Linear Accelerator QA: DAILY1,2

DOSIMETRY Non-IMRT IMRT SRS/SBRT

X-ray output constancy 3%
Electron output constancy (weekly) 3%

Laser Loc 2mm 1.5mm 1mm

Distance indicator ODI @ iso 2mm 2mm 2mm
Collimator size indicator 2mm 2mm 1mm

Door interlock Functional

Door closing safety Functional
Audiovisual monitors Functional
Stereotactic interlocks NA NA Functional
Radiation area monitor Functional
Beam on indicator Functional
Linear Accelerator QA: MONTHLY1,2

DOSIMETRTY Non-IMRT IMRT SRS/SBRT

X-ray output constancy 2%
Electron output constancy 2%
Backup monitor chamber constancy
Typical dose rate output constancy NA 2% (@IMRT dose 2% (@stereo dose rate,
rate) MU)

Photon beam profile constancy 1%

Electron beam profile constancy 1%
Electron beam energy constancy 2%/2mm

Light/radiation field coincidence 2mm or 1% on a side

Light/radiation field 2mm or 1% on a side
coincidence(asymmetric)
Distance check device for lasers compared 1mm
with front pointer
Gantry/col angle indicators (@cardinal 1.0
angles)(digital only)
Accessory trays (port film graticule tray) 2mm
Jaw position indicators (symmetric) 2mm
Jaw position indicators (asymmetric) 1mm
Cross-hair centering (walkout) 1mm
Tx couch position indicators 2mm/1 2mm/1 1mm/0.5
Wedge placement accuracy 2mm
Compensator placement accuracy 1mm
Latching wedges, blocking tray Functional
Localizing lasers |2mm 1mm <1mm

Laser guard-interlock test Functional

Beam output constancy 2%

Phase, amplitude beam control Functional
In-room respiratory monitoring system Functional
Gating interlock Functional
Linear Accelerator QA: ANNUAL1,2

DOSIMETRY Non-IMRT IMRT SRS/SBRT

X-ray flatness change from baseline 1%
X-ray symmetry change from baseline 1%
Electron flatness change from baseline 1%
Electron symmetry change from baseline 1%
SRS are rotation mode (range:0.5- NA NA MUs set vs. delivered:
10MU/deg) 1.0 MU or 2%
(whichever is greater)
Gantry are set vs.
delivered: 1.0 or 2%
(whichever is greater)
X-ray/electron output calibration (TG-51) 1% (absolute)
Spot check of FS dependent output factors 2% for FS <4x4cm2,
for x-ray (two or more FSs) 1% 4x4cm2
Output factors for electron applicators 2% from baseline
(spot check of one applicator/energy)
X-ray beam quality (PDD10 or TMR2010) 1% from baseline
Electron beam quality (R50) 1mm
Physical wedge transmission factory 2%
constancy
X-ray monitor unit linearity (output 2%5MU 5% (2-4MU) 5%(2-4MU)
constancy) 2% 5MU 2% 5MU
Electron monitor unit linearity (output 2% 5MU
constancy)
X-ray output constancy vs. dose rate 2% from baseline
X-ray output constancy vs. gantry angle 1% from baseline
Electron output constancy vs. gantry angle 1% from baseline
Electron and x-ray off-axis factor constancy 1% from baseline
vs. gantry angle
Arc mode (expected MU, degrees) 1% from baseline
TBI/TSET mode Functional
PDD or TMR and OAF constancy 1%(TBI) or 1mm PDD shift (TSET) from baseline
TBI/TSET output calibration 2% from baseline
TBI/TSET accessories 2% from baseline

Col rotation isocenter 1mm from baseline

Gantry rotation isocenter 1mm from baseline
Couch rotation isocenter 1mm from baseline
Electron applicator interlocks Functional
Coincidence of radiation and mechanical 2mm from baseline
isocenter
Table top sag 2mm from baseline
Table angle 1.0
Table travel maximum range movement in 2mm
all directions
Stereotactic accessories, lockouts, etc. NA NA Functional

Follow manufacturers test procedure Functional

Beam energy constancy 2%

Temporal accuracy of phase/amplitude gate 100ms of expected
on
Calibration of surrogate for respiratory 100ms of expected
phase/amplitude
Interlock testing Functional
Imaging QA of Medical Accelerators1

Procedure
non-SRS/SBRT SRS/SBRT
Daily
Planar kV and MV (EPID)
imaging
Collision interlocks Functional Functional
Positioning/repositioning 2 mm 1 mm
Imaging and treatment 2 mm 1 mm
coordinate coincidence (single
gantry angle)

Cone-beam CT (kV and MV)

Collision interlocks Functional Functional

Imaging and treatment 2 mm 1 mm

coordinate coincidence
Positioning/repositioning 1 mm 1 mm

Monthly
Planar MV imaging (EPID)
Imaging and treatment 2 mm 1 mm
coordinate coincidence (four
cardinal angles)
Scaling 2 mm 2 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline

Planar kV imaging
Imaging and treatment 2 mm 1 mm
coordinate coincidence (four
cardinal angles)
Scaling 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline

Cone-beam CT (kV and MV)

Geometric distortion 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
HU constancy Baseline Baseline
Uniformity and noise Baseline Baseline

Annual
Planar MV imaging (EPID)
Full range of travel SDD _ 5 mm 5 mm
Imaging dose Baseline Baseline

Planar kV imaging
Beam quality/energy Baseline Baseline
Imaging dose Baseline Baseline

Cone-beam CT (kV and MV)

Imaging dose Baseline Baseline
QC tests recommended for CT-based IGRT systems2

Frequency Quality check Tolerance

DAILY Collision and other interlocks Functional
Warning lights Functional
Laser/image/treatment isocenter 2 mm
coincidence OR
Phantom localization and 2 mm
repositioning with couch shift

MONTHLY or upon upgrade Geometric calibration maps OR Replace/refresh

kV/MV/laser alignment 1 mm
Couch shifts: accuracy of motions 1 mm
Scale, distance, and orientation Baseline
accuracy
Uniformity, noise Baseline
High contrast spatial resolution 2 mm (or _ 5 lp/cm)
Low contrast detectability Baseline

If used for dose calculation CT number accuracy and stability Baseline

ANNUALLY Imaging dose Baseline
X-ray generator
performance (kV systems only) Baseline
tube potential, mA, ms accuracy,
and linearity
Anteroposterior, mediolateral, and Accurate
craniocaudal orientations are
maintained (upon upgrade from CT
to IGRT system)
Long and short term planning of Support clinical use and current
resources (disk space, manpower, imaging policies and procedures
etc.)
PM QA of SIMULATORS1

Frequency Procedure Tolerance

DAILY Localizing lasers 2 mm
Distance indicator 2 mm

MONTHLY Field size indicator 2 mm

Gantry/col angle indicators 1
Cross-hair centering 2 mm diameter
Focal spot-axis indicator 2 mm
Fluoro image quality Baseline
Emergency/collision avoidance Functional
Light/radx field coincidence 2 mm or 1%
Film processor sensitometry Baseline

ANNUAL Mechanical checks

Col rotation isocenter 2 mm diameter
Gantry 2 mm diameter
Couch 2 mm diameter
Coincidence of col, gantry,
couch axes and isocenter
Tabletop sag 2 mm diameter
Vertical travel of couch 2 mm
2 mm
Radiographic checks
Exposure rate
Tabletop exposure w/
fluoro Baseline
kVp and mAs calibration
High- and low-contrast
resolution
CT SIM: Test Specs for Image Performance Evaluation2

Performance Parameter Frequency Tolerance Limits

CT number accuracy
Image noise
In plane spatial integrity
Field uniformity
Electron density to CT number
conversion
Spatial resolution
Contrast resolution
DailyCT number for water
Monthly4-5 different materials
Annuallye- density phantom
Daily
DailyX or Y direction
Monthlyboth directions
Monthlymost commonly used
kVp
Annuallyother used kVp settings
Annuallyor after scanner cal
Annually
Annually
For water 05 HU
Manufacturer specs
1mm
Within 5 HU
Consistent w commissioning results
and test phantom manufacturer
specs
manufacturer specs
manufacturer specs

Instrument QA

Device Frequency
Ionization chamber & electrometer submitted to
Every 2 years
ADCL for calibration
Intercomparison of thermometers & barometers Time of purchase, semi-annually, whenever device has
inconsistencies
Diodes & MOSFETs Initial use, monthly
TLD Initially, monthly/frequently depending upon use
Film Initially, dependent upon use
Survey meters Yearly calibration, battery & constancy check day of
measurements
Brachytherapy QA4

Applicators
Inspect integrity of applicator
Positional accuracy verification
for afterloading system
Check integrity of device before
and after sterilization

Radioactive Sources
Know location of sources at all
times. Keep a log
Leak testing required before Required semi-annually
initial use and regularly

Remote Afterloading Equipment

Safety procedures policy
required and safety training
Know location of sources at all
times. Keep a log
Daily QA Survey meters, radiation
monitors, door interlocks,
radiation on lights
Verify tx display of time, date, Daily QA prior to treating first
and current source strength patient
Test of source-position accuracy, Daily QA prior to treating first
dwell-time accuracy, and normal patient
termination of treatment
Verify afterloader is operational Daily QA prior to treating first
patient
Pig and long forceps present Daily QA prior to treating first
patient
Monthly QA Verify and check source activity
against a decay chart, measure
source transit time, measure
timer linearity.
Treatment Planning QA Brachytherapy4

Target coverage Check proper prescription dose isodose line adequately covers
target volume
Homogeneity Verify range of acceptable dose and acceptable maximum dose
across volume
Dose prescription Verify correct dose, check for previous treatments
Normal structure doses Dose to normal structures is within tolerance
Consistency Total strength corresponds with normal dose specified to the
isodose surface
Duration Total delivery time is calculated correctly
Independent dose check Activity is appropriate.
mCi/Gy for permanent implants, mCi-hr/Gy for LDR temporary
implants, or Ci-s/Gy for HDR implants
QA of TPS5,6

Integrity of treatment planning data including beam data, CT #/ HU

data, tx machine data, brachy source data
Integrity and functionality of software
Functionality of auto-contouring, deformable registration, IMRT
optimization.
Check input from and output to other systems; in particular, output
to the treatment unit be it direct or through a ROIS

Multiplanar reconstructed Inconsistencies in the image dataset will produce inconsistencies

images 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 3-D structures onto reconstructed images may
show inconsistencies or problems in
1. original axial contours
2. 3-D structure
3. Structure identification on different imaging studies.

3-D surface displays Surface displays help verify that component 2-D contours are
consistent and realistic.

Dataset registration review 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 datasets.

Target definition checks Projection of a CT-defined target volume onto BEV images, which
are then compared to simulator films, can help physicians and staff
check target location, patient positioning, and beam orientation.

Point dose calculations Hand calculations of dose to the prescription point and/or
normalization point help verify correct delivery of dose to the
patient.

Plan visualization and Plots in appropriate non-axial planes can be used to show beam,
documentation techniques wedge, and block orientations for non-axial beams, electron cutout
accuracy.

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

Monitor unit review Monitor unit calculations should be reviewed by a second physicist,
preferably before treatment starts, but certainly before the third
fraction or 10% of the dose has been delivered.
SSD Checks SSD to the central axis of each treatment field should be measured
 during simulation and periodically during treatment and compared
to that used in the treatment plan.

External beam plan The physicist or therapist should confirm before the first treatment
implementation review 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 ( interference or collision of
machine gantry with table and/or patient and/or immobilization
devices)

Brachytherapy plan The physicist or therapist should confirm before the brachytherapy
implementation review 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 source location and loading, if possible, should be
performed as soon after loading as possible.
QA of a Treatment Planning Computer6

Confirm that the measured

data entered into treatment
planning computer represents
the range of clinical
conditions likely to be
encountered
Inaccuracies in measured data 1. Measurement of beam data
2. Measurements of patient
specific data.
Inaccuracies of Data Entry
Inaccuracies of Data Output
Algorithm Inaccuracy 1. Test of reproducibility 2% or 2mm in regions of high
2. Test evaluation calculation dose gradient
accuracy

QA of Treatment Plan and TPS6

Pretreatment physics second Independent check of the

check of each patient's plan treatment mu

MOSFET measurements

QA of IMRT6

Verify secondary barrier required to handle leakage radiation

Increased neutron dose when energy above 10MV is used.
Verify that the dose intended is the dose delivered
1. Point dose measurements for
a single field
2. Point dose measurements for
all fields
3. Planar dose measurements for
a single field
-measured using film, ion
chamber, or diodes
-an ion chamber or composite
film used to sample dose at
specified points
-measured using film or an array
of diodes. Dose profiles or
isodose lines may be compared
using software.

4. Planar dose measurements for -measured using film. Dose

multiple fields profiles or isodose lines may be
compared to treatment plan
1. Klein EE, Hanley J, Yin F, et al. Task group 142 report of quality assurance of medical
accelerators. Med Phys. 2009; 36(9). 4197-4212. http://dx.doi.org/10.1118/1.3190391.
2. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5thPhiladelphia, PA: Lippincott Williams
& Wilkins; 2014.
3. Bissonnette JP, Balter PA, Dong L, et al. Quality assurance for image-guided radiation therapy
utilizing CT-based technologies: A report of the AAPM TG-179. Med Phys.2012;39(4): 1946-1963.
http://dx.doi.org/10.1118/1.3690466.

4. Thomason C, Lenards N. QA Brachytherapy. [SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry

Program; 2017.
5. 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.
6. Thomason C, Lenards N. QA of TPS, IMRT, SRS. [SoftChalk]. La Crosse, WI: UW-L Medical
Dosimetry Program; 2017.