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Lisa Spanovich
DOS 542 Quality Assurance

Daily - Linear
Accelerator QA1
Procedure Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray consistency (all energies) 3%
Electron output consistency 3%
Mechanical
Laser localization 2mm 1.5mm 1mm
Distance indicator ODI@ Iso 2mm 2mm 2mm
Collimator size indicator 2mm 2mm 1mm
Safety
Door interlock Functional
Door closing safety Functional
Audiovisual monitor Functional
Stereotactic interlocks (lockout) N/A N/A Functional
Radiation area monitor (if used) Functional
Beam on indicator Functional

Monthly Linear
Accelerator QA1
Procedure Non-IMRT IMRT SRS/SBRT
Dosimetry
X-ray output
Electron output 2%
Backup monitor
Typical dose rate output consistency N/A 2% (@IMRT DR) 2% (@ IMRT DR,
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
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Lisa Spanovich
DOS 542 Quality Assurance
Light/radiation field coincidence 1mm or 1% on a
side
Distance check device for lasers 1mm
compared with front pointer
Gantry/collimator angle indicators 1.0
Accessory trays (i.e. port film gradicle 2mm
tray)
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
Safety
Laser guard-interlock test Functional
Respiratory Gating
Beam output constancy 2%
Phase, amplitude beam control Functional
In-room respiratory monitoring system Functional
Gating interlock Functional

Annual - Linear
Accelerator 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 are rotation mode (range: 0.5-10 N/A N/A MU set vs.
MU/deg) delivered: 1.0
mu or 2%
(whichever is
greater)
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Lisa Spanovich
DOS 542 Quality Assurance
X-ray/electron output calibration (TG-51) 1% absolute
Spot check of field size dependent output 2% for field size
factors for x-ray (2 or more FSs) < 4 x 4 cm2, 1%
4 x 4 cm2
Output factors for electron applicators(spot 2% from
check of one applicator/energy) baseline
X-ray beam quality (PDD10 or TMR1020) 1% from
baseline
Electron beam quality (R50) 1mm
Physical wedge transmission factor 2%
constancy
X-ray MU linearity (output constancy) 2% 5 MU 5% (2-4 MU), 5% (2-4 MU),
2% 5 MU 2% 5 MU
Electron MU linearity (output constancy) 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 constancy 1% from
vs. gantry angle baseline
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 2mm from 2mm from 1mm from
isocenter baseline baseline baseline
Table to sag 2mm from
baseline
Table angle 1
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Lisa Spanovich
DOS 542 Quality Assurance
Table travel maximum range movement in 2mm
all directions
Stereotactic accessories, lockouts, etc. N/A N/A Functional
Safety
Follow manufacturers test procedures Functional
Respiratory gating
Beam energy constancy 2%
Temporal /accuracy of phase/amplitude 100ms of
gate on expected
Calibration of surrogate for respiratory 100ms of
phase/amplitude expected
Interlock testing Functional

Radiation &
Patient
Safety3
Performance Test Frequency Tolerance
Parameter Objective Limits
Shielding survey To verify exposure Initially NCRP
levels around the CT- recommendations or
scanner room applicable regulatory
limits
Patient dose from CT- To verify safe dose Annually or after 20% of manufacturer
scan, CTDI delivered from the major CT-scanner specifications
scanner component
replacement

Lisa Spanovich
DOS 542 Quality Assurance
CT Simulator
QA1
Performance
Parameter
Alignment of gantry lasers
with the center of imaging
plane
Orientation of gantry lasers
with respect to the imaging
plane
Spacing of lateral wall lasers
with respect to lateral gantry
lasers and scan plane
Orientation of wall lasers
with respect to the imaging
plane
Orientation of the ceiling
laser with respect to the
imaging plane
Orientation of the CT
scanner tabletop with
respect to the imaging plane
Table vertical and
longitudinal motion
Table indexing and position
Gantry tilt accuracy
Scan localization
5
Test Objective Frequency Tolerance
Limits
To verify proper Daily 2 mm
identification of scan plane
with gantry lasers
To verify that the gantry Monthly and after 2 mm over the
lasers are parallel and laser adjustments length of laser
orthogonal with the imaging projection
plane over the full length of
laser projection
To verify that laser wall Monthly and after 2 mm
lasers are accurately spaced laser adjustments
from the scan plane. This
distance is used for patient
localization marking
To verify that the wall lasers Monthly and after 2 mm over the
are parallel and orthogonal laser adjustments length of laser
with the imaging plane over projection
the full length of laser
projection
To verify that the ceiling Monthly and after 2 mm over the
laser is orthogonal with the laser adjustments length of laser
imaging plane projection
To verify that the CT scanner Monthly or when 2 mm over the
tabletop is level and daily laser quality length and width
orthogonal with the imaging assurance tests of the tabletop
plane reveal rotational
problems
To verify that the table Monthly 1 mm over the
longitudinal motion scan of table
according to digital motion
indicators is accurate and
reproducible
To verify table indexing and Annually 1 mm over the
position accuracy under scan range
scanner control
To verify accuracy of gantry Annually 1 over the
tilt indicators gantry tilt range
To verify accuracy of scan Annually 1 mm over the
location for pilot images scan range
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Lisa Spanovich
DOS 542 Quality Assurance
Radiation profile width To verify that the radiation Annually [this test Manufacturer
profile width meets is optional if the specifications
manufacturer specifications Communications
Test Design Inc.
(CTDI) accuracy
has been verified]
Semiannually
Sensitivity profile width To verify that the sensitivity Semiannually 1 mm of
profile width meets nominal value
manufacturer specifications
Generator tests To verify proper operation of After Manufacturer
the x-ray generator replacement of specifications or
recommendations major generator Report No. 39
component

CT Simulator
Image
performance
Evaluation1
Performance Frequency Tolerance Limits
Parameter
CT number accuracy Daily- CT number for water For water, 0 5 HU
Monthly- 4-5 different
materials
Annually- electron density
phantom
Image noise Daily Manufacturer specifications
In plane spatial integrity Daily- X or Y direction 1 mm
Monthly- both directions
Field uniformity Monthly- most commonly used Within 5 HU
kvp
Annually- other used kvp
settings
Electron density to CT number Annually- or after scanner Consistent with commissioning
conversion calibration results and test phantom
manufacturer specifications
Spatial resolution Annually Manufacturer specifications
Contrast resolution Annually Manufacturer specifications
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Lisa Spanovich
DOS 542 Quality Assurance

Periodic QA
of
Radiographic
Simulators1
Frequency Procedure Tolerance
Daily Localizing lasers 2 mm
Distance indicator (ODI) 2 mm
Monthly Field size indicator 2 mm
Gantry/collimator angle indicators 1
Cross-hair centering 2 mm diameter
Focal spot-axis indicator 2 mm
Fluoroscopic image quality Baseline
Emergency/collision avoidance Functional
Light/radiation field coincidence 2 mm or 1%
Film processor sensitometry Baseline
Annual Mechanical checks
Collimator rotation isocenter 2 mm diameter
Gentry rotation isocenter 2 mm diameter
Couch rotation isocenter 2 mm diameter
Coincidence of collimator, gantry, 2 mm diameter
couch axes, and isocenter
Tabletop sag 2 mm
Vertical travel of couch 2 mm
Radiographic checks
Exposure rate Baseline
Tabletop exposure with fluoroscopy Baseline
kVp and mAs calibration Baseline
High- and low-contrast resolution Baseline
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Lisa Spanovich
DOS 542 Quality Assurance

Daily- CT- based

IGRT systems6
Quality Metric Quality Check Tolerance
Safety Collision and other interlocks Functional

Warning lights Functional

System operation and accuracy Laser/image/treatment 2 mm
isocenter coincidence OR
Phantom localization and 2 mm
repositioning with couch shift

Monthly- (or upon upgrade)

CT-based IGRT
systems6
Quality Metric Quality Check Tolerance
Geometric Geometric calibration maps Replace/refresh
OR
kV/MV/laser alignment 1 mm
Couch shifts: accuracy of 1 mm
motions
Image quality Scale, distance, and orientation Baseline
accuracy
Uniformity, noise Baseline
High contrast spatial resolution 2 mm (or 5 lp/cm)
Low contrast detectability Baseline
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Lisa Spanovich
DOS 542 Quality Assurance

Annual CT-based (if used for dose

calculation)
IGRT systems6
Quality Metric Quality Check Tolerance
Image quality CT number accuracy and Baseline
stability
Dose Imaging dose Baseline
Imaging system performance x-ray generator Baseline
Performance (kV systems only): Baseline
tube potential, mA, ms
accuracy, and linearity
Geometric Anteroposterior, medilateral, Accurate
and craniocaudal orientations
are maintained (upon upgrade
from CT to IGRT system)
System operation Long and short term planning Support clinical use and current
of resources (disk space, imaging policies and
manpower, etc.) procedures

Daily- QA for Imaging

Systems2
Procedure Non-SRS/SBRT SRS/SBRT
Planar kV and MV (EPID) Imaging
Collision interlocks Functional Functional
Positioning/repositioning 2 mm 1 mm
Imaging and treatment coordinate coincidence 2 mm 1 mm
(single gantry angle
Cone-beam CT (kV and MV)
Collision interlocks Functional Functional
Imaging and treatment coordinate coincidence 2 mm 1 mm
Positioning/repositioning 1 mm 1 mm
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Lisa Spanovich
DOS 542 Quality Assurance

Monthly- QA for Imaging

Systems2
Procedure Non-SRS/SBRT SRS/SBRT
Planar kV and MV (EPID) Imaging
Imaging and treatment coordinate coincidence 2 mm 1 mm
(4 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 coordinate coincidence 2 mm 1 mm
(4 cardinal angles)
Scaling 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity 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- QA of Imaging
Systems2
Procedure Non-SRS/SBRT SRS/SBRT
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)
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Lisa Spanovich
DOS 542 Quality Assurance
Imaging dose Baseline Baseline

Multileaf
Collimation QA1
Frequency Test Tolerance
Patient Specific Check of MLC-generated field 2 mm
vs. simulator film (or DRR)
before each field treated
Double check of MLC field by Expected field
therapists for each fraction
One-line imaging verification Physician discretion
for patient on each infraction
Portfilm approval before Physician discretion
second fraction
Quarterly Setting vs. light field vs. 1 mm
radiation field for two
designated patterns
Testing of network system Expected fields over network
Check of interlocks All must be operational
Annually Setting vs. light vs. radiation 1 mm
field for patterns over range of
gantry and collimator angles
Water scan of set patterns 50% radiation edge within 1
mm
Film scans to evaluate interleaf Interleaf leakage < 3%, abutted
leakage and abutted leaf leakage < 25%
transmission
Review of procedures and in- All operations must fully
service with therapists understand operation and
procedures
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Lisa Spanovich
DOS 542 Quality Assurance

Treatment
Planning System
and Monitor Unit
Calculations QA5
Frequency Test Tolerance
Commissioning and Understand algorithm Functional
following software
update
Single field or source isodose 2% or 2 mm
distributions
MU Calculations 2%
Test cases 2% or 2 mm
I/O system 1 mm
Daily I/O devices 1 mm
Monthly Checksum No change
Subset of reference QA test set 2% or 2 mm
(when checksums not available)
I/O system 1 mm
Annual MU Calculations 2%
Reference QA test set 2% or 2 mm
I/O system 1 mm
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Lisa Spanovich
DOS 542 Quality Assurance

Intracavitary
Source and
Applicator QA4
Procedure End Point Frequency
Evaluate dimensions/ Source identity Initially
Physical length and diameter
serial number
Superposition of auto- Active source length and Initially
uniformity, capsule thickness
and transmission Accuracy of source construction
radiographs
Source leak test Capsule integrity NRC requires leak testing,
generally at 6 month intervals
Source calibration Source strength Initially, annually
Dosimetric evaluation of Magnitude and geometric Initially
characteristics of shielding
applicator effect
Orthogonal radiographs Correct source position, Initially, annually
mechanical integrity, internal
of applicators shield positioning coincidence
of dummy and radioactive
source
Measure applicator Correct diameter and length, Initially, annually
correct diameter of all colpostat
dimensions caps and cylinder segments
Source inventory Correct source number Quarterly
Source preparation area Safety of brachytherapy As needed
personnel
survey
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Lisa Spanovich
DOS 542 Quality Assurance

Interstitial
source and
applicator QA4
Procedure End Point Frequency
Evaluate spacing and Ribbon geometry and seed quantity Initially
number of seeds/ ribbon
Source calibration Source strength Initially, each use
Strength per seed or Source strength uniformity Initially
strength per unit length
Applicator integrity Varies: Initially, annually
Metal needles: sharpness and
straightness
Templates: 0-ring integrity and hole
locations
Evaluate dummy ribbon Coincidence of dummy and Initially, annually
radioactive sources
geometry
Source leak test Capsule integrity Quarterly
Source inventory Correct source number Quarterly
Source preparation Safety or brachytherapy brachytherapy Quarterly
Area survey personnel

Brachytherapy
source QA4
Type of source Test Frequency Tolerance
Long half-life: Physical/chemical form Initial purchase Documented
description
Source encapsulation Initial purchase Documented
Radionuclide distribution Initial purchase Documented
and source uniformity
Location of radionuclide Initial purchase 1 mm
Long half-life: Mean of batch Initial purchase 3%
calibration
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Lisa Spanovich
DOS 542 Quality Assurance
Deviation from mean Initial purchase 5%, Documented
a
Calibration verification Every use
Short half-life: Physical/chemical form Initial purchase Documented
description
Source encapsulation Initial purchase Documented
Short half-life: Mean of batch Every use 3%
calibration
Deviation from meanb Every use 5%
Radionuclide distribution Every use Vc
and source uniformity
a
Visual check of source color code or measurement in a calibrator.
b
For short half-life sources this may not always be practical (see Sec. V A 2 c).
c
V, visual check, autoradiograph, or ionometric check.

Remote
Afterloading
Brachytherapy
Unit QA5
Frequency Test Tolerance
Each treatment day Room safety door interlocks, Functional
lights, and alarms
Console functions, switches, Functional
batteries, printer
Visual inspection of source Free of kinks and firmly
guides attached
Verify accuracy of ribbon Autoradiograph
preparation
Weekly Accuracy of source and dummy 1 mm
loading (dummies used for
spacing and/or
simulation/verification)
Source positioning 1 mm
At each source change Calibration 3%
or quarterly
Timer function 1%
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Lisa Spanovich
DOS 542 Quality Assurance
Check accuracy of source 1 mm
guides and connectors
Mechanical integrity of Functional
applicators (by x ray if
appropriate)
Annual Dose calculation algorithm (at 3%, 1 mm
least one standard source
configuration for each isotope)
Simulate emergency conditions
Verify source inventory

Dynamic/
Universal/
Virtual
Wedge
QA2
Frequency Procedure Dynamic Universal Virtual
Daily Morning check- Functional
out run for one
angle
Monthly Wedge factor C.A. axis 45 or C.A. axis 45 or 5% from unity,
for all energies 60 WF (within 60 WF (within otherwise 2%
2%) 2%)
Annual Check of wedge Check of off- Check of off- Check of off-
angle for 60, center ratios @ center ratios @ center ratios @
full field and 80% field width 80% field width 80% field width
spot check for @ 10 cm to be @ 10 cm to be @ 10 cm to be
intermediate within 2% within 2% within 2%
angle, field size
***Dynamic-including EDW (Varian), virtual (Siemens), universal (Elekta) wedge quality assurance.
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Lisa Spanovich
DOS 542 Quality Assurance

Periodic RTP
Process QA
Checks7
Recommended Item Comments/Details
Frequency
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
planning errors, problems, complications, difficulties. Resolve
problems
Monthly CT data input into Review the CT data within the planning system for
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
Annual 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
parameterization due to machine changes or problems
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Lisa Spanovich
DOS 542 Quality Assurance
Software changes, Checks and/or recommissioning may be required
including operating due to changes in the RTP software, any support/
system additional software such as image transfer
software, or the operating system
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Lisa Spanovich
DOS 542 Quality Assurance
References

1. Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014:396-398.
2. Klein E, Hanley J, Bayouth J, et al. Task Group 142 Report: Quality assurance for medical
accelerators. Med Phys. 2009;36(9):4197-4212. https://doi.org/10.1118/1.3613300.
3. Mutic S, Palta J, Butker E, 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):2762-2792. https://doi.org/10.1118/1.1609271.
4. Nath R, Anderson LL, Meli 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.
https://doi.org/10.1118/1.597966.
5. Kutcher GL, Coia L, Gillin M, et al. Comprehensive QA for Radiation Oncology. AAPM Report
No. 46. TG-40. Med Phys. 1994;21(4):581-618. https://doi.org/10.1118/1.597316.
6. Bissionnette 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. https://doi.org/10.1118/1.3690466.
7. 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):1773-1828. https://doi.org/10.1118/1.598373.