Taisa Polishchuk

DOS 542 Quality Assurance (Final QA Table)

10/15/2015
Daily QA for Linear Accelerators1, 2
Type of procedure
Dosimetry
Dosimetry
Mechanical
Mechanical
Mechanical
Safety
Safety
Safety
Safety
Safety

Sub-type of procedure
X-ray output constancy
Electron output constancy
Localizing lasers
Distance indicator (ODI)
Collimator size indicator
Door interlock (beam off)
Door closing safety
Beam on indicator
Audiovisual monitor
Radiation area monitor (if

Tolerance
3%
3%
2 mm
2 mm
2 mm
Functional
Functional
Functional
Functional
Functional

used)
Monthly QA for Linear Accelerators1, 2
Type of procedure
Dosimetry
Dosimetry
Dosimetry
Dosimetry

Sub-type of procedure
X-ray output constancy
Electron output constancy
Backup monitor constancy
X-ray central axis dosimetry

Tolerance
2%
2%
2%
2%

parameter (PDD, TAR)

Dosimetry

constancy
Electron central axis

2 mm at therapeutic depth

dosimetry parameter
Dosimetry
Dosimetry

constancy (PDD)
X-ray beam flatness constancy 2%
Electron beam flatness
3%

Dosimetry
Mechanical

constancy
X-ray and electron symmetry
Light/radiation field

3%
2 mm or 1% on side

Mechanical

coincidence
Gantry/collimator angle

1 degree

Mechanical

indicators
Wedge position

2 mm (or 2% change in
transmission factor)

Mechanical
Mechanical
Mechanical
Mechanical
Mechanical

Tray position
Applicator position
Field size indicator
Cross-hair centering
Treatment couch position

2 mm
2 mm
2 mm
2 mm diameter
2 mm/1 degree

Mechanical

indicator
Latching of wedges, blocking

Functional

Mechanical
Mechanical
Safety
Safety

tray
Jaw symmetry
Field light intensity
Emergency off switches
Wedge, electron cone

2 mm
Functional
Functional
Functional

interlocks
Annual QA for Linear Accelerators1, 2
Type of procedure
Dosimetry

Sub-type of procedure
X-ray/electron output

Tolerance
2%

Dosimetry

calibration constancy
Field size dependence of x-ray

2%

Dosimetry

output constancy
Output factor constancy for

2%

Dosimetry

electron applicators
Central axis parameter

2%

Dosimetry
Dosimetry

constancy (PDD, TAR)

Off-axis factor constancy
Transmission factor constancy

2%
2%

Dosimetry

for all treatment accessories

Wedge transmission factor

2%

Dosimetry
Dosimetry

constancy
Monitor chamber linearity
X-ray output constancy versus

1%
2%

Dosimetry

gantry angle
Electron output constancy

2%

Dosimetry

versus gantry angle

Off-axis factor constancy

2%

Dosimetry
Mechanical

versus gantry angle

Arc mode
Collimator rotation isocenter

Manufacturers specifications
2 mm diameter

Mechanical
Mechanical
Mechanical

Gantry rotation isocenter

Couch rotation isocenter
Coincidence of collimator,

2 mm diameter
2 mm diameter
2 mm diameter

gantry, and couch axes with

Mechanical

isocenter
Coincidence of radiation and

2 mm diameter

Mechanical
Mechanical
Safety

mechanical isocenter
Table top sag
Vertical travel of table
Follow manufacturers test

2 mm
2 mm
Functional

procedures

QA of CT Simulators2, 3
Frequency
Daily
Daily
Monthly
Monthly

Type of procedure
Localizing lasers
Distance indicator (ODI)
Field size indicator
Gantry/collimator angle

Tolerance
2 mm
2 mm
2 mm
1 degree

Monthly
Monthly
Monthly
Monthly

indicators
Cross-hair centering
Focal spot-axis indicator
Fluoroscopic image quality
Emergency/collision

2 mm diameter
2 mm
Baseline
Functional

Monthly

avoidance
Light/radiation field

2 mm or 1%

Monthly
Annually
Annually
Annually
Annually

coincidence
Film processor sensitometry
Collimator rotation isocenter
Gantry rotation isocenter
Couch rotation isocenter
Coincidence of collimator,

Baseline
2 mm diameter
2 mm diameter
2 mm diameter
2 mm diameter

gantry, couch axes, and

Annually
Annually
Annually
Annually

isocenter
Table top sag
Vertical travel of couch
Exposure rate
Table top exposure with

2 mm
2 mm
Baseline
Baseline

Annually

fluoroscopy
Kilovolt peak and

Baseline

Annually

milliamperage calibration
High and low contrast

Baseline

resolution
Daily and monthly QA for electromechanical components of CT Simulator2, 3
Frequency

Procedure

Procedures

Tolerance

Daily

Alignment of gantry

objective
To verify proper

+/- 2 mm

lasers with the center

identification of scan

of imaging plane

plane with gantry

Monthly and after

Orientation of gantry

lasers
To verify that the

+/- 2 mm over the

laser adjustments

lasers with respect to

gantry lasers are

length of laser

the imaging plane

parallel and

projection

orthogonal with the

imaging plane over
the full length of laser
Monthly and after

projection
Spacing of lateral wall To verify that lateral

laser adjustments

lasers with respect to

wall lasers are

lateral gantry lasers

accurately spaced

and scan plane

from the scan plane.

+/- 2 mm

This distance is used

for patient localization
Monthly and after

Orientation of wall

marking
To verify that the wall

laser adjustments

lasers with respect to

lasers are parallel and

length of laser

the imaging plane

orthogonal with the

projection

+/- 2 mm over the

imaging plane over

the full length of laser
Monthly and after

Orientation of the

projection
To verify that the

+/- 2 mm over the

laser adjustments

ceiling laser with

ceiling laser is

length of laser

respect to the imaging

orthogonal with the

projection

Monthly or when

plane
Orientation of the CT-

imaging plane
To verify that the CT-

+/- 2 mm over the

daily laser QA tests

scanner tabletop with

scanner tabletop is

length and width of

reveal rotational

respect to the imaging

level and orthogonal

the tabletop

problems

plane

with the imaging

Table vertical and

plane
To verify that the

+/- 1 mm over the

longitudinal motion

table longitudinal

range of table motion

Monthly

motion according to
digital indicators is
accurate and
reproducible

Semi-annual and annual QA for electromechanical components of CT Simulator2, 3

Frequency
Semiannually

Procedure

Procedures

Tolerance

Sensitivity profile

objective
To verify that the

+/- 1 mm of nominal

width

sensitivity profile

value

width meets
manufacturer
Annually

Table indexing and

specification
To verify table

+/- 1 mm over the

position

indexing and position

scan range

accuracy under
Annually
Annually

Gantry tilt accuracy

scanner control
To verify accuracy of

+/- 1 degree over the

Gantry tilt position

gantry tilt indicators

To verify that the

gantry tilt range

+/- 1 degree or +/- 1

accuracy

gantry accurately

mm from nominal

returns to nominal

position

position after tilting

Annually

Scan localization

To verify accuracy of

+/- 1 mm over the

scan localization from

scan range
Manufacturer

Annually (this test is

Radiation profile

pilot images
To verify that the

optional if the CTDI

width

radiation profile width specifications

accuracy has been

meets manufacturer

verified)
After replacement of

specification
To verify proper

Manufacturer

major generator

operation of the x-ray

specifications or

component

generator

Report No. 39

Generator tests

recommendations
QA for image performance evaluation of CT Simulator2, 3
Frequency
Daily
Daily
Daily

Procedure
CT number accuracy for water
Image noise
In plane spatial integrity X or

Tolerance
0 +/- 5 HU
Manufacturer specifications
1 mm

Monthly

Y direction
CT number accuracy for 4-5

0 +/- 5 HU

Monthly

different materials
In plane spatial integrity for

1 mm

Monthly

both X and Y directions

Field uniformity: most

Within +/- 5 HU

Annually

commonly used kVp

CT number accuracy with an

0 +/- 5 HU

Annually

electron density phantom

Field uniformity utilizing

Within +/- 5 HU

Annually

other kVp settings

Electron density to CT number Consistent with
conversion

commissioning results and test

phantom, manufacturer

Annually
Annually

Spatial resolution
Contrast resolution

specifications
Manufacturer specifications
Manufacturer specifications

The clinical Treatment Planning Process4

Procedure
Patient Positioning and Immobilization
Image Acquisition and Input

Procedures objectives
Establish patient reference

marks/patient coordinate system

Acquire and input CT, MR, and other
imaging information into the planning

Anatomy Definition

system
Define and display contours and
surfaces for normal and critical

structures.
Geometrically register all input data
( CT, MR), including registration with
initial simulation contours, films,

patient position, etc.

Define target contours, generate 3D
target surface using surface expansion,
import target information from multiple

imaging modalities.
Generate electron density
representation from CT or from

Beam/Source Technique

Dose Calculations

assigned bulk density information.

Determine beam or source

arrangements.
Generate beams-eye-view display.
Design field shape (blocks, MLC).
Determine beam modifiers

(compensators, wedges).
Determine beam or source weighting.
Select dose calculation algorithm and
methodology, calculation grid and

window, etc.
Perform dose calculations.
Set relative and absolute dose
normalizations.

Plan Evaluation

Plan Implementation

Input the dose prescription.

Generate 2D and 3D dose displays.
Perform dose calculations.
Set relative and absolute dose

normalizations.
Input the dose prescription.
Align (register) the real patient with the
plan (often performed at a plan

Plan Review

verification simulation).
Calculate Monitor Units or implant

duration.
Generate hardcopy output.
Transfer plan into record and verify

system.
Transfer plan to treatment machine.
Perform overall review of all aspects of
plan before implementation.

Acceptability criteria for external beam dose calculations (TPS)4

Situation

Square fields

Abs. Dose

Central

Inner

Penumbra

Outer

Buildup

@normpt

Axis (%)

Beam

(nm)

Beam

Region

(%)
0.5

(%)
1.5

(%)
2

(%)
20

0.5

1.5

20

20

(Homogeneous
phantom)
Rectangular
fields
(Homogeneous
phantom)
Asymmetric
fields
(Homogeneous

phantom)
Blocked fields

50

20

50

0.5

20

1.5

40

(Homogeneous
phantom)
MLC-shaped
fields
(Homogeneous
phantom)
Wedged fields
(Homogeneous
phantom)
External surface
variations
(Homogeneous
phantom)
SSD variations
(Homogeneous
phantom)
Slab
inhomogeneities
(Inhomogeneou
s phantom)
3D
inhomogeneities
(Inhomogeneou
s phantom)

Periodic RTP Process QA Checks4

Frequency
Daily

Procedure
Error log

Details
Review report log listing
system failures, error
messages, hardware
malfunctions, and other

problems. Triage list and

remedy any serious problems
Daily

Change log

that occur during the day.

Keep log of

Weekly
Weekly

Digitizer
Hardcopy output

hardware/software changes.
Review digitizer accuracy.
Review all hardcopy output,
including scaling for plotter
and other graphics-type

Weekly

Computer files

output.
Verify integrity of all RTP
system data files and
executables using checksums
or other simple software
checks. Checking software
should be provided by the

Weekly

Review clinical planning

vendor.
Review clinical treatment
planning activity. Discuss
errors, problems,
complications, difficulties.

Monthly

CT data input into RTP system

Resolve problems.
Review the CT data within the
planning system for
geometrical accuracy, CT
number consistency (also
dependent on the QA and use
of the scanner), the derived

Monthly

Problem review

electron density.
Review all RTP problems
(both for RTP system and
clinical treatment planning)
and prioritize problems to be

Monthly

Review of RTP system

resolved.
Review current configuration
and status of all RTP system
software, hardware, and data

Annual

Dose calculation

fields.
Annual checks. Review
acceptability of agreement
between measured and
calculated doses for each

Annual

Data and I/O devices

beam/source.
Review functioning and
accuracy of digitizer tablet,
video/laser digitizer, CT input,
MR input, printers, plotters,
and other imaging output

Annual

Critical software tools

devices.
Review BEV/DRR generation
and plot accuracy, CT
geometry, density conversions,
DVH calculations, other
critical tools, machine-specific
conversions, data files, and

Variable

Beam parameterization

other critical data.

Checks and/or
recommissioning may be
required due to machine

Variable

Software changes, including

changes or problems.
Checks and/or

operating system

recommissioning may be
required due to changes in
RTP software, any
support/additional software
such as image transfer

software, or the operating

system.

QA During the Treatment Process4

Test
Multiplanar reconstructed images

Reasons
Inconsistencies in the image dataset will
produce inconsistencies or artifacts in the
reconstructed images.
Beam orientation and patient anatomy which is
difficult to visualize on axial images is often
easily seen on non-axial planes.
Contours cut from 3D structures onto
reconstructed images may show
inconsistencies or problems in 1) the original
axial contours; 2) the 3D structure; 3) the way
the structure was identified on different

3D surface displays

imaging studies.
Surface displays help verify that component

Dataset registration review

2D contours are consistent and realistic.

The responsible physician should review the
accuracy of registration of multiple datasets
and the transfer of information such as tumor
or critical normal structure delineation between

Point dose calculations

orientation.
Hand calculations of dose to the prescription
point and/or normalization point help verify

Plan visualization and documentation

correct delivery of dose to the patient.

Plots in appropriate non-axial planes can be

techniques

used to show beam, wedge, and block

orientations for non-axial beams, electron

Treatment plan review

cutout accuracy.
The physician and a second treatment
planner/physicist should review the plan,
including all treatment parameters, before

Monitor unit review

implementation.
Monitor unit calculations should be reviewed
by a second physicist, preferably before
treatment starts, but certainly before the third

SSD Checks

fraction or 10% of the dose has been delivered.

SSD to the central axis of each treatment field
should be measured during simulation and
periodically during treatment and compared to

External beam plan implementation review

that used in the treatment plan.

The physicist or therapist should confirm
before the first treatment that all treatment
parameters were transferred correctly from
plan to patient chart and/or record and verify
system.
Periodic port films or port images help verify
the correct positioning of the patient and
correct orientation of the blocks.
Consider feasibility of treatment plan (re:
interference or collision of machine gantry
with table and/or patient and/or immobilization

Brachytherapy plan implementation review

devices).
The physicist or therapist should confirm
before the brachytherapy sources are placed
into the patient that all source and plan
information was correctly transferred from
treatment plan to the treatment documentation
or patient chart.
Dose calculations and prescription should be

verified as accurate and appropriate before

treatment begins.
Confirmation of sources location and loading,
if possible, should be performed as soon after
loading as possible.

Acceptance testing procedures for Remote Afterloaders2

Functional performance
Console functions

Main power, battery power, source on/off, door

Source control

open/close, etc.
Source dwell time and source retraction at the
end of preset time, unplanned interruption or

Battery voltage

emergency shutoff.
Adequacy of battery voltage under load
conditions and functional performance under

Timer
Decay correction

battery power.
Timer accuracy and end-time effects.
Accuracy of computer-calculated decay

Multichannel indexer

corrections.
Proper source sequencing and channel

Backup systems

selection.
Proper functioning during simulated power
failures or air pressure losses (for

Radiation detectors
Facility check and survey
Door interlocks

pneumatically driven devices).

Proper functioning as specified.
Source retracts when the door is opened; the
unit does not start until the door is closed and

Radiation warning lights

the interlock is reset.

Proper functioning to indicate radiation on/off

Patient viewing and communication

condition.
Proper functioning of closed-circuit TV and the

Radiation survey

intercommunication system.
Exposure rates outside the radiation facility
should meet the Nuclear Regulatory

Commission regulations and the leakage

radiation rates around the unit should be
acceptable.
Source calibration and transport
Source calibration and transport

Check of source specifications, leak testing,

calibration, transport to the applications,
autoradiograph of simulated source positions,
and isodose distribution to determine dose
anisotropy.

References:
1. Klein EE, Hanley J, Bayouth J, et al. Task Group 142 report: quality assurance of medical
accelerators. Med Phys. 2009;36(9):4197-4212. http://dx.doi.org/10.1118/1.3190392
2. Khan FM. Quality assurance. In: KhanFM, ed. The Physics of Radiation Therapy. 4th ed.
Baltimore, MD: Lippincott, Williams, and Wilkins; 2010: 375-404.
3. Mutic S, Palta JR, Butker EK, et al. Quality assurance for computed-tomography simulators
and the computed-tomography-simulation process: report of the AAPM radiation therapy
committee task group No. 66. Med Phys. 2003;30(10):2762-2792.
http://dx.doi.org/10.1118/1.1609271
4. Fraass B, Doppke K, Hunt M, et al. American Association of physicists in medicine radiation
therapy committee task group 53: quality assurance for clinical radiotherapy treatment
planning. Med Phys. 1998;25(10):1773-1829. http://dx.doi.org/10.1118/1.598373