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Tables
Table 1. Daily QA for Linear Accelerator

Linear Accelerator Daily QA1-2

Procedure Non IMRT IMRT SRS/SBRT

Dosimetry
X-ray output constancy 3%
Electron output constancy* 3%
Mechanical
Laser localization 2mm 1.5mm 1mm
ODI at isocenter 2mm 2mm 2mm
Collimator size indicator 2mm 2mm 1mm
Safety
Door interlock Functional
Door closing safety Functional
Audiovisual monitors Functional
Stereotactic interlocks N/A N/A Functional
Radiation area monitor (if used) Functional
Beam on indicator Functional

*Only done weekly, except for machines with specific e-monitoring requiring daily checks.
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Table 2. Monthly QA for Linear Accelerator

Linear Accelerator Monthly QA1-2
Procedure Non IMRT IMRT SRS/SBRT
Dosimetry
X-ray output constancy 2%
Electron output constancy 2%
Backup monitor chamber constancy 2%
Typical dose rate output constancy N/A 2% (IMRT dose rate) 2% (stereo dose rate)
Photon beam profile constancy 1%
Electron beam profile constancy 1%
Electron beam energy constancy 2%/2mm
Mechanical
Light/radiation field coincidence 2mm or 1% on a side
Light/radiation field coincidence 1mm or 1% on a side
(asymmetric)
Distance check (laser to pointer) 1mm
Gantry/Collimator angle indicator* 1.0°
Accessory trays 2mm
Jaw position indicator (symmetric) 2mm
Jaw position indicator (asymmetric) 1mm
Cross-hair centering 1mm
Treatment couch position indicators 2mm/1° 2mm/1° 1mm/0.5°
Wedge placement accuracy 2mm
Compensator accuracy 1mm
Latching of wedges/block tray Functional
Localizing lasers +/- 2mm +/- 1mm < +/- 1mm
Safety
Laser-guard interlock test Functional
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Respiratory Gating
Beam output constancy 2%
Phase, amplitude beam control Functional
In-room respiratory monitoring system Functional
Gating interlock Functional
*At cardinal angles (digital only)
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Table 3. Annual QA for Linear Accelerator

Linear Accelerator Annual QA1
Procedure Non-IMRT IMRT SRS/SBRT
Dosimetry
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 arc rotation mode (range: 0.5-10 MU/deg) N/A N/A MU set vs delivered = 1.0 MU or
2%. Gantry arc set vs delivered =
1.0° or 2%
(whichever greater for both)
X-ray/electron output calibration (TG 51) +/- 1% (absolute)
Spot check of FS dependent output factors for x-ray 2% for FS < 4x4 cm2,
(2 or more FS’s) 1% > 4x4 cm2
Output factors for electron applicators +/- 2% from baseline
X-ray beam quality (PDD10 or TMR 2010) +/- 1% from baseline
Electron beam quality (R50) +/- 1mm
Physical wedge transmission factor +/- 2%
X-ray MU linearity 2% > 5 MU +/- 5% (2-4 MU) +/- 5% (2-4 MU)
+/- 2% > 5 MU +/- 2% > 5 MU
Electron MU linearity +/- 2% > 5 MU
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 vs gantry angle +/- 1% from baseline
Arc mode (expected MU, degrees) +/- 1% from baseline
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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
Mechanical
Collimator 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 isocenter +/- 2mm from +/- 2mm from baseline +/- 1mm from baseline
baseline
Table top sag 2mm from baseline
Table angle 1°
Table travel maximum range movement +/- 2mm
(in all directions)
Stereotactic accessory lockouts, etc. N/A N/A Functional
Safety
Follow manufactures test procedures Functional
Respiratory
Gating
Beam energy constancy 2%
Temporal accuracy of Phase/Amplitude gate on 100ms of expected
Calibration of surrogate for respiratory 100ms of expected
phase/amplitude
Interlock testing Functional

Table 4. CT Simulator QA
Procedure
Alignment of gantry lasers with center of
imaging plane
CT number accuracy
Image noise
In plane spatial integrity
Orientation of gantry lasers with respect
to the imaging plane*
Spacing of lateral wall lasers with respect
to the imaging plane*
Orientation of wall lasers to imaging
plane*
Orientation of ceiling laser to imaging
plane*
Orientation of CT table top to imaging
plane (Monthly or when daily laser QA
reveals rotational problems)
Table vertical and longitudinal motion
CT number accuracy
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CT Simulator QA3
Test Objective Tolerance Limits
Daily QA
Verify proper identification of scan plan +/- 2mm
with gantry lasers
For water CT number for water 0 +/- 5 HU
Manufacturer specifications
X or Y direction +/- 1mm
Monthly QA
Verify gantry lasers are parallel and +/- 2mm over the length of laser
orthogonal with the imaging plane over projection
the full length of projection
Verify lateral wall lasers are accurately +/- 2mm
spaced from scan plane
Verify wall lasers are parallel and +/- 2mm over the length of the laser
orthogonal with the imaging plane over projection
the full length of laser projection
Verify the ceiling laser is orthogonal with +/- 2mm over the length of the laser
the imaging plane projection
Verify that the CT table top is level and +/- 2mm over the length and width of the
orthogonal with the imaging plane table top
Verify the table long motion according to +/- 1mm over the range of table motion
digital indicators is accurate and
reproducible
4-5 different materials tested monthly For water, 0 +/- 5 HU
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In plane spatial integrity Both x and y directions +/- 1mm

Field uniformity (most common used kVp +/- 5 HU
settings)
SemiAnnual QA
Sensitivity profile width Verify that radiation profile width meets +/- 1mm of nominal value
manufacturer specs
Annual QA
Table indexing and position Verify table index/position accuracy +/- 1mm over the scan range
under scanner control
Gantry tilt accuracy Verify gantry tilt indicators +/- 1° over gantry tilt range
Gantry tilt position accuracy Verify gantry accurately returns to +/- 1° or +/- 1mm from nominal position
nominal position after tilting
Scan localization Verify accuracy of scan localization from +/- 1mm over the scan range
pilot images
Radiation profile width Verify rad profile width meets Manufacturer specifications
manufacturer specifications
CT number accuracy Electron density phantom For water, 0 +/- 5 HU
Field uniformity (other used kVp settings) +/- 5 HU
Electron density to CT number conversion Test done annually or after calibration Consistent with commissioning results
and test phantom manufacturer specs
Spatial resolution Manufacturer specifications
Contrast resolution Manufacturer specifications
After Replacement of Major Generator Component
Generator tests Verify proper operation Manufacturer specs or report #39
*Monthly and after laser adjustments
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Table 5. QA of Instruments
Instruments QA4
Instrument QA Procedures
Ionization Chambers and Electrometers  All facilities must have to act as their primary standard
 Submitted to ADCL for calibration at least every 2 years
 Recommended to have additional ion
chamber/electrometer to inter-compare with primary
instrument at least twice a year
 Inter comparisons should be done before and after
primary instrument sent to ADCL
Beam Scanning Systems  Functionality of scanning detectors, accuracy, and
reproducibility of moving in x, y, z directions and
functionality in the software
 When software upgrades released, a subset of
commissioning testing may need to be repeated
Ruler  Calibration traceable to the national institute of standards
and technology (NIST)
Thermometers and Barometers  Need to have at least 2 of each instrument, with one set
as a reference
 NIST traceable is advised
 Inter-comparisons should be performed at time of
purchase and at least semi-annually
Diodes, MOSTFETs, TLDs, and Film  QA for diodes/MOSTFETs monthly
 TLDs often depend on use
 QA film dependent on use
Survey Meters  Yearly calibration
 Daily battery check
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 Daily constancy check (using low activity radioactive

check source)

Table 6. Imaging QA
QA of Imaging Systems1
Procedure Non-SRS/SBRT Tolerances SRS/SBRT Tolerances
Daily QA:
Planar kV and MV imaging
Collision interlocks Functional Functional
Positioning/Repositioning < 2mm < 1mm
Imaging & Tx Coordinate Coincidence < 2mm < 1mm
Daily QA:
Cone-beam CT (kV and MV)
Collision interlocks Functional Functional
Imaging & Tx Coordinate Coincidence < 2mm < 1mm
Positioning/Reposition < 1mm < 1mm
Monthly QA:
Planar MV Imaging
Imaging & Tx Coordinate Coincidence < 2mm < 1mm
Scaling < 2mm < 2mm
Spatial Resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and Noise Baseline Baseline
Monthly QA:
Planar kV Imaging
Imaging & Tx Coordinate Coincidence < 2mm < 1mm
Scaling < 2mm < 1mm
Spatial Resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and Noise Baseline Baseline
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Monthly QA:
Cone-beam CT (kV and MV)
Geometric distortion < 2mm < 1mm
Spatial Resolution Baseline Baseline
Contrast Baseline Baseline
HU Constancy Baseline Baseline
Uniformity and Noise Baseline Baseline
Annual QA:
Planar MV Imaging
Full range of travel SDD +/- 5mm +/- 5mm
Imaging dose Baseline Baseline
Annual QA:
Planar kV Imaging
Beam quality/energy Baseline Baseline
Imaging dose Baseline Baseline
Annual QA:
Cone-beam CT (kV and MV)
Imaging dose Baseline Baseline
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Table 7. Acceptance Testing of TPS

Treatment Planning System QA5
Daily
Error Log Review any error messages or hardware malfunctions and keep
log of changes
Weekly
Computer files Verify integrity of RTP system data files
Review clinical planning Review clinical treatment planning activity
Monthly
CT data input Review imported CT data into TPS to verify geometric
accuracy, CT number consistency, and electron density
Problem review Review the RTP problems and prioritize to be solved
Review of RTP system Review current configuration and status of all RTP system
software, hardware, and data files
Annual
Dose calculations Annual checks, review acceptability of agreement between
measured and calculated doses for each beam/source
Critical software tools Review BEV/DRR generation and plot accuracy, CT geometry,
density conversions, DVH calcs, other critical tools, machine-
specific conversions, data files, and other critical data
Data and I/O devices Review functioning accuracy of CT input, MR input, printers,
plotters, and other output devices
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Table 8. MLC QA
MLC QA2
Test Tolerance
Patient Specific
Check of MLC generated field vs DRR 2mm
Double check of MLC field by therapists for each fraction Excepted field
On-line imaging verification for patient on each infraction Physician discretion
Port film approval before second fraction Physician discretion
Quarterly
Setting vs light field vs radiation field (for 2 designated patterns) 1mm
Testing network system Expected fields over network
Check of interlocks All must be operational
Annually
Setting vs light vs radiation field for patterns over range of 1mm
gantry and collimator angles
Water scan of set patterns 50% radiation edge within 1mm
Film scans to evaluate interleaf leaking and abutted leaf Interleaf leakage < 3%
transmission Abutted leakage < 25%
Review of procedures and in-service with therapists All operators must fully understand operation and procedures
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Table 9. Acceptance Testing for Remote Afterloaders

Acceptance Testing for Remote Afterloaders2
Functional performance  Console functions: main power, battery power, source
on/off, door open/closed
 Source control: source dwell time and retraction,
unplanned interruption, emergency shutoff
 Battery voltage
 Timer
 Decay correction
 Multichannel indexer: proper source sequencing and
channel selection
 Backup systems: proper functioning during simulated
power failures or loss of air pressure (pneumatically
driven devices)
 Radiation detectors proper functioning
Facility check and survey  Door interlocks
 Radiation warning lights
 Patient viewing and communication
 Radiation survey: should meet NRC regulations and
leakage radiation rates
Source calibration and transport  Check of source specifications, leak testing, calibration,
transport to the applicators, autoradiograph of simulated
source positions, and isodose distribution to determine
anistrophy
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Table 10. IMRT QA

IMRT QA6
Radiation Safety  Common to have 3-4x the number of MU for IMRT
compare to conventional
 Primary barrier not a concern
 Secondary barrier required to handle leakage radiation
especially above 10 MV
Treatment Planning  Commissioned for IMRT by verifying that the dose
predicted by the planning system is accurate within
acceptable limits
 Geometric test patterns with predictable or known dose
are performed
Machine Characteristics  MLC
 Dose delivery
Patient-Specific Dose Verification  Must irradiate phantom to verify dose distribution for
each course, done by:
o Point dose measurements for single field (film,
ion chamber, diodes)
o Point dose measurements for ALL fields
(composite film, ion chamber)
o Planar dose measurements for single field
(specified depth in phantom, using array of
diodes)
o Planar dose measurements for multiple fields
(typically using film)
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Table 11. Dynamic Wedge QA

Dynamic/Universal/Virtual Wedge QA1
Frequency Procedure Dynamic Universal Virtual
Daily Morning checkout run Functional
for one angle
Monthly Wedge factor for all C.A. axis 45° or 60° C.A. axis 45° or 60° 5% from unity,
energies WF (within 2%) WF (within 2%) otherwise 2%
Annual Check for wedge angle Check of offcenter
for 60°, full field and ratios at 80% field width
spot check for at 10cm to be within 2%
intermediate angle,
field size
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Table 12. Brachytherapy Source QA

Brachytherapy Source QA7
Type of Source Test Frequency Tolerance
Phyical/chemical form Initial purchase Documented
Long half-life: Description Source encapsulation Initial purchase Documented
Radionuclide distribution and Initial purchase Documented
source uniformity
Mean of batch Initial purchase 3%
Long half-life: Calibration Deviation from mean Initial purchase 5%
Calibration verification Every use Visual check of color code or
measurement in calibrator
Short half-life: Description Physical/chemical form Initial purchase Documented
Source encapsulation Initial purchase Documented
Mean of batch Every use 3%
Short half-life: Calibration Deviation from mean Every use 5%
Radionuclide distribution and Every use Visual check, autoradiograph,
source uniformity or ionometric check
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Table 13. Intracavity Source and Applicator QA

Intracavity Source and Applicator QA7
Procedure Endpoint Frequency
Evaluate dimensions/serial number Source identity physical length and Initially
diameter
Superposition of auto and transmission Active source length and uniformity, Initially
radiographs capsule thickness accuracy of source
construction
Source leak test Capsule integrity NRC requires leak testing, generally 6
month intervals
Source calibration Source strength Initially, annual
Dosimetric evaluation of applicator Magnitude and geometric characteristics Initially
of shielding effect
Orthogonal radiographs of applicators Correct source position, mechanical Initially,
integrity, internal shielding positioning annually
coincidence of dummy
and radioactive source
Measure applicator dimensions Correct diameter and length, correct Initially,
diameter of all colpostat caps and cylinder Annually
segments
Source inventory Correct source number Quarterly
Source preparation area survey Safety of brachytherapy personnel As needed
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Table 14. Radiographic Simulator QA (Daily, Monthly, Annually)

Radiographic Simulator QA1
Procedure Tolerance
Daily
Localizing lasers 2mm
Distance indicator (ODI) 2mm
Monthly
Field size Indicator 2mm
Gantry/collimator angle indicator 1°
Cross-hair centering 2mm diameter
Focal spot-axis indicator 2mm
Fluoroscopic image quality Baseline
Emergency collision/avoidance Functional
Light/radiation field coincidence 2mm or 1°
Film processor sensitometry Baseline
Annual
(Mechanical Checks)
Collimator rotation isocenter 2mm diameter
Gantry rotation isocenter 2mm diameter
Couch rotation isocenter 2mm diameter
Coincidence of collimator, gantry, couch axes, and isocenter 2mm diameter
Tabletop sag 2mm
Vertical travel of couch 2mm
Annual
(Radiographic Checks)
Expose rate Baseline
Tabletop exposure with fluoroscopy Baseline
kVp and mAs calibration Baseline
High and Low-contrast resolution Baseline
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