Patrick Sheil

Dos 542: Quality Assurance

Daily Quality Assurance (LINAC)1,2

Procedure: Non-IMRT IMRT SRS/SBRT

Dosimetry:
Electron Output Constancy (Weekly) 3%
X-ray Output Constancy (All Energies) 3%

Mechanical:
Collimator Size Indicator 2mm 2mm 1mm
Distance Indicator (ODI) @ISO 2mm 2mm 2mm
Laser localization 2mm 1.5mm 1mm

Safety:
Audio & Visual Monitors Functional
Beam on Indicator Functional
Door Closing Safety Functional
Door Interlock (Beam off) Functional
Radiation Area Monitor Functional
Stereotactic Interlocks (lockout) N/A N/A Functional
 Monthly Quality Assurance (LINAC)1,2
Procedure: Non-IMRT IMRT SRS/SBRT
Dosimetry:
Backup monitor chamber constancy 2%
Electron output constancy (weekly) 2%
X ray output constancy (all energies) 2%
Photon beam profile constancy 1%
Electron beam profile constancy 1%
Electron beam energy constancy 2% / 2mm
Typical dose rate output constancy N/A 2% 2%

Mechanical:
Light/Radiation Field Coincidence 2mm or 1% on side
Light/Radiation Field Coincidence (asymmetric) 1mm or 1% on side
Distance Check Device for Lasers Compared with Front 1mm
Pointer
Gantry/Collimator Angle Indicators 1.0
Accessory Trays (i.e., port film graticle tray) 2mm
Jaw Position Indicators (symmetric) 2mm
Jaw Position Indicators (asymmetric) 1mm
Cross Hair Centering (walkout) 1mm
Treatment Couch Position Indicators 2mm/1 2mm/1 1mm/0.5
Wedge Placement Accuracy 2mm
Compensator Placement Accuracy 1mm
Latching of Wedges, Blocking Tray Functional
Localizing Lasers +/- 2mm +/-1mm <+/-1mm

Respiratory Gating:
Beam output constancy 2%
Phase, amplitude beam control Functional
In-room respiratory monitoring system Functional
Gating Interlock Functional

Safety:
Laser guard-interlock test Functional
 Annual Quality Assurance (LINAC)1,2
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 rotation mode (range: 0.5-10 MU/deg) N/A N/A 1.0 MU or 2%

X-ray/Electron output calibration (TG-51) +/-1% (absolute)

Spot check of field size dependent output factors for X- 2% for Field Size < 4x4cm2, 1% 4x4cm2
ray (two or more FSs)
Output factors for electron applicators (spot check of +/-2% from baseline
one applicator/energy)
X-ray beam quality (PDD or TMR) +/-1% from baseline
Electron beam quality +/-1mm
Physical wedge transmission factor constancy +/-2%
X-ray monitor unit linearity (output constancy) +/-2% 5MU +/-5% (2-4MU), +/- +/-5% (2-4MU), +/-
2% 5MU 2% 5MU
Electron monitor unit linearity (output constancy) +/-2% 5MU
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 vs. gantry +/-1% from baseline
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

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 +/-1mm from baseline
baseline baseline
Table top sag 2mm from baseline
Table angle 1
Table travel maximum range movement in all +/-2mm
directions
Stereotactic accessories, lockouts, etc. N/A N/A 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

Safety:
Follow manufacturers test procedures Functional
 SIMULATOR QA2,3
DAILY
Procedure Tolerance
Electromechanical Component
Localizing Lasers 2mm
Alignment of gantry lasers with center of imaging plane 2mm
Distance indicator (ODI) 2mm
Image Performance
CT number accuracy (for water) 0 5 HU
Image noise Manufacturer specifications
In plane spatial integrity (X or Y direction) 1mm

MONTHLY
Electromechanical Component
Door Interlock Functional
Equipment Limit Switches Functional
Beam On Lights Functional
Field Size Indicator 2mm
Gantry/Collimator angle indicators 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
Orientation of gantry lasers 2mm
Spacing of lateral wall lasers with respect to lateral gantry lasers
2mm
and scan plane
Orientation of wall lasers 2mm
Orientation of the ceiling laser 2mm
Orientation of the CT scanner tabletop 2mm
Table vertical and longitudinal motion 1mm
 Image Performance
Field uniformity (most commonly used kVp) Within 5 HU
CT number accuracy (Multiple different materials) Baseline
In plane spatial integrity X & Y directions 1mm

ANNUAL
Mechanical
Collimator, Gantry, Couch rotation isocenter 2mm diameter
Coincidence of collimator, gantry, couch axes, and isocenter 2mm diameter
Tabletop sag 2mm
Vertical travel of couch 2mm
Electromechanical Components
Table indexing and position 1mm
Gantry tilt accuracy 1
Gantry tilt position accuracy 1 or 1mm
Scan localization 1mm
Radiation profile width Manufacturer specifications
Sensitivity profile width *semiannual* 1mm of nominal value
Generator tests Manufacturer specifications (or Report No. 39)
Image Performance
CT number accuracy electron density phantom Baseline
Field uniformity other used kVp settings Within 5 HU
Electron density to CT number conversion Manufacturer specifications
Spatial resolution Manufacturer specifications
Contrast resolution Manufacturer specifications
Radiographic
Exposure rate Baseline
High- and low-contrast resolution Baseline
kVp and mAs calibration Baseline
Tabletop exposure with fluoroscopy Baseline
 IMAGING QA1
DAILY
Tolerance
Procedure Non-SRS/SBRT SRS/SBRT
Collision interlocks Functional Functional
CBCT Positioning/repositioning 2mm 1mm
Imaging and treatment coordinate 1mm 1mm
coincidence
Collision interlocks Functional Functional
Planar kV/MV Positioning/repositioning 2mm 1mm
Imaging and treatment coordinate
2mm 1mm
coincidence (single gantry angle)

MONTHLY
Geometric distortion 2mm 1mm
Spatial resolution Baseline
CBCT Contrast Baseline
HU constancy Baseline
Uniformity & noise Baseline
Imaging & treatment coordinate
2mm 1mm
coincidence (4 cardinal angles)
Planar kV/MV Scaling 2mm 2mm (MV) / 1mm (kV)
Spatial resolution Baseline
Contrast Baseline
Uniformity & noise Baseline

ANNUAL
Planar MV Full range of travel SDD 5mm
Imaging dose Baseline
CBCT & Planar kV Beam quality/energy Baseline
Imaging dose Baseline
 INSTRUMENT QA4
Procedure Tolerance/Frequency
Ionization chamber & electrometer Bi-annual (Every 2 years)
Thermometers & Barometers Time of purchase, semi-annually, device gives skeptical reading
Diodes Initial install, monthly
TLD Initial install, monthly & dependent on use
Film Initially, monthly & dependent on use
Survey Meters Yearly calibration, daily battery & constancy check

TREATMENT PLANNING SYSTEM QA5

Topic
CT Input
Anatomical Description
Beam Description
Photon Beam Dose Calculations
Electron Beam Dose Calculations
Brachytherapy Dose Calculations
Dose Display, DVHs
Test
Create anatomical description based on a standard set of CT scans
provided by the vendor, in the format which will be employed by
the user
Create a patient model based on the standard CT data discussed
above. Contour the external surface, internal anatomy, etc. Create
3-D objects & display
Verify all beam technique functions work, using a standard beam
description provided by the vendor
Perform dose calculations for a standard photon beam dataset.
Tests should include various open fields, different SSDs, blocked
fields, MLC-shaped fields, inhomogeneity test cases, multi-beam
plans, asymmetric jaw fields, wedged fields & others
Perform a set of dose calculations for a standard electron beam
dataset. Include open fields, different SSDs, shaped fields,
inhomogeneity test cases, surface irregularity test cases & others
Perform dose calculations for single sources of each type, as well
as several multi-source implant calculations, including standard
implant techniques such as a GYN insertion with tandem &
ovoid, two-plane breast implant
Display dose calculation results. Use a standard dose distribution
provided by the vendor to verify that the DVH code works as
described. User-created dose distributions may also be sued for
additional tests
 IMRT QUALITY ASSURANCE PROGRAM6
Frequency Procedure Tolerance
Before first treatment Individual field verification, plan 3% (point dose), other per clinical
verification significance
Daily Dose to a test point in each IMRT field 3%
Static field vs. sliding window field dose 3% in dose delivery
Weekly distribution as a function of gantry and
collimator angles
All commissioning procedures: stability of 3% in dose delivery, other per clinical
leaf speed, leaf acceleration and significance
deceleration, multi-leaf collimator
Annually transmission, leaf positional accuracy,
static field vs. sliding window field as a
function of gantry and collimator angles,
standard plan verification

Brachytherapy: Remote Afterloading7

Daily Tests:
Checking all equipment: door interlocks, radiation on lights, emergency off button, treatment interrupt button, audiovisual monitors,
room radiation monitors, dtect missing or misconnected applicators or transfer tubes should be tested
Treatment unit displays of time, date, current source strength verified
Test source-position accuracy, dwell-time accuracy, normal termination of treatment (Test-jig)
Mechanical integrity of applicator connections to treatment unit verified
Availability & integrity of emergency response equipment verified

Monthly Tests:
Source positioning accuracy
Verification of source activity
Integrity of applicators used most often checked for mechanical damage, ease of coupling, kinks, & mechanical deformation
Transfer tubes inspected & measured
Timer checked to verify accuracy & linearity
Power failure test (interruption)
 Brachytherapy: Applicators7
Tests:
All parts fit together & work properly

Radiograph with radio-opaque dummy markers inside should be taken

An autoradiograph should be taken to verify positional accuracy of the applicator to understand geometry of applicator for a remote
after loading system
Retain images for regulatory purposes and future reference/comparisons

Brachytherapy: Sources7
Tests:
Location of all sources must be tracked

Periodic inventory (quarterly to yearly)

Leak testing is required before initial use and on regular basis after (semi-annually)

References:
1. Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins.
2. 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
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): 2762-2791.
http://dx.doi.org/10.1118/1.1609271.
4. Thomason C, Lenards N. QA of Instruments. [SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry Program; 2017.
5. Thomason C, Lenards N. QA of TPS, IMRT, SRS. [SoftChalk]. La Crosse, WI: UW-L Medical Dosimtry Program; 2017.
6. Khan F, Gibbons J. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2014.
7. Thomason C, Lenards N. QA Brachytherapy. [SoftChalk]. La Crosse, WI: UW-L Medical Dosimtry Program; 2017.