Int. J. Radiation Oncology Biol. Phys., Vol. 71, No. 1, Supplement, pp.

S113S117, 2008
Copyright 2008 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/08/$see front matter

doi:10.1016/j.ijrobp.2007.10.001

QA FOR RT SUPPLEMENT

HELICAL TOMOTHERAPY QUALITY ASSURANCE

JOHN BALOG, PH.D.,* AND EMILIE SOISSON, M.S.y

* Department of Radiation Oncology, Mohawk Valley Medical Physics, Rome, NY; and y Department of Human Oncology,
University of Wisconsin, Madison WI

Helical tomotherapy uses a dynamic delivery in which the gantry, treatment couch, and multileaf collimator leaves
are all in motion during treatment. This results in highly conformal radiotherapy, but the complexity of the deliv-
ery is partially hidden from the end-user because of the extensive integration and automation of the tomotherapy
control systems. This presents a challenge to the medical physicist who is expected to be both a system user and an
expert, capable of verifying relevant aspects of treatment delivery. A related issue is that a clinical tomotherapy
planning system arrives at a customers site already commissioned by the manufacturer, not by the clinical phys-
icist. The clinical physicist and the manufacturers representative verify the commissioning at the customer site
before acceptance. Theoretically, treatment could begin immediately after acceptance. However, the clinical phys-
icist is responsible for the safe and proper use of the machine. In addition, the therapists and radiation oncologists
need to understand the important machine characteristics before treatment can proceed. Typically, treatment
begins about 2 weeks after acceptance. This report presents an overview of the tomotherapy system. Helical
tomotherapy has unique dosimetry characteristics, and some of those features are emphasized. The integrated
treatment planning, delivery, and patient-plan quality assurance process is described. A quality assurance protocol
is proposed, with an emphasis on what a clinical medical physicist could and should check. Additionally, aspects of
a tomotherapy quality assurance program that could be checked automatically and remotely because of its
inherent imaging system and integrated database are discussed. 2008 Elsevier Inc.

INTRODUCTION structed to provide an image that can be registered with the

The helical TomoTherapy Hi-ART system was designed for
dedicated integrated image-guided intensity-modulated
radiotherapy (IMRT). Helical tomotherapy is characterized
by radiation delivery in which the patient is constantly trans-
lated through a continuously rotating radiation beam
mounted on a slip-ring gantry (13). A short in-line 6-MV
linear accelerator and its associated radiofrequency system
are mounted on a computed tomography (CT)-like ring gan-
try. A primary collimator shapes the radiation beam to be 40
cm in the transverse direction and 5 cm in the longitudinal
direction (into the gantry bore), creating a fan beam. A set
of moveable jaws further collimates the fan beam down to
as little as 1 cm wide in the longitudinal direction, and
a binary multileaf collimator (MLC) continuously provides
intensity modulation during the helical radiation delivery.
The MLC has 64 leaves across the transverse beam direction.
Image guidance is accomplished with an on-board megavolt-
age CT (MVCT) detector mounted on the gantry opposite the
linear accelerator. The linear accelerator is detuned to operate
at approximately 3 MV when used as an imaging source.
Data collected in the detector during the scan are recon-
planning reference image (4, 5).
The integrated, dynamic nature of helical tomotherapy
requires quality assurance (QA) that is different, than that
for conventional linear accelerators. Although the dynamic
components and synchrony requirements add new challenges
to QA (68), other design simplifications make the process
easier. For example, the collimator does not rotate, no
wedges or other accessories are used, and the couch does
not rotate. At present, only three longitudinal field widths,
5, 2.5, and 1.0 cm, have been commissioned into the planning
system. All field widths are collimated by the single move-
able set of jaws. Only one photon energy is provided for treat-
ment (nominally 6 MV), and no electron mode is available.
Furthermore, without a flattening filter and associated beam
steering, it is less likely that related beam profile asymmetries
will arise.
Specific QA protocols vary among users but most should
follow American Association of Physicists in Medicine
Task Group report 40 guidelines (9), applicable. Conven-
tional external beam QA is component based such that the
clinical physicist starts measuring basic machine parameters

Reprint requests to: John Balog, Ph.D., Department of Radiation
Oncology, Mohawk Valley Medical Physics, 127 Dixon Dr., Rome,
NY 13440. Tel: (315) 271-9614; (315) 671-1803; E-mail: JPB@
mvmp.net
Conflict of interest: J. Balog owns common stock in
S113
TomoTherapy Inc; and E. Soisson receives financial support from
TomoTherapy Inc.
Received Feb 17, 2007, and in revised form Sept 13, 2007.
Accepted for publication Oct 2, 2007.
S114 I. J. Radiation Oncology d Biology d Physics
(i.e., profiles, percentage depth dose [PDD], output factors)
and then progresses to planning system commissioning and
plan verification. Tomotherapy QA is process orientated.
The focus is on verification of dynamic treatment delivery.
At present, it is important for physicists to take responsibility
to thoroughly educate themselves about the system and pro-
cess to determine first what can go wrong and then what tests
to perform, and the associated specifications, to prevent any
adverse consequences.
TOMOTHERAPY TREATMENT PLANNING
COMMISSIONING AND ACCEPTANCE TESTING
In contrast to conventional systems, TomoTherapy sets the
output of the linear accelerator and the configuration of the
collimation only to a fixed standard. This defines a specific
energy fluence model for its convolution-superposition-
based planning system that depends on the slice width (1,
2.5, or 5 cm width defined at the isocenter). A full set of
beam data is collected at the factory, alignment tests are
performed, and the machine is adjusted to meet in-house
specifications for agreement with the standard model. Clini-
cal physicists should receive copies of those data for eventual
comparison with the annual QA data. On-site acceptance test-
ing of the machine consists of a set of alignment and dosimet-
ric verification tests. The site acceptance testing procedure is
performed by the clinical physicist in cooperation with an on-
site TomoTherapy representative.
The linear accelerator and MLC mechanical alignment is
tested first. The MLC offset must be less than 1.5 mm. It
is also necessary to ensure that the linear accelerator is cen-
tered with respect to the primary collimator in the longitudi-
nal direction to within 0.5 mm. Finally, it is important to
ensure that the beam does not diverge in the longitudinal
direction more than 0.5 mm. Also, the jaw and MLC twist
should be less than 0.5 .
The treatment machine has a stationary green laser system
that is centered on the virtual isocenter, which is 70 cm out of
the bore from the actual isocenter. This facilitates patient
setup, because it is done unencumbered by the bore. All green
lasers must be accurate to within 1 mm. The home positions
of the moveable red lasers are matched to this location to
within 1 mm.
It must be verified that the couch moves perpendicular
to the gantry plane with a divergence in the International
Electrotechnical Commission-X direction of <2 mm. Diver-
gence must also be <2 mm with the couch moving to its
full extent in the International Electrotechnical Commis-
sion-Z direction. The cobra motion of the couch is also tested
at this time. The couch must be within 2 mm of its expected
horizontal position throughout the useful vertical range. In ad-
dition, the couch must be level in its fully retracted position.
The MLC characteristics are tested as a part of the machine
commissioning. The MLC response is quantified during
commissioning by way of detector analysis (10). The leaves
do not move in and out of the fan beam instantaneously but
have latencies resulting from their transit time of about 20 ms.
Volume 71, Number 1, Supplement, 2008
TomoImage verification also occurs during commission-
ing. A scan of the TomoTherapy-provided cylindrical phan-
tom, cheese phantom, with a set of density and resolution
plugs inserted should be scanned to ensure that all plugs are
visible on a normal scan with no ring, streak, or button
artifacts present in the image. The scan dose should be mea-
sured at this time and be <2.0 cGy. The largest three rows of
holes on the resolution plugs should be able to be distin-
guished from their neighbors.
As is consistent with other treatment units, commissioning
includes taking a full set of profiles in the transverse and lon-
gitudinal directions at several depths using a water tank, in
addition to a PDD measurement for each field width. The pro-
files collected with a water tank system should match the
standard model. If the profiles do not match, the beam-line
parameters should be adjusted until the shapes agree to
a gamma value of 1 that corresponds to a 2% dose difference
and 2 mm distance-to-agreement value. The 25% width of the
transverse profiles at 15 cm should match to within 1% of the
reference values. Likewise, the 50% field width should be
within 1% of the standard. The PDD profiles should be within
2% of the reference values from 10 to 200 mm.
Beam stability should be checked to ensure a rotational
variation of less than 2 mm. The output should be measured
in centigrays per minute at a 1.5 cm depth and 85 source-
to-axis distance, and the monitor chambers should be cali-
brated so that 1 monitor unit is approximately equal to 1
cGy on this display, although this is not necessary to ensure
correct output. Finally, the beam ramp-up time should be
determined to be <10 s.
After the static beam measurements have been verified,
IMRT delivery verification can be performed using the
standard factory IMRT plans. This set of six plans is set
up the same at every site. Two plans are run for each field
width, one with an on-axis target and the other with an off-
axis target. Six measurements are taken across a plane
across the central axis, with two measurements in the
high-dose region and four outside the target volume in gra-
dient regions. The measured dose should be within 3% of
the calculated in-treatment region and within 3 mm in the
gradient regions.
Before commissioning is complete, baseline values should
be acquired that can be used for future testing. Once the
machine has met all the aforementioned specifications,
a Rotational Variation procedure is run in which data
are collected from the detector during a 5-min procedure in
which the gantry is rotating constantly for 5 min while the
field is opened to the maximal jaw setting (42 mm). The
energy fluence is collected by the on-board detectors and
compared with the standard data set regularly by the Tomo-
Therapy field service engineer.
TOMOTHERAPY QA
Daily machine QA
Daily QA can be performed by qualified radiation thera-
pists but must be under the direction of a qualified medical
 Helical TomoTherapy QA d J. BALOG AND E. SOISSON
physicist. Daily QA should verify the MVCT image quality,
red and green laser positions, visible and audible indica-
tors, couch translation accuracy, energy, and integral dose
output.
After running an Airscan procedure to calibrate the de-
tector array, MVCT image quality can be confirmed on a daily
basis by noting the presence of any new imaging artifacts.
Red and green lasers are generally checked by noting their
position relative to some baseline position. Sites that choose
to treat any patients without MVCT image guidance should
be more diligent about daily laser testing.
Daily output measurements should be integrations of the
dose as the chamber and phantom pass through the beam.
This IMRT delivery verification should be in lieu of (or in
addition to) the static output measurements typically made
at the beam central axis, because the dose delivered to any
point is the integration of dose from the start to the end of
patient motion. Integral dose measurements made with the
phantom setup at the virtual isocenter test the couch and laser
accuracy, the beam output, and the longitudinal field width.
Daily output checks can be done for one treatment field width
with a tolerance of 3% for physicist notification and 5% for
halting treatment.
In addition to a rotational output check, daily energy ver-
ification is also recommended, as well as a check of the
displayed monitor units per minute. Energy is generally mea-
sured by taking a ratio of the measurements at two different
depths and ensuring that the ratio of these values is within
2% of the baseline. Any major shifts in the monitor units
per minute (more than 2%) should also be reported to
a physicist.
Monthly machine QA
A qualified clinical medical physicist should perform QA
tests on a monthly basis. The monthly QA should include
more comprehensive tests of those parameters included in
the daily tests, as well as testing couch motion integrity and
machine synchrony.
Again, all visible and audible indicators should be checked
monthly. The bunker door is interlocked and should be in-
cluded in the monthly QA program. Likewise, the numerous
emergency-off buttons should be cycled through the monthly
QA program.
More comprehensive laser testing should be done at the
monthly QA testing. An easy test is to center the cheese phan-
tom on the virtual isocenter and then acquire TomoImages.
Several slices should be selected in front of the virtual isocen-
ter and the same number behind it. The resultant images
should confirm that the phantom image is centered. The radi-
opaque markers present on the phantom center should be
viewable on the center slice.
The extent of imaging QA should depend on how the sys-
tem is being used. If MVCT images are regularly used for
treatment planning, it is important to ensure that the CT num-
bers remain constant and that the images are void of any
significant artifacts. It is necessary only to perform a qualita-
tive assessment of overall image quality for image fusion
S115
purposes only. Using density and image resolution plugs
in the cheese phantom, high- and low-contrast resolution,
noise, and uniformity can be quantified, if desired.
A measure of beam energy by sampling the output ratios at
two depths should be obtained. The monthly energy ratio
should be within 2% of the baseline. TomoTherapy recom-
mends taking measurements at 10- and 20-cm depths in solid
water and comparing both to a measurement at 1.5 cm for
completeness. In addition, the static integral dose output at
1.5 cm should be within 2% of the expected value.
Intensity-modulated RT plan verification should be per-
formed using a standard plan. An absolute dose measurement
should be taken in the high-dose region and should be within
3% of the calculated dose. It is important to test the plans
run for all commissioned field widths. Verifying a plan run
with one field width does not ensure that plans run with all
field widths are within the specifications. All field widths
should be verified in this manner on a schedule deemed rea-
sonable by the user.
The moving couch presents many QA challenges. The pa-
tient would be overdosed 1% if the couch traveled 1% too
slow, because all treated areas would be within the primary
beam 1% longer. Additionally, the patient areas would even-
tually be mistreated as the couch-speed error continued. A
5% speed error for a total treatment length of 20 cm would
result in a 1-cm positional error at the end of treatment.
The most dangerous error possible with tomotherapy would
be for the couch to stop during treatment. Therapists should
be instructed to verify that the couch position continuously
changes during treatment by observing the graphical user
interface readout. However, that relies on the manufacturers
system properly displaying such information and is not inde-
pendent. Visual verification is difficult because of the slow
speed (<1 mm/s). The manufacturer has extensive verifica-
tion in the couch control, but clinical testing is important.
The clinical physicist should independently verify couch
motion during treatment at least once a month.
Monthly integral dose output and longitudinal beam profile
shapes should be checked at a single depth for each commis-
sioned field width, because they are so important for the inte-
gral dose delivered. A 1-mm profile change for a 10-mm field
width would result in an approximate 10% dose change. The
profile shape should be analyzed for each commissioned field
width. This should include an analysis of the full width half
maximum of each profile to submillimeter accuracy. Gener-
ally, field widths are checked using one of two methods. To-
pographic procedures using an ion chamber passing through
the beam and resultant charge profiles can be measured. In ad-
dition, film can be used by irradiating it with a static field for
all three field widths. With the film at 85 cm source-to-axis
distance, the full width half maximum of the Y-axis film pro-
file should match the nominal field to within 1%.
Some measure of the transverse profile shape should be
quantified on a monthly basis to ensure that no indications
of target failure are present. Off-axis ratios should be within
2% of expected values. One method to record lateral profile
S116 I. J. Radiation Oncology d Biology d Physics
constancy is to use film. Devices are also available from var-
ious manufacturers for this purpose.
The couch and gantry synchrony can be tested using film
as described by Fenwick et al. (6). Alternatively, they can
be tested using the TomoTherapy-supplied multichannel
electrometer that can sample as fast as every 100 ms, which
allows output vs. gantry position and output vs. couch posi-
tion to be analyzed (7).
Annual machine QA
Annual QA measurements should be performed by aquali-
fied clinical physicist. Annual testing should mimic the tomo-
therapy commissioning procedures and specifications but be
adapted to use the equipment and QA tools available to the
physicist performing the tests. The physicist should refer to
the machine commissioning section for specific procedures
and specifications. Some details of the annual QA testing
are described in the following paragraphs.
First, static beam data should be collected using a water
tank. Longitudinal profile shapes at the standard commis-
sioning depths (1.5, 5.0, 10.0, 15.0, and 20.0 cm) should be
measured and compared with initial commissioning data.
The transverse field profiles, cone profiles, at commission-
ing depths should also be measured. A Task Group report 51-
type calibration can be performed for a static beam and has
been described previously (12), or another check of machine
output should be performed.
Annual measurements should include a check of the
beam geometry (11). All tests described in the machine
commissioning should be included. The linear accelerator
and MLC alignment can be checked as described in To-
moTherapy Treatment Planning Commissioning and Ac-
ceptance Testing but using film instead of the detector if
no software to analyze the detector data is available. Most
of the necessary .xml files for the tests performed in
commissioning should be located in the hard drive of the
operators station computer, if they are not already listed
in the database, and can be used in the annual testing.
The beam geometry should be consistent with the commis-
sioning specifications.
Image parameters such as resolution, geometric accuracy,
density, and dose should also be verified. Again, the extent of
this testing is up to the discretion of the user.
Demanding, but clinically realistic, IMRT plans should
be delivered either annually or whenever beam changes
are suspected. The PDD, longitudinal field shapes, trans-
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Volume 71, Number 1, Supplement, 2008
verse field shape, and MLC response could all change
within tolerances, but the combined effect on a treatment
might not be clear. The clinical physicist should anticipate
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treatment delivery.
Patient-specific QA
Patient-specific QA starts by transferring the delivered
dose distribution onto a phantom using an integrated tab
within the planning station. The user selects a previously
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The tomotherapy machine and treatment process differs
from conventional treatment accelerators in a number of
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stand the tomotherapy differences and similarities to fulfill
their role in ensuring correct technical treatment delivery.
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