. The ability check”sionofismonitor
requiredunit for calculations
SRS/SBRT machines. for IMRT; (b) Making as 3D
to differentiate ±1.0 mm on film can be difficult with recommendations on the clinical
2. The following methods and materials are broken implementation of cal- users
the naked eye. Some software suites are available culation programs (e.g.,
down according to machine use: number of points, locations, when i
that can quantify the deviations in light field (usually accuracy,
a. Non-evaluation
IMRT machines: methods, and heterogeneities); (3)
represented by radiopaque markers on the film) and Describing
(i) A determination of theand
commissioning truebenchmark
mechanical QAisocenter
of sec-
radiation field. In the absence of film and/or analyz- ondary MU calculation programs, proposing
of the machine is required to align the lasers cor- additional 2 |
ing software, certain electronic hardware is available measurements,
rectly. The ifgantrynecessary; and (4) Describing
and collimator need to be set clini-in MU V
to test light or radiation field coincidence. One could cal testing and periodic QA of secondary
their neutral or standard position (0° or 180°) and MU calcula- CO M
also use MV imaging, if available. tion programs
the isocenter and recommendations
verified. on test tolerance.
2. If film is used (silver halide based or radiochromic The
(ii) A possible method is to note the drift follows
terminology used in this report or “walk-thatout” 2.1 |
film), one could either physically mark the edge of the used of in the
other sagittal crosshair from the lightincluding
AAPM Task Group reports field as the in
light field (score with a pen or pin prick) before the ra- particular:
gantry is rotated when set at isocenter. Set the The im
diation exposure of the film. The resultant image will approximate isocenter to the couch surface or de- as IMR
show any misalignment between the light field mark- 1. Shall viceindicates a procedure
with a crosshair. that iscrosshair
The sagittal essentialis for ei- the com
ings and the radiation field. An alternative to marking either (a) establishment of uniform
ther marked or aligned with the device. The gantry practices, or potenti
the film is to expose a device with radiopaque mark- (b) isthe most ±45°,
rotated safe and and effective
the projection result ofand/or main-
the sagittal of radi
ers, which are aligned to the light field. taining established standards of
crosshair is observed. Movement left or right of thepractice to ensure therefo
3. If an electronic device is used, the commercial theprojected
accuracycrosshairof dose/MU from the determination.
original or vertical po- verifica
software may have the ability to detect field edge 2. Should indicates an
sition indicates the couch topadvisory recommendation
or device is not thatat rors b
variation. This variation must correspond to the ac- is to be applied when practicable.
the isocenter. Raise or lower the couch until the The task group measu
tual light field that is aligned to the detector edges. favors the crosshair
sagittal indicated no procedure
longer drifts but understands
left or right asthat the deliver
Misalignment of the device will give erroneous re- there are other procedures
gantry is rotated. An alternate method which can accomplish
would be to tion ch
sults. The device or software must also be able to theuse same the goal. Deviations
mechanical front from pointers the provided
recommended by the rays. E
detect variations smaller than the tolerance limit for procedure
manufacturer. should only be carried out after careful advanc
this test. analysis
(iii) Thedemonstrates
collimator must that be an setequivalent
at its true result will
neutral in both
4. If the linac is used for the test (i.e., using MV imag- be position
produced. to properly align the lasers. With the gan- shown
ing), the image analysis must be able to detect varia- 3. May tryindicates
rotated toa astatement
side position, that is a likely
bubble,(ortorpedo,
probably) or plans.6
tions smaller than the tolerance limit. to be correct but the task group does
a digital level can be used to level the collimator. not make any ity of o
recommendations.
Caution must be exercised when using a level, as pretrea
2.C.2.2 | Lasers the surface of the collimator face may not be level. ment p
2.C.2.2.1 | Objective. Lasers are conventionally As Any partinaccuracy
of this work, in the the levelAAPMitself community
can be removed was of pati
used for the initial setup of a patient regardless of the surveyed in 2012 regarding the
by rotating the level 180° and splitting any discrep-type of software niques
type of treatment. With the advent of IGRT, patient setups beingancy. used.An According
alternate to the responses,
method would be to a dose/MU
place the cation
|
e844
15 |
A couch
N D TGtop at an SSD of approximately 130 cm. Set
CH A RG ES 2 jority of IMRT/VMAT treatment plans although ap-
the field size to its largest setting (40 × 40 cm ).
With the gantry at 0°, place a piece of tape on the
couch top along the transverse crosshair as pro-
jected by the light field. Rotate the gantry ±45°
and mark the location of the light field central axis
on the tape. Set the gantry to 0° using a level and
mark the central axis. Align the collimator with the
marks on the tape.
(iv) Once the true mechanical isocenter is de-
termined and all axes are neutral (i.e., gantry at
zero, collimator set to 0° or 180°), a precise laser
alignment tool48 can be used. Align the laser align-
ment tool with the crosshairs and check all lasers.
Alternatively, the lasers can be aligned to the front
pointer as a surrogate for the true mechanical iso-
and geometry into consideration. While these programs F I Gmeasurements
. 3 Winston- Lutz(typically
setup with the
coneMLC dosimetric
and film leaf gap
holder. [Color
center. The tolerance will depend on the use of the
figure measurements)
can be were also required during com-
viewed at wileyonlinelibrary.com]
machine.
(v) It should be noted that, while lasers are typically
aligned based on the isocenter plane, the practi- size or MLC shape) should be small enough to
cal application of using the lasers to align patients detect misalignment with the Winston- Lutz test
using skin marks occurs in a plane away from the object. Software can be used to analyze the result-
isocenter. Therefore, it is important to verify laser ing images if it can calculate the full width at half
alignment away from the isocenter plane. There maximum between the test object and field edge.
are laser alignment tools and techniques that ac- Visual inspection of the images can detect obvious
complish this, for example, the method described misalignments but may be difficult to quantify the
culation programs49 (e.g., number of points, locations, when interpreting the survey.
by Hwang et al. results.
b. IMRT machines: (iii) If lasers are used for initial patient setup with
(i) The same methodology used for non-IMRT ma-
ondary MU calculation programs, proposing additional 2 imaging
| ROas LEthe O Ffinal
DOSE determination of patient
/
chines can be used for IMRT machines with the alignment, the preceding methods for IMRT ma-
exception of requiring a tighter tolerance. chines may suffice. If the lasers are not the pri-
c. SRS/SBRT machines: mary method of aligning a patient for SRS/SBRT, a
(i) Machines used for SRS/SBRT may require the lesser tolerance for the lasers may be used at the
tightest tolerance for laser alignment depending on discretion of the QMP.
how the lasers are used. For treatments where the
lasers are used to align a patient to isocenter as 2.C.2.3 | Gantry or collimator angle
the primary means for setup, the laser tolerance 2.C.2.3.1 | Objective. The objective is to determine
will need to be better than ±1 mm. For SRS/SBRT the accuracy of the digital readout of gantry and
treatments that are based on imaging for the final collimator angles. In many treatment situations, multiple
isocenter alignment, better than ±1 mm accuracy fields are used to treat the target. These fields are
of the lasers may not be necessary. The QMP delivered at different gantry angles as well as different
should determine and set the necessary tolerance. collimator angles. To ensure accurate dose delivery
(ii) If the lasers are the primary method of alignment to the target and to spare the sensitive organs, it is
for patient setup with imaging as a supplement, necessary to ensure that correct gantry and collimator
the Winston- Lutz method (see Fig. 3) is recom- angles are set as requested in the clinical plan.
mended.50,51 The Winston- Lutz test can use either
film or EPIDs for imaging.52– 54 The Winston- Lutz 2.C.2.3.2 | Tolerance. The tolerance is ±1°
test should be performed over the range of gantry- regardless of the use of the machine. Tighter tolerances
couch combinations used clinically. The QMP can be used at the discretion of the QMP.
should determine the number of combinations
tested, but the range should include worst-case 2.C.2.3.3 | Methods and equipment.
scenarios used clinically (gantry-couch combina- 1. To verify the collimator angles, the same setup
tions with the greatest known error). Also, if treat- used to align the lasers can be used for this test
ing with cones, the cones should be used as the [see Section 2.C.2.2.3 (2)(a)(iii)]. With the couch at
collimation during the test. Likewise, if MLCs are 130 cm SSD and using the initial marks used to set
used for treatment, the MLCs should be used for the collimator to true 0°/180°, rotate the collimator
collimation. The radiation field size chosen (cone ±90°. Align the crosshairs with the same marks on
REPORT OF AAPM TASK GRO
|
TASK16 |
GROUP 198 REPORT 2 TASK GROUP 198e845
REPORT
the tape at each angle. Record each digital readout. 1 2.C.2.5 | STATE | Jaw M ENT positionO Findicators
TH E PRO BLE M verification
Alternatively, one can use a level for this test. The A ND TG CH A RG ES
2.C.2.5.1 | Objective. Jaw positions are important jority of I
level can be tested on a known flat surface. Rotate for setting the field edges. For asymmetric jaws, there proximate
the gantry to 90° or 270°. Set a level on a flat spot An independent
should be additional check of scrutiny
dose/monitor for beam units matching
has been and verification
on the collimator housing. Rotate the level ±180° to and the accuracy of dynamic or virtual wedgeassur-
continue to be an important part of quality delivery time. The
correct for any error in the level itself. Caution should ance which depends strongly on jaw positioning accuracy. in the sur
(QA) for patient treatment plans. AAPM Report
be used when using a level for this test. As a true flat Task Group 71 reports on the formalism for calculat- most com
1
spot may be difficult to find on the collimator housing, ing 2.C.2.5.2 | Tolerance. The tolerance for symmetric ported in
monitor units. AAPM Task Group 114 reports on
the projection of jaws or the crosshairs can be com- methods
is ±2 and mm requirements
per jaw, asymmetric for verification
±1 mm of per data
jawfor when CA). This
2
pared with a plumb line on a vertical surface, on a conformal external beam plans.
used for field matching at the central axis. The need for mon- of these p
wall or something attached to the table, for example. itor unit verification programs was identified early in criteria for
Check the digital readout for the indicated collimator the adoption
2.C.2.5.3 of | Methods and equipment. Align graph IMRT (51%
IMRT treatment planning and delivery
3
angles. techniques. Several
paper or template with different typesrectangular
predefined of programs werewith though 30
shapes
2. To measure the gantry angles, place a level on the in- developed ranging from confirmation
the crosshairs at collimator angle = 0°, 100 cm from of dose at a sin- the rate. More
terface mount or on the accessory mount and obtain gle source. Adjust the collimators to match several field sizes their calcu
point in a simple phantom geometry to calculation
the true angle for the four orthogonal gantry angles. of dose
coveringat a the single pointrange.
clinical while taking
Recordpatient anatomy
the digital readout. (3D) volum
Rotate the level ±180° to offset any error in the level and Do this for the upper and lower jaws (in symmetric and measurem
geometry into consideration. While these programs
itself. Check the digital readout. have been in use
asymmetric for some
modes). time, guidance
Asymmetric jaws shouldwas be checked (DLG) mea
lacking
3. For machines used to treat patients at extended dis- in how to commission such technologies
at settings of 0.0 (central axis) and 10.0 cm. as well as their missioning
tances, for example, 130 cm, a 0.5° gantry misalign- role as part of an IMRT QA program as was noted in the cation cal
ment will appear as a 3 mm translation of the isocenter ASTRO 2.C.2.6 white paper entitled
| Crosshair centering “Safety Considerations for in use at t
4,5
(30 cm × tan 0.5°). The calibration of the gantry angle IMRT”.2.C.2.6.1 | Objective. The centering of the gorithm.” N
at 0° and 180° should be more stringent, when pos- This task group
crosshairs as was the charged
collimatorwith: rotates reflects the with more
(a) Reviewing
sible, for these machines. and accuracy of the mechanical alignment of the collimator. troduction
evaluating the algorithms for “independent/second
4. For machines used to treat TBI/TSET patients at ex- check”Foroftreatments
monitor unit calculations
involving for IMRT;
the rotation of (b) collimator as 3D volu
theMaking
tended distances, the calibration of the gantry at the recommendations
from neutral position, the alignment is important,cal-
on the clinical implementation of as the users shou
treatment angle, typically 90° or 270°, should also be culation programs (e.g.,
MLCs or compensators can be shifted. number of points, locations, when inter
more stringent when possible. accuracy, evaluation methods, and heterogeneities); (3)
Describing
2.C.2.6.2 commissioning
| Tolerance. andCrosshair
benchmark QA of sec-
centering or walk-
2.C.2.4 | Accessory trays ondaryout should have a radius of ≤1.0 mm for additional
MU calculation programs, proposing all machines. 2 | RO
2.C.2.3.1 | Objective. The objective is to determine measurements, More stringent if necessary;
tolerances are andup (4)toDescribing
the site QMP. clini- M U V ER
the positioning of the accessory tray with respect to cal testing and periodic QA of secondary MU calcula- CO M PR
isocenter at the four cardinal gantry angles. Accessory tion programs and recommendations
2.C.2.6.3 | Methods and equipment. Set field size on test tolerance.
trays are used to hold beam-shaping blocks at a fixed The = 10terminology
× 10 cm2. used Align ingraphthis paper
report orfollows
template thatwith 2.1 | R
position with reference to isocenter. The trays are slid used in other AAPM Task Group
predefined rectangular shapes and crosshairs with reports including in the
into an accessory slot on the linac head. The trays are particular:
collimators at collimator angle = 0°, 100 cm from the The implem
locked into place by a latch. If the latch does not function source. Record the radius of the smallest circle, which as IMRT/V
as intended, the tray could become dislodged, presenting 1. Shall
includes indicates
all thea crosshairprocedurecentral that isaxis essential
projections for at the comple
a safety concern. In addition, any deviation from the either (a) establishment
collimator angles of 0°, 90°, and 270°. of uniform practices, or potential fo
intended position as the gantry rotates can cause a (b) the most safe and effective result and/or main- of radiothe
misalignment of the treatment portal with respect to taining established standards
2.C.2.7 | Treatment couch position indicators of practice to ensure therefore e
isocenter. If there are no patients being treated clinically the2.C.2.7.1 | Objective. Digital treatment couch position verification
accuracy of dose/MU determination.
with blocks, then this test can be omitted. 2. Should
indicators indicates
are used antoadvisory
both verifyrecommendation
that day-to-day treatment that rors befor
issetups
to be are applied when practicable. The task
occurring in a reproducible manner and that measurem group
2.C.2.4.3 | Tolerance. Latching is functional, favors the indicated
shifts for patient alignment procedure but understands
are implemented accurately.that The delivery o
deviation of block position from zero gantry angle there are other procedures which can
treatment couch position indicators include longitudinal, tion cham accomplish
position within ±2 mm. the same
lateral, goal. and
vertical, Deviations
rotational from
digital thereadouts.
recommended In the case rays. Expe
procedure should only be carried out
of SRS/SBRT treatments, if the linac digital readout has a advanced after careful
2.C.2.4.4 | Methods and equipment. Rotate gantry analysis
scale of demonstrates
zero, it is up to the thatQMP an equivalent
to determine result will
an alternate in both ma
to 0°. Insert accessory tray with custom blocking into be produced.
method to perform the couch rotation test. shown to
the accessory slot on the linac head and ensure tray 3. May indicates a statement that is likely (or probably) plans.6-11 R
latches. Measure deviation of accessory tray central to2.C.2.7.2 be correct| but the task group
Tolerance. does not make
The tolerance for non- anyIMRT ity of only
axis (usually scribed on tray) from the machine recommendations.
is ±2 mm/±1°, IMRT ±2 mm/±1°, SRS/SBRT ±1 mm/±0.5°. pretreatme
crosshairs. Rotate gantry to 90°, 180°, and 270° and ment plann
measure the deviation at each angle. The collimator As part of this work,
2.C.2.7.3 | Methods and equipment. the AAPM community was of patients
should be rotated such that the latch is placed toward surveyed
1. For longitudinal verification, place the gantry and niques ste
in 2012 regarding the type of software
the floor at gantry angles 90° and 270°. being used.
collimator According
at a neutral to theposition
responses, (at zeroa dose/MU
angles). Set cation may
|
2
TASKe846
GROUP 198 REPORT
MU VERIFICATION FOR IMRT
17
1 paper
graph | STATE or a ruler MatENT 100 cm O FSSD THonEthe PROcouch BLE M verification
2.C.2.8.2 | Tolerance.programFor wasvisual
generally used forthe
inspection, the ma-
A N D TG CH A RG ES
and draw lines that are aligned with the crosshairs. tolerance is ±2 mm for all machines. The dosimetric ap-
jority of IMRT/VMAT treatment plans although
Note the current digital longitudinal reading. Shift proximately
comparison 31% of axis
of the central responders
wedge factor did not use dose/MU
should be
An independent check of
the table longitudinally toward and away from thedose/monitor units has been verification software for
within ±2%. Tighter tolerances can be set by theVMAT treatment plans
siteat that
andby
gantry continue to be an(e.g.,
a set distance important
15 cm part fromofthe quality
initial assur- QMP iftime. The most common commercial system reported
desired.
ance (QA) for patient treatment
position) by using the marks on the graph paper or plans. AAPM Report in the survey was RadCalc (Lifeline, Tyler, TX). The
Task Group
ruler and the center of 71 reports on the formalism for calculat- 2.C.2.8.3 | Methodstreatment
most common planning Alignment
system (TPS) re-
1 the crosshairs. Note the ac- and equipment. of
ing monitor units. AAPM Task
tual digital reading at each location and record the Group 114 reports on ported in the survey was
the wedge can be checked visually on some machines, Eclipse (Varian, Palo Alto,
methods and requirements for verification of data for
difference. CA).beThis
or it can is not to dosimetrically
performed be consideredwith as an endorsement
reference
2
conformal external beam plans.
2. For lateral displacement, the same setup for the lon- The need for mon- of these products. The
to baseline readings taken at commissioning. most common passing
For rate
itor unit verification programs
gitudinal verification can be used, instead shifting the was identified early visual verification of external hard wedges, the light5% for
in criteria for dose/MU verification software was
the adoption of IMRT treatment
couch laterally 3and noting the digital lateral position planning and delivery IMRT
field must be(51%)
visible. and “Noneinserting
Simply Specified” thefor VMAT
wedge is (34%),
not al-
techniques.
indicators. Several different types of programs were though 30% of VMAT responders
an acceptable surrogate for this test. The wedge will used 5% as passing
developed
3. To test the rotationalrangingdigital from readouts,
confirmation there of are
dose sev-at a sin- rate.
obstruct theMore than 50%
light unless the of users used
collimator can abesingle
opened point for
gle point in a simple phantom
eral methods that one can use. If the mechanical geometry to calculation their calculations and only
outside the boundaries of the wedge. The shadow of 6% used three- dimensional
of dose
readout on at thea floor
singlehas point while
been taking patient
deemed accurate, anatomy (3D)
the edge volumetric
of the wedge can dose be in the 2012and
measured survey.
compared Additional
one can simply rotate the couch ±90° and record While these programs measurements (typically the
with baseline readings with reference to the central MLC dosimetric leaf gap
have been in use for some
the digital readings. If the mechanical readings time, guidance was lacking axis. If visual inspection of the wedge is not possible, com-
(DLG) measurements) were also required during
in how to commission such technologies
are not reliable or are nonexistent, the crosshairs as well as their missioning.
dosimetric alignment Theofmost common
the wedge can IMRT dose/MU
be used with verifi-
role as part of an IMRT QA
can be used as a reference. The collimator must program as was noted in the cation calculation algorithm
chamber measurements or with an array type device. represented by software
ASTRO
be at the true white paper entitled “Safety Considerations for in use at the time was a “factor- based calculation al-
4,5 neutral position if it is to be used for Readings at the central axis or off-axis are compared
IMRT”.
this test. With the graph paper or ruler aligned to gorithm.” Note that the clinical
with baseline readings. It is important to obtain readings practice has changed,
This task
the sagittal group unlock
crosshair, was charged the couch with:longitudi-
(a) Reviewing with more
by rotating the wedge widespread use of for
or collimator VMAT as well
internal wedgeas the in-
and evaluating the algorithms
nal brake and run the couch first toward the gantry for “independent/second ±180° to ensure the mechanical wedge central axis (such
troduction and adoption of new software tools
and then toward the foot of the couch. Observe the for IMRT; (b) Making as 3D
coincides withvolumetric
the photoncalculation
central axis. systems)
A similar since
central2012, so
recommendations on the clinical
sagittal crosshair as it aligns with the graph paper implementation of cal- users should consider the age
axis dose should be measured in both orientations, and and context of the data
culation programs (e.g., number
or ruler. If the sagittal crosshair does not track par- of points, locations, when interpreting the survey.
the average of the two readings should be compared
allelaccuracy,
to the line evaluation
on the graph methods, paper andorheterogeneities);
the edge of (3)
with the baseline. It is recommended to use the largest
the Describing
ruler, rotatecommissioning
the couch slightly and benchmark
until the sagittal QA of sec- wedge (i.e., 60° wedge) for this test.
ondaryruns
crosshair MU parallel
calculation as theprograms,
table isproposing
driven in and additional 2 | RO LE O F DOSE /
measurements, if necessary;
out. Record the digital angle. For ±90°, the trans- and (4) Describing clini-
2.C.2.9M U| VCompensator
ER I FI CATI O NS I Naccuracy
placement A
cal testing and
verse crosshair is used. periodic QA of secondary MU calcula- 2.C.2.9.1 | Objective. Solid compensators R are
CO M PR EH ENSI V E Q A PROG AM
tion programs and recommendations
4. For the vertical digital table readout, the ODI and/ on test tolerance. used with machines without MLCs or in situations
or frontThe terminology
pointer can be used. used Set in thisthe report
couch top followsto that where 2.1 | Review
compensators of thea problem
produce better plan. As with
used in other AAPM Task
100.0 cm SSD using the ODI and verify with the Group reports including in
MLC positioning for IMRT plans, compensators should
particular:
mechanical front pointer. Record the digital vertical The with
be aligned implementation
similar precision of new to treatment techniques such
produce satisfactory
couch reading. Raise and lower the couch a known as IMRT/VMAT
dosimetric results. in a radiotherapy department increases
1. Shall indicates a procedure
amount (e.g., ±10.0 cm) using the ODI and verifying that is essential for the complexities in planning and delivery and thus, the
either (a) establishment
with the mechanical front pointer. Alternatively use of uniform practices, or potential for serious
2.C.2.9.2 | Tolerance. Compensator errors in the planning and
placement delivery
(b) the most safe and
the wall lasers and a ruler held vertically. effective result and/or main- of radiotherapy. An
accuracy should be ±1 mm at the isocenter.effective set of QA procedures is
taining established standards
5. In addition to the relative couch position tests sug- of practice to ensure therefore essential. The goal of a routine pretreatment
gestedthe in TGaccuracy142, we of propose
dose/MUan determination.
absolute couch verification
2.C.2.9.3 | Methods procedure is to identify and resolve andany er-
2. Should indicates an advisory
test. We suggest one clinically relevant point, for ex- recommendation that rors before patient treatment.
equipment. Compensators are mounted on trays For IMRT, verification
ample,iscouch
to bevertical
appliedreading when practicable.
at 100 cm SSD Thetotask the group which measurements
slide into the accessory are commonly mount usedon thetomachine.
verify correct
favors the indicated procedure
couch surface. This is typically couch vertical equal but understands that delivery of treatment plans,
Alignment can be checked visually with a blank tray for example with
andioniza-
to zero.there are other procedures which can accomplish tion chambers, films, or multidimensional
compared with the crosshairs or dosimetrically against detector ar-
the same goal. Deviations
6. All these tests can be performed using phantoms from the recommended rays. Experimental methods for
a known isodose distribution. The dosimetric evaluation patient- specific QA in
procedure should only
of known dimensions. There are also commercially be carried out after careful advanced radiotherapy are,
can be performed either with a chamber placed at the however, time- consuming
analysis
available devices demonstrates
with knownthat an equivalent
distances scribed resulton will centralinaxis
bothand manpower
compared andwithaccelerator
a baseline timereading
and have or been
them. be produced. shown
with a detector to be unable to detect
array, film, or MV imager (EPID). some unacceptable
2.C.2.8 to| beWedge correctplacement
but the task group does not make any
accuracy ity of| only
2.C.2.10 5% to of
Latching detect
wedges, IMRTblocking
plan errors
12,13 tray using IMRT
recommendations.
2.C.2.8.1 | Objective. The objective is to verify the pretreatment
2.C.2.10.1 | Objective. The measurements. objective Moreover, is as to treat-
position of the external hard wedge or internal dynamic ment planning becomes more
determine the functionality of the accessory tray and efficient and the number
As part of this work,
hard wedge with respect to the treatment isocenter. the AAPM community waswedge latching mechanisms at all collimator or gantry tech-
of patients treated with advanced radiotherapy
surveyed in 2012 regarding
Misalignment of either will cause undesired shifts in the type of software angle niques steadilythat
combinations increases,
places the measurement-
latch toward based
the verifi-
being used. According
isodose lines with respect to the isocenter. to the responses, a dose/MU cation may result in a continued
floor. Accessory trays are used to hold beam-shaping increase in workload.
|
2
TASK18
|
GROUP 198 REPORT TASK GROUP 198e847
REPORT
1 | STATE M ENT O F TH E PRO BLE M verification

blocks at a fixed position with reference to isocenter.
A ND TG CH A RG ES jority of I
The trays are slid into an accessory slot on the linac
proximate
head. The trays are locked into place by a latch.
An independent check of dose/monitor units has been verification
Similarly, the physical wedges are held in place by a
and continue to be an important part of quality assur- time. The
latch. If the latch does not function properly, the tray
ance (QA) for patient treatment plans. AAPM Report in the sur
or wedge could become dislodged, presenting a safety
Task Group 71 reports on the formalism for calculat- most com
concern.
ing monitor units.1 AAPM Task Group 114 reports on ported in
methods and requirements for verification of data for CA). This
2.C.2.10.2 | Tolerance. The tolerance is functional.
conformal external beam plans.2 The need for mon- of these p
itor unit verification programs was identified early in criteria for
2.C.2.10.3 | Methods and equipment. Rotate
the adoption of IMRT treatment planning and delivery IMRT (51%
linac to a collimator and gantry angle combination that
techniques.3 Several different types of programs were though 30
places the latch toward the floor. Insert wedge into the
developed ranging from confirmation of dose at a sin- rate. More
appropriate slot in the treatment head. Confirm that the
gle point in a simple phantom geometry to calculation their calcu
wedge is latched securely. Repeat for all wedges and
of dose at a single point while taking patient anatomy (3D) volum
the blocking tray.
and Fgeometry into consideration. While these programs
I G . 4 LaserGuard collision test setup. Object is setup on measurem
havecouch
been in use
such that itfor
will some time,
enter the guidance
protection was
zone of lacking
the LaserGuard (DLG) mea
system.
in how Once in protection
to commission suchzone, all motion should
technologies beas
as well inhibited.
their missioning
2.C.3 | Safety role [Color
as partfigure can be viewed at wileyonlinelibrary.com]
of an IMRT QA program as was noted in the cation cal
ASTRO white paper entitled “Safety Considerations for in use at t
As part of the monthly safety tests recommended in TG
IMRT”.4,5 gorithm.” N
142, the TG recommends that the monthly QA form be in a typical treatment position but relatively close
This task group was charged with: (a) Reviewing with more
used to document the QMP’s sign off on the daily QA, (e.g., 10 cm if that is the boundary) to the collimator.
and evaluating the algorithms for “independent/second troduction
machine logbook, and machine service reports. Daily Rotate the gantry as if it was to collide with the couch.
check” of monitor unit calculations for IMRT; (b) Making as 3D volu
QA is preferably signed daily but at a minimum of once The LaserGuard should activate the motion stop and
recommendations on the clinical implementation of cal- users shou
per week by the QMP. This frequency has increased prevent the collision. To test the touch guard system,
culation programs (e.g., number of points, locations, when inter
since TG 142, which had recommended a minimum of ensure that there is sufficient clearance and begin
once per month. As discussed in Section 2.A, more to rotate the gantry. Depress one of the touch guard
recently, QA management systems are being used. switches; gantry motion should be inhibited. With the
ondary MU calculation programs, proposing additional 2 | RO
These systems can be configured to automatically alert switch activated, attempt to move the collimator and
measurements, if necessary; and (4) Describing clini- M U V ER
the QMP should a daily QA result exceed tolerance, treatment couch. Motion should be prevented. Repeat
cal testing and periodic QA of secondary MU calcula- CO M PR
and the daily sign off is therefore inherent in the sys- for all touch guard switches.
tem. Machine logbooks and service reports are usually
The terminology used in this report follows that 2.1 | R
signed upon completion of service.
2.C.4 | Respiratory gating
particular: The implem
2.C.3.1 | LaserGuard or touch guard— interlock
as IMRT/V
test All the tests in this section can be accomplished with the
1. Shall indicates a procedure that is essential for the comple
2.C.3.1.1 | Objective. The objective is to test the same QA patient in the respiratory gating software. The
either (a) establishment of uniform practices, or potential fo
functionality of the LaserGuard or touch guard systems. QA patient is typically created by recording the respira-
(b) the most safe and effective result and/or main- of radiothe
LaserGuard or touch guards are integrated patient and tory trace of a QA device or reciprocating phantom and
taining established standards of practice to ensure therefore e
equipment collision detection systems. The LaserGuard setting the appropriate phases and/or displacement
the accuracy of dose/MU determination. verification
system uses an infrared laser scanning device that magnitude thresholds. It should be noted that, in con-
2. Should indicates an advisory recommendation that rors befor
monitors the region between the collimator face and trast to TG 142, all references to amplitude have been
is to be applied when practicable. The task group measurem
the patient. This area is defined as the protection zone. replaced with displacement or displacement magnitude
favors the indicated procedure but understands that delivery o
If an object enters the protection zone, the system to align with TG 76, “The Management of Respiratory
there are other procedures which13 can accomplish tion cham
inhibits motion before a potential collision. Touch guard Motion in Radiation Oncology.” Respiratory moni-
the same goal. Deviations from the recommended rays. Expe
systems consist of physical pressure switches. If a toring systems require QA to ensure that they are re-
procedure should only be carried out after careful advanced
switch is depressed, the appropriate motion, gantry, sponding consistently to breathing motion in the form
analysis demonstrates that an equivalent result will in both ma
collimator, or table is prevented. of thoracic motion, abdominal motion, or inhalation
be produced. shown to
volume. The Varian Real-Time Position Management
3. May indicates a55statement that is likely (or probably) plans.6-11 R
2.C.3.1.2 | Tolerance. The tolerance is functional, (RPM) system uses a charge- coupled device camera
to be correct but the task group does not make any ity of only
activating all motion stop if an object breaks the zone of to detect the motion of infrared reflecting markers em-
recommendations. pretreatme
protection or touch guard switch is depressed. bedded in a marker block (breathing surrogate). To test
ment plann
the system functionality, place the marker block on the
As part of this work, the AAPM community was of patients
2.C.3.1.3 | Methods and equipment. Turn on the vendor-supplied reciprocating phantom (see Fig. 5).
surveyed in 2012 regarding the type of software niques ste
LaserGuard system. Place a phantom on the treatment Open a patient in the RPM software. Select a new
being used. According to the responses, a dose/MU cation may
couch (see Fig. 4). Place the couch under the gantry treatment field and create a reference session. If the
|
2
TASKe848
GROUP 198 REPORT MU VERIFICATION 19
FOR IMRT
system1 is functioning
| STATE M ENTtheOsoftware
properly, F TH Eshould PROdis- BLE M verification
2.C.4.1.3 | Methods program and was generallyOpen
equipment. usedthe forQA the ma-
A N D TG CH A RG ES
play the breathing pattern of the surrogate device. The patient in the gating software. Use the same setup as ap-
Anzai respiratory monitoring system is a belt-based 56 proximately
the monthly beam 31% output of constancy
responders(Section did not 2.C.1.1.).
use dose/MU
An independent check of dose/monitor
system that uses a strain gauge to measure respiratory units has been verification software for VMAT
This can be done by irradiating a QA device with treatment planstheat that
and continue to be an important
phase. Functionality of the Anzai respiratory monitoring part of quality assur- time. The most common commercial
standard (nongated) radiation beam to a known dose, system reported
system can be accomplished by applying a “load cell” plans. AAPM Report then irradiating the same device with a gated beam to The
in the survey was RadCalc (Lifeline, Tyler, TX).
Task Group
of known mass to the strain 71 reports on the formalism
gauge. The strain gauge for calculat- mostdose.
the same common treatmentforplanning
The readings nongatedsystem and gated (TPS) re-
1
is contained in a plastic button with a 3 cm diameter Group 114 reports on ported in the
beams should be within ±2%. survey was Eclipse (Varian, Palo Alto,
methods and requirements
and a 1 cm height. The load cell is a cylinder for verification of
that fits data for CA). This is not to be considered as an endorsement
aroundconformal
the button, external
with a metal plans.2weight
beam central The need that ap- for mon- 2.C.4.2of these
| Phase, products. The mostmagnitude
displacement common beam passing rate
plies a known pressure to the strain gauge. The Anzai was identified early in
controlcriteria for dose/MU verification software was 5% for
the adoption
control system is started, of IMRT treatment planning
a QA “patient” is loaded, and and delivery IMRT (51%) and “None Specified”
2.C.4.2.1 | Objective. The objective is to verify that for VMAT (34%), al-
3
techniques. Several different
the operator determines if the pressure applied to the types of programs were though 30% of VMAT responders
phase and displacement magnitude controls hold the used 5% as passing
developed ranging from confirmation
strain gauge results in the same simulated breathing of dose at a beam as indicated. It is necessary for the beam control for
sin- rate. More than 50% of users used a single point
percentage displacement magnitude position, for ex- geometry to calculation systemtheir calculations
to gate the radiation and only beam6% at usedthethree- dimensional
appropriate
of dose at a single point while
ample, 50%. If a large deviation from the displacement taking patient anatomy phases and/or displacement magnitudes during Additional
(3D) volumetric dose in the 2012 survey. the
magnitude of, for example, 10% is noted, the strain While these programs measurements
treatment. Otherwise, (typically
the targetthe may MLCnot dosimetric
be within the leaf gap
gauge may be damaged and require replacement, or time, guidance was lacking (DLG) measurements) were
planning target volume when the beam is turned on. also required during com-
the overall system may require recalibration. Another as well as their missioning. The most common IMRT dose/MU verifi-
popular rolesystem
as partis of an
theIMRT ActiveQABreathing
program as was noted in the
Coordinator cation| calculation
2.C.4.2.2 Tolerance. algorithm represented
The tolerance by software
is functional,
ASTRO
57
system. It uses white paper entitled “Safety
a spirometer to track the patient’s lung Considerations for in use at the time was a “factor-
creating a beam hold within the desired settings of the based calculation al-
4,5
IMRT”.
volume. The system uses a balloon valve to prevent gorithm.” Note that
phase or displacement magnitude. the clinical practice has changed,
This task
airflow through thegroupspirometerwas charged
when thewith: (a) is
patient Reviewing
in with more widespread use of VMAT as well as the in-
breath hold. The balloon valve is controlled by the pa- for “independent/second troduction
2.C.4.2.3 | Methodsand adoption of new software
and equipment. Observe tools
the (such
tient via a patient control switch. Daily QA consists of for IMRT; (b) Making as 3D volumetric calculation
gated beam output constancy test beam delivery. Verifysystems) since 2012, so
a check of system conductivity, functionality of the pa- implementation of cal- users should consider the
that the appropriate beam holds are activated. age and context of the data
tient control switch button, and system calibration with of points, locations, when interpreting the survey.
a 3.0 Laccuracy,
calibrated evaluation
syringe. methods, and heterogeneities); (3) 2.C.4.3 | In-room respiratory monitoring system
Describing commissioning and benchmark QA of sec- 2.C.4.3.1 | Objective. The objective is to check
2.C.4.1 ondary| BeamMU calculation
output constancyprograms, proposing additional the in-2room RO LE Omonitoring
| respiratory F DOSEsystem / for proper
2.C.4.1.1 | Objective. The objective is to check and (4) Describing functionality. The computer system Nshould
clini- M U V ER I FI CATI O NS I A monitor
the gatedcal testing
beamand periodic
output QA of
against thesecondary
nominal MU beam calcula- CO M PR
the respiratory EH ENSI
motion V E Q Awith
appropriately, PROG R AtoM
the ability
output. tion programs
58– 60 and recommendations on test tolerance. adjust the settings used for phase and displacement
The terminology used in this report follows that 2.1 control.
magnitude | Review of the problem
2.C.4.1.2 | Tolerance. Output for a gated beam Group reports including in
shouldparticular:
be ±2% as compared with measurements from The implementation
2.C.4.3.2 | Tolerance. of new
The treatment
device used techniques
to monitor such
a static, nongated beam. Tighter constraints can be as IMRT/VMAT in a radiotherapy
the respiratory motion and generate the gating signal department increases
1. Shall
applied per the QMP. indicates a procedure that is essential for the complexities
should be functional. in planning and delivery and thus, the
(b) the most safe and effective result and/or main- of radiotherapy.
2.C.4.3.2 | MethodsAnand effective set of QA
equipment. procedures
Start the is
taining established standards of practice to ensure therefore essential. The goal
respiratory gating software. Open the QA patient and of a routine pretreatment
the accuracy of dose/MU determination. deliververification
the gated procedure
beam for the is tooutput
identify and resolve
constancy test.any er-
2. Should indicates an advisory recommendation that rors before patient treatment.
If the beam can be delivered, the system is functioning For IMRT, verification
properly.
there are other procedures which can accomplish 2.C.4.4tion | chambers, films, or multidimensional detector ar-
Gating interlock
the same goal. Deviations from the recommended 2.C.4.4.1 | Objective. methods
rays. Experimental The objective for patient-
is to specific
test theQA in
procedure should only be carried out after careful advanced radiotherapy are, however,
interlock for preventing a patient prescribed a gated time- consuming
analysis demonstrates that an equivalent result will in both manpower and accelerator
radiation delivery from being treated in a nongated time and have been
be produced. shown
treatment mode. to be unable to detect some unacceptable
to be correct but the task group does not make any ity of |only
2.C.4.4.2 5% to detect
Tolerance. IMRT plan
Gating errors using
interlock is IMRT
12,13
recommendations. pretreatment
functional. measurements. Moreover, as treat-
2.C.4.4.3 | Methods treated with andadvanced equipment. radiotherapy
Open tech-
surveyed in 2012 regarding the
F I G . 5 Reciprocating phantom with marker block for respiratory
type of software the QA patient and deliver the gated beam for the verifi-
niques steadily increases, measurement- based
being used. According to the responses,
gating tests for the Varian real-time position management system. a dose/MU outputcation may result
constancy test. Turnin a continued increase inmotion
off the respiratory workload.
[Color figure can be viewed at wileyonlinelibrary.com]
|
TASK20 |
REPORT
measurement system. Attempt to deliver the gated 1 2.D | STATE | Annual M ENT O F TH E PRO BLE M verification
beam. An interlock should be triggered that prevents A ND TG CH A RG ES jority of I
the beam from turning on. The first annual QA performed on the machine after ac- proximate
An independent
ceptance andcheck of dose/monitor
commissioning units critical
is the most has been for the verification
and treatment
continue to unit. A full series of tests, closely resembling time. The
be an important part of quality assur-
2.C.5 | Volumetric modulated arc therapy ance (QA)
commissioning, for patient treatment
should plans. AAPM
be performed. This Report
amount of in the sur
(VMAT) Task Group
detailed testing 71 reports
has the potential to identify any system- most com
on the formalism for calculat-
1
ing atic
monitor problems that mayTask
units. AAPM have Groupoccurred 114during
reports theon com- ported in
VMAT is an extension of IMRT that synchronizes dy- methods and requirements
missioning process. Subsequent for verification
versions of the annual CA). This
of data for
2
namic MLC position, dose rate, and gantry speed as conformal
QA can be less comprehensive whileneed
external beam plans. The for mon-
still being detailed of these p
the gantry rotates around the patient to deliver the pre- itor unit verification programs was
enough to monitor machine performance with respect identified early in criteria for
scribed treatment. The routine linac QA and IMRT QA the adoption
to baseline. of IMRT
For example, during the first annual QA, IMRT (51%
treatment planning and delivery
3
described in this report are prerequisites for VMAT. techniques.
it is recommendedSeveral different
that, fortypes
photon of programs
flatness and weresym- though 30
metry, a minimum number of field sizes for measure- of dose at a sin- rate. More
2.C.5.1 | Test patient-specific VMAT QA gle point in a simple phantom geometry
ments is four (5 × 5, 10 × 10, 20 × 20, and 40 × 40 cm , to calculation 2 their calcu
2.C.5.1.1 | Objective. The objective is to ensure of dose at a single

or maximum fieldpoint
sizewhile takingInpatient
available). subsequent anatomy years, (3D) volum
the linac can deliver VMAT plans that pass VMAT QA and a single field can be used. The justification for this is measurem
criteria. have been
that, forinphoton
use forbeams,
some time, it hasguidance
been shown that beam (DLG) mea
was lacking
quality is sensitive to beam profile changes. as well as 44,69,70 missioning
their
2.C.5.1.2 | Tolerance. The tolerance is institutional role Therefore, percentage depth dose measurements for cation cal
as part of an IMRT QA program as was noted in the
61 ASTRO white paper entitled “Safety Considerations for
VMAT QA passing criteria based on TG 218 a single
4,5
field are sufficient if they are accompanied by in use at t
guidelines. corresponding profile checks for a field size of at least gorithm.” N
IMRT”.
This
30 ×task 30 cm group
2 was charged
. Similarly, for the first with:annual QA for elec- with more
(a) Reviewing
2.C.5.1.3 | Methods and equipment. Patient- and trons, the recommended number of applicator sizes for troduction
specific VMAT QA is performed for every patient prior check” of monitor
flatness, symmetry, unit calculations
and percentage for IMRT;depth (b)dose
Making meas- as 3D volu
to treatment. There are many ways to perform VMAT urements is two (10 × 10 and 25 × 25 cm , or what was users shou
recommendations on the clinical implementation 2 of cal-
QA 62– 68
using commercially available phantoms, culation
specifiedprograms at the time(e.g.,ofnumber
acceptance). of points, locations, flat- when inter
Subsequently,
film, or EPIDs. Typically, the patient’s treatment plan accuracy,
ness, symmetry, and percentage depth doses for(3)elec-
evaluation methods, and heterogeneities);
is transferred to the phantom setup in the treatment Describing
tron beams commissioning
can be adequately and benchmark assessedQA byof sec-only
using
planning system and the dose calculated. The DICOM ondary MU calculation
the largest available applicator. programs, proposing additional 2 | RO
dose is exported for comparison with the measured measurements, if necessary; and (4) Describing clini- M U V ER
dose. The treatment plan is exported to the R&V system cal testing and periodic QA of secondary MU calcula- CO M PR
for delivery on the treatment unit. The QMP or designee tion programs
2.D.1 | Dosimetry and recommendations on test tolerance.
then delivers the treatment to the QA phantom. The The terminology used in this report follows that 2.1 | R
measured dose is compared with the treatment used in other AAPM Task
2.D.1.1 | Photon flatness and symmetry Group reports including in
planning system dose using TG 21861 guidelines. particular:
2.D.1.1.1 | Objective. The flatness and symmetry The implem
At least one patient-specific VMAT QA plan should of the treatment beams need to be consistent to as IMRT/V
be evaluated per month on a linac that is used for clin- 1. Shall
enable indicates
accurate a procedure
and reproducible that is essentialdose delivery.for the comple
ical VMAT delivery. In the unlikely event there are no either (a) establishment of uniform
The flatness and symmetry of all energies used for potential fo practices, or
VMAT patients on treatment, the plan for a patient (b) the most
treatment safe be
should andchecked
effectiveagainst result theand/or
datamain-
acquired of radiothe
scheduled to start treatment, or a plan used for the taining
during commissioning to confirm the delivered dose is therefore e
established standards of practice to ensure
annual patient-specific VMAT QA (Section 2.D.5.1) is the accuracywith
consistent of the
dose/MU determination.
dose calculated by the treatment verification
acceptable for this test. 2. planning system. The flatness and symmetrythat
Should indicates an advisory recommendation values rors befor
The time required for monthly QA will vary widely is to be applied when practicable.
should be determined by measuring the largest measurem The task group
with the machine capabilities and energy choices. For favors
available the field
indicated procedure
size, using 80% of butfield
understands
width. FFFthat beams delivery o
single energy machines with limited imaging capabili- there are other procedures which can
are handled in the same manner as flattened beams.41 tion cham accomplish
ties (i.e., MV only), a full monthly QA may take 1–1.5 h. the
All same
photongoal. beams Deviations
should from be tested the recommended
for flatness and rays. Expe
High performance machines with multiple energies, procedure
symmetry annually. should only be carried out after careful advanced
photon and electron, imaging, MLCs, stereotactic ca- analysis demonstrates that an equivalent result will in both ma
pabilities, etc., may require more than 6.5 h for data be produced.
2.D.1.1.2 | Tolerance. The tolerance for photon shown6-11to
acquisition and analysis. Commercial software suites 3. May indicates
flatness is ±1% a statement
deviation thatfromis likely (or probably)
baseline, and the plans. R
may shorten the time spent assessing data and help to to be correct but the task group
tolerance for photon symmetry is ±1% deviation from does not make any ity of only
trend data. Phantoms that measure several parameters recommendations.
baseline. pretreatme
with single tests can also decrease time spent perform- ment plann
ing monthly QA. These time estimates do not include As part of
2.D.1.1.3 | Methods this work, the AAPM
and community
equipment. It was is of patients
any adjustments that may occur (output corrections, surveyed recommended in 2012 toregardingmeasure the the flatness
type ofand software
symmetry niques ste
MLC calibration, etc.). beingin aused.
waterAccording
tank usingtoa suitable
the responses, ionization a chamber
dose/MUwith cation may
|
TASKe850
GROUP 198 REPORT |
TASK GROUP 198 REPORT
21
high spatial resolution. However, film dosimetry as well 2.D.1.3 | Photon or electron output calibration
as two-dimensional (2D) ionization chamber or diode 2.D.1.3.1 | Objective. The output of linac beams does
arrays may be used if a baseline was established using not tend to change rapidly over time.39 However, changes
the same devices during the commission procedures or if in output can occur from multiple sources such as major
a baseline is established when the linac is demonstrated component replacement, failure or drift of monitoring
to be in a dosimetrically equivalent state as when it was devices (i.e., circuit boards), or inadvertent adjustment.
commissioned. The beam profile measurements should Absolute calibration of the linac should be performed
be performed for multiple depths and field sizes per with a valid ADCL calibrated ionization chamber and
energy. The recommended minimum 2number of field electrometer under controlled conditions, specifically
sizes for measurements is two, with sizes of 10 × 10 those outlined by TG 51.38,71 All available photon and
and 40 × 40 cm2, or the maximum field size available. electron beams should be checked on an annual basis.
The recommended measurement depths are dmax and a Note that any changes detected in energy, either from
depth of 10 cm, or wherever the vendor specifies flatness flatness and symmetry or beam quality measurements,
and symmetry at the time of acceptance. Flatness and should be addressed before output calibration.
symmetry should be calculated using the same formula
that was used for commissioning. Compare these values 2.D.1.3.2 | Tolerance. The tolerance for output
with the baseline values and verify that they are within constancy should be within ±1% of the dose calculated
the stated tolerances. using the TG 51 protocol measured in water under
standard conditions (e.g., baseline is 1.000 cGy/MU
2.D.1.2 | Electron flatness and symmetry at d , 10 × 10 cm2 field size, 100.0 cm SSD). As in
ASTRO white paper entitled “Safety Considerations for maxin use at the time was a “factor- based calculation al-
2.D.1.2.1 | 4,5 Objective. As with photons, the flatness the tolerance set by the monthly output constancy,
and symmetry of the treatment beams need to be the institution may choose a smaller tolerance. If the
consistent to enable accurate and reproducible dose tolerance is exceeded, adjustments should be made to
delivery. The flatness and symmetry of all electron bring the machine within tolerance.
energies used for treatment should be checked Note that the need for large adjustments (e.g., >3%)
against the treatment planning system data acquired is extremely rare. If a large adjustment is indicated by
during commissioning to ensure the calculated dose is initial measurements, carefully review the measure-
consistent with the intended dose. It is recommended to ment setup, all calculations, and the history of monthly
use the largest available cone for each electron energy. output constancy to verify that the indicated adjustment
The flatness and symmetry values should be measured is necessary.
using the center 80% of the field along the in-plane and
cross-plane directions. All electron energies should be 2.D.1.3.3 | Methods and equipment. Absolute
tested for flatness and symmetry annually. calibration of high- energy photons and electrons
is outlined in TG 51. Absolute calibration must be
2.D.1.2.2 | Tolerance. The tolerance for electron performed in a water tank with a calibrated ionization
flatness is ±1% deviation from baseline, and the chamber and electrometer. The calibration equipment
tolerance for electron symmetry is ±1% from baseline. shall have a National Institute of Standards and
Technology (NIST) traceable calibration performed
2.D.1.2.3 | Methods and equipment. It is within the last 2 years. Once the output has been
recommended to measure the flatness and symmetry in established in water, intercomparisons should be
a water tank using a suitable ionization chamber with a made with the secondary measurement system used
high spatial resolution. However, film dosimetry as well as for monthly QA and the tertiary system for daily QA to
2D ionization chamber or diode arrays may be used if a reestablish baselines for those systems.
baseline was established using the same devices during
the commission procedures or if a baseline is established 2.D.1.4 | Output factors
when the linac is demonstrated to be in a dosimetrically 2.D.1.4.1 | Objective. Output factors are required
equivalent state as when it was commissioned. Perform by all treatment planning systems to determine dose.
beam profile measurements for a single depth and one Output factors for all beams used for patients’ treatment
applicator size per energy. The recommended applicator should be checked against the commissioning data
size is the largest electron applicator available. The or treatment6-11planning system baseline established
3. May indicates a statement that is likely (or probably) plans. Recent studies have demonstrated a sensitiv-
recommended depth is at the reference depth or the during commissioning to ensure the calculated dose
depth measured at time of commissioning. Flatness and is consistent with the intended dose. At the time
symmetry should be calculated using the same formula of commissioning, it is common to obtain a large
that was used at the time of commissioning. Compare set of output factors to obtain more accurate dose
these values with the baseline values and verify that they calculations. It is not essential to duplicate these
are within the stated tolerances. efforts; a smaller subset of output factors will suffice to
|
2
TASK22 |
GROUP 198 REPORT TASK GROUP 198e851
REPORT
verify constancy. The recommended fields for photons 1 | than STATE M ENTdepth
the standard O F ofTH E 10
5 or PRO cm BLE M
for photons. verification
are the smallest field size used clinically, the reference A ND TG CH A RG ES
Additionally, some clinics elect to normalize their jority of I
field size, the largest field size used clinically, and one readings to an applicator other than the 10 × 10 cm2 proximate
additional field size intermediate of the former two, for An independent
applicator.check of dose/monitor
It is important to verify units has been that verification
the conditions
2 and continue to be an important part of quality assur-
example, 2 × 2, 10 × 10, 20 × 20, and 40 × 40 cm . were used at the time of commissioning and dupli- time. The
The measurement depth for each field size should ance (QA)
cate those for patient treatment
for output constancy plans.checks.
AAPM Report in the sur
replicate the commissioning data or treatment planning Task Group 71 reports on the formalism for calculat- most com
1
system baseline. Appropriate detectors should be ing monitor units.
2.D.1.5 | Photon beam qualityAAPM Task Group 114 reports on ported in
used for small field geometries to obtain accurate methods and requirements
2.D.1.5.1 | Objective. Precise for verification determination of CA). This
of data for
2
measurements. 14,72–75
Small volume ionization conformal
beam quality or energy is essential toforaccurately
external beam plans. The need mon- of these p
chambers, diodes, or scintillators are more appropriate itor calculate doses in patients and to generate models for criteria for
unit verification programs was identified early in
choices under these conditions. The recommended the adoption of
treatment IMRT treatment planning and delivery IMRT (51%
3 planning. Beam quality for a linac is typically
fields for electrons are the smallest applicator used very stable. The possibility of mechanical failure, drift though 30
techniques. Several different types of programs were
2 developed ranging from confirmation of dose at a sin-
clinically, the reference applicator (usually 10 × 10 cm ), in electronic stability, or positioning of the target and/or rate. More
and the largest applicator used clinically. gle point
flattening in a filter
simple phantom
exists on a linac,geometry to calculation
and therefore, it is vital their calcu
to verify beam quality on an annual basis. taking patient anatomy (3D) volum
2.D.1.4.2 | Tolerance. The tolerance for photon and geometry into consideration. While these programs measurem
2
fields smaller than 4 × 4 cm and electron applicators have 2.D.1.5.2 | Tolerance. The tolerance for the photon (DLG) mea
been in use for some time, guidance was lacking
is ±2% deviation from the output factors established in howbeam to commission
quality is within such±1% technologies
of the baseline as wellvalue.
as their missioning
at the time of commissioning due to potential setup role as part of an IMRT QA program as was noted in the cation cal
uncertainty. For photon fields larger than or equal to ASTRO 2.D.1.5.3white paper entitled “Safety
| Methods and equipment. Considerations for in use at t
4,5
2
4 × 4 cm , the tolerance is a ± 1% deviation. IMRT”.1. Water tank scanning systems are most often used gorithm.” N
Thistotask obtain group was charged with:
the commissioning data (a) serve as the with more
thatReviewing
2.D.1.4.3 | Methods and equipment. There are and baseline. It is recommended to measure the photon troduction
many options on how to measure output factors as well check” of monitor
beam quality unit
in calculations
a water tankfor IMRT;
using (b) Making
a suitable ioniza- as 3D volu
as conditions under which to measure them. The most tion chamber with high spatial resolution. Beam flat- users shou
recommendations on the clinical implementation of cal-
common methods are with an ionization chamber in culation nessprogramshas been (e.g.,
shownnumber to beofsensitive
points, to changes in when inter
locations,
either water or in solid water. Most treatment planning accuracy, evaluation
the photon beam quality. methods, and
44,45heterogeneities); (3)
If film dosimetry or ioni-
system vendors will specify the setup conditions Describing zation commissioning
chamber arrays and werebenchmark
used during QAthe of commis-
sec-
of the system they require for commissioning. It is ondary sioning process to establish the baseline flatness as 2 | RO
MU calculation programs, proposing additional
important that the setup conditions used at the time of measurements,
a surrogate if necessary;
for photon beam and (4) Describing
quality, then the clini-same M U V ER
commissioning are replicated at the time of constancy cal device can be used to measure beam quality on an CO M PR
testing and periodic QA of secondary MU calcula-
checks. Regardless of the setup conditions, the typical tion programs
annual basis. and recommendations on test tolerance.
workflow is similar and outlined below: The2. Depending on used
terminology how the in machine
this report wasfollows
calibrated,that it is 2.1 | R
used inrecommended
other AAPM to Task Group reports
obtain beam quality measurements including in
1. Setup the phantom (water or solid water) and ion- particular:(PDD or TMR) at a minimum of one field size for each The implem
ization chamber on the treatment couch or ap- photon energy used clinically. The recommended field as IMRT/V
propriate support device. Replicate the conditions 1. Shall size indicates a procedure
is the calibration field size,thatusually
is essential
10 × 10 cm for 2. the comple
used at the time of commissioning (SSD, SAD, either
3. Setup the water tank, field ionization chamber,or
(a) establishment of uniform practices, refer- potential fo
ionization chamber depth, etc.). (b) the
ence ionization chamber, and electrometer per ven- of radiothe
most safe and effective result and/or main-
2
2. Acquire measurements for a 10 × 10 cm open field. taining dor established
specifications. standards of practice to ensure therefore e
This is the reference field that all other values for the the4. Acquire depth dose scans at the recommended field verification
same energy will be normalized to. Three measure- 2. Should sizes. indicates an advisory recommendation that rors befor
ments should be obtained to allow for any drift that is to be applied when practicable. The
5. Compare the acquired raw data with the baseline val- measurem task group
can occur. Variation between each reading should favors uesthe indicated
obtained procedure
during but understands that
commissioning. delivery o
not exceed ±0.5%. there are other procedures which can
6. Verify that the acquired scans are within stated tol- tion cham accomplish
3. Acquire a set of measurements at the recommended the same goal.
erances of theDeviations
baselinefrom the recommended
values, namely PDD10 or rays. Expe
field sizes. procedure
TMR20:10. should only be carried out after careful advanced
4. Divide the acquired readings by the reference read- analysis demonstrates that an equivalent result will in both ma
ing for the same energy. These values should be be produced.
2.D.1.6 | Electron beam quality shown to
6-11
within the tolerances listed above relative to the out- 3. May2.D.1.6.1 | Objective. Like photon beam quality, plans.
indicates a statement that is likely (or probably) R
put factors obtained at the time of commissioning. to be correct but the task group does
precise determination of electron beam quality is essential not make any ity of only
5. Repeat this procedure for each photon energy. recommendations.
to ensure accurate beam modeling and dose delivery. pretreatme
6. Repeat this procedure for each electron energy. The ment plann
reference conditions for electrons are different than As 2.D.1.6.2 | Tolerance. The tolerance for the of patients
part of this work, the AAPM community was
those used for photon measurements. It is common surveyed
electron in beam
2012 qualityregardingis withinthe ±1 typemmofof software
the baseline niques ste
to acquire output factors for electrons at dmax rather being used.
value. According to the responses, a dose/MU cation may
|
2
TASKe852
FOR IMRT
2.D.1.6.31 | | STATE Methods and M ENT O F TH E PRO BLE M

equipment. verification
2.D.1.8.3 | Methods program and was generally used for the ma-
equipment.
A N D TG CH A RG ES
1. The setup for electron beam quality is the same as 1. MU linearity should be tested over theplans
jority of IMRT/VMAT treatment range although
of MUs ap-
for photon beam quality. It is recommended that at proximately 31% of responders
used clinically on the treatment machine. did not use dose/MU
least two applicator sizes are used for measurement units has been 2. For photons, MU linearity should be tested for bothat that
verification software for VMAT treatment plans
and continue
10 × 10 and 25 × 25 cm . to be an
2 important part of quality assur- time.(nonsegmented)
static The most common and commercial
dynamic (segmented)system reported
2. Acquire depth dose measurements for the recom- plans. AAPM Report in the survey was RadCalc
beams, as the beam control systems can differ. (Lifeline, Tyler,One TX). The
Task Group
mended applicator field 71 reports on
sizes. the formalism for calculat- simple way to test the beam in segmented beam re-
most common treatment planning system (TPS)
1
ing monitor units. AAPM
3. Compare the measured R50 value with the baseline Task Group 114 reports on ported
mode is toindeliver
the surveya beam was withEclipse
a 10 ×(Varian,
10 field Palo
size Alto,
value and verify that it is within the specified for verification of
tolerance. data for CA). This is not to be considered
but program the MLC leaf furthest from the central as an endorsement
2
It is conformal
important toexternal note thatbeam R50, and plans.
not I50The, is theneed
recom-for mon- axis of to
these
moveproducts.
during treatmentThe most common passing rate
delivery.
mended metric for evaluating electron beam quality. was identified early in criteria for dose/MU verification
3. MU linearity can be performed in a water software tankwasor in5% for
the adoption of IMRT treatment planning and delivery solid IMRT (51%) and “None Specified”
water with an ionization chamber and an elec- for VMAT (34%), al-
3
techniques. Several
2.D.1.7 | Physical wedge transmission factor different types of programs were though 30% of VMAT responders
trometer. Typical setup is 10 × 10 field size at 100 SSD. used 5% as passing
developed ranging from
2.D.1.7.1 | Objective. Physical wedges are subject confirmation of dose at a 4. Setup the phantom and the ionization chamber such for
to mechanical abuse over time. The measurement of geometry to calculation their
that thecalculations
ionization chamber and onlyis6% along usedthethree-
central dimensional
axis
of dose at a single point
physical wedge transmission factors helps to ensure while taking patient anatomy (3D) volumetric
of the beam. dose in the 2012 survey. Additional
and geometry
the integrity of the wedge into consideration.
is not changed. WhileAll these
wedgeprograms measurements
5. Deliver 400 MU with (typically the MLC
a clinically relevantdosimetric
dose rate leaf gap
angles that are used clinically should be checked. A time, guidance was lacking and record the measurement. Take a total of three com-
in how to commission such
single field size is recommended for each wedge angle.technologies as well as their missioning.
readings The most
and calculate thecommon
average.IMRT dose/MU verifi-
role as part of an IMRT QA program as was noted in the cation calculation
6. Using the same setup conditions, algorithm represented
deliver 100 by MUsoftware
ASTRO
2.D.1.7.2 | 4,5 white paper entitled
Tolerance. The tolerance for the “Safety Considerations for in use at the time was a “factor-
with the same dose rate. Take a total of three read- based calculation al-
IMRT”.
physical wedge transmission factor is within ±2% of the gorithm.” Note that
ings and calculate the average. the clinical practice has changed,
baseline This value.task group was charged with: (a) Reviewing7. Verify with that
morethe widespread
average result use ofisVMAT one-fourthas well of as
thethe in-
and evaluating the algorithms for “independent/second 400 troduction and adoption
MU average reading to within tolerance.of new software tools (such
check” of monitor unit
2.D.1.7.3 | Methods and equipment. It is most calculations for IMRT; (b) Making as 3D volumetric calculation
8. Deliver 2 MU for photons, or 50 MU for electrons, systems) since 2012, so
efficient to perform this test at the same time as the implementation of cal- users should consider the age
with the same dose rate and setup conditions. Take and context of the data
outputculation
factor test, programs using the (e.g.,methods
number and of points,
equipment locations, a total whenofinterpreting
three readings the and
survey.calculate the average.
accuracy,
used in Section 2.D.1.5. evaluation methods, and heterogeneities); (3)
9. Verify that the average result is one-fiftieth for pho-
Describing commissioning and benchmark QA of sec- tons, or one-half for electrons, of the 100 MU aver-
1. Repeatondary MU calculation
a series of three open programs, proposing additional age
field measurements 2 reading
| RO to LE
within Otolerance.
F DOSE /
measurements,
under reference conditions. if necessary; and (4) Describing clini- M U V ER I
10. Repeat for all photon and FI CATI O NS electronI N energies.
A For
cal testing and periodic QA
2. Acquire readings with each physical wedge in place. of secondary MU calcula- CO M PR EH ENSI V E
electrons use 50 MU or another value representa- Q A PROG R AM
When tionobtaining
programsoutput and recommendations
factors for wedges, onmeasure-
test tolerance. tive of the range used clinically.
The terminology
ments should be made with the wedge in two used in this report follows
op- that 2.1 | Review of the problem
used in other AAPM Task Group
posing orientations. Doing so will help verify that the reports including in
2.D.1.9 | Photon output versus dose rate
wedge particular:
is centrally placed along the beam axis. The implementation
2.D.1.9.1 | Objective. The of new treatment
objective is techniques
to verify such
3. Calculate the ratio of the reading with the wedge in as IMRT/VMAT in a radiotherapy
that clinical output does not vary with dose rate. department increases
It
1. Shall indicates
place to the reference open field value.a procedure that is essential for the complexities in planning
is common for institutions to incorporate different and delivery and thus, the
4. Compare either the (a)result establishment
with the known of transmission
uniform practices, fac- or potential
dose rates for serious
depending on errors
the type in the planning and
of treatment being delivery
tor and verify that they are within tolerance values. result and/or main- of radiotherapy. An effective
performed. Additionally, the advent of modulated set of QA procedures is
taining established standards of practice to ensure therefore essential. The
therapy that uses various dose rates throughout goal of a routine pretreatment
2.D.1.8 the | MU accuracylinearity of dose/MU determination. deliveryverification
has made procedure is to identify
the verification of outputand resolve
vs doseany er-
2. Should indicates an
2.D.1.8.1 | Objective. Testing of MU linearity is advisory recommendation that rors before patient treatment.
rate a critical assessment to ensure proper delivery For IMRT, verification
of
is to be applied when
important due to the advent of dynamic or segmented practicable. The task group measurements
dose to patients. are commonly used to verify correct
favors the indicated
field dose delivery. This delivery uses numerousprocedure but understands that delivery of treatment plans, for example with ioniza-
there are other procedures
segments that can range from a high number of MUs to which can accomplish tion chambers, films, or
2.D.1.9.2 | Tolerance. The measured values at multidimensional detector ar-
as few as 2 MU. It is vital to ensure MU linearity in these from the recommended rays. Experimental methods
each dose rate should be within ±2% of the most used for patient- specific QA in
procedure should
situations so that precise dose is delivered. only be carried out after careful advanced radiotherapy
clinical dose rate for each energy. are, however, time- consuming
be produced.
2.D.1.8.2 | Tolerance. Electron delivery tolerance shown
2.D.1.9.3 | 6-11to be unable
Methods and to detect some
equipment. It isunacceptable
most
3. May indicates a statement
is ±2% when five or more MUs are delivered. Photon that is likely (or probably) efficient to perform this test at the same time as theaMU
plans. Recent studies have demonstrated sensitiv-
to be correct but the
tolerances vary depending on the type of treatmenttask group does not make any ity of only 5% to detect
linearity test, using the methods and12,13 IMRT equipment used in IMRT
plan errors using
recommendations.
being delivered. For all types of delivery, if more than pretreatment
Section 2.D.1.8. measurements. Moreover, as treat-
5 MU are delivered, the tolerance is ±2%. During IMRT ment planning becomes more efficient and the number
As part of this work, the
and SRS/SBRT delivery, it is common to have fewer than AAPM community was
1. Using the same setup to determine MU linearity, tech-
5 MU delivered for a particular segment or beam. In that the type of software niques
deliver a setsteadilynumber increases,
of MUs measurement-
with at least based
two verifi-
being used. According to the
scenario, the tolerance is ±5% for 2 to 4 MU delivered. responses, a dose/MU cation may result in
other clinically relevant dose rates. a continued increase in workload.
|
TASK24 |
REPORT
2. Verify that each reading is the same to within the 1 2. STATE

| Acquire M ENTmeasurements
additional O F TH E PRO at theBLE other M cardi- verification
specified tolerance. A ND TG CH
nal gantry angles. A RG ES jority of I
3. Repeat for all photon energies. 3. Verify that the dose at the same off-axis distances proximate
An independent
matches the check
values of dose/monitor
obtained withunits has been
the gantry at 0° to verification
2.D.1.10 | Output constancy versus gantry angle and continue to
within tolerance. be an important part of quality assur- time. The
2.D.1.10.1 | Objective. The objective is to verify ance (QA) for patient treatment
4. Repeat for all photon and electron energies. plans. AAPM Report in the sur
that clinical output does not vary with gantry angle. Task Group 71 reports on the formalism for calculat- most com
1
As a clarification to TG 142, and to align with “Medical ing monitor units.
2.D.1.12 | Arc mode AAPM Task Group 114 reports on ported in
9
Physics Practice Guideline 8.a” , output constancy vs methods and requirements
2.D.1.12.1 | Objective. The for verification
objective is to verify CA). This
of data for
2
gantry angle and off-axis factor constancy vs gantry conformal external beam
that the MUs delivered and the degree plans. The need forofmon- rotation of these p
angle reading obtained at nonzero gantry angles are itor unit verification programs
traversed through a standard or SRS arc treatmentwas identified early in criteria for
compared with the readings obtained at gantry zero. the adoption
(constant offield size, constant gantry rotation speed, IMRT (51%
3
techniques.
and constant MU/° Several different
value) types
matches of programs
those which werewere though 30
2.D.1.10.2 | Tolerance. The measured output developed ranging from confirmation
prescribed. If SRS arcs are used clinically, then of dose at a sin-SRS rate. More
should be within ±1% of the value acquired at gantry 0°. gle point in a simple
dose rates must be evaluated. phantom geometry to calculation their calcu
2.D.1.10.3 | Methods and equipment. and 2.D.1.12.2 | Tolerance. For non- SRS arcs, the MUs measurem
1. Institutions may have several options for measuring have been in use
delivered and for thesomeactualtime,degreesguidance of rotation traversed (DLG) mea
was lacking
output at various gantry angles, for example, daily in how to commission such technologies
should be within ±1% of the prescribed values. For as well as theirSRS missioning
QA device mounted to the gantry, ion chamber in air role as part of an IMRT QA program
arcs, the tolerance is a ±1 MU discrepancy between as was noted in the the cation cal
at isocenter, ion chamber or film in solid water, cy- ASTROMUs white paper entitled “Safety Considerations
prescribed and those delivered (or 2%, whichever for in use at t
4,5
lindrical phantoms with assigned chambers, and/or is greater). The tolerance for gantry motion is ±1° gorithm.” N
IMRT”.
commercially available cylindrical devices. This task group
discrepancy was charged
between what was with: (a) Reviewing
prescribed and what with more
2. It is recommended that output is checked at the four and evaluating the algorithms
was delivered (or 2%, whichever is greater). for “independent/second troduction
cardinal gantry angles at a minimum. check” of monitor unit calculations for IMRT; (b) Making as 3D volu
3. Verify that the difference in the measurements is recommendations on the
2.D.1.12.3 | Methods and equipment. clinical implementation of cal- users shou
within the stated tolerance. 1. Deliver arc treatments, non-SRS and SRS, as ap- when inter
culation programs (e.g., number of points, locations,
4. Repeat for all photon and electron energies. accuracy, evaluation
propriate, methods,
covering and heterogeneities);
the range of parameters for(3) which
Describing commissioning and benchmark
the linac is used clinically. The arcs should QA of sec- encom-
2.D.1.11 | Off-axis factor constancy versus gantry ondarypass MU calculation
the range of programs,
known MUs, proposing
degrees of rotation, 2 | RO
additional
angle measurements, if
and MUs per degree. necessary; and (4) Describing clini- M U V ER
2.D.1.11.1 | Objective. The objective is to verify cal 2. Verify that the delivered MUs and gantry angle mo- CO M PR
that the off-axis factors do not vary with gantry rotation tion programs
tion match andthe recommendations
prescribed values ontotest tolerance.
within stated tol-
or position. The terminology used in this
erances. This can be accomplished by reading report follows that the 2.1 | R
used inMUs other delivered and the start/stop of the gantryinfrom
AAPM Task Group reports including
2.D.1.11.2 | Tolerance. The measured off-axis particular:the treatment console or through analysis of the tra- The implem
factors should be within ±1% of the value acquired at jectory logs on a Varian linac, if equipped. as IMRT/V
gantry 0°. 1. 3. This test should be repeated for all energies that are the comple
Shall indicates a procedure that is essential for
either used (a)forestablishment
the delivery ofof uniformarcs
standard practices,
clinically.or potential fo
2.D.1.11.3 | Methods and equipment. Measurements (b) the most safe and effective result and/or main- of radiothe
can be accomplished in several ways. Radiographic taining established
2.D.1.13 | TBI/TSET mode standards of practice to ensure therefore e
or radiochromic film can be supported at isocenter on the
2.D.1.13.1 | Objective. Bone marrow or stem cell verification
phantom material with appropriate buildup. Alternatively, 2. Should
transplant indicates an advisory
protocols have specific recommendation
parameters that for TBI rors befor
a diode or ion chamber array can either be mounted on is to be applied when practicable. The
which typically include dose rate. Similarly, TSET can measurem task group
the gantry and rotated with the linac or supported on the favors
also have the indicated procedure but
specific parameters understands
for irradiation. thatlinac delivery o
If the
treatment couch with phantom material. If the latter setup there are other procedures which
has a user-selectable mode that is used for TBI or tion cham can accomplish
is used, then measurements with the gantry at 180° the
TSET, same thegoal. Deviations
functionality of from
this mode the recommended
should be tested rays. Expe
can pose a challenge, as the beam will be attenuated procedure
as described below. should only be carried out after careful advanced
by the couch. One solution is to creatively support the analysis demonstrates that an equivalent result will in both ma
measurement device over the end of treatment couch. If be produced.
2.D.1.13.2 | Tolerance. TBI/TSET mode on the shown6-11to
this cannot be accomplished safely, then we suggest the 3. linacindicates
May is functional. a statement that is likely (or probably) plans. R
reading at gantry 180° be eliminated. to be correct but the task group does not make any ity of only
recommendations.
2.D.1.13.3 | Methods and equipment. Enter clinical pretreatme
1. Acquire measurements with the gantry at 0° and mode on the accelerator and program up TBI/TSET ment plann
determine the output at various points off-axis. A As part of this
treatment. Ensure work, thattheall AAPM
interlocks community
are cleared was and of patients
minimum of two points along the x and y axes surveyed
that you can deliver the treatment. Alternatively, enter niques ste
is recommended. beingR&V used.mode According
and send to the TBI/TSET
a test responses, a dose/MU
patient to the linac cation may
|
2
TASKe854
FOR IMRT
control1 console.
| STATE EnsureMthat ENT O F TH EarePRO
all interlocks cleared BLE M verificationand
commissioning program
compare was generally
the results used withforthe the ma-
A N D TG CH A RG ES
and that you can deliver the treatment. Note that this baseline. These measurements are often performed ap-
test is not performed separately, as it is inherently proximately
by translating 31% of responders
ion chambers in phantomdid not use
material alongdose/MU
An independent
included in the next three tests. check of dose/monitor units has beenthe principal axes of the field and acquiring a seriesat that
of readings under mosttreatment
common conditions.
commercial Alternativesystem reported
ance (QA) for patient
2.D.1.14 | TBI/TSET TMR/PDD and OAF treatment plans. AAPM Report in the survey was RadCalc
methods include the use of film or diode arrays (Lifeline, Tyler, to TX).
ac- The
Task
constancy Group 71 reports on the formalism for calculat- quire data at multiple locations within the treatment re-
most common treatment planning system (TPS)
1
ing monitor
2.D.1.14.1 | Objective. The units. AAPM Task Group
objective 114
is reports
to on
field. ported in the survey was Eclipse (Varian, Palo Alto,
independently verify the TMR/PDD and for verification
off-axis factorof data for CA). This is not to be considered as an endorsement
2
conformal external beam
constancy for TBI/TSET treatments. However, if the plans. The need for mon- of these
2.D.1.15 products.output
| TBI/TSET The most common passing rate
calibration
accelerator has demonstrated constancy regarding was identified early in criteria for dose/MU
2.D.1.15.1 | Objective. The verification softwareiswasto5% for
objective
the adoption
energy (PDD/TMR/flatness) of IMRT treatment planning
and profiles, there is and delivery IMRT (51%) and “None
independently verify the machine output Specified” for VMAT for TBI/(34%), al-
3
no fundamental unique delivery modality (such as types of programs were though 30% of VMAT responders
TSET treatments. However, if the accelerator has used 5% as passing
the case with Siemens low dose rate mode), and the confirmation of dose at a demonstrated constancy regarding energy (PDD/TMR/ for
room conditions and ancillary devices are the same, geometry to calculation their
flatness) andcalculations
profiles, thereand only
is no6% used three-unique
fundamental dimensional
then the TBI/TSET measurements specific for energy while taking patient anatomy delivery modality (such as the case with Siemens Additional
(3D) volumetric dose in the 2012 survey. low
and profiles are optional at the extended treatment While these programs measurements
dose rate (typicallyindependent
mode which requires the MLC dosimetric calibration), leaf gap
distance. If TBI/TSET TMR/PDD and off-axis factors time, guidance was lacking and neither the room conditions nor any devices in com-
are to be measured at the extended treatment distance, as well as their missioning.
the beam The most
path changed, thencommon
the TBIIMRT dose/MU verifi-
measurements
the tolerances will be increased due to the possible program as was noted in the cation calculation algorithm
specific for energy and profiles are optional at represented by the software
ASTRO white
variability in reproducing paper entitled “Safety
the baseline measurements. Considerations for in use at the time
extended treatment distance. was a “factor- based calculation al-
2.D.1.14.2This| task group was
Tolerance. Thecharged tolerance with: for(a) Reviewing
TBI with more
2.D.1.15.2 widespreadThe
| Tolerance. usetolerance
of VMAT for as well as the in-
the TBI/
TMR/PDD is ±5% from baseline measured at the for “independent/second TSET output calibration is ±3% from baseline measured (such
extended treatment distance, TSET ±3 mm PDD shift, for IMRT; (b) Making at the as 3D volumetric
extended treatment calculation
distance systems)when the since program 2012, so
recommendations on the
OAF constancy ±5% from baseline measured at the clinical implementation of cal- users should
was commissioned. consider the age and context of the data
culation programs
extended treatment distance. (e.g., number of points, locations, when interpreting the survey.
accuracy, evaluation methods, and heterogeneities); (3) 2.D.1.15.3 | Methods and equipment. Perform
Describing
2.D.1.14.3 | Methods commissioningand equipment. and benchmark To performQA of sec- calibration for all energies according to the standard
TMR ondary MU calculation
measurements for TBI programs,
treatments, proposing
setup a additional
full 2 | protocol
department RO LEusing O F an DOSE /
ionization chamber or
scatter phantom, usually solid water, in treatment and (4) Describing electrometer system with a current NNIST
clini- M U V ER I FI CATI O NS I A traceable
calwith
position testing
the and periodic
ionization QA of secondary
chamber at the treatment MU calcula- CO M
calibration PRSection
(see EH ENSI V E Q A PROG R A M
2.C.1.1.).
distance. Open the jaws to the treatment field size. on test tolerance.
Select theThetreatment
terminology energy, usedTBI in dose
this report follows that
rate, deliver 1. TBI:2.1Setup | aReview
full scatter of the
phantom problem in treatment po-
the field, and record the reading. Without moving Group reports including in sition with the ionization chamber at the extended
particular:chamber, incrementally add buildup
the ionization The implementation
treatment distance. The of new treatment
source- to-chamber techniques
distance such
to a total of 25 cm at 5 cm increments in front of the as IMRT/VMAT in a radiotherapy
(SCD) is equal to the treatment distance plus dmax department increases
.
chamber. Deliver the same MU each time and record that is essential for the complexities in planning
Set the jaws to treatment field size used at com-and delivery and thus, the
either (a)readings.
the electrometer establishment Compute of TMRs.
uniformCompare practices, or missioning potentialand for serious
the gantry errors in the
to the planningangles.
treatment and delivery
the results with the baseline TMRs measured when theeffective result and/or main- of radiotherapy. An effective
In addition, any treatment accessories should be set of QA procedures is
program was commissioned. Repeat for all energies of practice to ensure therefore essential. The goal
placed in the beam path, for example, blocking trayof a routine pretreatment
used for the accuracy
treatment. of dose/MU
To verify the TMR determination.
measurements, verification
or beam spoiler procedure
or screen. is to identify
Deliver theand resolveatany er-
exposure
calculate the MUs to deliver 100 cGy to the phantom recommendation that rors before patient treatment.
the treatment dose rate and compute the average For IMRT, verification
midline. Measure the delivered dose. Repeat the practicable. The task group of at least three electrometer readings. The TBIcorrect
measurements are commonly used to verify
measurements for two relevant depths, as additional but understands that delivery
output is thenof treatment
calculatedplans, for example
by multiplying the with
stan-ioniza-
verification compares the measured with the expected which can accomplish tion chambers, films, or multidimensional
dard TG 51 output by the ratio of the readings detector ar-
doses. the same goal. Deviations from the recommended rays. Experimental methods
at the treatment distance divided by readings at for patient- specific QA in
For TSET, depth dose data can be acquired with a be carried out after careful advanced radiotherapy are,
the calibration distance scaled for MU. Compare however, time- consuming
analysis
parallel-plate demonstrates
ionization chamberthat an equivalent
overlaid with varying result will the inresult
both manpower and accelerator
with the baseline measured timewhen and have the been
be produced.
thicknesses of phantom material. A small amount of phan- shown
program 6- wasto be unable
commissioned. to detect some unacceptable
11
3. May surrounding
tom material indicates a statement the chamber thatsuffices
is likely for(or this
probably) plans.
2. TSET: Recent
A detailed studies have
description of thedemonstrated
output calibra- a sensitiv-
measurement and is described in detail in TG 30’s report group does not make any ity of only 5% to detect
tion for TSET is given in Section12,13 IMRT 6.E of TG 30’s re- IMRT
plan errors using
recommendations.
“Total Skin Electron Therapy: Technique and Dosimetry.” 76 pretreatment measurements.
port “Total Skin Electron Therapy: Technique Moreover, and as treat-
The results should be compared with the baseline PDDs ment
Dosimetry.” planning
76 becomes more efficient and the number
measured when the program was commissioned. the AAPM community was3. To confirm that the output is invariant with dose rate, tech-
To perform off-axis factor constancy for TBI/ the type of software niques
repeat thesesteadily increases,formeasurement-
measurements all linac dosebased rates verifi-
TSET, being
76,77 used. According to the responses, a dose/MU
use the same technique used during cation may result
used for TBI/TSET treatment. in a continued increase in workload.
|
TASK26 |
REPORT
4. It should be noted that, in some instances, a polar- 1 mechanical

| STATEfront M ENT pointer Ocalibrated
F TH E PRO at timeBLE M
of machine verification
ity effect has been observed for TBI/TSET measure- A ND TG CH A RG ES
commissioning. The position of the front pointer should jority of I
ments. 76,77
The QMP should verify the polarity effect represent the location of the mechanical and radiation proximate
of their measurement system. An independent
isocenters within checkthe of acceptance
dose/monitorspecificationunits has been for the verification
and machine.
continue to With the gantry set to 0°, the front pointer time. The
be an important part of quality assur-
2.D.1.16 | TBI/TSET accessories ance assembly ispatient
(QA) for mounted treatment
to the plans.head and AAPM the Report
calibrated in the sur
2.D.1.16.1 | Objective. TBI/TSET treatments Task Group
pointer inserted.71 reports A piece of paper is secured to the top most com
1
are delivered using special setups unique to those ing monitor units.
of the couch which is then AAPM Task raisedGroup to114 reports
almost touchon the ported in
treatments. As such, there are many accessories methods and requirements
front pointer. The collimator rotation for verificationisocentricity can be CA). This
of data for
2
associated with the treatments. These can range from conformal external beam
checked by marking the tip of the pointerplans. The need on for the
mon- paper of these p
diodes for in vivo dose measurements to rice bags itor unit verification programs was
every 30° to 45° over the full range of rotation of identified early in the criteria for
and compensators used to ensure a uniform dose is the adoption
collimator. of The marked locations should be enclosed IMRT (51%
3
delivered to the whole patient’s body. techniques. Several
in a circle with diameter different types less than of programs
the tolerance were of though 30
the machine. The center of the circle is the collimator of dose at a sin- rate. More
2.D.1.16.2 | Tolerance. The tolerance for all gle rotation isocenter. The front pointer should be left in their calcu
accessories is ±2% from baseline. of dose
placeatfor a the
single next point
test.while taking patient anatomy (3D) volum
and geometry into consideration. While these programs measurem
2.D.1.16.3 | Methods and equipment. For TBI/TSET have been in use for some
2.D.2.2 | Gantry rotation isocenter time, guidance was lacking (DLG) mea
treatments, accessories are often used to make the in how2.D.2.2.1 | Objective. The objective is to make missioning
to commission such technologies as well as their
dose delivered to the patient uniform. Some accessories role as part
sure that of the
an IMRTdeviationQA program
of gantryasmechanical
was noted in the
isocenter cation cal
such as blocking trays and beam spoilers are of a fixed ASTRO remains white within tolerance of the established baseline. in use at t
paper entitled “Safety Considerations for
4,5
thickness, whereas others such as compensators and IMRT”. gorithm.” N
rice bags vary from treatment to treatment. To measure 2.D.2.2.2 | Tolerance. The tolerance is ±1 mm with more
accessory transmission, setup an ionization chamber at and evaluating
from baseline. the algorithms for “independent/second troduction
depth 5 cm, for example, in a phantom under treatment check” of monitor unit calculations for IMRT; (b) Making as 3D volu
conditions appropriate for the modality, and take a series 2.D.2.2.3 | Methods and equipment. The front users shou
of three measurements. For those accessories that vary culation
pointer programs
remains(e.g., number
in place from of the
points, locations,
previous test. A when inter
in thickness, place various thicknesses of the accessory accuracy, evaluation methods, and
second pointer with a fine tip is secured horizontally heterogeneities); (3)
material at the treatment location and take a series of Describing commissioning and benchmark
off the end of the tabletop so that its tip is near the QA of sec-
three measurements for each thickness. Calculate the ondary MU calculation
collimator programs,
rotation isocenter proposing
defined front pointer. 2 | RO
by theadditional
accessory transmission factor and compare with the measurements, if necessary; and
The gantry is rotated through 360°, and the deviation (4) Describing clini- M U V ER
baseline measured when the program was commissioned. cal of the front pointer is monitored against the stationary CO M PR
Repeat for all energies used for TBI treatments. tion programs
pointer. The and recommendations
deviations should beon test tolerance.
enclosed in a circle
Diodes are often used to verify TBI/TSET treat- Thewith diameter less than the tolerance follows
terminology used in this report that
of the machine. 2.1 | R
ments. These diodes should be calibrated under treat- used in other AAPM Task Group reports
The center of the circle is the gantry rotation isocenter. including in
ment conditions. Setup the TBI/TSET phantom and particular: The front pointer should be left in place for the next test. The implem
deliver a known dose under TBI/TSET conditions. As as IMRT/V
diode performance can drift over time, a new dose cal- 1. Shall indicates a procedure
2.D.2.3 | Treatment couch rotation isocenter that is essential for the comple
ibration file should be made for each energy used for either (a) establishment of uniform
2.D.2.3.1 | Objective. The objective is to make potential fo practices, or
treatment. To verify the new calibration, deliver known (b)sure thethat most thesafe and effective
deviation of couchresult and/or main-
mechanical isocenter of radiothe
doses to the TBI/TSET phantom and simulate several taining
remains within tolerance of the established baseline. therefore e
patients’ separations. the accuracy of dose/MU determination. verification
2. Should
2.D.2.3.2 | Tolerance. The tolerance is ±1 mm rors befor
indicates an advisory recommendation that
isfromto be applied when practicable. The task group
baseline. measurem
2.D.2 | Mechanical favors the indicated procedure but understands that delivery o
there are other procedures which
2.D.2.3.3 | Methods and equipment. This test tion cham can accomplish
2.D.2.1 | Collimator rotation isocenter theshouldsamebe goal. Deviationsdirectly
performed from the recommended
after the collimator rays. Expe
2.D.2.1.1 | Objective. The objective is to make sure procedure
rotation isocenter test. With the front pointer careful
should only be carried out after and paper advanced
that the deviation of collimator mechanical isocenter analysis
still in place, translate the couch longitudinallywillso a in both ma
demonstrates that an equivalent result
remains within tolerance of the established baseline. be produced.
clean section of the paper is under the front pointer. shown6-11to
3. MayThe treatmenta couch
indicates statement that is through
is rotated likely (or 180°, probably)
and the plans. R
2.D.2.1.2 | Tolerance. The tolerance is ±1 mm to be correct but the task group
position of the end of the pointer is marked every 45° does not make any ity of only
from baseline. recommendations.
on the paper. The marked locations should be enclosed pretreatme
in a circle with diameter less than the tolerance of the ment plann
2.D.2.1.3 | Methods and equipment. The most As part ofThe
machine. thiscenter
work,ofthe the AAPMcircle iscommunity
the treatment wascouch of patients
common technique to check and verify the isocentricity surveyed
rotation isocenter. If the gantry collimator and couch niques ste
of the collimator is to use the vendor-supplied being used. According
isocenters are all within to thetolerance,
responses, thena dose/MU
the position cation may
|
2
TASKe856
FOR IMRT
of the 1front| pointer

STATE M ENT
at gantry zero, Ocollimator
F TH E PRO zero can BLE M verification
commercially program
available was generally
software to analyzeused for the ma-
the results
A N D TG CH A RG ES
be used to represent the mechanical isocenter of the or draw lines in the centers of exposed band on films. ap-
machine. Frequently, the lasers would be aligned to proximatelyof31%
The intersection the lines of responders
should be did not use
enclosed dose/MU
within
mechanical isocenter at this point in the process. dose/monitor units has beena circle within tolerance for the machine. More recently,at that
the Winston- Lutzmost testcommon
has been commercial
used to measure system reported
all
ance (QA) for patient
2.D.2.4 | Electron applicator interlocks treatment plans. AAPM Report in the survey
three axes in one test, was RadCalc
52,79,80
and this is the Tyler,
(Lifeline, preferred TX). The
Task |Group
2.D.2.4.1 71 reports
Objective. The on the formalism
electron interlockforis calculat-
a method.most Thecommon
typical method treatment planning
places system (TPS)
a radiopaque ball re-
1
safety feature that is required for delivery of electron Group 114 reports on
(5– 6 mm) at the mechanical isocenter defined by the Alto,
ported in the survey was Eclipse (Varian, Palo
beams. This interlock should be examined for verification of
for proper data for
lasersCA).
fromThis is not to be
the previous tests.considered
Images of asthean ball
endorsement
are
2
operation to ensure (a) that an electron beam cannot plans. The need for mon- acquired with film or an EPID with a predefinedpassing
of these products. The most common small rate
itor unit ifverification
be delivered the applicator programs is notwas identified
inserted in the early square
in criteria for dose/MU
field (e.g., 2 × 2 cm)verification
or cone (e.g., software
1 cm was cone)5% for
head of machine 3and (b) no photon beam treatment is planning and delivery IMRT (51%) and “None Specified”
at various gantry, collimator, and couch angles. The for VMAT (34%), al-
allowed when the applicator is inserted in the head of types of programs were though 30% of VMAT responders
displacement of the radiopaque ball center from the used 5% as passing
developed
the machine. ranging from confirmation of dose at a radiation field center is calculated either manually for
gle point in a simple phantom geometry to calculation or via their calculations
dedicated software. and Du onlyet6% al.used
52 three- dimensional
concluded that
2.D.2.4.2 | Tolerance. The tolerance is functional.while taking patient anatomy eight images, the four cardinal gantry angles with Additional
(3D) volumetric dose in the 2012 survey. two
and geometry into consideration. While these programs measurements
opposing collimator angles (typically the MLC
for each, weredosimetric
sufficient leaf to gap
have been
2.D.2.4.3 | Methods in use for some
and time, guidance
equipment. Insert was lacking reduce the isocenter localization error with respect to com-
in how to commission such
applicator in the head of the machine, select an technologies as well as gantrymissioning.
their and collimator Thetomost less thancommon0.2 mm. IMRT An dose/MU
additional verifi-
electron beam, and prepare to deliver dose. Ensure program as was noted in two images at couch angles 90° and 270° can beby
the cation calculation algorithm represented software
used
ASTRO
that the correct white paper entitled “Safety
applicator and field size is displayed on Considerations for in use at the time was a
to complete the test with respect to the couch. As “factor- based calculation al-
4,5
IMRT”.
the treatment console. Remove the applicator before gorithm.” Note that the clinical
the gantry rotation isocenter has both a mechanical practice has changed,
delivery This
and try tasktogroup turn the wasbeam charged on. with: (a) Reviewing
The machine (gantrywithsag)more andwidespread
energy-specific use of component
VMAT as well as the in-
(beam
should not be able to deliver any dose, and an interlock for “independent/second steering) the Winston- Lutz test should be repeated for (such
should have been activated. Insert the applicator in the for IMRT; (b) Making as 3Dused
all energies volumetric calculation
for stereotactic systems) since 2012, so
treatments.
head of the machine to clear the interlock and select a implementation of cal- users should consider the age and context of the data
culation programs (e.g.,
photon beam. The machine interlock should not allownumber of points, locations, when interpreting
2.D.2.6 | Treatment couch top flex the survey.
accuracy,
the user to choose evaluation
any photon methods,beam and while heterogeneities);
the electron (3)
2.D.2.6.1 | Objective. The objective is to examine
Describing
applicator commissioning and benchmark QA of sec-
is in position. the rigidity and the integrity of the treatment couch
ondary MU calculation programs, proposing additional when 2 | RO
a heavy LE (or
object O Fpatient)
DOSE is /positioned on its
measurements, if
2.D.2.5 | Coincidence of radiation and necessary; and (4) Describing top. This test was called tabletop sagIin
clini- M U V ER I FI CATI O NS NTG A 142.
cal testing
mechanical isocenter and periodic QA of secondary MU calcula- CO M PR EH ENSI V E Q A PROG R AM
2.D.2.5.1 | Objective. The objective is to determine on test tolerance. 2.D.2.6.2 | Tolerance. The tolerance is ±2 mm
The terminology
the coincidence of the used radiation in this andreport follows that
mechanical 2.1 | Review of the problem
from baseline.
used
isocenter. in other AAPM Task Group reports including in
particular: The implementation
2.D.2.6.3 | Methods and of new treatment techniques
equipment. With the such
2.D.2.5.2 | Tolerance. The tolerance is ±2 mm for as IMRT/VMAT in a radiotherapy
couch fully extended, mark the position of the horizontal department increases
non-IMRT and IMRT machines, ±1 mm for stereotactic that is essential for
laser near isocenter (one can use a marker block orthus,
the complexities in planning and delivery and a the
machines. Note these are absolute values as opposed of uniform practices, or potential for serious errors in the
piece of tape attached the side of the couch). Next, place planning and delivery
(b) the
to a deviation frommost safe and
baseline effective result
recommended in TGand/or
142. main- a heavyof radiotherapy.
weight (aboutAn 100–effective
150 lb)set of QA
evenly procedures is
distributed
taining established standards of practice to ensure therefore essential. The
on the couch top. Measure the flex of the couch goal of a routine pretreatment
top
the accuracy of dose/MU
2.D.2.5.3 | Methods and equipment. The radiation determination. relative to the laser projections determined without theany er-
verification procedure is to identify and resolve
2. Should
isocentricity for indicates
each axis an advisory
(collimator, recommendation
gantry, and that weight.rors before patient
Alternatively, the flex treatment.
can be For IMRT, using
measured verification
treatment couch) is commonly checked using the practicable. The task group measurements
the front pointer set. are commonly used to verify correct
78 procedure
Starshot technique. The coincidence of the radiation but understands that delivery of treatment plans, for example with ioniza-
and mechanical isocenter can then be checked. For which can accomplish tion chambers,
2.D.2.7 | Treatment couch angle films, or multidimensional detector ar-
each axis, place a film (radiographic or radiochromic) from the recommended rays. Experimental methods
2.D.2.7.1 | Objective. The objective is to verify the for patient- specific QA in
procedure should only be
between two slabs of plastic water. Orient the film, using carried out after careful advanced radiotherapy are, however,
couch rotational accuracy against the digital readout. In time- consuming
the lasers analysis demonstrates
as a surrogate for that an equivalent
mechanical isocenter,result will in bothsituations,
many clinical manpower the and accelerator
digital readout istime usedand have been
to setup
be produced.
such that it is in the plane of the mechanical isocenter shown
the patient for to be unable to detect
a specific field of treatment. This is like some unacceptable
and the3. May indicates
film center is a statement
close that is likely
to mechanical (or probably)
isocenter. plans.6-
the monthly
11
couch Recentanglestudies have demonstrated
test (Section 2.C.2.7.3), except a sensitiv-
Mark the position of the mechanical isocenter, astask group does not make any ity of only 5% to detect
measurements are taken at additional12,13 IMRT plan errors
couch angles. using IMRT
recommendations.
determined by the lasers, on the film. Open the jaws pretreatment measurements. Moreover, as treat-
(oriented such that it is perpendicular to the plane of ment planning
2.D.2.7.2 | Tolerance. Note becomes more efficient
tolerances and the
have number
film) by ±2As mm part symmetrically
of this work, from the AAPM central community
axis. Use was changedof patients
from TGtreated 142 and with areadvanced
aligned with radiotherapy
“AAPM- tech-
surveyed
low energy photons in 2012to deliverregarding the type MU
the appropriate of software
for niques steadily
RSS Medical Physics increases, measurement-
Practice Guideline 9.a”81based
: non- verifi-
the film at different angles (every 30°– 45°). Use either responses, a dose/MU cation may result
IMRT ±1°, IMRT ±1°, SRS/SBRT ±0.5°. in a continued increase in workload.
|
TASK28 |
REPORT
2.D.2.7.3 | Methods and equipment. Place a piece 1 | STATE M ENT O F TH E PRO BLE M verification
of graph paper or rectilinear grid at 100 cm SSD at A ND TG CH A RG ES jority of I
isocenter. Rotate the couch 45° using the crosshairs proximate
and the grid. Record the couch angle readout. Repeat An independent check of dose/monitor units has been verification
every 45°. and continue to be an important part of quality assur- time. The
2.D.2.8 | Treatment couch maximum range Task Group 71 reports on the formalism for calculat- most com
1
2.D.2.8.1 | Objective. The objective is to examine ing monitor units. AAPM Task Group 114 reports on ported in
the accuracy of the treatment couch travel over the methods and requirements for verification of data for CA). This
2
whole range in all three axes. In clinical treatment conformal external beam plans. The need for mon- of these p
situations the couch is sometimes moved to a new itor unit verification programs was identified early in criteria for
position to treat a different isocenter, that is, match the adoption of IMRT treatment planning and delivery IMRT (51%
3
fields. The test should also ensure that the couch techniques. Several different types of programs were though 30
movement is linear and accurate. developed ranging from confirmation of dose at a sin- rate. More
2.D.2.8.2 | Tolerance. The tolerance is ±2 mm. of dose at a single point while taking patient anatomy (3D) volum
and Fgeometry into consideration.
I G . 6 Stereotactic motion lockouts Whileon athese
Varianprograms
linac. [Color measurem
have figure
been caninbeuseviewed
for at wileyonlinelibrary.com]
some time, guidance was lacking (DLG) mea
2.D.2.8.3 | Methods and equipment. Position
the treatment couch at the level of isocenter location. in how to commission such technologies as well as their missioning
Place and secure (using tape) a tape measure such role as part of
2.D.3 | Safety an IMRT QA program as was noted in the cation cal
that the couch can move along the ruler length for ASTRO white paper entitled “Safety Considerations for in use at t
4,5
the whole range of travel along each axis. Record the IMRT”.2.D.3.1 | Follow manufacturer’s test procedures gorithm.” N
couch position on the machine console in the direction This task group
2.D.3.1.1 was charged
| Objective. Thewith:objective
(a) Reviewing is to with more
of motion before any movement. Project the crosshair and follow the manufacturer’s recommended safety troduction
on the ruler and move the couch in periodic intervals. check” of monitor unit calculations for IMRT; (b) Making
procedures. as 3D volu
Record and compare the readout from the machine recommendations on the clinical implementation of cal- users shou
console and the ruler. In addition, record the maximum 2.D.3.1.2 | Tolerance. The tolerance is as per when inter
extent of the couch travel. These procedures should accuracy, evaluationtolerances.
manufacturer’s methods, and heterogeneities); (3)
be repeated for each axis (lateral, longitudinal, and Describing commissioning and benchmark QA of sec-
vertical). The difference between the console readout ondary MU calculation programs,
2.D.3.1.3 | Methods and equipment. proposing additionalReview the 2 | RO
and the measurement should be within specified measurements,
manufacturer’s user manuals for the linac and clini-
if necessary; and (4) Describing ancillary M U V ER
tolerance. cal devices. Determine which tests can be performed by CO M PR
tion aprograms
physicistand or recommendations
service personnel.onIftest thetolerance.
tests are to
2.D.2.9 | Stereotactic accessories or lockouts The terminology used
be performed by the service personnelin this report follows
as partthat of the 2.1 | R
2.D.2.9.1 | Objective. Stereotactic interlocks used in other AAPM Task Group reports
preventive maintenance program, it is the responsibility including in
(see Fig. 6) ensure that the devices to be used are particular:
of the physicist to ensure that they have been completed The implem
interlocked and the dose rate for a given modality is on an annual basis. as IMRT/V
only allowed under this condition. 1. Shall In addition, carefully read and understand all safety- the comple
indicates a procedure that is essential for
either
related(a)information
establishment in theofdocuments
uniform practices,
provided by or the potential fo
2.D.2.9.2 | Tolerance. The tolerance is functional. (b)manufacturer. These documents may include user of radiothe
the most safe and effective result and/or main-
taining
manuals, established
safety guides,standardstechnical of practice
manuals, to etc.
ensureSafety- therefore e
2.D.2.9.3 | Methods and equipment. Attach the therelated information will generally be identified as warn- verification
stereotactic device to the head of the linac. The linac 2. ings orindicates
Should cautionsanwithin advisory these recommendation
documents. Additional that rors befor
should indicate an interlock related to this attachment is to be applied when practicable. The
safety-related information may be communicated via measurem task group
and prevent you from beam delivery. Based on the favors
letters, thesuch
indicated procedure
as technical but understands
bulletins that
or safety notifica- delivery o
manufacturer, take the recommended steps to clear there are other procedures which can accomplish
tions. Be sure to fully understand all safety-related in- tion cham
the interlock. Program a stereotactic beam. If the the same goal.
formation Deviations
and contact from the recommended
the manufacturer with questions. rays. Expe
stereotactic device is coded for the machine, check procedure should only be carried
The QMP should review the manufacturer recommen- out after careful advanced
that the machine code and associated jaw settings are analysis demonstrates that an equivalent
dations and determine which tests are appropriate for in both ma result will
correct. Repeat for all coded accessories. Deliver a be theproduced.
user’s clinic. In addition, the QMP should period- shown6-11to
set dose that is designated for QA purposes. Remove 3. Mayically review a
indicates thestatement that is likely
quality control (or probably)
procedures to ensure plans. R
the device and attempt to deliver the same dose. The to be correct but the task group does
that they properly address all potential safety issues. not make any ity of only
linac should not be able to deliver the dose when the recommendations.
Technical bulletins or safety notifications should be pretreatme
interlock is activated. Test all the motor motion disable signed and dated by the QMP documenting any cor- ment plann
functionality if available on the machine. As part action
rective of thistaken.work, the AAPM community was of patients
|
2
TASKe858
FOR IMRT
2.D.41 | | Respiratory
STATE M ENTgatingO F TH E PRO BLE M verification
to do these program ifwas
measurements generally point
a radiopaque used object
for the ma-
A N D TG CH A RG ES is moved by the phantom and imaged over the gated ap-
2.D.4.1 | Beam energy constancy period.proximately
Woods and 31% Rong of responders
55
used both didthenot MV use and
dose/MU
2.D.4.1.1 | Objective. The objective is to determinedose/monitor units has beenkV imagers to measure the positional displacementat that
if the photon beam energy in the gated mode does not part of quality assur-betweentime. The most
triggered and common commercial
static images for asystemrange reported
of
differ significantly from the nongated mode. Photon plans. AAPM Report in the
motion speeds. survey was RadCalc (Lifeline, Tyler, TX). The
beam Taskenergy Groupmay 71 notreports
reach
1
on the
the formalism
nominal value for when calculat- most common treatment planning system (TPS) re-
beam- on times are short, which has been reported to Task Group 114 reports on
2.D.4.3ported in the survey
| Calibration was Eclipse
of surrogate for (Varian,
respiratory Palo Alto,
occur during free-breathing respiratory gating for verification of
if temporal data for CA). This is not
phase or displacement magnitude to be considered as an endorsement
2
gatingconformal
windows are external
allowed beam
below plans.
500 ms. The need
58,82– 84 for mon- of these
2.D.4.3.1 products. Several
| Objective. The most common
different passing
types of rate
itor unit verification programs was identified early surrogates in criteria
of respiratory pattern may be used clinically, for5% for
for dose/MU verification software was
the adoption
2.D.4.1.2 | Tolerance. of IMRT treatment
The tolerance is the planning and delivery IMRT
example, optical,(51%) andgauge
strain- “Nonebelts Specified” for VMAT
with pressure (34%), al-
sensors,
3
percentage depth dose ±2% from that of the beam in types of programs were though 30% of VMAT responders
and spirometry. The objectives of this test are to verify used 5% as passing
developed
nongated mode. ranging from confirmation of dose at a that the phase and displacement magnitude indicated by for
gle point in a simple phantom geometry to calculation their calculations
the respiratory surrogateand only 6%
motion used three-system
measurement dimensional
2.D.4.1.3 | Methods and equipment. Beam energy while taking patient anatomy (3D) volumetric dose
accurately indicate the actual motion phase. in the 2012 survey. Additional
constancy for the gated beam can be quantified with While these programs measurements (typically the MLC dosimetric leaf gap
a pair of ionization chambers at 10 and 20 cm depths time, guidance was lacking 2.D.4.3.2 | Tolerance. The actual and measured com-
or alternatively dmax and 10 cm in liquid or solid water. as well as motionmissioning.
their traces should Thebemost within common
±100 ms IMRT
of each dose/MU
other. verifi-
The gated beam is used to deliver a predetermined program as was noted in the cation calculation algorithm represented by software
ASTRO white paper entitled
dose to the4,5chambers, and the ratio of the two “Safety Considerations for in use at the time was
2.D.4.3.3 | Methods and equipment. An example a “factor- based calculation al-
IMRT”.
readings is compared with that for the beam in a gorithm.” Note that the clinical
test for a pressure sensor is placing a series of fixed practice has changed,
nongatedThis mode. task group was charged with: (a) Reviewing weightswithonmore widespread
the sensor use of VMATthe
and determining asgainwell and
as the in-
and evaluating the algorithms for “independent/second offset values that produce a desired displacement (such
check” of monitor
2.D.4.2 | Temporal accuracy of phase orunit calculations for IMRT; (b) Making as 3Dfor
magnitude, volumetric
example, calculation
50%. For optical systems)systems,sincethis2012, so
recommendations
displacement magnitude gate on on the clinical implementation of cal- users should consider the age
can be accomplished by placing a fiducially marked block and context of the data
2.D.4.2.1 | Objective. The objective of this test is to of points, locations, when interpreting the survey.
surrogate at a series of fixed known locations within the
quantifyaccuracy,
the timeevaluation
delay that occurs methods, and heterogeneities);
between the moment (3)
field of view and comparing the reported displacements
when Describing
the gated radiation commissioning beam isand benchmark
expected to turn QAonof sec- with the known values. Once spatial accuracy is
or off ondary
and theMU moment calculation
when programs,
it is actuallyproposingturned onadditional
or 2 | phase
confirmed, ROconfirmation
LE O F DOSE can be/ established with
off as triggered by the gating system. The trigger may and (4) Describing a periodic motion phantom. As NS
clini- M U V ER I FI CATI O I N Aby Chang et
described
cal testing and periodic QA of secondary MU calcula- 85 CO M PR EH ENSI V E Q A PROG R A M
be based on direct motion measurement (ExacTrac) al., a phantom capable of periodic motion of known
tion programs
or motion measurement and recommendations
using a respiratory on test tolerance.
motion displacement magnitude and period can be monitored
surrogateThe terminology
(Varian RPM, Anzai usedstrain in this gauge, report follows that
VisionRT 2.1surrogate
using the | Review system, ofand
thetheirproblem
motion traces can
patient surface motion, C- Rad patient surface motion). Group reports including in
then be overlaid and compared. Woods and Rong55
particular: The the
compared implementation
motion trace of new treatment
caption by the gating techniques
system such
2.D.4.2.2 | Tolerance. The time delay should be with the surrogate motion to determine deviationsincreases
as IMRT/VMAT in a radiotherapy department in
within ±100 ms of the expected value measured as that is essential for the complexities
surrogate position. To determine in planning and delivery
deviations and thus, the
in surrogate
baseline.either (a) establishment of uniform practices, or timing,potential
they comparedfor serious seterrors
duty incycle
the planning
with the and cycledelivery
(b) the most safe and effective result and/or main- of radiotherapy. An
period recorded by the gating system. effective set of QA procedures is
taining established
2.D.4.2.3 | Methods and equipment. A phantom standards of practice to ensure therefore essential. The goal of a routine pretreatment
capable the accuracy predictable
of exhibiting of dose/MUperiodic determination. motion of 2.D.4.4verification
| Interlock proceduretestingis to identify and resolve any er-
a radiopaque object and/or film can be used for this recommendation that rors before
2.D.4.3.1 | Objective. An patient treatment.
interlockForshould
IMRT, be verification
in
measurement. A technique for determining gated time practicable. The task group place to prevent a patient prescribed a gated radiationcorrect
delay from favors the indicated
a pattern delivered procedure
to a filmbut understands
undergoing a that delivery
delivery from being of treatment
treated plans, for example
in a nongated with ioniza-
treatment
known motion pattern has been described by Chang which can accomplish tion chambers, films, or
mode. Such an occurrence could result in the dosemultidimensional detector
to ar-
84,85the same goal. Deviations from the recommended rays. Experimental methods for patient- specific QA in
et al. A small, known radiation field is delivered the planning target volume being lower than planned,
to a moving film, and the ends of the profile in the be carried out after careful advanced radiotherapy are,
and the dose to the surrounding normal tissue being however, time- consuming
directionanalysis
of motion demonstrates
are then determined that an equivalent
by measuring result will greaterinthan
bothplanned.
manpower and accelerator time and have been
be produced.
half- local- maximum positions (80% to 20% of local shown to be unable to detect some unacceptable
6-11
maximum of both ends) and compared with the that is likely (or probably) plans.
2.D.4.3.2 | Tolerance. Recent studies Thehave demonstrated
gating interlock a sensitiv-
is
expected profile ends. The time delay can then betask group does not make any
either functional or nonfunctional. 12,13 errors using IMRT
ity of only 5% to detect IMRT plan
calculated recommendations.
based on the difference between delivered pretreatment measurements. Moreover, as treat-
and expected profile lengths, which is straightforward 2.D.4.3.3 | Methods and equipment. The and
ment planning becomes more efficient same the
testnumber
when the motion pattern is sinusoidal and of known the AAPM community wasdefined in monthly QA can be done for annual QA to verify tech-
displacement magnitude. An EPID could also be used the type of software niquesofsteadily
functionality the gating increases, measurement-
interlock (see based verifi-
Section 2.C.4.4).
|
TASK30 |
REPORT
2.D.5 | Volumetric modulated arc therapy 1 order

| STATE
of 1 mm. M ENT
This does O F TH
allow E jaw
for the PRO BLE
speed M
to change. verification
(VMAT) A ND TG CH A RG ES
This test ensures that the dynamic wedge is functional. 86 jority of I
proximate
2.D.5.1 | Test patient-specific VMAT QA An independent
2.E.1.1.3 | Method and equipment. This can be verification
check of dose/monitor units has been
constancy and continue tobybeeither
performed an important
engineers part
or of quality assur-
physicists, although time. The
2.D.5.1.1 | Objective. The objective is to test the ance more likely RTTs. Any error messages should be in the sur
(QA) for patient treatment plans. AAPM Report
year-to-year constancy of VMAT delivery. Task Group 71 reports
propagated to eitheron engineering
the formalismorforphysics. calculat-One most com
1
ing enhanced
monitor units. AAPM Task Group
dynamic wedge field should be programmed 114 reports on ported in
2.D.5.1.2 | Tolerance. The tolerance is the pass methods and requirements
as part of the morning warmup for verification
and delivered. The CA). This
of data for
2
rate greater than or equal to the baseline pass rate conformal external beam
result should be documented in the plans. The need
morningfor mon-QA log of these p
minus 2% and plan passes institutional VMAT QA itor unit verification programs was
and should be reviewed by the engineers or physicists. identified early in criteria for
criteria (Section 2.C.5.1.2.) using the baseline tolerance. the adoption of IMRT treatment planning and delivery IMRT (51%
3
techniques. Several
2.E.1.2 | Monthly checks different types of programs were though 30
2.D.5.1.3 | Methods and equipment. See 2.E.1.2.1 | Objective. The objective is to ensure rate. More
developed ranging from confirmation of dose at a sin-
Section 2.C.5.1.3. The baseline passing rate should be gle point
that the in acentral
simpleaxis phantomdose geometry
delivered by the enhanced their calcu
to calculation
acquired at the time of VMAT commissioning or the previous of dose
dynamic wedge is constant for all energies.anatomy
at a single point while taking patient (3D) volum
annual QA. If the VMAT QA fails tolerance and all other and geometry into consideration. While these programs measurem
annual QA tests pass, repeating the vendor acceptance have 2.E.1.2.2 | Tolerance. The calculated wedge factor (DLG) mea
been in use for some time, guidance was lacking
testing process for VMAT may be an effective approach for in how to commission
should be within ±2% suchoftechnologies
baseline. as well as their missioning
bringing the VMAT QA passing rates back within tolerance. role as part of an IMRT QA program as was noted in the cation cal
ASTRO white
2.E.1.2.3 | Method and equipment. This test can in use at t
paper entitled “Safety Considerations for
4,5
2.D.5.2 | Interruption test IMRT”.be performed with the same setup as the monthly gorithm.” N
2.D.5.2.1 | Objective. The objective is to test This
photon task output
group was charged(largest
constancy with: (a)field size at a with more
Reviewing
the accuracy of VMAT delivery when the treatment is and depth where the wedge angle is defined typically, troduction
interrupted and restarted. check”10 of cm,monitor
see unit Sectioncalculations
2.C.1.1).forWe IMRT; (b) Making that as 3D volu
recommend
tests be performed for the 60° wedge angle. implementation of cal-The users shou
2.D.5.2.2 | Tolerance. The tolerance is ±1% wedge transmission factor is calculated as the ratio when inter
deviation from uninterrupted passing rate. accuracy,
of the evaluation
dynamic wedge methods, fieldand heterogeneities);
to the open field.86–(3) 90
The
Describing commissioning and benchmark
calculated wedge factor is compared with baseline. QA of sec-
2.D.5.2.3 | Methods and equipment. Setup the ondary RepeatMU for calculation
all photon programs,
energies.proposing additional 2 | RO
QA phantom for clinical measurements. Deliver the measurements, if necessary; and (4) Describing clini- M U V ER
test VMAT field. Analyze results. Repeat delivery of the cal testing and periodic
2.E.1.3 | Annual checks QA of secondary MU calcula- CO M PR
test VMAT field and interrupt the beam during delivery. tion programs and recommendations
2.E.1.3.1 | Objective. The objective is to ensure that on test tolerance.
Resume treatment. Compare the interrupted delivery QA The terminology
the enhanced used wedge
dynamic in this delivery
report is follows that as 2.1 | R
functioning
passing rate with uninterrupted delivery QA passing rate. used in other AAPM
expected for all wedge angles. Task Group reports including in
The annual linac QA described in this section would particular: The implem
require 30– 45 person-hours. However, one should be 2.E.1.3.2 | Tolerance. Off-axis ratios should be as IMRT/V
aware that the number of person-hours depends on the 1. withinindicates
Shall ±2% of baselinea procedure for thethat centralis essential
80% of the forfield the comple
machine as well as availability of the appropriate equip- either (a) establishment
width at a depth of 10 cm. of uniform practices, or potential fo
ment that facilitates these QA procedures. This time (b) the most safe and effective result and/or main- of radiothe
also includes analysis of the data, comparison with the taining
2.E.1.3.3 | Method and equipment. The profile for therefore e
baseline data, and report generation. thetheaccuracy
enhancedofdynamic dose/MU wedgesdetermination.
should be measured at verification
one gantry angle. Profiles can be measured with recommendation thatfilm, rors befor
isionization
to be applied when
chamber, or diode. practicable. 86– 96 The task group
As with the monthly measurem
2.E | Dynamic, virtual, or universal wedges favors the indicated procedure but
review, it should be performed at the depth at which understands that the delivery o
there are other procedures which can
wedge angle is defined, typically 10 cm. Profiles should tion cham accomplish
2.E.1 | Enhanced dynamic wedges the same goal.
be measured forDeviations
the 60° angle from thelargest
for the recommended
field size and rays. Expe
procedure
one other intermediate wedge angle with a 10careful
should only be carried out after × 10 cm2 advanced
2.E.1.1 | Daily checks analysis demonstrates that an
field size. The measured profiles are compared withequivalent result will the in both ma
2.E.1.1.1 | Objective. The objective is to ensure that be produced.
baseline profiles. Repeat for all photon energies. shown to
the enhanced dynamic wedge software and enhanced 3. May indicates a statement that is likely (or probably) plans.6-11 R
dynamic jaw positioning are working as expected. to be correct but the task group does not make any ity of only
recommendations.
2.E.2 | Universal wedge pretreatme
2.E.1.1.2 | Tolerance. As this is simply a software ment plann
check, whereby a self-monitoring system looks at collimator As part of this
2.E.2.1 | Daily checks work, the AAPM community was of patients
position referencing MUs to be delivered, tolerances are surveyed 2.E.2.1.1 in 2012 regardingThe
| Objective. the type of software
objective is to niques ste
set by the manufacturer, in this case, Varian, to be on the being ensure that the universal wedge, particular to cation may
used. According to the responses, a dose/MU
|
2
TASKe860
FOR IMRT
Elekta1 machines,
| STATE M ENT O F
is functioning. In TH E PRO
contrast to theBLE M verification
2.E.3.2.3 | Method program and was generally Equipment.used forSee the ma-
A N D TG CH A RG ES
enhanced dynamic wedge, the universal wedge is jority of
Section 2.E.1.2.3. IMRT/VMAT treatment plans although ap-
static and in place for certain percentage of the proximately 31% of responders did not use dose/MU
An independent
total MUs. 97,98 check of dose/monitor units has been 2.E.3.3verification
| Annual software
checksfor VMAT treatment plans at that
2.E.3.2.1 | Objective. most common commercial
The objective is system
to ensure reported
2.E.2.1.2 | Tolerance. The universal wedge is plans. AAPM Report that the virtual wedge delivery is functioning as The
Task
functional. Group 71 reports on the formalism for calculat- most
expected forcommon
all wedgetreatmentangles. planning system (TPS) re-
methods
2.E.2.1.3 and requirements
| Method and for equipment.
verification ofSee data for CA). This
2.E.3.2.2 is not to beOff-
| Tolerance. considered
axis ratiosasoran off-endorsement
center
2
conformal
Section 2.E.1.1.3. external beam plans. The need for mon- ratios should be within ±2% of baseline for the passing
of these products. The most common central rate
itor unit verification programs was identified early 80% in ofcriteria
the fieldforwidth
dose/MU verification
at a depth of 10 cm. software was 5% for
the adoption
2.E.2.2 | Monthly of IMRT
checks treatment planning and delivery IMRT (51%) and “None Specified” for VMAT (34%), al-
3
2.E.2.2.1 | Objective. The objective is to ensure types of programs were though
2.E.3.2.3 | Method30% of VMAT responders
and used
equipment. 5% as See passing
that the central axis dose delivered by the universal of dose at a sin- rate. More
Section 2.E.1.3.3. than 50% of users used a single point for
gle point in a simple
wedge is constant for all energies. phantom geometry to calculation their calculations and only 6%
The time required for daily QA is 1–2 min and is used three- dimensional
of dose at a single point while taking patient anatomy simply(3D) volumetric
delivering one dose field.inMonthly
the 2012 QAsurvey.
may take Additional
and geometry
2.E.2.2.2 | Tolerance. The into consideration. While
calculated these
wedgeprograms measurements (typically the
15–20 min, which includes approximately 10 min for MLC dosimetric leaf gap
have been in use for
factor should be within ±2% of baseline.some time, guidance was lacking setup and 5 min per energy. Annual QA takes approx- com-
in how to commission such technologies as well as their imatelymissioning.
twice as long Theas most common IMRT
an additional wedgedose/MU
angle is verifi-
role as
2.E.2.2.3 | Method part of an IMRT QA
and program as was
equipment. See noted in the cation calculation algorithm
checked. The times quoted include time for analysis represented by software
ASTRO
Section 2.E.1.2.3. white paper entitled “Safety Considerations for in use at
and documentation. the time was a “factor- based calculation al-
2.E.2.3 This task group
| Annual checks was charged with: (a) Reviewing with more widespread use of VMAT as well as the in-
2.E.2.3.1 | Objective. The objective is to ensure for “independent/second 2.F troduction
| Multileaf and collimators
adoption of new (MLCs)software tools (such
that the universal wedge delivery is functioning as for IMRT; (b) Making as 3D volumetric calculation systems) since 2012, so
recommendations
expected for all wedge angles. on the clinical implementation of cal- users
2.F.1 | Weekly should consider the age and context of the data
accuracy,
2.E.2.3.2 evaluation methods,
| Tolerance. Off-axis and ratios heterogeneities);
should be (3)
2.F.1.1 | Qualitative test (picket fence)
Describing commissioning and
within ±2% of baseline for the central 80% of the fieldbenchmark QA of sec-2.F.1.1.1 | Objective. The objective of this test
width atondary
a depth MUofcalculation
10 cm. programs, proposing additional 2 | RO
is to assess LE O
variation inFleafDOSE position/ accuracy and
measurements, if necessary; and (4) Describing clini- M U V ER I FI CATI
interleaf leakage transmission by visually O NS I N A inspecting
cal testing
2.E.2.3.3 | Method and periodic
and QA of secondary
equipment. See MU calcula- the 2D dose distribution at the junction ofPROG
CO M PR EH ENSI V E Q A abutting R AM
fields
tion programs
Section 2.E.1.3.3. and recommendations on test tolerance. defined by the MLC leaves. The pattern created by
The terminology used in this report follows that these 2.1
abutting| Review of thetoproblem
fields is referred as the picket fence
used in other AAPM Task Group reports including pattern. in 99
Examples of passing and failing MLC leaf
2.E.3particular:
| Siemens virtual wedge The
patterns canimplementation
be found in the ofliterature.
new treatment 99
Leaftechniques
gap width such
as IMRT/VMAT in a radiotherapy
in dynamic MLC mode can also be assessed with department increases
a
1. Shall indicates
2.E.3.1 | Daily checks a procedure that is essential for the complexities in planning
different version of the picket fence pattern. and delivery
100,101and thus, the
2.E.3.1.1either (a) establishment
| Objective. The objectiveof uniformis to practices,
ensure or potential for serious errors in the planning and delivery
that the virtual wedge software and dynamic jaw result and/or main- of radiotherapy.
2.F.1.1.2 | Tolerance. An Theeffective set ofisQA
tolerance ±2 procedures
mm. A is
taining established
positioning are working as expected. standards of practice to ensure therefore essential. The goal
well- calibrated MLC should generate a regular pattern of a routine pretreatment
the accuracy of dose/MU determination. at the verification
location of procedure
the abutting is to identify
fields. Theand resolve
Elekta MLCany er-
2.E.3.1.2 | Tolerance. Virtual wedge field is recommendation that
models rors
102 before patient treatment. For IMRT, verification
will generate a fairly homogenous dose at
functioningis toandbedeliverable
applied when practicable.
without error. The task group measurements
the junction are commonly
of the abutting fields asused to verify
the leaves arecorrect
favors the indicated procedure but understands that calibrated based on the radiation field edge location. Forioniza-
delivery of treatment plans, for example with
there
2.E.3.1.3 | Method are other procedures
and which can
equipment. See accomplish tion chambers,
the Varian MLC, the dose films, or multidimensional
at the junction should appear detector ar-
the
Section 2.E.1.1.3. same goal. Deviations from the recommended slightly higher than the surrounding dose distribution asQA in
rays. Experimental methods for patient- specific
the leaves radiotherapy
are calibrated basedare, however,
on the physical time- consuming
location
analysis
2.E.3.2 | Monthly checks demonstrates that an equivalent result will in both
of the leaf tips. manpower
103–105
Leaves out of alignment with have
and accelerator time and their been
be produced.
2.E.3.2.1 | Objective. The objective is to ensure shown
neighbors will to be unable to detect
break the regular pattern at the location some unacceptable
6-11
virtual3. May indicates
wedge delivery isa exactly
statement that is likely (or probably)
as expected. plans.
of field junctions, Recentandstudies have demonstrated
displacement ≥1 mm should a sensitiv-
to be correct but the task group does not make any ity of only 5% to detect
be detectable. For a given leaf pair, IMRT plan
difference in leaf IMRT
errors using
12,13
recommendations.
2.E.3.2.2 | Tolerance. The tolerance is to ensure position between the opposed leaves will Moreover,
pretreatment measurements. create a lower as treat-
that the wedge factor for a given wedge angle and field ment planning becomes more
or higher dose at the location of the field junctions, efficient and the number
As part of this work, the AAPM
size is within ±5% from unity. For other wedges of different community was and an error of ≥1 mm should be visually detectable. tech-
surveyed in 2012 regarding the
field sizes, ensure that the wedge factor is within ±2%. type of software niques
This test doessteadily
not verify increases, measurement-
the leaf position accuracy based
with verifi-
|
TASK32 |
REPORT
respect to the radiation isocenter but will indicate leaf 1 with | STATE the crosshairs M ENT O F TH angle
at collimator E PRO BLE M
0°, gantry angle verification
misalignment. A ND TG CH A RG ES
0°, 100 cm from the source. Program the MLC to move jority of I
to several field sizes covering the clinical range. Record proximate
2.F.1.1.3 | Methods and equipment. The morning An independent
the position check of the of dose/monitor
light field relative units has been and verification
to isocenter
therapist is mostly likely to perform this test after the and continue to be an important
compare with the programmed MLC field. Do part of quality assur-
this for time. The
machine has been properly warmed up. The results ance (QA) for
both MLC leaf banks. patient treatment plans. AAPM Report in the sur
should be reviewed by a physicist. The abutting Task Group 71 reports on the formalism for calculat- most com
1
beams used to generate the picket fence pattern ing monitor units. AAPM
2.F.2.2 | Backup diaphragm settings Task Group 114 reports on ported in
should include all MLC leaves and cover the entire methods
2.F.2.2.1 | Objective. The2 objective of this test is CA). This
and requirements for verification of data for
MLC leaf travel range. For example, eight fields of conformal
to assess external backup beam plans. The
diaphragm needaccuracy
position for mon-with of these p
2
5 × 40 cm spaced every 5 cm can be used. The itor unit verification programs
respect to the radiation isocenter location. Some was identified early linacs,
in criteria for
2D dose distribution produced with the picket fence the adoption
Elekta Infinity, of IMRT for example, use backup diaphragms IMRT (51%
3
beams can be measured with a radiographic film techniques. Several
that are partial-attenuation different types jaws of thatprograms
overlap were with the though 30
of sufficient dimensions placed at treatment unit developed ranging from confirmation
MLC leaf banks to increase their attenuation and of dose at a move rate. More
sin-
isocenter (100 cm). An equal number of MUs should gle in the same direction as the MLC leaves. The backup their calcu
be used for each beam of the picket fence pattern. of dose at a single
diaphragms are point
typicallywhile taking patient
calibrated to be locatedanatomy about (3D) volum
Radiochromic films can replace radiographic films, but and 1 mm behind the leaves. This distance will vary due to measurem
their limited dimensions might require more than one have been inofuse
linearity for somebut
calibration, time,theguidance
field edgewas should always (DLG) mea
lacking
film or to limit the test to a smaller field size (limited in howbe defined by the most retracted leaves across the missioning
to commission such technologies as well as their
number of leaves and leaf travel). Alternatively, the film role as part
given of an
field IMRT QA program as was noted in the
sizes. cation cal
can be moved closer to the target, and an appropriate ASTRO white paper entitled “Safety Considerations for in use at t
4,5
magnification factor can be used. Megavoltage EPIDs IMRT”.2.F.2.2.2 | Tolerance. The tolerance is ±1 mm on gorithm.” N
can also be used as a replacement for radiographic This
eachtask group backup
individual was charged diaphragm with:position,
(a) Reviewing ±2 mm on with more
film.106 and evaluating the
backup diaphragm opening. algorithms for “independent/second troduction
For Varian accelerators, a dynamic MLC beam de- check” of monitor unit calculations for IMRT; (b) Making as 3D volu
signed to produce a 1 mm irradiation strip every 2 cm 2.F.2.2.3 | Methods and equipment. Using film, users shou
can be used to assess dynamic leaf gap width consis- culation programsor(e.g.,
radiographic number of orpoints,
radiochromic, an EPID, locations,acquire when inter
99
tency. This test is appropriate for Varian accelerators accuracy, evaluation methods,
an image of two regular beams limited by the backupand heterogeneities); (3)
as the minimum dynamic leaf gap for different manu- Describing commissioning and
diaphragm and measure the diaphragm position with benchmark QA of sec-
facturers and MLC models can limit the application of ondary respectMU calculation
to the radiation programs,isocenter. proposing
This test is usually 2 | RO
additional
this test. measurements, if necessary;
performed in service mode using stored beams and (4) Describing which M U V ER
clini-
To assess impact of gravity on MLC leaf position cal allow the backup diaphragm to extend beyond the MLC CO M PR
accuracy, it is recommended that a different cardinal tion programs
leaves. The and MLC recommendations
leaves should on be test tolerance.
retracted at least
gantry angle is used each week, so that all four cardinal The terminology used in this
1 cm behind the backup diaphragm for this test. Fields report follows that of 2.1 | R
angles are covered during the month. This fulfills the used5 ×in20 other
and 20 AAPM × 20 cm Task 2 Group reports including in
can be used to assess the backup
gantry angle dependence requirement that was pro- particular:
diaphragm position accuracy. The backup diaphragm The implem
posed in the monthly section in TG 142. position should correspond to the 50% penumbra point as IMRT/V
1. Shall
position indicates
for each a procedure
diaphragm. that The isnormalization
essential forpoint the comple
(100%) can be selected as the maximum intensity of uniform practices, or potential fo
2.F.2 | Monthly (b)in the open field. Detect the location of the radiation of radiothe
taining
isocenter. established
This can standards
be done byofplacing practice to ensure
a fiducial marker therefore e
2.F.2.1 | Leaf position accuracy (non- IMRT) thebased on light field. The radiation isocenter can also be verification
2.F.2.1.1 | Objective. The objective of this test is 2. Should
determined indicates based anon advisory
the location recommendation
of the field center that for rors befor
to assess leaf position accuracy with respect to the is to be applied when practicable.
different collimator angles. Appropriate image analysis measurem The task group
radiation isocenter location. It differs from the weekly favors
software the can indicated
be used procedure
to analyze butthisunderstands
test. that delivery o
picket fence test as it involves a quantitative assessment there are other procedures which can accomplish tion cham
of leaf positioning accuracy instead of the weekly visual the same goal.
2.F.2.3 | Leaf travel speed Deviations from the recommended rays. Expe
inspection. procedure should only be carried
2.F.2.3.1 | Objective. The objective of this test advanced out after careful
analysis
is to identify demonstrateslag in leaf thatmotion
an equivalent
and suboptimum result will leaf in both ma
2.F.2.1.2 | Tolerance. The tolerance is ±1 mm per be produced.
speed. Leaves exhibiting slower leaf motion will shown6-11to
leaf, ±2 mm on field width. 3. May indicates
generate a statement
undesirable holdoffsthat is in likely
clinical (ordynamic
probably) beam plans. R
todeliveries.
be correctA but the task group does
reduction in leaf speed might also indicate not make any ity of only
2.F.2.1.2 | Methods and equipment. First, recommendations.
that the corresponding MLC motor is approaching its pretreatme
determine that the crosshairs represent the radiation end of life. ment plann
isocenter. This should have already been performed As part of this work, the AAPM community was of patients
during the annual QA and checked monthly. Align large surveyed
2.F.2.3.2 | Tolerance. Max leaf speed for Varian niques ste
graph paper or template that has millimeter resolution being used. According
Millennium, Elekta MLCi, to the Elektaresponses, Agility,a and dose/MU
Siemens cation may
|
2
TASKe862
FOR IMRT
are 2.5,1 2.0, STATE

| 3.5, and 4.0 M ENT
cm/s. Leaf O F speedTH E should PRO be BLE M of theverification
light crosshair program as was generallyand
a surrogate usedplacing
for the ma-
A N D TG CH A RG ES
within ±0.5 cm/s of the maximum leaf speed set for a fiducial marker at that location. Use of the light ap-
the dynamic MLC QA beam. For example, for a Varian proximately
field crosshair as 31%
well as of responders
the accuracy didofnot use dose/MU
placement
Millennium MLC test, leaf speed should be 2.5 cm/s,dose/monitor units has been verification software for
of the fiducial marker will introduce additionalVMAT treatment plans at that
and the measured leaf speed should be greater than part of quality assur- time. The most common commercial
uncertainty in the test results and might make the system reported
ance
2.0 cm/s. (QA) for patient treatment plans. AAPM Report test more user dependent. The location of the The
Task Group 71 reports on the formalism for calculat- mostisocenter
radiation commoncan treatment planningbysystem
be determined averaging (TPS) re-
1
2.F.2.3.3 | Methods and equipment. This test can Task Group 114 reports on
the location of the radiation field center at different Alto,
be performed by analyzing the treatment for verification of
unit log file data for CA). This
collimator angles is notfortoaberegular
considered beamassuch an endorsement
as a
2
conformal external beam plans.
for a particular beam delivery. Deliver a dynamic MLC The need for mon- of these products. The
square field. Radiographic or radiochromic films most common passingas rate
itor unit verification 2 programs was identified early in
beam with a 1 × 40 cm aperture that travels 15 cm criteria for
well as megavoltage EPID dose/MU verification
109 –115
can be used with5% for
software was
in the right-to-left3 direction (±7.5 cm each side of the planning and delivery IMRT (51%) and “None
the appropriate image analysis software Specified” fortoVMATperform(34%), al-
isocenter). The travel distance can be increased if the types of programs were though 30% of VMAT responders
this test. Perform for one photon energy per month used 5% as passing
MLC model supports a longer travel for a given leaf of dose at a sin- rate. More than 50%
and cycle through all photon energies. of users used a single point for
carriage position. The total number of MUs to be used geometry to calculation their calculations and only 6%
Alternatively, this test can be performed using the used three- dimensional
for thisofdynamic
dose at MLC a singlebeam point
to be while takingatpatient
delivered max leaf anatomy method (3D) volumetric
in Section dose in
2.F.2.1.3, the penumbra
if the 2012 survey. Additional
location
and geometry
speed is given by. into consideration. While these programs can be resolved to better than the tolerance, 1 mm. leaf gap
measurements (typically the MLC dosimetric
MU = [MLC travel (cm) × dose rate (MU/s)]/max MLCtime, guidance was lacking (DLG) measurements) were also required during com-
in how
speed (cm/s). to commission such technologies as well as their missioning. The most common IMRT dose/MU verifi-
role as part of an IMRT QA program
Retrieve the log file corresponding to the beam deliv- as was noted in 2.F.3 cation
the | Annualcalculation algorithm represented by software
ery. The MLC4,5speed can be calculated using the MLC “Safety Considerations for in use at the time was a “factor- based calculation al-
IMRT”.
position and the timestamps in the log file. 107
Kaurin gorithm.”
2.F.3.1 | MLC Note that the clinical practice has changed,
transmission
106 This task group was charged with: (a) Reviewing
et al. uses the same equation without the use of a 2.F.3.1.1 | Objective. Theuse
with more widespread of VMATofas this
objective well test
as the in-
log file to determine the maximum MLC speed for a for “independent/second is to ensure that the average inter- and intra- MLC (such
check” of
dynamic MLC delivery. monitor unit calculations for IMRT; (b) Making as 3D volumetric
leaf transmission for all calculation
photon energiessystems) does since not 2012, so
This test can also be performed using the EPID. implementation of cal- users should consider the age
change over time and that it remains consistent with and context of the data
In this approach, deliver a dynamic MLC beam with a of points, locations, when interpreting the survey.
the original data for treatment planning system beam
1 × 20accuracy,
cm2 aperture evaluation methods,
that travels 15 cmandin heterogeneities);
the right-to- (3)
modeling.100,116–124
left direction (±7.5 cm each side of the isocenter) and benchmark QA of sec-
acquire ondary
a movie MU of calculation
the MLC programs,delivery using proposing
the EPID. additional 2 || RO
2.F.3.1.2 LE O FThe
Tolerance. DOSE tolerance / is ±0.5% from
Detect leaf positions on each frame of the EPID movie and (4) Describing clini- M U V ER I FI CATI
baseline, example baseline = 1.5%, tolerance O NS I N A range =
cal testing and periodic
and calculate the MLC speed using the EPID frame QA of secondary MU calcula- 1–2%. CO M PR EH ENSI V E Q A PROG R A M
rate. The EPID field of view is not sufficient to detect on test tolerance.
The terminology
all MLC leaves, and the testused mustinbethis reportatfollows
repeated least that 2.1 | | Method
2.F.3.1.3 Review andofequipment.
the problem Setup a small
used in other
twice to verify all leaves. AAPM 108 Task Group reports including in
volume ionization chamber in a solid water phantom
particular: on theThe implementation
central axis at 5 cm of new
depth treatment
with thetechniques
phantom such
2.F.2.4 | Leaf position accuracy (IMRT) as IMRT/VMAT in a radiotherapy
surface at 100 cm SSD. The long axis of the chamber department increases
2.F.2.4.1 | Objective. The objective of this test is that is essential for the complexities in planning
should be perpendicular to the leaf travel to measure and delivery and thus, the
to assess leaf position accuracy with respect to the of uniform practices, or potential for serious errors
both interleaf and intraleaf transmission. Deliver in the planning and delivery
radiation isocenter location. This test is like the leaf result and/or main- of radiotherapy. An effective
100 MU with a 10 × 10 cm field and record the 2 set of QA procedures is
position accuracy (non-IMRT) test but has a more of practice to ensure therefore essential. The goal
ionization chamber reading as the open field reading. of a routine pretreatment
stringentthe accuracyand
tolerance of dose/MU
can be determination.
performed either Close verification
the field using procedure
the MLCisand to identify
repeat the andionization
resolve any er-
2. Should indicates
radiographically or by visual inspection.an advisory recommendation that
chamber measurement with 1000 MU, ensuringverification
rors before patient treatment. For IMRT, leaf
is to be applied when practicable. The task group gap ismeasurements
not directly over arethe commonly
chamber.used to verifythecorrect
Determine
2.F.2.4.2favors the indicated
| Tolerance. The procedure
tolerancebut is understands
±1 mm on that delivery
ionization chamberof treatment
reading plans,(R) perfor MUexample
for the closedwith ioniza-
each individual leaf position for linacs used for IMRT which can accomplish and open fields (R/MU) closed and (R/MU) open.detector
tion chambers, films, or multidimensional The ar-
delivery. the same goal. Deviations from the recommended rays. Experimental methods
average MLC transmission is the ratio of ionization for patient- specific QA in
procedure should only be carried out after careful advanced radiotherapy
chamber R per MU for closed and opened fields. are, however, time- consuming
2.F.2.4.3analysis
| Methods demonstrates and that an equivalent
equipment. Fieldsresult will in both manpower
Alternatively, this test can andbeaccelerator
expandedtime and have
by using film been
be produced. 2
of 5 × 40 and 20 × 40 cm can be used to assess shown
or a 2D detector to be unable
array 125 to detect some unacceptable
to measure transmission
6-11
3. May indicates
leaf position accuracy.a statementTake an image that is of likely
an (or
MLC- probably) plans.
for more Recent
leaf pairs. studies
Repeat allhave
stepsdemonstrated
for each photon a sensitiv-
defined beam and measure the leaf position, as task group does not make any ity of
energy available.only 5% to detect IMRT plan errors using IMRT
12,13
recommendations.
defined by the 50% penumbra point, with respect pretreatment measurements. Moreover, as treat-
to the radiation isocenter. The normalization point ment planning becomes
2.F.3.2 | Leaf position repeatability more efficient and the number
(100%) can As part of this work,
be selected as the themaximum
AAPM community intensity was of patients
2.F.3.2.1 treated The
| Objective. with objective
advancedof radiotherapy
this test is to tech-
in the open field. The location of the radiation the type of software assess the MLC leaf positioning reproducibilitybased
niques steadily increases, measurement- in the verifi-
isocenter can be determined using the projectionto the responses, a dose/MU cation may result
context of an IMRT delivery. in a continued increase in workload.
|
TASK34 |
REPORT
2.F.3.2.2 | Tolerance. The tolerance is ±1 mm 1 helps | STATE obtaining M aENT more O F TH E

accurate PRO BLE
estimation. TheM EPID verification
maximum difference between repeat leaf position A ND TG CH A RG ES
can be used to replace the film; however, a radiopaque jority of I
measurements. marker must be used on the EPID to mark the location proximate
An independent
of the light field check of dose/monitor units has been
crosshair. verification
2.F.3.2.3 | Method and equipment. If this test is and continue to be an important part of quality assur- time. The
performed using the EPID, the procedure for the monthly ance (QA) for patient treatment
2.F.3.4 | Coincidence of light-radiation fields plans. AAPM Report in the sur
leaf position accuracy test (IMRT) can be repeated 5– Task 2.F.3.4.1 | 1Objective. The objective of this test is most com
Group 71 reports on the formalism for calculat-
10 times without moving the EPID to determine the leaf ing monitor
to verify units. AAPM Taskbetween
the coincidence Group 114 lightreports on
and radiation ported in
position repeatability. The procedure for the monthly methods
fields as defined by the MLC2 and ensure that the light CA). This
and requirements for verification of data for
test can be simplified, as the location of the radiation conformal
field is an external
acceptable beamsurrogate
plans. The for theneed for mon-
radiation field. If of these p
isocenter is not required for the assessing leaf position itor unit verification programs was
the light field is not used to setup patients, this test identified early in can criteria for
repeatability. This test can also be performed using the the adoption
be omitted. of IMRT
Note that this test could be performed at IMRT (51%
3
light field. In this case, set the gantry, collimator, and techniques.
the same time as different
Several test 2.6.2.1 types of programs were
or 2.6.2.4. though 30
couch angles at 0°. Set the tabletop at 100 cm SSD and developed ranging from confirmation of dose at a sin- rate. More
align a piece of millimeter scale graph paper with the gle 2.F.3.4.2 | Tolerance. The tolerance is ±2 mm per their calcu
light field crosshair. Toggle the MLC between two fields of dose
MLCatbank. a single point while taking patient anatomy (3D) volum
2
(e.g., 10 × 40 and 5 × 40 cm ) 5–10 times and mark on and geometry into consideration. While these programs measurem
paper the variation in leaf positions for at least one of have been in use
2.F.3.4.3 | Methods for some time, andguidance equipment. Setup (DLG) mea
was lacking
the two fields. in how to commission such
the gantry and the collimator angle technologies as well
at 0°. Place a missioning
as their
The light field-based approach is faster than the role as part of an IMRT QA program
radiographic or radiochromic film on the surface as was noted in theof a cation cal
EPID method. It should be noted that, while the light ASTROflat4,5phantom. Load a field (e.g., 20 × 20 cm ). Mark in use at t
white paper entitled “Safety Considerations 2 for
field-based approach is acceptable, it is less accurate the location of the light crosshairs as well as the light gorithm.” N
IMRT”.
than the EPID approach. In addition, because of the This
fieldtaskedgegroup using was charged from
the pressure with: a(a) pen or pin prick. with more
Reviewing
EPID field- of-view limitation, additional images must be and Cover the film with sufficient buildup. Radiopaque troduction
acquired to cover all MLC leaves. check”
markersof monitor
can also unit calculations
be used to mark for IMRT; (b) Making
the location of the as 3D volu
light field crosshair and the field edges. Place these users shou
2.F.3.3 | MLC spoke shot culation
markers programs
on the (e.g.,top of number
the buildup. of points, the film with when inter
Exposelocations,
2.F.3.3.1 | Objective. The objective of this test is to accuracy, evaluation methods, and
sufficient dose to darken the film and process it. heterogeneities); (3)The
determine the alignment of the MLC with respect to the Describing commissioning and benchmark
coincidence can be assessed determining the location QA of sec-
radiation isocenter and the collimator mechanical axis ondary of 50% MU calculation
radiation penumbra programs, proposing location on each field 2 | RO
additional
of rotation. measurements, if necessary;
edge using a point densitometer and measuring and (4) Describing clini- the M U V ER
distance between the radiation and light field edges. CO M PR
cal testing and periodic QA of secondary MU calcula-
2.F.3.3.2 | Tolerance. The tolerance is ≤1 mm tion programs andfilm
Alternatively, recommendations
dosimetry software on test can tolerance.
be used to
radius. The terminology used in this
analyze the scanned film and determine the distance report follows that 2.1 | R
usedbetween
in otherthe AAPM Task Group reports
light and radiation field edges. The EPID including in
2.F.3.3.3 | Methods and equipment. As a particular:
can be used to replace the film; however, radiopaque The implem
prerequisite for this test, the MLC should be markers must be used to mark the light field, and as IMRT/V
symmetrical around the radiation isocenter. This can 1. Shall
dedicatedindicates software a procedure
is required. thatRepeatis essential for
for all photon the comple
be checked by irradiating a film with a half-beam block either
energies. (a) establishment of uniform practices, or potential fo
field at 0° and 180° of collimator angle and making (b) the most safe and effective result and/or main- of radiothe
sure that the field edges are well aligned. Set the taining established
2.F.3.5 | Moving window IMRT standards of practice to ensure therefore e
gantry, collimator, and couch angles to 0°. Place a the
2.F.3.5.1 | Objective. The objective of this test is verification
radiographic or radiochromic film at depth of maximum 2. Should
to assess indicates an advisory
the agreement recommendation
between the delivered that and rors befor
dose (dmax) in a solid water phantom with the phantom is to be applied when practicable.
planned leaf positions for a moving window IMRT test measurem The task group
surface at 100 cm SSD. Mark the location of the light favors
pattern. theNoteindicated the testprocedure
for segmentalbut understands
IMRT (step that and delivery o
field crosshair using a pin prick or fine tip pen before there are other procedures
shoot) was not applicable and has been removed. which can accomplish tion cham
covering the film with the solid water. Irradiate film the same goal. Deviations from the recommended rays. Expe
2
with a narrow MLC- defined field (e.g., 0.4 × 20 cm ) at procedure should
2.F.3.5.2 | Tolerance. The only be carried out
mean after careful
positioning advanced
intervals of 30° of collimator angles to create a star analysis demonstrates that
deviation from the planned position [defined withan equivalent result will the in both ma
pattern. Use sufficient dose per irradiation to darken be produced.
root mean square (RMS) of leaf positioning error] shown6-11to
the film. Determine the centerline of each narrow 3. May
<0.35 indicates
cm foraall statement
leaves. In that is likely ≥95%
addition, (or probably)
of the leaf plans. R
field. The intersection of all field centerlines should be to be correct but the task
positioning deviations should be <0.35 cm. group does not make any ity of only
within a circle of 1 mm radius. The distance between recommendations. pretreatme
the pin prick or pen mark and the center of the circle 2.F.3.5.3 | Methods and equipment. Deliver a ment plann
that contains all field centerline intersections should As part of this work, the AAPM
moving window IMRT test pattern on the linac. The community was of patients
be within 1 mm. The analysis can be done manually, surveyed test patternin 2012 should regarding
exercise the all MLC typeleaves
of software
and should niques ste
but the use of dedicated film analysis software usually beingcover the maximum leaf travel range. A sweeping gap cation may
used. According to the responses, a dose/MU
|
2
TASKe864
FOR IMRT
1 | can
IMRT pattern STATE be used M forENT O F Retrieve
this test. TH E PRO the linac BLE M verificationThe
SRS treatment. program
tolerance wasforgenerally
the monthly used for the ma-
imaging
A N D TG CH A RG ES
delivery log file and analyze the positioning deviations and treatment coordinate coincidence tests remains ap-
between planned and delivered MLC leaf positions proximately 31% of responders did not use dose/MU
unchanged.
An independent
using dedicated software. check 107of dose/monitor units has been
Positioning deviations verification
It should be noted software for VMAT
that there are sometreatment plans at that
differences
are assessed per leaf and for the entire MLC. The test part of quality assur- time. The most common
between this TG’s recommendations and “AAPM commercial system reported
pattern should be delivered at the four cardinal gantry plans. AAPM Report Medical Physics Practice Guideline 2.a” with respect The
in the survey was RadCalc (Lifeline,
8 Tyler, TX).
Task Group
angles. An additional method 71 reports on the formalism
for this using the EPID is for calculat- most common
to frequency of testing.treatment planning
Medical physics system
practice (TPS) re-
guide-
1 126
ing monitor
described by Agnew et al. units. AAPM Task Group 114 reports on
lines recommend a minimum subset of tests. As such Alto,
The time required for weekly QA is25–15 min, with for verification of data for CA).
“Medical This isPractice
Physics not to be considered
Guideline 2.a”as an endorsement
recommends
the lower times corresponding to EPID acquisition. plans. The need for mon- of these products. The most
image quality be tested annually as opposed to this common passing
TG, rate
Frequency may be reduced following a history of past was identified early in criteria for dose/MU
which recommends monthly. verification software was 5% for
the adoption
results. Monthly QA of IMRT treatment
may take 12–15 min for non-IMRT planning and delivery IMRT (51%) and “None Specified” for VMAT (34%), al-
3
and approximately 50–100 min for IMRT, where the high types of programs were though 30% of VMAT responders used 5% as passing
developed
end would be for ranging
film-based fromQA. confirmation
Tests for the of dose
backup at a sin- 2.G.1rate.| More
Daily— than kV50% andofMV users(EPID)used imaging
a single point for
diaphragm in Elekta could add 20– 30 min. Assuming geometry to calculation their calculations and only 6% used three- dimensional
two to three beam energies for MLC transmission with taking patient anatomy (3D) volumetric
2.G.1.1 | Collision interlocks dose in the 2012 survey. Additional
an ionization chamber, annual QA takes approximately While these programs measurements (typically the
2.G.1.1.1 | Objective. There is potential for MV MLC dosimetric leaf gap
80 min using a combination EPID and light field, or up time, guidance was lacking and kV detectors (KVDs), and the kV source, to collide com-
to 130 min with film. The times quoted include time for as well as their missioning.
with the patient and/orThe most the common
treatmentIMRT couch. dose/MU
These verifi-
role as part
analysis and documentation.of an IMRT QA program as was noted in the cation calculation algorithm
devices are equipped with collision detectors which, represented by software
ASTRO white paper entitled “Safety Considerations for in use at the time was a “factor-
when depressed, will halt all mechanical movements based calculation al-
IMRT”.4,5 gorithm.” Note that the clinical
of the treatment unit. The proper functioning of these practice has changed,
2.G | This task group was
Radiographic charged with: (a) Reviewing
imaging with is
interlocks more widespread
essential use safety.
for patient of VMAT The asobjective
well as the in-
and evaluating the algorithms for “independent/second troduction and adoption of new software
of this test is to check the functionality of all the collision tools (such
A summary of the time, staffing, and equipment re- for IMRT; (b) Making as
detectors. 3D volumetric calculation systems) since 2012, so
quirements for imaging QA is contained in Table VII. implementation of cal- users should consider the age and context of the data
The times for each task are estimated based on the number of points, locations, when interpreting the survey.
2.G.1.1.2 | Tolerance. The tolerance is all interlocks
accuracy,
assumption that evaluation
each task is methods,
carried out andindependently.
heterogeneities); (3) functional.
As toolsDescribing commissioning
are commercially availableand to benchmark
address multi- QA of sec-
ondary
ple tasks withMU calculation
a single image programs,
acquisition, proposing
the overalladditional 2 || RO
2.G.1.1.3 Methods LE O andF equipment.
DOSE / The collision
time required to accomplish several tasks in the same and (4) Describing clini- M U V ER I FI
interlocks for the megavoltage CATI O NS I N A kilovoltage
detector,
cal testing and periodic QA
category, such as planar kV imaging, can substantially of secondary MU calcula- detector, and kilovoltage source can PROG
CO M PR EH ENSI V E Q A be tested R AbyM
speed up the QA process. Significant time savings can on test tolerance. physically pressing the corresponding collision
The terminology
also be realized by using aused standard in thistest report
patient follows
in the that 2.1 sequentially
detectors | Review andofensuring
the problem that all mechanical
R&V system. The test patient can be setup to contain Group reports including in
movements are halted.
fields particular:
for all the MV, kV, and cone beam computed to- The implementation of new treatment techniques such
mography (CBCT) image acquisitions. In addition, the 2.G.1.2as IMRT/VMAT
| Positioning in aorradiotherapy
repositioning department increases
R&V system can be used to document and store the that is essential for
2.G.1.2.1 | Objective. The objective of this and
the complexities in planning and delivery testthus,
is the
images. If necessary, the images can be exported for of uniform practices, or potential for serious errors in
to ensure that the EPID-based planar imaging system the planning and delivery
(b) theand
further review most safe and effective result and/or main-
analysis. can be of used
radiotherapy.
to detectAn effective
patient set of QA
positioning procedures
errors and is
It should be noted that the recommendations for of practice to ensure therefore essential.
accurately correct for them. The goal of a routine pretreatment
the accuracy
the tolerances for the daily of dose/MU
QA testsdetermination.
for positioning or verification procedure is to identify and resolve any er-
repositioning and imaging and treatment coordinate recommendation that rors before
2.G.1.2.2 | Tolerance.patient treatment.
The tolerance For isIMRT,
≤2 mm verification
for
coincidence provided in TG 142 have been modified. practicable. The task group non- SRS/SBRT and ≤2 mm for SRS/SBRT, ≤1 mm daycorrect
This reportfavors
aligns thewithindicated
TG 179,procedure
30
“QA for but Image- understands
Guided that of SRS.delivery
Note of thistreatment
was adjusted plans, from for example
TG 142.with Theioniza-
Radiation Therapy Utilizing CT- Based Technologies,” which can accomplish tion chambers, films,
change was made to align with TG 179. or multidimensional
30 detector ar-
and “AAPM Medical Physics Practice Guideline 2.a” from the recommended 8 rays. Experimental methods for patient- specific QA in
in recommending the tolerance for these tests for SRS/ carried out after careful advanced
2.G.1.2.3 | Methods radiotherapy and are, however,
equipment. Theretime- consuming
analysis be
SBRT machines demonstrates
increased tothat ≤2 an from equivalent
≤1 mm. The result will in bothcommercially
are many manpower and accelerator
available cubetimephantoms
and have been
be produced.
rationale behind these changes is that these daily tasks shown to
containing radiopaque be unable to detect
markers that can be used some unacceptable
to
6-11 127
typically must be performed rapidly, and as a result, that is likely (or probably) plans.
perform the test Recent studies have demonstrated
(e.g., see Fig. 7). The phantom a sensitiv-
is
there is atoreduction
be correct but precision.
in test the task group The one does not make any
exception placedityonof the
onlycouch
5% to indetect IMRT planmanner
a predefined 12,13
errors using
using IMRT
recommendations.
to this increase is for the clinical situation where IGRT the room lasers and/or light field crosshairs, shifted treat-
pretreatment measurements. Moreover, as
is to be used with SRS. Under that circumstance, it is away ment
from planning
the target becomesposition more byefficient
a known andthree-
the number
the recommendation of this TG that the QMP must val-the AAPM community wasdimensional (3D) vector (usually defined by marks on tech-
idate the IGRT imaging tests to ≤1 mm on the day of the type of software niques steadily
the phantom), imaged,increases,
and shifted measurement-
back to its nominal based verifi-
|
TASK36 |
REPORT
1 | STATE M ENT F I GO
. F
7 TH E kVPRO
Planar imagesBLEof a M verification
cube phantom used for positioning or
A ND TG CH A RG ES
repositioning tests. A central target BB,
jority of I
along with two setup BBs are visible. proximate
An independent check ofThe dose/monitor
blue crosshairsunits are the has been
digital verification
and continue to be an important graticule. [Colorpartfigure
of quality
can be assur-
viewed at time. The
ance (QA) for patient treatment wileyonlinelibrary.com]
plans. AAPM Report in the sur
target position using the imaging registration tools. and geometry into consideration.
2.G.2 | Daily— CBCT (kV and MV) While these programs measurem
The displacement between the laser positions on have been in use for some time, guidance was lacking (DLG) mea
the phantom after the final shift and the marks on in how to commission
2.G.2.1 | Collision interlockssuch technologies as well as their missioning
the phantom used for the initial phantom setup are role as part of an
See Section 2.G.1.1. IMRT QA program as was noted in the cation cal
reported as the position or repositioning accuracy for ASTRO white paper entitled “Safety Considerations for in use at t
4,5
the daily test. IMRT”.
2.G.2.2 | Positioning or repositioning gorithm.” N
2.G.2.2.1 | Objective. The objective of this test is with more
2.G.1.3 | Imaging and treatment coordinate and evaluating
to ensure that the thealgorithms
cone beam imaging system can be troduction
for “independent/second
coincidence check” of monitor unit calculations
used to detect patient positioning errors for IMRT; and accurately as 3D volu
(b) Making
2.G.1.3.1 | Objective. The objective of this test is to recommendations
correct for them. on the clinical implementation of cal- users shou
ensure that the same isocenter is shared by the planar culation programs (e.g., number of points, locations, when inter
imaging and treatment systems, within tolerance. accuracy, evaluation methods, and
2.G.2.2.2 | Tolerance. The tolerance is ≤2 mm for heterogeneities); (3)
Describing
non- SRS/SBRT commissioningand ≤2and mm benchmark
for SRS/SBRT, QA ≤1 of sec-
mm day
2.G.1.3.2 | Tolerance. The tolerance is ≤2 mm for ondary MU
of SRS. calculation programs, proposing additional 2 | RO
non- SRS/SBRT and ≤2 mm for SRS/SBRT, ≤1 mm day measurements, if necessary; and (4) Describing clini- M U V ER
of SRS. Note this was adjusted from TG 142. cal testing and
2.G.2.2.3 | Methods periodic QA of secondary
and equipment. See CO M PR
MU calcula-
tion Section
programs and
2.G.1.2.3.recommendations on test tolerance.
2.G.1.3.3 | Methods and equipment. The imaging The terminology used in this report follows that 2.1 | R
and treatment coordinate coincidence can be measured used in other AAPM Task Group
2.G.2.3 | Imaging and treatment coordinate reports including in
using a cube phantom containing radiopaque markers. particular: coincidence The implem
There are many commercially available cube phantoms 2.G.2.3.1 | Objective. To ensure that the same as IMRT/V
that can be used for this test. The phantom is leveled 1. Shall
isocenterindicates
is shareda procedure
by the CBCT thatimaging
is essential
and treatmentfor the comple
and positioned on the treatment couch using the room either (a) establishment
systems, within tolerance. of uniform practices, or potential fo
lasers. The system is imaged at the four cardinal angles (b) the most safe and effective result and/or main- of radiothe
(270°, 0°, 90°, and 180°), and the deviation between taining
2.G.2.3.2 | Tolerance. The tolerance is ≤2 mm for therefore e
the appropriate markers and electronic crosshairs the
non- accuracy
SRS/SBRT of dose/MU
and ≤2 mmdetermination.
for SRS/SBRT, ≤1 mm day verification
on each rent image there represents the deviation 2. Should indicates an
of SRS. Note this was adjusted advisory recommendation
from TG 142. that rors befor
between the imaging and treatment coordinates. 127 is to be applied when practicable. The task group measurem
This test assumes that the crosshairs, which could be favors the indicated
2.G.2.3.3 | Methods procedure and but understands that
equipment. Ideally, delivery o
either electronic or using a graticule, are aligned to the there are other procedures
the phantom used for these tests which can accomplish
contains multiple tion cham
radiation isocenter. the same goal. Deviations from the recommended
radiopaque targets to facilitate quick and easy 3D image rays. Expe
An alternative technique for this test is to perform the procedure
registration should
between onlyreference
be carried CTout andafter
CBCT careful
images. advanced
daily CBCT test first, which involves applying the corre- analysis demonstrates that
A cube phantom containing radiopaque markers, an equivalent result will for in both ma
sponding table shifts and verifying that the appropriate be produced.
example, the one used for kV and MV planar imaging, shown6-11to
shifts are within the appropriate tolerance relative to the 3. May
could indicates
be useda for statement
this test. thatNoteis likely
that, (or
as probably)
this phantom plans. R
known shifts. After the CBCT test, an orthogonal pair to be correct but the task group
typically has an asymmetric marker configuration, does not make any ity of only
of 2D images (1 kV and 1 MV image) of the phantom recommendations.it can also be used to test for coordinate flips. The pretreatme
is acquired, and the residual shifts from the 2D images phantom is leveled and positioned on the treatment ment plann
are calculated based on the electronic crosshairs and/ As partusing
couch of thisthework, the AAPM
room lasers community
as a surrogate was
of radiation of patients
or graticule. If the residual shifts are within the toler- surveyed
isocenter. The phantom is imaged and registered with niques ste
ance, the test passes. beingtheused.
referenceAccordingCT. The to the responses,
deviation betweena dose/MUthe CBCT cation may
|
2
TASKe866
FOR IMRT
1 | STATE
and reference isocenters M ENT O F TH
represents theE deviation
PRO BLE M softwareverification
and hardware program canwas generally
result used for the ma-
in a considerable
A N D TG CH A RG
between the imaging and treatment coordinates. ES 127 jority of IMRT/VMAT
time saving for these imaging tests. treatment plans although ap-
This test assumes that the crosshairs, which could be proximately 31% of responders did not use dose/MU
either electronic or using a graticule, are aligned to the units has been verification software
2.G.3.3 | Spatial resolution for VMAT treatment plans at that
radiation isocenter. An alternative method to perform part of quality assur- time. The most common
2.G.3.3.1 | Objective. The objective is to ensurecommercial system reported
ance
the test (QA) for by
is described patient
Chang treatment
et al.127 plans. AAPM Report that thein spatial
the survey was of
resolution RadCalc
the EPID (Lifeline,
has not Tyler, degraded TX). The
Task Group 71 reports on the formalism for calculat- most
with time. common treatment planning system (TPS) re-
2.G.3methods| Monthly— and requirements
planar MV for imaging
verification of data for
2
CA). This
2.G.3.3.2 is not to beThe
| Tolerance. considered
toleranceas an endorsement
is better than
(EPID) conformal external beam plans. The need for mon- of these products. The
or equal to baseline measured during acceptance. most common passing rate
the adoption
2.G.3.1 | Imaging of IMRT treatment
and treatment coordinate planning and delivery IMRT|(51%)
2.G.3.3.3 Methodsand “None and Specified”
equipment.forEach VMATlinac (34%), al-
3
techniques.
coincidence Several different types of programs were though 30% of VMAT responders
vendor typically supplies a spatial resolution test used 5% as passing
2.G.3.1.1 | Objective. The objective is to ensureconfirmation of dose at a phantom. These phantoms can be imaged to verify for
that the same isocenter is shared by the planar MV geometry to calculation that thetheirMV calculations
imaging system’s and only spatial
6% used three- dimensional
resolution has
imaging and treatment systems, within tolerance. while taking patient anatomy (3D) volumetric dose in the
not fallen below baseline. The phantom images contain 2012 survey. Additional
and geometry into consideration. While these programs measurements
bar patterns or hole(typically
patternsthe thatMLC candosimetric
be visually leaf gap
2.G.3.1.2 | Tolerance. The tolerance is ≤2 mm for time, guidance was lackinganalyzed. Typical bar patterns have spatial frequencies com-
in how to commission
non- SRS/SBRT and ≤1 mm for SRS/SBRT. such technologies as well as their
between missioning.
0.1 and 0.8 Theline most common
pairs IMRT dose/MU
per millimeter. Typical verifi-
role as part of an IMRT QA program as was noted in the hole patterns contain holes of diameters rangingbyfrom
cation calculation algorithm represented software
2.G.3.1.3 | 4,5Methods and equipment. The same test “Safety Considerations for in use at the time was a
0.5 to 15 mm. More sophisticated analysis, such as“factor- based calculation al-
IMRT”.
used for daily QA can be used, although action is often gorithm.” Note that the clinical
modulation transfer function, can be applied using practice has changed,
Thisthe
taken during task groupQA
monthly was charged
process if thewith:
imaging(a) Reviewing
and with more
commercially widespread
available software.use An of VMAT
example as image
well asofthe in-
treatment coordinate coincidence can be improved. for “independent/second troduction and adoption
such a phantom is shown in Fig. 8. of new software tools (such
Winston- Lutz tests using commercially available for IMRT; (b) Making as 3D volumetric calculation systems) since 2012, so
automated image processing can be especially useful implementation of cal- users
2.G.3.4 | Contrastshould consider the age and context of the data
to guide the process of applying modifications to number of points, locations, when interpreting the survey.
2.G.3.4.1 | Objective. The objective is to ensure
bring accuracy,
the imaging evaluation methods,
and treatment and heterogeneities);
isocenters to within (3)
that the contrast resolution of the EPID has not
Describing
tolerance. Linac vendorscommissioningalso provideand benchmark
equipmentQA andof sec- degraded with time.
ondary
software MU calculation
to perform this test.128 programs, proposing additional 2 | RO LE O F DOSE /
measurements, if necessary; and (4) Describing clini- M U |V ER
2.G.3.4.2 I FI CATI
Tolerance. O NS Ishould
Contrast N A be better
cal testing
2.G.3.2 | Scaling and periodic QA of secondary MU calcula- CO M PR EH ENSI
than or equal to baseline measured during V E Q A PROG acceptance. R AM
2.G.3.2.1 | Objective. The position of the MV on test tolerance.
imager isThe terminology
variable. For image usedcomparison
in this report follows that
purposes, 2.1 | | Methods
2.G.3.4.3 Reviewand of the problem
equipment. A QA device
the dimensions of the images are scaled to isocenter. Group reports including in
such as the Las Vegas phantom can be imaged to verify
particular:
The purpose of this test is to ensure that 2D planar MV that theThe
MVimplementation
imaging system’sofcontrast new treatment
has not fallen techniques
below such
images scale correctly. as IMRT/VMAT in a radiotherapy
baseline. The Las Vegas phantom is a square aluminum department increases
1. Shall indicates a procedure that is essential for the complexities in planning and
phantom with 28 circular holes with different diameters delivery and thus, the
2.G.3.2.2 | Tolerance. The tolerance is ≤2 mm for of uniform practices, or potential for serious errors in
and depths shown in Fig. 9. When imaged, the visibilitythe planning and delivery
(b) the most safe
non- SRS/SBRT and ≤1 mm for SRS/SBRT. and effective result and/or main- of radiotherapy. An effective set
of these holes is a measure of the contrast resolution of of QA procedures is
taining established standards of practice to ensure therefore essential. The goal
the MV EPID. Distribution and number of visible holes of a routine pretreatment
2.G.3.2.3the| accuracyMethods of dose/MU and determination.With
equipment. verification
is visually compared procedure is to identify
with baseline. More and resolve any er-
sophisticated
the gantry at 0°, a device containing at least five recommendation that rors before patient treatment.
phantoms are available commercially, and they can For IMRT, verification
be
radiopaque markers is placed on the treatment practicable. The task groupanalyzed automatically using the accompanying software.correct
couch, withfavors onethe indicated
marker along procedure
the central but axis
understands
of the that delivery of treatment plans, for example with ioniza-
beam and the others peripheral to the central marker which can accomplish 2.G.3.5 tion |chambers,
Uniformity films,
andor multidimensional detector ar-
noise
at known distances and in the plane perpendicular from the recommended rays. Experimental
2.G.3.5.1 | Objective. The objective methods for patient-
is tospecific
ensureQA in
to the central axis of the beam. The QA device is be carried out after careful advanced radiotherapy
that the performance of the EPID with respect are, however, time- consuming
to
analysis demonstrates
placed at a known SSD, and a pair of planar MV and that an equivalent result will
uniformity and noise has not degraded with time. have been
in both manpower and accelerator time and
kV images be produced.
is then taken. The distance between the shown to be unable to detect some unacceptable
central marker and the peripheral markers can be that is likely (or probably) plans.|6-11Tolerance.
2.G.3.5.2 Recent studies have demonstrated
Uniformity and noise should a sensitiv-
measured and compared with the known distance task group does not make any ity of only 5% to detect
be better than or equal to baseline12,13 IMRT plan
measured during IMRT
errors using
recommendations.
(Chang et al. ). 127 pretreatment
acceptance. measurements. Moreover, as treat-
Automated, commercially available techniques also ment planning becomes more efficient and the number
exist to do the scaling, spatial resolution, contrast, and AAPM community was
2.G.3.5.3 | Methods and equipment. A stack of tech-
uniformity and noise QA based on single kV and MV the type of software niques30steadily
5- cm thick, × 30 cm, increases, measurement-
buildup material is placed based on verifi-
being used. According to
images. These techniques that use a combination of the responses, a dose/MU cation may result in a continued
a uniform treatment couch top between the radiation increase in workload.
|
TASK38 |
REPORT
1 is| often
STATEtakenMif ENT O F TH
the imaging andEtreatment
PRO BLE M
coordinate verification
A ND TG CH A RG ES
coincidence can be improved. Linac vendors also jority of I
provide equipment and software to perform this test.128 proximate
and 2.G.4.2
continue to be
| Scaling an important part of quality assur- time. The
ance2.G.4.2.1
(QA) for patient treatment
| Objective. For plans. imageAAPM comparison in the sur
Report
Taskpurposes,
Group 71the reports
dimensions of the images are scaled to most com
1
ing isocenter.
monitor units. AAPM Task
The purpose of this Group
test is114 reportsthat
to ensure on 2D ported in
planar kV images scale correctly. for verification of data for CA). This
itor 2.G.4.2.2
unit verification | Tolerance. The tolerance is ≤2 mm for criteria for
programs was identified early in
the non-
adoptionSRS/SBRTof IMRT andtreatment
≤1 mm for planning
SRS/SBRT. and delivery IMRT (51%
developed ranging
2.G.4.2.3 | Methods from confirmationand of equipment. See rate. More
dose at a sin-
gle point in a simple
Section 2.G.3.2.3. phantom geometry to calculation their calcu
and 2.G.4.3
geometry |intoSpatial consideration.
resolution While these programs measurem
have2.G.4.3.1
been in use | Objective. The objective is to ensure (DLG) mea
for some time, guidance was lacking
in how to commission
that the spatial resolution such technologies
of the kV as imager has not missioning
well as their
role degraded
as part of an IMRT
with time. QA program as was noted in the cation cal
F I G . 8 Planar megavoltage image of an image quality phantom 4,5
2.G.4.3.2 | Tolerance. The tolerance is better than gorithm.” N
IMRT”.
for monthly quality assurance. The bar patterns or line pairs along
the central axis can be used to determine spatial resolution. [Color This task togroup
or equal baselinewasmeasured
charged with: during(a) Reviewing
acceptance. with more
figure can be viewed at wileyonlinelibrary.com] and evaluating the algorithms for “independent/second troduction
2.G.4.3.3 | Methods and equipment. A QA device as 3D volu
check” of monitor unit calculations for IMRT; (b) Making
recommendations
such as the Leeds on the clinical implementation
phantom, shown in Fig. 10, can be users shou
of cal-
127
source and the detector (Chang et al. ). A planar MV imaged to verify that the kV imaging system’s contrast when inter
image is then taken at the most used clinical settings. accuracy,
has notevaluation
fallen below methods,
baseline. and The heterogeneities);
Leeds Phantom(3) (TOR
Image uniformity and noise can be quantified by Describing
18FG) is placed on the cover of the KVDQA
commissioning and benchmark withof the
sec-KVD
measuring the average pixel intensity in 1 × 1 cm square ondary MU calculation
positioned at a known programs,
distance. proposing additional are 2 | RO
The collimators
regions of interest placed at the image center and 7.5 cm measurements, if necessary; and
set to the manufacturer recommended field size, (4) Describing clini- and M U V ER
off- center left, right, top, bottom. The measured values cal the 1-mm copper plate is inserted over the phantom. CO M PR
of center, left, right, top, and bottom should agree with tion programs
The sameand x-rayrecommendations
techniques (kVp, on mA,
test tolerance.
ms) used at
the baseline values. To quantify image noise, a 5 × 5 cm The terminology used in
commissioning are used for image acquisition.this report follows thatThe 2.1 | R
square ROI is placed at the center of the radiation field. usedimages in other areAAPM
visuallyTask Grouptoreports
inspected determine including in
the smallest
The mean image intensity and the standard deviation particular:
discernable group of bars visible in the images, which The implem
of the intensity within the ROI are calculated. Fractional corresponds to a certain line pair per millimeter values. as IMRT/V
deviation (expressed as the ratio of standard deviation 1. Shall indicates
This value a procedure
is compared that is essential for
with baseline. the comple
to the mean) should agree with baseline values. The either (a) establishment of uniform practices, or potential fo
image noise and uniformity calculation processes can (b) the most
2.G.4.4 | Contrast safe and effective result and/or main- of radiothe
be automated using commercially available phantoms taining
2.G.4.4.1 | Objective. If kV imager is not functioning therefore e
and software. the accuracy
properly or ifofandose/MUinappropriate determination.
filter is applied to the verification
2. Should indicates an advisory recommendation
acquired images, the images may have poor contrast, that rors befor
iswhich
to becan applied when practicable. The task
compromise patient setup effectiveness due measurem group
2.G.4 | Monthly—planar kV imaging favors the indicated
especially to inability procedure but understands
to differentiate between tissues.that delivery o
there are other procedures which can accomplish tion cham
2.G.4.1 | Imaging and treatment coordinate the same goal. Deviations from the
2.G.4.4.2 | Tolerance. Contrast should be better rays. Expe recommended
coincidence procedure
than or equal should only bemeasured
to baseline carried out afteracceptance.
during careful advanced
2.G.4.1.1 | Objective. The objective is to ensure analysis demonstrates that an equivalent result will in both ma
that the same isocenter is shared by the planar kV be produced.
2.G.4.4.3 | Methods and equipment. A QA device shown6-11to
imaging and treatment systems, within tolerance. 3. suchindicates
May as the Leeds a statement phantom that canis likely (or probably)
be imaged to verify plans. R
tothat
be correct but the task group does
the kV imaging system’s contrast resolution has not make any ity of only
2.G.4.1.2 | Tolerance. The tolerance is ≤2 mm for recommendations. not fallen below baseline (see Fig. 11). The same pretreatme
non- SRS/SBRT and ≤1 mm for SRS/SBRT. image acquired in Section 2.G.4.3.3 can be used for ment plann
Asthispart
test.ofInspect
this work, the AAPM
the images visually community
to determine was the of patients
2.G.4.1.3 | Methods and equipment. The same surveyed
lowest contrast disk visible in the images. This value is niques ste
test used for daily QA can be used, although action being used. According
compared with baseline. to theIt responses,
should be noted a dose/MUthat there cation may
|
2
TASKe868
FOR IMRT
F I G . 9 Las Vegas phantom for megavoltage planar image quality assurance. The number of visible holes in the image should be
consistent with the number visible during acceptance testing. [Color figure can be viewed at wileyonlinelibrary.com]
F I G . 1in
0 how to commission
Leeds phantom for kVsuch
qualitytechnologies as well as their missioning. The most common IMRT dose/MU verifi-
role[Color
assurance. as part of an
figure canIMRT QAatprogram as was noted in the
be viewed cation calculation algorithm represented by software
wileyonlinelibrary.com]
particular:
are several commercially available software packages 2.G.5The| implementation
Monthly— CBCT of new(kVtreatment
and MV) techniques such
that will perform the analysis of these imaging tests as IMRT/VMAT in a radiotherapy department increases
1. Shall
automatically. indicates a procedure that is essential for the complexities
2.G.5.1 | Geometric distortion in planning and delivery and thus, the
either (a) establishment of uniform practices, or potential for serious errors in the planning
2.G.5.1.1 | Objective. The objective of this test is to and delivery
(b) the most
2.G.4.5 | Uniformity and noise safe and effective result and/or main- of radiotherapy. An effective set
ensure that point-to-point distances inside objects areof QA procedures is
2.G.4.5.1 | Objective. The objective is to ensure of practice to ensure therefore essential. The
preserved within images of the objects. goal of a routine pretreatment
the accuracyofofthe
that the performance dose/MU
kV imager determination.
with respect to verification procedure is to identify and resolve any er-
uniformity and noise has not degraded with time. recommendation that rors before
2.G.5.1.2 patient treatment.
| Tolerance. The tolerance For isIMRT,
≤2 mm verification
for
is to be applied when practicable. The task group measurements are
non- SRS/SBRT and ≤1 mm for SRS/SBRT.commonly used to verify correct
2.G.4.5.2 | Tolerance. Uniformity and noise should but understands that delivery of treatment plans, for example with ioniza-
be better than or equal to baseline measured during which can accomplish tion chambers, films, or multidimensional
2.G.5.1.3 | Methods and equipment. Geometric detector ar-
acceptance. the same goal. Deviations from the recommended rays. Experimental methods
distortion of the CBCT system can be measured for patient- specific QA in
procedure should only be carried out after careful advanced radiotherapy are,
using a phantom containing inserts or beads withhowever, time- consuming
2.G.4.5.3analysis
| Methodsdemonstrates that an equivalent
and equipment. The same result will
knowningeometrical
both manpower and accelerator
positions, the locations time and have been
of which
be produced.
process as used for MV imaging can be applied for kV shown
can be measured to be unable to detect
on the images acquired from asome unacceptable
imaging. 3. May indicates
It should a statement
be noted that therethat isarelikely (or probably)
additional plans.6-11calibrated
geometrically Recent studies spiralhave
CT demonstrated
scanner or from a sensitiv-
quantitative image evaluation methods for spatialgroup does not make any ity of only 5% to detect
the manufacturer’s specifications. IMRT plan Measurement IMRT
errors using
12,13
recommendations.
resolution, contrast, uniformity, and noise. 129,130
These pretreatment measurements.
should be made in both the X and Y directions. Moreover, Any as treat-
tests can be very sensitive to deterioration in image ment planning becomes more
image quality phantom with a combination of CT- efficient and the number
quality, most commonly caused by subpanel artifacts. community was
visible inserts or beads can be used for this task. For tech-
The use of local noise power spectrum and wavelet the type of software niquesthe
kV- CBCT, steadily
Catphan increases, measurement-
(The Phantom based verifi-
Laboratory,
analysis is described by Lee et al. to the
131 responses, a dose/MU
Salem, NY), shown in Fig. 12, is one exampleworkload.
cation may result in a continued increase in of a
|
TASK40 |
REPORT

proximate
F I G . 11 Leeds phantom image (left) and contrast sensitivity tablehave been
(right). [Colorinfigure
use can
for be
some time,
viewed guidance was lacking
at wileyonlinelibrary.com] (DLG) mea
in how to commission such technologies as well as their missioning
role as part of an IMRT QA program as was noted in the cation cal
as IMRT/V
3. May indicates a statement that is likely (or probably) plans.6-11 R
ment plann
surveyed in 2012
F I G . 1 2 Catphan phantom (a) photograph, (b) sagittal plane, and (c) CTP404 slice regarding
geometry the type
and sensitometry of [Color
module. software
figure can niques ste
be viewed at wileyonlinelibrary.com] being used. According to the responses, a dose/MU cation may
|
2
TASKe870
FOR IMRT
have been in use for some time, guidance was lacking
F I G . 1 3 Catphan high- resolution module with line pair frequency (left), line pair (DLG)
designmeasurements) were
diagram (middle), and kV-also
CBCTrequired during com-
image (right).
in how
[Color figure cantobecommission such technologies as well as their
viewed at wileyonlinelibrary.com] missioning. The most common IMRT dose/MU verifi-
4,5
F I G . 1IMRT”.
4 Catphan image uniformity gorithm.” Note that the clinical practice has changed,
module with This task
regions group used
of interest wasforcharged with: (a) Reviewing with more widespread use of VMAT as well as the in-
analysisandis shown [Color figure
evaluating can be
the algorithms for “independent/second troduction and adoption of new software tools (such
viewed at wileyonlinelibrary.com]
phantom appropriate for this test (different versions that is essential for the complexities
2.G.5.2.2 | Tolerance. in planning
Spatial and deliverycontrast,
resolution, and thus, the
supplied by Varian and Elekta). For MV- CBCT, the of uniform practices, or potential for serious errors in the
uniformity, and noise should be better than or equal planning and todelivery
CBCT image quality phantom (EMMA; supplied by effective result and/or main- of radiotherapy. An effective set
baseline measured during acceptance. HU constancy of QA procedures is
Siemens) is another example of a phantom that can of practice to ensure therefore
= ±40 HU. essential. The goal of a routine pretreatment
be used.the 132 accuracy of dose/MU determination. verification procedure is to identify and resolve any er-
2. Should indicates an advisory recommendation that rors before
2.G.5.2.3 | Methods patientandtreatment.
equipment. For These
IMRT, verification
tests
is to be applied when practicable.
2.G.5.2 | Spatial resolution, contrast, Hounsfield The task group
can be performed with any image qualityto phantom
measurements are commonly used verify correct
favors the
unit constancy, indicatedand
uniformity, procedure
noise but understands that delivery
that has of treatment
appropriate plans, forand
high-resolution example with ioniza-
low-contrast
2.G.5.2.1 | Objective. If an EPID or KV imager which can accomplish tion chambers, films, or multidimensional
test objects, in addition to a uniformity section and detector
HU ar-
the same goal. Deviations from
is not functioning properly or if an inappropriate filter the recommended rays. Experimental methods for patient-
material samples. It is important to use the same CBCT specific QA in
is applied to the acquired images, the images used carried out after careful advanced radiotherapy are, however,
technique for each monthly QA. For example, spatial time- consuming
clinically analysis
may appear demonstrates
blurred, thathave an poor
equivalent result will
contrast, in both
resolution manpower
for kV- CBCT and and accelerator
MV- CBCT cantime and have been
be measured
be produced.
have time- dependent Hounsfield units (HUs) for the shown
using Catphan to be unable to detect some
and EMMA, respectively. The Catphan unacceptable
6-11
same imaged object, appear nonuniform when the that is likely (or probably) plans. Recent studies have demonstrated
high resolution module is shown in Fig. 13. Appropriate a sensitiv-
to be correct but the task group
imaged object is uniform, or have high noise. All these does not make any ity of only 5% to detect
phantoms contain bar patterns that IMRT plan
can be visually IMRT
errors using
12,13
recommendations.
problems can make images difficult to interpret, result pretreatment measurements.
inspected or used for quantitative modulation Moreover, as treat-
transfer
in artifact, and/or obscure important details that are ment planning becomes more efficient
function analysis in the spatial resolution measurement, and the number
needed for patient setup. The objective of this test is to community was
high- and low-contrast inserts, and slices with uniform tech-
ensure imaging system performance has not degraded the type of softwaredensityniques steadily and
for uniformity increases, measurement-based
noise measurements, shown verifi-
being
with time. used. According to the responses, a dose/MU cation may result in a continued increase
in Fig. 14. The Catphan module for low contrast analysis in workload.
|
TASK42 |
REPORT

proximate
have been in use for some time, guidance was lacking (DLG) mea
role as part of an IMRT QA program as was noted in the cation cal
as IMRT/V
ment plann
surveyed incontrast
F I G . 1 5 (a) Catphan low- contrast module. (b) Transaxial image of Catphan low- 2012 model
regarding the regions
with analysis type for
of the
software
1% niques ste
being
supraslice targets. [Color figure can be viewed at wileyonlinelibrary.com] used. According to the responses, a dose/MU cation may
|
2
TASKe872
FOR IMRT
F I G . 1 6 (a) Catphan module with slice width, HU constancy, and pixel size measurement capability. Table of expected HU is shown. (b)
taining established standards of practice to ensure therefore
Transaxial image of Catphan low- contrast model with analysis regions for HU constancy essential.
(circles) The
and slice goal
width of a routine
(rectangle). pretreatment
[Color figure
the ataccuracy
can be viewed of dose/MU determination.
wileyonlinelibrary.com] verification procedure is to identify and resolve any er-
is shown in Fig. 15. The Catphan module with slice The task group
Elektameasurements
linacs with EPIDs are that
commonly
do not used
have to verify correct
adjustable
favors the indicated procedure but
width, HU constancy, and spatial linearity measurement understands that
SDDs. delivery of treatment plans, for example with ioniza-
there are other
capability is shown in Fig. 16. procedures which can accomplish tion chambers, films, or multidimensional detector ar-
the same goal. Deviations from the recommended rays. Experimental methods
2.G.6.1.2 | Tolerance. The tolerance is ±5 mm.for patient- specific QA in
2.G.6 analysis
| Annual— demonstrates
MV imaging that an(EPID)
equivalent result will in both
2.G.6.1.3 | manpower
Methods and andequipment.
accelerator time andpanel
The flat have been
detector is extended be unable to detect some
and made to travel along its full unacceptable
6-11
2.G.6.1 3. May indicates
| Full rangeaofstatement
travel SDDthat is likely (or probably)
range,plans.
and at Recent
the endstudies
of eachhave demonstrated
range, the distance a sensitiv-
to be correct but the task group
2.G.6.1.1 | Objective. The objective of this test is does not make any ity of only 5% to detect
between the face of the flat panel 12,13IMRT and a point on the IMRT
plan errors using
recommendations.
to ensure that the mechanical flat panel positioners gantry head, such as the accessory tray,Moreover,
pretreatment measurements. is measured. as treat-
can position the EPID at a source-to- detector distance ment planning becomes more
The measurements are compared with baseline and efficient and the number
that is within tolerance. This test is not applicable for community was of patients treated with advanced
must agree to within 5 mm for the test to pass. radiotherapy tech-
|
TASK44 |
REPORT
1 2.G.7.1.3
| STATE | M ENT O
Methods F equipment.
and TH E PROBeam
BLEquality
M verification
A ND TG CH A RG ES
for keV-range beams can be assessed using the jority of I
Raysafe Xi or X2 system. The Raysafe X2 device is proximate
An independent
straightforward check
to useof dose/monitor
and, when irradiated units has withbeen a keV- verification
and range
continue beam, provides beam quality in units of millimeters time. The
to be an important part of quality assur-
anceof (QA)
aluminum for patient
as welltreatment
as other relevant plans. AAPM Report
beam parameters, in the sur
TasksuchGroup 71
as kV, mA, reportsmAs, dose, dose rate, and pulse rate, most com
1
ing within
monitor units. AAPM
a matter of seconds. TaskThe Group user114 canreports
read the ondata ported in
off the device’s display or export for verification
time- dependent data CA). This
of data for
2
conformal
on a millisecond scale (for example)need
external beam plans. The for manyfor mon-of these of these p
itor parameters
unit verification programs was identified
for analysis and postprocessing if desired. early in criteria for
the An
adoption
example of IMRT
of a readout obtained with the system is IMRT (51%
3
techniques.
shown in Fig. 17. different types of programs were
Several though 30
F I G . 1 7 Display of RaySafe X2 device indicating measured kV gle point in a simple phantom geometry to calculation their calcu
parameters using the X2 R/F sensor. [Color figure can be viewed 2.G.7.2 | Imaging dose
at wileyonlinelibrary.com]
of 2.G.7.2.1 | Objective. The objective is to ensure (3D) volum
dose at a single point while taking patient anatomy
and that
geometry
patients into are
consideration.
receiving While these programs
the appropriate imaging measurem
havedoses
beenduringin use IGRT for some time,
procedures. guidance was lacking (DLG) mea
role 2.G.7.2.2
as part of an | Tolerance. The tolerance is ±20% of cation cal
IMRT QA program as was noted in the
ASTRO white paper
the baseline dose. entitled “Safety Considerations for in use at t
2.G.7.2.3 | Methods and equipment. Dose for keV- with more
and range
evaluating
beams thecan algorithms
be assessed using the Raysafe Xi or troduction
for “independent/second
X2 system or similar. Alternate methods for IMRT; (b) described as 3D volu
areMaking
recommendations
by Amer et al. on
133 the clinical implementation
and Osei et al. 134
Amer et al. of cal-used users shou
CT dose index (CTDI) phantoms and 10 cm CT pencil when inter
accuracy,
chambers evaluation
to measuremethods,CBCT and heterogeneities);
imaging dose on an (3) Elekta
accelerator. Osei et al. used a 0.6 cc Farmer benchmark QA of chamber
sec-
ondary MU calculation
in phantom and comparedprograms, proposing additional
measurements with a 10 cm 2 | RO
measurements,
CT chamber. if necessary; and (4) Describing clini- M U V ER
F I G . 1 8 Display of Raysafe X2 device indicating measured
CBCT parameters using the CT sensor. [Color figure can be
viewed at wileyonlinelibrary.com] The
2.G.8 terminology
| Annual— used CBCT in this report (kV and follows
MV) that 2.1 | R
2.G.6.2 | Imaging dose particular:
2.G.8.1 | Imaging dose The implem
2.G.6.2.1 | Objective. The objective is to ensure 2.G.8.1.1 | Objective. The objective is to ensure as IMRT/V
that patients are receiving the appropriate imaging 1. Shall indicates are
that patients a procedure
receiving the that appropriate
is essentialimaging for the comple
doses during IGRT procedures. either (a) establishment
doses during IGRT procedures. of uniform practices, or potential fo
2.G.6.2.2 | Tolerance. The tolerance is ±5% of the taining
2.G.8.1.2 | Tolerance. For the kV- CBCT imaging therefore e
baseline imaging dose per MU. the accuracy
dose, the toleranceof dose/MUdose isdetermination.
recommended to be ±20% verification
2. Should
of the baseline dose. For the recommendation
indicates an advisory MV- CBCT imaging thatdose, rors befor
2.G.6.2.3 | Methods and equipment. Megavoltage is to be applied when practicable.
the tolerance dose is recommended to be ±5% of the measurem The task group
imaging dose can be measured in the same manner as favors
baseline the imaging
indicateddose procedureper MU. butThe understands
tolerancethat for the delivery o
radiation dose for the treatment beams. there are other procedures which
MV- CBCT imaging dose is a lower percentage than tion cham can accomplish
the
for same
kV- CBCT goal.sinceDeviations
the MV- from
CBCT theimaging
recommended dose is far rays. Expe
procedure should only be carried
greater (about a factor of 10) than the kV- CBCT out after careful
imaging advanced
2.G.7 | Annual—kV imaging analysis demonstrates that an equivalent
dose for a given site and is easily adjustable using result will the in both ma
be produced.
same parameters as the treatment beam. shown to
2.G.7.1 | Beam quality or energy 3. May indicates a statement that is likely (or probably) plans.6-11 R
2.G.7.1.1 | Objective. Ensuring beam quality to2.G.8.1.3
be correct| but the task and
Methods group equipment.
does not make TGany 75135 ity of only
prevents beam hardening or softening from affecting recommendations.
“The Management of Imaging Dose During Image- pretreatme
image quality. Guided Radiotherapy” provides an overview of IGRT ment plann
As part of thisthe
techniques, work, the AAPM
associated community
radiation doses, was and of patients
2.G.7.1.2 | Tolerance. The tolerance is ±5% surveyed
techniques to measure them. For MV- CBCT, the niques ste
baseline energy. being used. dose
imaging According per MU to the canresponses,
be measured a dose/MU
for a fixed cation may
|
2
TASKe874
FOR IMRT
1I
TA B L E STATE M ENTrequirements
|Time/Staffing/Equipment O F TH E PRO
for daily QA.BLE M verification program was generally used for the ma-
A N D TG CH A RG ES Tolerance Non- IMRT/ jority of IMRT/VMAT treatment plans although ap-
Typical measuring Time required
Procedure IMRT/SRS proximately 31% of responders
device (range) did not use dose/MU
Personnel
Dosimetry
Photonance
and Electron
(QA) for Output Constancy
patient treatment±3% plans. AAPM Report Ionization
in the chamber,
survey was RadCalc 10-20 min(Lifeline,RTT
Tyler, TX). The
Diode/MOSFET
system
Mechanical
Laser conformal
Location 2
external beam plans.±2mm/±1.5mm/±1mm
The need for mon- Front
of pointer,
these reference
products. The 2 minmost common RTT passing rate
marks
Distance
theIndicator
adoption of IMRT treatment±2mm planning and delivery Front
IMRTpointer, jig and “None
(51%) 2 min
Specified” forRTT
VMAT (34%), al-
3
techniques.
Collimator Size Indicator Several different types of programs were
±2mm/±2mm/±1mm though
Graph paper,30%
ruler,ofjigVMAT3responders
min used 5% as passing
RTT
Safetydeveloped ranging from confirmation of dose at a sin- rate. More than 50% of users used a single point for
gle point
Door Interlock in a simple phantom geometry
Functional to calculation NAtheir calculations and1only min 6% used three-
RTT dimensional
of dose at
Door Closing Safety
a single point while taking patient anatomy
Functional NA
(3D) volumetric dose in
1 min
the 2012 survey.
RTT
Additional
Audiovisual Monitors Functional NA 1 min RTT
Stereotactic interlocks
in how to commission such technologies NA/NA/ Functional
as well as their NAmissioning. The most1 common min IMRTRTTdose/MU verifi-
roleArea
Radiation as part of an IMRT QA program
Monitors as was noted in the
Functional NAcation calculation algorithm 1 min represented
RTT by software
Beam-ASTRO white paper entitled “Safety
on Indicator Considerations for
Functional NAin use at the time was a “factor- based
1 min RTTcalculation al-
4,5
IMRT”.
NA = not applicable. gorithm.” Note that the clinical practice has changed,
TA B L E I I Profile constancy
as 3D volumetric calculation systems) since 2012, so
recommendations
calculation example. on the clinical implementation
Profile constancyof cal- users should consider the age and context of the data
culation programs (e.g., number measurements of points, locations, when C interpreting
T the G
survey. L R
accuracy, evaluation methods, andBaseline heterogeneities);
measurement(3) values 100.5 102.1 102.7 102.5 102.6
Monthly measurement values 100.2 101.2 102.5 102.5 102.1
ondary MU calculation programs, proposing additional
Profile Constancy Analysis
2 |
T/C
RO LE
G/C
O F DOSE
L/C
/R/C
Baseline
cal testing and periodic QA of secondary MU calcula- CO M PR EH ENSI V E Q A1.021
1.016 1.022 1.020
PROG R A M
tion programs and recommendations Monthlyon test tolerance. 1.010 1.023 1.023 1.019
The terminology used in thisTask report
- Basefollows
(Tolerance ±1%) 2.1−0.6%
that | Review 0.1% of 0.3% the problem −0.2%
used in other AAPM Task GroupPass/Fail reports including in Pass Pass Pass Pass
particular: The implementation of new
C= central axis, T = target point, G = gun point, L = left point, R = right point. treatment techniques such
beam delivered in cone beam imaging mode using an of uniform practices, or Thepotential
times forforeach serious
taskerrors in the planning
are estimated based on andthe
delivery
ionization chamber during the same process used for result and/or main- of radiotherapy. An effective
assumption that each task is carried out independently.set of QA procedures is
measuring photon beam outputs. For kV- CBCT, the of practice to ensure therefore essential. The goal
As tools are commercially available to address multi- of a routine pretreatment
Raysafe the Xi oraccuracy
X2 system of dose/MU
can be useddetermination.
to measure ple tasksverification procedure
with a single image is toacquisition,
identify andthe resolve
overallany er-
the imaging dose using human- representative head recommendation that rors before patient treatment.
time required to accomplish several tasks in the same For IMRT, verification
and body phantoms. A CTDI chamber is inserted into The task group category, such as planar kV imaging, can substantiallycorrect
each phantom for the measurements and scanned but understands that
speeddelivery
up the QA of process.
treatment plans, for example with ioniza-
there
using kV- CBCT. are 127other procedures which can accomplish
The dose can be reported as tion chambers, films, or multidimensional detector ar-
the integrated dose- length value and established from the recommended rays. Experimental methods for patient-specific QA in
as baseline at acceptance or commissioning of the carried out after careful3 | SUM M A RY O F are, however, time-consuming
advanced radiotherapy
analysis demonstrates that
linac. An example of a readout obtained with the an equivalent result will
R ECO in both
M Mmanpower
ENDATIand O NS accelerator
O R time and have been
be produced.
system is shown in Fig. 18. It is recommended that shown
I M PLE M 6- to
ENTATI be unable
O N SCH E M Esome unacceptable
to detect
11
users measure the dose for at least the minimum that is likely (or probably) plans. Recent studies have demonstrated a sensitiv-
and maximum dose CBCT protocols for a centrally group does not make any ity of only 5%
QA of linacs is just a subset to detect of IMRT plan
the12,13 errors using
departmental QA IMRT
recommendations.
located ion chamber annually to determine if the pretreatment measurements.
program. We reiterate the recommendation of TG 142 Moreover, as treat-
range of CBCT doses has remained constant. Once ment planning becomes more
that every department should have a QA committee efficient and the number
the baseline dose has been measured, an additional AAPM community wasthat oversees and monitors all the departmental QA. tech-
method for kV- CBCT dose constancy would be to use the type of software With the niques steadilycomplexity
increasing increases,of measurement- based verifi-
treatments delivered
an ionization chamber in air. to the
136,137 responses, a dose/MU cation may result in a continued
in a radiation oncology department, it has become increase in workload.
|
TASK46 |
REPORT
TA B L E I I I 1
Time/Staffing/Equipment requirements for Monthly QA. | STATE M ENT O F TH E PRO BLE M verification
Tolerance Non- IMRT/ A ND TG CH A RG ES jority of I
Procedure IMRT/SRS Typical measuring device Time required(range) Personnel proximate
Dosimetry
Photon and Electron ±2% ADCL Calibrated Ionization 45– 60 min QMP or
Output Constancy per Chamber/Electrometer Designee
beam Task
or Chamber/ Group 71 reports on the formalism for calculat- most com
1
ing monitor
Electrometer cross- units. AAPM Task Group 114 reports on ported in
methods
calibrated with ADCLand requirements for verification of data for CA). This
conformal external beam plans.2 The need for mon-
Chamber/Electrometer, of these p
solid phantom or water
phantom
Backup Monitor Chamber ±2% ADCL Calibrated Ionization Included above QMP or
Constancy Chamber/Electrometer Designee
developed
or Chamber/ ranging from confirmation of dose at a sin- rate. More
gle point
Electrometer cross- in a simple phantom geometry to calculation their calcu
of dose
calibrated at a single point while taking patient anatomy
with ADCL (3D) volum
Chamber/Electrometer,
phantom
Typical Dose Rate Output NA/±2%/±2% ADCL Calibrated Ionization 10–15 min
role as part of an IMRT QA program as was QMP notedorin the cation cal
Constancy Chamber/Electrometer Designee
ASTRO white paper entitled “Safety Considerations for
or Chamber/ in use at t
4,5
IMRT”.cross-
Electrometer gorithm.” N
calibratedThis task group was charged with: (a) Reviewing
with ADCL with more
phantom
Photon and Electron Beam ±1% Array, film, portal imager 10– 60 min QMP or
Profile Constancy
culation programs (e.g., number of points, locations, Designee
when inter
Electron Beam Energy ±2%/± 2 mm ADCL Calibrated Ionization 20– 30 min QMP or
Constancy
Describing commissioning and benchmark QA
of sec-
Designee
ondary MU
solid phantom, or watercalculation programs, proposing additional 2 | RO
phantommeasurements, if necessary; and (4) Describing clini- M U V ER
Mechanical cal testing and periodic QA of secondary MU calcula- CO M PR
Light/Radiation Field ±2.0 mm per Jaw
tion programs and30recommendations
Film or EPID
on testQMP
min (Film)15 min (EPID)
tolerance.
or
Coincidence The terminology used in this report follows that
Designee 2.1 | R
(Symmetric & used in other AAPM Task Group reports including in
Asymmetric) particular: The implem
Lasers ±2mm/ ±1 mm/ ≤ 1 mm Front pointer/Winston- Lutz 5 min QMP or as IMRT/V
deviation 1. Shall indicates a procedure
test equipment that is essential for
Designee the comple
Gantry/Collimator Angle ±1° Level either (a) establishment
5 min of uniform practices,
QMP or or potential fo
Indicators (@ cardinal (b) the most safe and effective result and/or main-
Designee of radiothe
angles, digital only) taining established standards of practice to ensure therefore e
Accessory Trays (i.e., port ±2 mm NA the accuracy of 1 min
dose/MU determination. QMP or verification
film graticule tray) Designee
Jaw Position Indicators ±2 mm per Jaw Graph paper,istemplate
to be applied15 min
when practicable. The QMP taskorgroup measurem
(Symmetric) Designee
Jaw Position Indicators ±2.0mm or ±1 mm per Graph paper,there
template
are other15procedures
min (can be done
which can QMP or
accomplish tion cham
(Asymmetric) jaw when used for simultaneously with Designee
field matching at the Symmetric)
central axis procedure should only be carried out after careful advanced
Cross- Hair Centering ≤1 mm Graph paper, template 15 min QMP or
(Walkout) be produced. Designee shown to
Treatment Couch Position ±2 mm, ±1°/ ±2 mm, Graph paper, ruler 15 min QMP or
Indicators ±1°/± 1 mm, ±0.5° to be correct but the task group does not make any
Designee ity of only
Wedge Placement visual inspection: Graph paper, ruler Ion 15 min QMP or
Accuracy ±2mm Dosimetric chamber, or device array Designee ment plann
Comparison: ±2% As part of this work, the AAPM community was of patients
being used. According to the responses, a dose/MU (Continues) cation may
|
2
TASKe876
FOR IMRT
1 I I I | (Continued)
TA B L E STATE M ENTO F TH E PRO BLE M verification program was generally used for the ma-
A N D TG CH A RG ES
Tolerance Non- IMRT/ jority of IMRT/VMAT treatment plans although ap-
Procedure IMRT/SRS proximately
Typical measuring device 31% of responders did
Time required(range) not use dose/MU
Personnel
Compensator Placement ±1mm Graph paper, ruler 15 min QMP or
and continue to be an important part of quality assur-
Accuracy time. The most common commercial system reported
Designee
ance (QA)
Latching of Wedges,
for patient treatment
Functional
plans. AAPM
NA
Report in the survey
5 min
was RadCalc (Lifeline,
QMP or
Tyler, TX). The
Task Group
Blocking Tray 71 reports on the formalism for calculat- most common treatment planning Designee (TPS) re-
system
1
Safety
Laser guard-interlock test Functional NA 1 min QMP or
conformal external beam plans.2 The need for mon- of these products. The most common Designee
passing rate
Respiratory Gating
Beam techniques.
output constancy3
Several± 2%different types of programs ADCL Calibrated
were Ionization
though 15 30% minof(using
VMAT same setup as QMP
responders used or 5% as passing
Chamber/Electrometer output constancy) Designee
developed ranging from confirmation of dose at a sin-
or Chamber/
rate. More than 50% of users used a single point for
gle point in a simple phantom geometry to Electrometer calculation cross-their calculations and only 6% used three- dimensional
of dose at a single point while taking patient anatomy
calibrated (3D) volumetric dose in the 2012 survey. Additional
with ADCL
and geometry into consideration. While theseChamber/Electrometer, programs measurements (typically the MLC dosimetric leaf gap
have been in use for some time, guidance was solidlacking
phantom or water
(DLG) measurements) were also required during com-
phantom
Phase,roledisplacement
as part of an IMRT Functional
QA program as was NAnoted in the 1 min
cation calculation algorithm represented QMP or by software
magnitude beam control Designee
In- room respiratory Functional NA 1 min QMP or
monitoring system Designee
Gating interlock Functional NA 1-2 min
and evaluating the algorithms for “independent/second troduction and adoption of new QMP or
software tools (such
Designee
VMAT
Patient- specific VMAT
culation QA
programs Institutional
(e.g., numberVMATof QApoints, VMAT QA phantom when interpreting
locations, 20– 30 min the survey. QMP or
passing criteria Designee
based on TG-218
guidelines
NA = not applicable.
more and more important to have detailed policies and on test tolerance.supervision of a QMP, an individual designated by the
procedures. The These
terminology
policiesused in this report
and procedures should followsbe thatQMP 2.1 | Review
and working underof thethe problem
supervision of the QMP,
used in other AAPM Task Group
readily available to all members of the departmental QA reports including in
and a QMP. The QMP should provide adequate train-
team. particular:
The policy should establish the roles and respon- ing of The implementation
the other team members, of new sotreatment techniques
that they clearly un- such
sibilities of involved QA personnel, and this TG makes as IMRT/VMAT in a radiotherapy
derstand and follow policies and procedures. All team department increases
1. Shall indicates
recommendations on the aappropriate
procedurepersonnel
that is essential
to perfor
membersthe complexities
are required to in be
planning
trainedand delivery
on the operationand thus,
of the
form the specific QA tasks. These recommendations of uniform practices, or potential for serious errors in
the appropriate QA equipment to perform the specificthe planning and delivery
are documented in Tables 1, III-VII I–VII In general, the result and/or main- of radiotherapy. An effective set
QA tasks. They should be trained to interpret the mea- of QA procedures is
daily QA tasks may be carried out by a radiation thera- of practice to ensure therefore essential. The goal
sured data and what to do when tolerance levels are of a routine pretreatment
pist. Thethe accuracy
monthly QA tasksof dose/MU
should bedetermination.
performed by an verification
exceeded. procedure is that
It is recommended to identify
the QMP andshould
resolvebeany er-
individual designated by the QMP and working under recommendation that
notified as soon as possible in the case tolerancesverification
rors before patient treatment. For IMRT, are
the supervision of the QMP. The annual measurements The task group measurements
exceeded. The QMP should are commonly
documentused to verify correct
the competency
should be favors the indicated
performed by a QMP procedure but understands
with proper involve- that of the delivery
QA teamofmembers treatment to plans,
performfortheexample
specific with tests.ioniza-
there are
ment of the entire QA team. other procedures which can accomplish tion chambers, films, or multidimensional
These competencies should be reviewed on an annual detector ar-
The TG would also like to provide some guidance on from the recommended basis. rays. Experimental methods for patient- specific QA in
procedure should only be carried
the interpretation of frequency and timing of the QA pro- out after careful advanced radiotherapy are,
The foundations of the TG 142 QA tests are the however, time- consuming
gram. We analysis
recommend demonstrates that an
that the daily QAequivalent
is performed result will in both
institution- manpower
specific baseline andandaccelerator
absolute time referenceand have
val- been
be produced.
before any patient treatment that day. For monthly QA, shown
ues for all QA to be unable to detect
measurements. Whenever a new piece of some unacceptable
3. May indicates
we recommend a statement
following calendarthat is likelyplus
months (or probably)
or plans.is6-11
equipment Recent studies
accepted have demonstrated
and commissioned a sensitiv-
into clinical
minus 1 wk. Similarly, for annual QA, we recommend group does not make any ity of only 5% to detect
use, it is especially important to take IMRT plan
great care in es- IMRT
errors using
12,13
recommendations.
that the maximum time spent between annuals is not tablishing these baseline values. These Moreover,
pretreatment measurements. values should as treat-
more than 13 months. ment planning becomes more
meet or preferably exceed the manufacturer’s toler- efficient and the number
A QMP should lead or play a central role in the AAPM community was
ance. Although TG 142 did not make specific recom- tech-
QA team. For the QA of linacs, the personnel fall into the type of software niques regarding
mendations steadily increases,
independent measurement-
acceptancebased tests verifi-
three categories: Registered RTT working under the responses, a dose/MU cation may result in a continued
for a new machine until TG 210 (acceptance testing of increase in workload.
|
TASK48 |
REPORT
TA B L E I V 1 QA.|
Time, staffing, and equipment requirements for annual STATE M ENT O F TH E PRO BLE M verification
A ND TG CH A RG ES Time jority of I
Typical measuring required proximate
Procedure An independentdevice
Tolerance Non- IMRT/IMRT/SRS check of dose/monitor
(range)units hasPersonnel
been verification
Dosimetry and continue to be an important part of quality assur- time. The
Photon Flatness Change from Baseline ±1% Large water tank 60–120 min QMP
Photon Symmetry Change from Baseline ±1% Large
1 water tank 60–120 min QMP
ing monitor units. AAPM Task Group 114 reports on ported in
Electron Flatness Change from Baseline ±1% Large water tankfor verification
methods and requirements 60–120 min of data
QMPfor CA). This
Electron Symmetry Change from Baseline ±1% conformal external Largebeam plans.2 60–
water tank The 120need
min forQMPmon- of these p
Photon/Electron Output Calibration38 ± 1% (Absolute) itor unit verification programs
Small/large water was identified
120–180 min early
QMP in criteria for
the adoption of IMRT treatment planning and delivery
tank. ADCL IMRT (51%
techniques.3 Several Calibrated
different types of programs were though 30
Ionization
developed rangingChamber/ from confirmation of dose at a sin- rate. More
gle point in a simple phantom geometry to calculation
Electrometer their calcu
Spot Check of Field Size- Dependent
of dose
±2% for field sizes < 4 × 4 cm2;
at a single point
Ionization
while taking patient anatomy
30– 60 min QMP
(3D) volum
Output Factors for Photon (2 or more and geometry
±1% for field sizes ≥ 4 × 4 cm 2 into consideration.
Chamber/ While these programs measurem
field sizes) have been in use for some time, guidance was lacking
Electrometer, (DLG) mea
in how to commission solidsuch technologies as well as their
phantom missioning
role as part of an IMRT or water
QA program as was noted in the cation cal
phantom
Output Factors for Electron Applicators ± 2% from baseline IMRT”.4,5 Ionization 60– 90 min QMP gorithm.” N
(spot check of one applicator/energy) Chamber/
Electrometer,
with more
and evaluating thesolid algorithms
phantom for “independent/second troduction
or water as 3D volu
recommendationsphantom on the clinical implementation of cal- users shou
Photon Beam Quality (PDD10 or TMR 20:10) ± 1% from baseline culation programs Large(e.g., number 30–
water tank of points,
60 min locations,
QMP when inter
Electron Beam Quality (R50) ± 1 mm accuracy, evaluation methods,
Large water tank and heterogeneities);
60– 90 min QMP(3)
Physical Wedge Transmission Factor ± 2% Describing commissioning
Ionization and benchmark
30– 60 min QA of
QMP sec-
constancy ondary MU calculation programs,
Chamber/ proposing additional 2 | RO
measurements, if Electrometer,
necessary; and (4) Describing clini- M U V ER
cal testing and periodicsolid phantom
QA of secondary MU calcula- CO M PR
tion programs andorrecommendations
water
on test tolerance.
phantom
Photon Monitor Unit Linearity (Output ± 2% ≥ 5 MU ± 5% (2– 4) MU, ± 2%
used in other AAPM Task Group 30–
Ionization 60 min
reports QMP
including in
Constancy) ≥ 5 MU ± 5% (2– 4) MU, ± 2% Chamber/
≥ 5 MU particular: Electrometer, The implem
solid phantom as IMRT/V
1. Shall indicates orawater procedure that is essential for the comple
phantom
Electron Monitor Unit Linearity (Output ± 2% ≥ 5 MU (b) the most Ionization
safe and effective30– result and/orQMP
60 min main- of radiothe
Constancy) taining established Chamber/
standards of practice to ensure therefore e
the accuracy ofElectrometer,
dose/MU determination. verification
solid phantom
2. Should indicates an
or wateradvisory recommendation that rors befor
is to be appliedphantom when practicable. The task group measurem
Photon Output Constancy vs Dose Rate favors
± 2% from clinical dose rate the indicated
Ionization procedure but understands
30– 60 min QMP that delivery o
there are otherChamber/procedures which can accomplish tion cham
the same goal.Electrometer,
Deviations from the recommended rays. Expe
procedure should solidonly
phantom
be carried out after careful advanced
or water
phantom
Photon Output Constancy vs Gantry Angle ± 1% of the value acquired at
3. May indicatesIonization
a statement that is 30– 90 min QMP
likely (or probably) plans.6-11 R
gantry 0 Chamber/
Electrometer. ity of only
recommendations. 2D/3- D Diode pretreatme
array ment plann
|
2
TASKe878
FOR IMRT
1 I V | (Continued)
TA B L E STATE M ENT
O F TH E PRO BLE M verification program was generally used for the ma-
A N D TG CH A RG ES jority of IMRT/VMAT treatment Time plans although ap-
proximately 31%
Typical measuring of responders
required did not use dose/MU
Procedure Tolerance units
Non-has been
IMRT/IMRT/SRS verification
device software for (range) VMAT treatment plans at that
Personnel
and continue to be an
Electron Output Constancy vs Gantry important part of quality assur-
± 1% of the value acquired at time. The most
Ionization common commercial
60–120 min system
QMP reported
ance
Angle (QA) for patient treatment plans. AAPM
gantry 0 Report in the survey
Chamber/ was RadCalc (Lifeline, Tyler, TX). The
Task Group 71 reports on the formalism for calculat- most common
Electrometer.treatment planning system (TPS) re-
ing monitor units.1 AAPM Task Group 114 reports on ported in 2D/3-
theD Diode
survey was Eclipse (Varian, Palo Alto,
array
Electron and Photon
conformal external beam plans.±2 1%
Off- Axis Factor Theof the valuefor
need acquired
mon-at of these Ionization
products. The60– 120 min
most common QMPpassing rate
Constancy vs Gantry Angle gantry 0 Chamber/
itor unit verification programs was identified early in criteria for dose/MU
Electrometer.
verification software was 5% for
the adoption of IMRT treatment planning and delivery IMRT (51%) and
2D/3- D Diode “None Specified” for VMAT (34%), al-
techniques.3 Several different types of programs were though 30%array of VMAT responders used 5% as passing
developed ranging
Arc Mode (expected MU, degrees) from confirmation of dose at a sin-
± 1% from baseline SRS Mode (±1 rate. More
NA than 50% of users
15 min used a single
QMP point for
gle point in a simple phantom geometry to calculation
MU or ±2%) and (±1° or ±2%) their calculations and only 6% used three- dimensional
of dose
TBI/TSET Modeat a single point while taking patient anatomy
Functional (3D) NAvolumetric dose in5 min the 2012 survey.QMP Additional
and geometry into
PDD or TMR and OAF Constancy
consideration. While these programs
TBI TMR/PDD ±5% from baseline
measurements
Ionization
(typically the MLC
90120 min
dosimetric
QMP
leaf gap
have been in use for
measured at extended treatment some time, guidance was lacking
TSET ±3 mm PDD shift, OAF (DLG) measurements)
Chamber/ were also required during com-
distance as well
Constancy ±5%as their
from missioning.
baseline The most common IMRT dose/MU verifi-
Electrometer,
role as part of an IMRT QA program as was noted in the cation calculation
TBI/TSET algorithm represented by software
ASTRO white paper entitled “Safety Considerations for in use atphantom.
the time was a “factor- based calculation al-
4,5 Calibration
IMRT”.
TBI/TSET Output ± 3% from baseline at extended gorithm.” Note that the clinical
Ionization 90–120 min practice
QMPhas changed,
This task group was charged with: distance
(a) Reviewing with more Chamber/
widespread use of VMAT as well as the in-
Electrometer,
TBI/TSET
check” of monitor unit calculations for IMRT; (b) Making as 3D volumetric
phantom. calculation systems) since 2012, so
recommendations
TBI/TSET Accessories
on the clinical implementation
± 2% from baseline
of cal- users should
Various.
consider the age and context
90–120 min QMP
of the data
Mechanical
Collimator Rotation Isocenter ± 1 mm from baseline Front pointer set. 10–15 min QMP
Gantryondary
RotationMUIsocenter
calculation programs,± 1proposing
mm from baseline
additional 2 | Front RO LE set.
pointer O F DOSE /
15– 30 min QMP
Couchmeasurements,
Rotation Isocenter if necessary; and ± 1(4)
mmDescribing
from baselineclini- M U Front
V ER I FI CATI
pointer set. O10–NS I N A QMP
15 min
calApplicator
Electron testing and periodic QA of secondary
Interlocks Functional MU calcula- CO M NAPR EH ENSI V10– E 15QminA PROG QMP R A M
Coincidence of Radiation and Mechanical on test
±2/ ±2/ ±1 mm tolerance. Front pointer 30– 60 min QMP
The terminology used in this report follows that
Isocenter 2.1 | set. Review
Film/ of the problem
used in other AAPM Task Group reports including in GafChromic
particular: film/EPID.
The implementation of new treatment techniques such
Couch Top Sag ± 2 mm from baseline as IMRT/VMAT
Front pointer inset.a radiotherapy
10–15 min department
QMP increases
1. Shall indicates a procedure that is essential for Lasers andin planning and delivery and thus, the
the complexities
ruler.
Couch Angle
(b) the most safe and effective ±1°/result
±1°/ ±0.5°
and/or main- Graph paper. An effective
of radiotherapy. 10–15 min
set of QA QMPprocedures is
taining
Couch Travel established
Maximum standards ±of2 mm
Range Movement practice to ensure therefore
Graphessential.
paper. Ruler. The 10–goal of a routine
15 min QMPpretreatment
in All Directions
2. Should
Stereotactic indicates
Accessories, an advisory
Lockouts, etc. recommendation
NA/ NA/ Functional that rors before
NA patient treatment.
10–15 minFor IMRT,QMP verification
Safety is to be applied when practicable. The task group measurements are commonly used to verify correct
Follow Manufacturer's procedureFunctional
Test Procedures but understands that delivery
NA of treatment plans, 30– 45 for
min example
QMP with ioniza-
there
Respiratory Gatingare other procedures which can accomplish tion chambers, films, or multidimensional detector ar-
Beam Energy Constancy ± 2% of nongated beam Ionization 15– 30 min QMP
Chamber/
analysis demonstrates that an equivalent result will in both manpower
Electrometer,and accelerator time and have been
be produced. shown to solidbe unable to detect some unacceptable
phantom
3. May indicates a statement that is likely (or probably) plans.6-11orRecent
water studies have demonstrated a sensitiv-
phantom
Temporalrecommendations.
accuracy of phase/displacement ±100 ms of expected Motion phantom. 60–12012,13
min Moreover,
QMP
pretreatment measurements. as treat-
magnitude gate on Film.
GafChromic
film. EPID
(Continues)
|
TASK50 |
REPORT
TA B L E I V (Continued) 1 | STATE M ENT O F TH E PRO BLE M verification

A ND TG CH A RG ES Time jority of I
Typical measuring required proximate
Procedure An independentdevice
Tolerance Non- IMRT/IMRT/SRS check of dose/monitor
(range)units has been
Personnel verification
Calibration of surrogate for phase/ ±100 ms of expected and continue to be an important
Motion phantom. part of
60-120 minquality assur-
QMP time. The
displacement magnitude ance (QA) for patient treatment plans. AAPM Report in the sur
Interlock testing Functional Task Group 71NA reports on the formalism 5–10 min for calculat-
QMP most com
1
VMAT
ing monitor units. AAPM Task Group 114 reports on ported in
Test patient-specific VMAT QA constancy Plan passes QA at a pass rate ≥ VMAT QA phantom 20– 30 min QMP
baseline pass rate minus 2%
of these p
AND Plan passesitor unit verification programs was identified early in
institutional criteria for
VMAT QA criteriathe adoption of IMRT treatment planning and delivery IMRT (51%
3
Interruption test ± 1% deviation from techniques.
uninterrupted Several VMAT QA different
phantomtypes 10–of
15 programs
min QMP were though 30
passing rate developed ranging from confirmation of dose at a sin- rate. More
NA = not applicable gle point in a simple phantom geometry to calculation their calcu
TA B L E V Time/Staffing/Equipment requirements for Dynamic/Virtual/Universal
in how to commission QA. such technologies as well as their missioning
role as part of an Typical QA program
IMRT Timeas was noted in the cation cal
ASTRO white paper measuringentitled “Safety Considerations for
required in use at t
Procedure IMRT”.4,5
Tolerance Non- IMRT/IMRT/SRS device (range) Personnel gorithm.” N
Daily This task group was charged with: (a) Reviewing with more
Morning check- out run for one angle Functional NA 1–2 min RTT
Monthly
Wedge factor for all energies ±2% culation programs Ionization
(e.g., number 15–of20 min
points,QMP or
locations, when inter
chamber, Designee
Array, film,
Describing commissioning portal imager and benchmark QA of sec-
Annual
Check of wedge angle for 60°, full field Check of off- center ratios @ 80% field Array, film, portal 20– 30 min QMP
and spot check for intermediate
cal testing
width @ 10 cm depth to be within
and periodic
imager
QA of secondary MU calcula- CO M PR
angle, field size ±2% tion programs and recommendations on test tolerance.
NA = not applicable
linacs) provides recommendations, we reiterate the use administrators on the additional demands and time as IMRT/V
of annual QA tests as a general guide when reviewing 1. that itindicates
Shall takes fora medical
procedure that is to
physicists essential
performforsuch the comple
vendor-specific acceptance tests and tolerance values. either (a) establishment of uniform
tasks. The ranges of time to perform all the tasks practices, orrec- potential fo
The QA team needs to monitor the measurement re- (b)
ommended by TG 142 are given in Tables I, IIIthrough of radiothe
sults against the established values on a daily, monthly, taining
VII. The established
total timestandards
required for of practice
the annual to ensure
QA is es- therefore e
and annual basis to ensure the machine performance the
timated to be in the range of 40– 60 person- hours. verification
and to prevent any clinically significant dose deviations 2. Should
Each tableindicates
has aan advisorywith
summary recommendation
recommendations that for rors befor
from the treatment planning calculations. During the is to be applied when practicable. The task
time saving. For example, for the daily and monthly measurem group
annual QA review, absolute machine output should be favors
imaging theQA, indicated procedure
test patients withbut understands
predefined fields that
could delivery o
calibrated as per the TG 51 calibration protocol using 38 there are other procedures which can accomplish
be setup in the departmental R&V system. It is worth tion cham
an ionization chamber with a NIST traceable calibration the same
noting that goal. Deviations
the times from the
also include recommended
analysis of the data, rays. Expe
factor. Once the machine output has been calibrated, procedure should only be carried
comparison with the baseline data, and report out after carefulgen- advanced
all secondary QA dosimeters, including the daily QA analysis demonstrates that an
eration. There are many commercial hardware equivalent result willand in both ma
and the monthly QA devices, should be cross- checked be produced.
software products that can produce significant time shown6-11to
against such calibrations. If necessary, this reestab- 3. May indicates
savings. Therea statement
will be a that is likely
tradeoff (or probably)
between the costs plans. R
lishes baselines for the daily and monthly QA to ac- to be correct but the task group does
of the equipment and the cost of the labor to perform not make any ity of only
count for any drift with these secondary measurement recommendations. the tests. In addition, there will be methods to improve pretreatme
devices. the testing efficiency and accuracy for modern linacs. ment plann
This report addresses the extra time that is nec- AsOne part of this work,
approach the AAPM community
is to automatically run test fields wasthat of patients
essary to perform the increased number of tests. We surveyed
are programmed or loaded in the machine with au- niques ste
expect that this will provide guidelines to oncology being used. change
tomatic According to the parameters
of setup responses, afordose/MU each field. cation may
|
2
TASKe880
FOR IMRT
RTT deliver, QMP or Designee review

QMP or Designee
QMP or Designee
QMP or Designee
QMP or Designee
Personnel
of these products. The most common passing rate

QMP
QMP
QMP
QMP
QMP
with the light-field
EPID: 15–20 min

EPID: 15–20 min
EPID: 15–25 min
EPID: 10–15 min

(for one energy)
for one energy.
Obj. 1: 20– 30 min

EPID method:
EPID. 15 min
Film: 25– 40 min
Film: 30– 35 min

Film: 30– 35 min
Log file method:
Film: 25–25 min

Film: 12–15 min
30– 40 min with

EPID: 5 min
Time required
Light Field:
10 min per
10–15 min
10–12 min
15-20 min
additional
approach
energies
10–20 min
12–15 min
(range)
Log file analysis software or
EPID and corresponding
Typical measuring device
Films or EPID and software

used as a surrogate for
Film or EPID and software
Film or EPID and software

the radiation isocenter.
Graph paper, template

opaque markers if the
Array, film, portal imager
light field crosshair is
Delivery log file analysis

EPID or graph paper for
Film or EPID and radio-
Ionization chamber and
the light field- based

Graph paper, template.
analysis application
scattering material.
analysis software
water equivalent
software tool
approach
CO M PR EH ENSI V E Q A PROG R A M
RMS of leaf positioning error < 0.35 cm

Tolerance Non- IMRT/IMRT/SRS
leaf speed within ±0.5 cm/s

±2mm per MLC bank
±0.5% from baseline
Time/Staffing/Equipment requirements for MLC QA.
either (a) establishment of uniform practices, or potential for serious errors in the planning and delivery for all leaves
≤1.0 mm radius
±2mm
±2mm
±2mm
±1mm
±1mm
Coincidence of light field and Photon field
Backup diaphragm settings (Elekta only)
MLC transmission (average of leaf and
interleaf transmission), all energies
Leaf position accuracy (non- IMRT)
Qualitative test - “picket fence”
Leaf position accuracy (IMRT)
Leaf position repeatability
Leaf Travel speed (IMRT)

Moving window IMRT
NA = not applicable.
(all energies)
MLC spoke shot

Procedure
TA B L E V I
Monthly
Weekly
Annual
|
TASK52 |
REPORT
TA B L E V I I 1 | STATE M ENT O F TH E PRO BLE M

Time/Staffing/Equipment requirements for Imaging QA. verification
Tolerance Non- SRS/SBRT SRS/ A ND TG
Typical CH A RG ES
measuring Time required jority of I
Procedure SBRT device (range) Personnel proximate
Daily
Planar kV and MV (EPID) imaging
Collision interlocks Functional Task NAGroup 71 reports on 5 min
the formalism for RTTcalculat- most com
Positioning/repositioning ≤2 mm / ≤2 mm/≤1 mm day of SRS ing Phantom units.1 AAPM10–
monitorcontaining Task
15 minGroup 114 RTTreports on ported in
methods radiopaque
and requirements for verification of data for CA). This
markers.
Imaging and treatment ≤2 mm / ≤2 mm/≤1 mm day of SRS itor Phantom containing programs
unit verification Includedwas
above. RTT early in
identified criteria for
coordinate coincidence radiopaque
the adoption
markers.
of IMRT treatment planning and delivery IMRT (51%
Cone beam CT (kV and MV)
Collision interlocks Functional gle NA
point in a simple phantom 5 min geometry to RTT calculation their calcu
Positioning/repositioning ≤2 mm / ≤2 mm/≤1 mm day of SRS of dose at containing
Phantom a single point 10–
while taking patient
15 min RTTanatomy (3D) volum
radiopaque
markers.
Imaging and treatment ≤2 mm / ≤2 mm/≤1 mm day of SRS in how
Phantom containing such
to commission Included above. as well
technologies RTT as their missioning
coordinate coincidence radiopaque
role asmarkers.
part of an IMRT QA program as was noted in the cation cal
Monthly
Planar MV imaging (EPID)
Imaging and treatment ≤2 mm / ≤1 mm andPhantom containing
evaluating 15–20 for
the algorithms min“independent/second
QMP or troduction
coordinate coincidence
check”radiopaque
of monitor unit calculations for IMRT; (b)Designee
Making as 3D volu
markers.
Scaling ≤2 mm / ≤1 mm Object of known
culation programs (e.g., 5number
min
of points,QMP or
dimensions Designee
Spatial resolution ≥ Baseline Manufacturer supplied 5–10 min
Describing commissioning and benchmark QMP QA of or
sec-
test phantom Designee
Contrast ≥ Baseline Manufacturer supplied 5–10 min QMP or
measurements,
test phantom
if necessary; and (4) Describing clini-
Designee
M U V ER
Uniformity and noise ≥ Baseline
tionManufacturer
programs and supplied 5–10 min
recommendations on testQMP or
tolerance.
Planar kV imaging
Imaging and treatment ≤2 mm / ≤1 mm Phantom containing
particular: 15–20 min QMP or The implem
coordinate coincidence radiopaque Designee
markers.
as IMRT/V
Scaling ≤2 mm / ≤1 mm Object of known 5 min QMP or
either (a)
dimensions
establishment of uniform practices,
Designee
or potential fo
Spatial resolution ≥ Baseline Manufacturer supplied 5–10 min QMP or
taining established
test phantom
standards of practice to ensure
Designee
therefore e
2. Should indicates
test phantom
an advisory recommendation that
Designee
rors befor
Uniformity and noise ≥ Baseline Manufacturer supplied 5–10 min QMP or
test phantom procedure but understands that
Designee delivery o
Cone beam CT (kV and MV)
Geometric distortion ≤2 mm / ≤1 mm phantom of known and
procedure should only15– 20 min
be QMP or
carried out after careful advanced
dimensions Designee
Spatial resolution ≥ Baseline Object of known 5 min QMP or
dimensions Designee
HU constancy ± 40 HU from baseline Manufacturer supplied 5–10 min QMP or
ment plann
|
2
TASKe882
FOR IMRT
1 V I |I
TA B L E STATE M ENT
O F TH E PRO BLE M
(Continued) verification program was generally used for the ma-
A N D TG CH A RG ES
Tolerance Non- SRS/SBRT SRS/ Typical jority of IMRT/VMAT
measuring treatment plans although ap-
Time required
Procedure SBRT device proximately 31% of responders did
(range) not use dose/MU
Personnel
Uniformity and noise ≥ Baseline Manufacturer supplied 5–10 min QMP or
and continue to be an important part of quality assur- test phantom time. The most common commercial system reported
Designee
Annual
Planar MV imaging (EPID) 1
Full range
methodsof traveland
SDDrequirements
±5 mm for verification of data for Tape measure
CA). This is not5–to 10 be
min consideredQMP as an endorsement
2
Imagingconformal
dose external beam ± 5% of plans.
the baseline The needdose
imaging for mon- of these products.
Radiographic 15– 30 The
min most common QMP passing rate
itor unit verification programs per monitorwas unit identified early in dosimetry system
criteria for dose/MU verification software was 5% for
Planarthe adoption of IMRT treatment planning and delivery
kV imaging IMRT (51%) and “None Specified” for VMAT (34%), al-
3
Beamtechniques.
quality/energy Several± different5% Baseline types
energy of programs were though 30% of 15–
Radiographic VMAT30 minrespondersQMP used 5% as passing
developed ranging from confirmation of dose at a sin- dosimetry rate.system
More than 50% of users used a single point for
Imaginggledosepoint in a simple± phantom 20% of the geometry
baseline dose to calculation their calculations
Radiographic 15–and
30 minonly 6% used QMP three- dimensional
of dose at a single point while taking patient anatomy dosimetry (3D) system
volumetric dose in the 2012 survey. Additional
Cone and
beamgeometry
CT (kV andintoMV) consideration. While these programs measurements (typically the MLC dosimetric leaf gap
have
Imaging dose been in use for some time, guidance
Baseline ± 20% for kV- CBCT, was lacking (DLG) measurements)
Radiographic 15– 30 minwere also QMP required during com-
Baseline ± 5% for MV- as well as their dosimetry
CBCT missioning.
system The most common IMRT dose/MU verifi-
NA = notrole as part of an IMRT QA program as was noted in the
applicable. cation calculation algorithm represented by software
IMRT”.4,5 gorithm.”
2. Kutcher GJ, CoiaNote thatM,the
L, Gillin clinical
et al. practiceQAhas
Comprehensive changed,
for radi-
This task group was
Some of these approaches have been provided by charged with: (a) Reviewing with
ation more
oncology: widespread
report of AAPM use of
Radiation VMAT
Therapyas well as
Committee the in-
vendors for machine performance testing. However, for “independent/second troduction
Task Group 40. Med and adoption
Phys. of
1994;21:581– new 618.software tools (such
check” of monitor unit calculations for IMRT; (b) Making 3. Fought
as 3DAM,volumetric
Trager M, Yin FF, Kirkpatrick
calculation J, Adamson
systems) sinceJ. Re-
2012, so
the equivalence of the machine performance checks examining TG-142 recommendations in light of modern tech-
with the machine QA activities should be carefully ex- implementation of cal- users should consider the age and
niques for linear accelerator based radiosurgery. Med Phys.
context of the data
amined culation
by the programs
QMP. (e.g., number of points, locations, 2016;43:5437. when interpreting the survey.
accuracy, evaluation methods,
As clearly described in Section 1.B, the recommen- and heterogeneities); (3) 4. Al- Hallaq HA, Chmura S, Salama JK, et al. Rationale of techni-
dations of this TG are not intended to be used as reg- benchmark QA of sec- cal requirements for NRG- BR001: the first NCI-sponsored trial
ondary MUrecommendations
calculation programs, of 2
SBRT| forRO LE O F
the treatment DOSE
of multiple /
metastases. Pract radiat
ulations. These are proposing
guidelines additional
for oncol. 2016;6:e291– e298.
QMPsmeasurements,
to use and appropriatelyif necessary; and (4)
interpret forDescribing
their indi- clini-5. Roper M UJ, V ER I FI CATI O NS I N A
Chanyavanich V, Betzel G, Switchenko J, Dhabaan
cal testing and periodic QA of
vidual institution and clinical setting. Each institution secondary MU calcula- CO M PR
A. Single- isocenter EHmultiple-
ENSItarget V E stereotactic
Q A PROG R AM
radiosurgery:
may have site-specific needs and requirements which on test tolerance. risk of compromised coverage. Int J Radiat Oncol Biol Phys.
may modify Thetheir terminology
usage of these used recommendations.
in this report follows that 2015;93:540– 2.1 | Review 546. of the problem
used in other AAPM Task Group reports including in6. Langen KM, Papanikolaou N, Balog J, et al. QA for helical to-
motherapy: report of the AAPM Task Group 148. Med Phys.
CO N FL particular:
I C T O F I NT E R EST The implementation of new treatment techniques such
2010;37:4817– 4853.
The members of AAPM TG 198 listed below attest as IMRT/VMAT
7. Dieterich S, Cavedonin C,aChuang
radiotherapy
CF, et al.department
Report of AAPM increases
that they have no potential conflict of interest related to that is essential for the complexities in planning and delivery
TG 135: quality assurance for robotic radiosurgery. Med Phys. and thus, the
the subject matter or materials presented in this docu- of uniform practices, or potential
2011;38:2914– for serious
2936. errors in the planning and delivery
(b) the most safe and effective result and/or main- 8. Fontenot
of JD, Alkhatib An
radiotherapy. H, Garrett
effective JA, set
et al.
of AAPM
QA medical
procedures is
ment: Joseph Hanley, Sean Dresser, William Simon, physics practice guideline 2.a: commissioning and quality as-
Ryan Flynn, Eric Klein, Daniel Létourneau, Chihray Liu, of practice to ensure therefore essential. The goal of a routine
surance of x- ray- based image- guided radiotherapy systems. J
pretreatment
Fang- Fang theYin, accuracy of dose/MULijun
Bijan Arjomandy, determination.
Ma, Francisco verification
Appl Clin Med Phys. procedure is to identify and resolve any er-
2014;15:4528.
Aguirre, Jimmy Jones. The members of AAPM TG 198 recommendation that rors before patient treatment.
9. Smith K, Balter P, Duhon J, et al. AAPM medical For IMRT,
physicsverification
prac-
listed below disclose the following potential conflict(s) The task group measurements
tice guideline 8.a.: are
linear commonly
accelerator used
performance to verify
tests. J Appl correct
favors the indicated procedure but understands that Clin Med Phys.
delivery of 2017;18:23–
treatment 39.plans, for example with ioniza-
of interest related to subject matter or materials pre-
sented inthere are other John
this document: procedures
Bayouth which can accomplish10. Huq
has ownership
MS, Fraass BA, Dunscombe PB, et al. The report of Task
tion chambers, films, or multidimensional detector ar-
Group 100 of the AAPM: application of risk analysis methods to
interest in MR Guidance, LLC, which provides commis- from the recommended rays. Experimental
radiation therapy methods Med
quality management. for Phys.
patient- specific QA in
2016;43:4209.
sioning consulting services for MRI- guided radiation carried out after careful advanced radiotherapy are,
11. Report 24. Journal of the International Commission however, time- consuming
on
analysis demonstrates that
therapy. Todd Holmes is an employee and shareholder an equivalent result will in both
Radiation manpower
Units and and accelerator
Measurements. time
1976;os13. and have been
https://doi.
org/10.1093/jicru/ os13.1.report24
of VarianbeMedical produced. Systems. Carlos Sandin is an em- shown to be
12. ICRU Report
unable to detect some unacceptable
6-1124. Bethesda, MD; 1976.
3. May
ployee of Elekta LTD. indicates a statement that is likely (or probably) plans. Recent studies have demonstrated a sensitiv-
13. Keall PJ, Mageras GS, Balter JM, et al. The management of
to be correct but the task group does not make any respiratory ity of only 5% to detectoncology:
motion in radiation IMRT plan reporterrors
of AAPM using
Task IMRT
12,13
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|
2
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54GROUP 198 REPORT TASK GROUP 198 e883
REPORT
15. Medical electron accelerators-functional performance charac- 1 39. STATE

| Hossain M ENT
M. Output O characteristics,
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ment plann

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Received: 9 February 2021 | Revised: 16 March 2021 | Accepted: 28 April 2021

AAPM SCIENTIFIC REPORT

AAPM Task Group 198 Report: An implementation guide

Joseph Hanley1 | Sean Dresser2 | William Simon3 | Ryan Flynn4 |

Author to whom correspondence should

Consultants: Carlos Sandin (Elekta)

© 2021 American Association of Physicists in Medicine

Table of Contents 1 Contents

Physics Practice Guideline 2.a”8 and “Medical Physics 1this|TGSTATE

to make necessary corrective actions should be avail- 12.A.1.3

measurement system may be used for monthly QA and 11. The

6. If adjustments are made to the outputs, any devices 12. Once

machine. Major changes or repairs to devices in the 1rely|lessSTATE M ENT

1 | STATE M ENT O F TH E PRO BLE M verification

2.C.5.1.1 | Objective. The objective is to ensure of dose at a single

2.D.1.6.31 | | STATE Methods and M ENT O F TH E PRO BLE M

2. Verify that each reading is the same to within the 1 2. STATE

4. It should be noted that, in some instances, a polar- 1 mechanical

of the 1front| pointer

2.D.5 | Volumetric modulated arc therapy 1 order

are 2.5,1 2.0, STATE

2.F.3.2.2 | Tolerance. The tolerance is ±1 mm 1 helps | STATE obtaining M aENT more O F TH E

1 | STATE M ENT O F TH E PRO BLE M verification

1 | STATE M ENT O F TH E PRO BLE M verification

TA B L E I V (Continued) 1 | STATE M ENT O F TH E PRO BLE M verification

RTT deliver, QMP or Designee review

of these products. The most common passing rate

with the light-field

EPID: 15–20 min

EPID: 15–25 min

EPID: 10–15 min

Obj. 1: 20– 30 min

Film: 30– 35 min

Log file method:

Film: 25–25 min

30– 40 min with

Films or EPID and software

IMRT”.4,5 gorithm.” Note that the clinical practice has changed,

Film or EPID and software

Film or EPID and software

Graph paper, template

light field crosshair is

Delivery log file analysis

Ionization chamber and

the light field- based

RMS of leaf positioning error < 0.35 cm

particular: The implementation of new treatment techniques such

Leaf position accuracy (IMRT)

be produced. shown to be unable to detect some unacceptable

recommendations. pretreatment measurements.12,13 Moreover, as treat-

TA B L E V I I 1 | STATE M ENT O F TH E PRO BLE M

15. Medical electron accelerators-functional performance charac- 1 39. STATE

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