Alex Murray 1

DOS 542 Quality Assurance

Linear Accelerator
Daily QA
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray output constancy (all 3%
energies)
Electron output constancy
(weekly, except for machines 3%
with unique e-monitoring
requiring daily)
Mechanical
Laser localization 2mm 1.5mm 1mm
Distance indicator (ODI) @ iso 2mm 2mm 2mm
Collimator size indicator 2mm 2mm 1mm
Safety
Door interlock (beam off) Functional
Door closing safety Functional
Audiovisual monitor(s) Functional
Stereotactic interlocks (lockout) NA NA Functional
Radiation area monitor (if Functional
used)
Beam on indicator Functional
Alex Murray 2
DOS 542 Quality Assurance
Linear Accelerator
Monthly QA
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray output constancy 2%
Electron output constancy 2%
Backup monitor chamber 2%
constancy
Typical dose rate output NA 2% (@ IMRT 2% (@ stereo
constancy dose rate) dose rate, MU)
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 device for lasers 1mm
compared with front pointer
Gantry/collimator angle
indicators (@ cardinal angles) 1.0
(digital only)
Accessory trays (i.e., port film 2mm
graticle tray)
Jaw position indicators 2mm
(symmetric)
Jaw position indicators 1mm
(asymmetric)
Cross-hair centering (walkout) 1mm
Treatment couch position 2mm/1 2mm/1 1mm/0.5
indicators
Wedge placement accuracy 2mm
Compensator placement accuracy 1mm
Latching of wedges, blocking tray Functional
Localizing lasers 2mm 1mm <1mm
Safety
Laser guard-interlock test Functional
Respiratory gating
Beam output constancy 2%
Phase, amplitude beam control Functional
In-room respiratory monitoring Functional
system
Gating interlock Functional
Alex Murray 3
DOS 542 Quality Assurance
Linear Accelerator
Annual QA
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray flatness change from 1%
baseline
X-ray symmetry change form 1%
baseline
Electron flatness change from 1%
baseline
Electron symmetry change from 1%
baseline
SRS arc rotation mode (range: NA NA MU set vs
0.5-10 MU/degree) delivered: 1.0
MU or 2%
(whichever is
greater)

Gantry arc set

vs. delivered:
1.0 or 2%
(whichever is
greater)
X-ray/electron output calibration 1% (absolute)
(TG-51)
Spot check of field size dependent
output factors for x-ray (2 or more 2% for field size <4x4cm2, 1% 4x4cm2
FSs)
Output factors for electron
applicators (spot check of one 2% from baseline
applicator/energy)
X-ray beam quality 1% from baseline
Electron beam quality (R50) 1mm
Physical wedge transmission 2%
factor constancy
X-ray monitor unit linearity 2% 5 MU 5% (2-4 MU), 5% (2-4 MU),
(output constancy) 2% 5 MU 2% 5 MU
Electron monitor unity linearity 2% 5 MU
(output constancy)
X-ray output constancy vs dose 2% from baseline
rate
X-ray output constancy vs gantry 1% from baseline
angle
Electron output constancy vs 1% from baseline
gantry angle
Alex Murray 4
DOS 542 Quality Assurance
Electron and x-ray off-axis factor 1% from baseline
constancy vs gantry angle
Arc mode (expected MU, degree) 1% from baseline
TBI/TSET mode Functional
PDD or TMR and OAF constancy 1% (TBI) or 1 mm 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 2mm from 2mm from 1mm from
mechanical isocenter baseline baseline baseline
Table top sag 2mm from baseline
Table angle 1
Table travel max range movement 1mm
in all directions
Stereotactic accessories, lockout, NA NA Functional
etc.
Safety
Follow manufacturers test Functional
procedures
Respiratory gating
Beam energy constancy 2%
Temporal accuracy of 100ms of expected
phase/amplitude gate on
Calibration of surrogate for 100ms of expected
respiratory phase/amplitude
Interlock testing Functional
Alex Murray 5
DOS 542 Quality Assurance
CT Simulator
Test Specifications for Electromechanical Components
Test Objective Tolerance Limits
Daily
Alignment of gantry To verify proper identification of scan
lasers with the center of plane with gantry lasers 2mm
the imaging plane
Monthly
Orientation of gantry To verify that the gantry lasers are parallel 2mm over the
lasers with respect to the and orthogonal with the imaging plane length of laser
imaging plane projection
Spacing of lateral wall To verify that lateral wall lasers are
lasers with respect to accurately spaced from the scan plane.
lateral gantry lasers and This distance is used for patient 2mm
scan plane localization marking
Orientation of wall To verify that the wall lasers are parallel
lasers with respect to the and orthogonal with the imaging plane 2mm over the
imaging plane over the full length of laser projection length of laser
projection
Orientation of the ceiling To verify that the ceiling laser is 2mm over the
laser with respect to the orthogonal with the imaging plane length of laser
imaging plane projection
Orientation of the CT To verify that the CT scanner tabletop is 2mm over the
scanner tabletop with level and orthogonal with the imaging length of laser
respect to the imaging plane projection
plane
Table vertical and To verify that the table longitudinal
longitudinal motion motion according to digital indicators is 1mm over the
accurate and reproducible length of laser
projection
Semiannually
Sensitivity profile width To verify that the sensitivity profile width
meets manufacturer specifications 1mm of nominal
value
Annually
Table indexing and To verify table indexing and position
position accuracy under scanner control 1mm over the scan
range
Gantry tilt accuracy To verify accuracy of gantry tilt indicators 1 over the gantry
tilt range
Gantry tilt position To verify that the gantry accurately returns 1 or 1 from the
accuracy to nominal position after tilting nominal position
Scan localization To verify accuracy of scan localization 1mm over the scan
from pilot images range
Radiation profile width To verify that the radiation profile width Manufacture
meets manufacturer specifications specifications
Alex Murray 6
DOS 542 Quality Assurance
CT Simulator
Test Specifications for image performance evaluation
Tolerance Limits
CT number accuracy
DailyCT number for water
Monthlyfour to five different materials For water, 0 5 HU
Annuallyelectron density phantom
Image noise
Daily Manufacturer specifications
In plane spatial integrity
DailyX or Y direction 1mm
Monthlyboth directions
Field uniformity
Monthlymost commonly used kVp
Annuallyother used kVp settings Within 5 HU
Electron Density to CT number conversion
Annuallyor after scanner calibration Consistent with commissioning results and
test phantom manufacturer specifications
Spatial resolution
Annually Manufacturer specifications
Contrast resolution
Annually Manufacturer specifications
Alex Murray 7
DOS 542 Quality Assurance
Periodic Quality Assurance of Radiographic Simulators
Procedure Tolerance
Daily Localizing lasers 2mm
Distance indicator (ODI) 2mm
Monthly Field size indicator 2mm
Gantry/collimator angle indicators 1.0
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
Annually Mechanical checks
Collimator rotation isocenter 2mm diameter
Gantry rotation isocenter 2mm diameter
Couch rotation isocenter 2mm diameter
Coincidence of collimator, gantry, couch 2mm diameter
axes, and isocenter
Tabletop sag 2mm
Vertical travel of couch 2mm
Radiographic checks
Exposure rate Baseline
Tabletop exposure with fluoroscopy Baseline
kVp and mAs calibration Baseline
High and low contrast resolution Baseline
Alex Murray 8
DOS 542 Quality Assurance
IGRT QA
Frequency Quality metric Quality check Tolerance
Daily Safety Collision and other interlocks Functional
Warning lights Functional
System Laser/image/treatment isocenter 2mm
operation and coincidence OR
accuracy Phantom localization and 2mm
repositioning with couch shifts
Monthly or Geometric Geometric calibration maps OR Replace/refresh
upon kV, MV laser alignment 1mm
upgrade Couch shifts: accuracy of 1mm
motions
Image quality Scale, distance, and orientation Baseline
accuracy
Uniformity, noise Baseline
High contrast spatial resolution 2mm (or 5 1p/cm)
Low contrast detectability Baseline
If used for Image quality CT number accuracy and Baseline
dose stability
calculations
Annually Dose Imaging dose Baseline
Imaging system X-ray generator performance Baseline
performance (kV systems only): tube
potential, mA, ms accuracy,
linearity
Geometric Anteroposterior, mediolateral, Accurate
and craniocaudal orientations
are maintained (upon upgrade
from CT to IGRT system)
System Long and short term planning of Support clinical use and
operation resources (disk space, current imaging policies
manpower, etc.) and procedures
Alex Murray 9
DOS 542 Quality Assurance
Instrumentation QA
Tolerance
Barometers and Calibrate at time of purchase, semiannually, or when a device gives a
Thermometers suspect reading
Pressure intercomparison with nearest weather station
Inspect before each use
Ionization Submit to an ADCL every 2 years
Chamber and Intercomparison with secondary chamber/electrometer twice yearly, when
Electrometer readings show significant change, and before and after ADCL calibration
Inspect before each use
Diodes and QA on monthly basis
MOSFETS Inspect before each use
TLD and Film QA on monthly basis or based on frequency of use
Inspect before each use
Survey Meter Yearly calibration per NRC
Daily battery check
Daily constancy check with low radioactive source

Multileaf Collimation QA
Test Objective Tolerance Limits
Patient specific Check of MLC-generated field vs. simulator 2mm
film (or DRR) before each field treated
Double check of MLC field by therapists for Expected field
each fraction
Online imaging verification for patient on Physician discretion
each infraction
Port film approval before second fraction Physician discretion
Quarterly Setting vs. light field vs. radiation field for 2 1mm
designated patterns
Testing of network system Expected fields over
network
Check of interlocks All must be operational
Annually Setting vs. light vs. radiation field for patterns 1mm
over range of gantry and collimator angles
Water scan of set patterns 50% radiation edge within
1mm
Film scans to evaluate interleaf leakage and Interleaf leakage <3%,
abutted leaf transmission abutted leakage <25%
Review of procedures and in-service with All operators must fuller
therapists understand operation and
procedures
Alex Murray 10
DOS 542 Quality Assurance
Periodic RTP Process QA Checks
Item Comments/Details
Daily Error log Review report log listing system failures, error messages,
hardware malfunctions, and other problems. Triage list and
remedy any serious problems that occur during the day.
Change log Keep log of hardware/software changes.

Weekly Digitizer Review digitizer accuracy

Hardcopy output Review all hardcopy output, including scaling for plotter and
other graphics-type output.
Computer files Verify integrity of all RTP system data files and executables
using checksums or other simple software checks. Checking
software should be provided by the vendor.
Review clinical Review clinical treatment planning activity. Discuss errors,
planning problems, complications, difficulties. Resolve problems.
Monthly CT data input Review the CT data within the planning system for
into RTP system geometrical accuracy, CT number consistency also dependent
on the QA and use of the scanner , and derived electron
density.
Problem review Review all RTP problems both for RTP system and clinical
treatment planning and prioritize problems to be resolved.

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

Annually Dose calculations Annual checks. Review acceptability of agreement between

measured and calculated doses for each beam/source.
Data and I/O Review functioning and accuracy of digitizer tablet,
devices video/laser digitizer, CT input, MR input, printers, plotters,
and other imaging output devices.
Critical software Review BEV/DRR generation and plot accuracy, CT
tools geometry, density conversions, DVH calculations, other
critical tools, machine-specific conversions, data files, and
other critical data.
Variable Beam Checks and/or recommissioning may be required due to
parameterization machine changes or problems.

Software Checks and/or recommissioning may be required due to

changes, changes in the RTP software, any support/additional software
including such as image transfer software, or the operating system.
operating system
Alex Murray 11
DOS 542 Quality Assurance
General Brachytherapy Dose Calculation Commissioning Tests
Test 137Cs 192Ir 125I Others
Source entry Orthogonal film Orthogonal film Orthogonal film Stereo film seed
tests linear source seed entry, seed seed entry, entry, CT source
entry strings random seeds and seed entry, 3-
film seed entry
methods
Source library Various linear Must maintain Must maintain Specialized
description source inventory for inventory for inventory
configurations 'transient' seeds "transient" seeds procedures may
be required
Source Yes Yes Yes Yes
strength +
decay
Single source Yes Yes Yes Yes
tests
Multiple Gyn, Fletcher- 2-plane breast Volumetric Yes
source implant Suit Applicator boost implant
tests
Mixed source Yes Yes Yes Yes
type tests
Miscellaneous Low-Dose Rate Hi-Dose Rate -Stereotactic Others
Afterloader Afterloader brain implant
-Eye Plaque
-Planned Prostate
volume implants
Alex Murray 12
DOS 542 Quality Assurance
QA Tests for Brachytherapy Sources
Test Frequency Tolerance
Long half-life Physical/chemical form Initial purchase Documented
Description Source encapsulation Initial purchase Documented
Radionuclide Initial purchase Documented
distribution and source
uniformity
Location of
radionuclide
Long half-life: Mean of batch Initial purchase 3%
Calibration Deviation from mean Initial purchase 5%, Documented
Calibration verification At every use Visual check of source
color code or
measurement in a
calibrator
Short half-life: Physical/chemical form Initial purchase Documented
Description Source encapsulation Initial purchase Documented
Short half-life: Mean of batch At every use 3%
Calibration Deviation from mean At every use 5%
Radionuclide At every use Visual check,
distribution and source autoradiograph, or
uniformity ionometric check
Alex Murray 13
DOS 542 Quality Assurance
Intracavitary source and applicator quality assurance
End point Frequency
Evaluate Source identity Initially
dimensions/serial Physical length and diameter
number
Superposition of auto- Active source length and uniformity, Initially
and transmission capsule thickness accuracy of source
radiographs construction
Source leak test Capsule integrity NRC requires leak
testing, generally 6
mo. intervals
Source calibration Source strength Initially, annually
Dosimetric evaluation of Magnitude and geometric characteristics Initially
applicator of shielding effect

Orthogonal radiographs Correct source position, mechanical Initially, annually

of applicators integrity, internal shielding positioning
coincidence of dummy and radioactive
source
Measure applicator Correct diameter and length, correct Initially, annually
dimensions diameter of all colpostat caps and
cylinder segments
Source inventory Correct source number Quarterly
Source preparation area Safety of brachytherapy personnel As needed
survey
Alex Murray 14
DOS 542 Quality Assurance
Interstitial source and applicator quality assurance
End point Frequency
Evaluate spacing and # Ribbon geometry and seed quality Initially
of seeds/ribbon
Source calibration Source strength Initially, each use
Strength per seed or Source strength uniformity Initially
strength unit length
Applicator integrity Varies: Initially, annually
Metal needles: sharpness and straightness
Templates: o-ring integrity and hole
locations
Evaluate dummy ribbon Coincidence of dummy and radioactive Initially, annually
geometry sources

Source leak test Capsule integrity NRC requires leak

testing, generally 6
mo. intervals
Source inventory Correct source number Quarterly
Source preparation area Safety of brachytherapy personnel As needed
survey
Alex Murray 15
DOS 542 Quality Assurance
Reference

1. Klein E, Hanley J, Baymouth J. 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 F. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams and
Wilkins; 2014.
3. Bissonnette J, Balter P, 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 of Instruments [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. doi:10.1118/1.598373.
6. Nath R, Anderson LL, Miel JA, et al. Code of practice for brachytherapy physics: Report of
the AAPM Radiation Therapy Committee Task Group No. 56. Med Phys. 1997;24(10):1557-
1598. Doi:10.1118/1.597966.