Table 1.

Linear Accelerator Quality Assurance: Daily1

Machine-type tolerance
Procedure
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-Ray output constancy (all energies)
Electron output constancy (weekly, except for machines with 3%
unique e-monitoring requiring daily)

Mechanical
Laser localization 2 mm 1.5 mm 1 mm
Distance indicator @ Iso 2 mm
Collimator size indicator 2 mm 1 mm

Safety
Door interlock (beam off)
Door closing safety Functional
Audio-visual monitor
Stereotactic interlocks (lockout) NA Functional
Radiation area monitor (if used)
Functional
Beam on indicator

Table 2. Linear Accelerator Quality Assurance: Monthly1

Machine-type tolerance
Procedure
Non-IMRT IMRT SRS/SBRT
Dosimetry
X-Ray output constancy
Electron output constancy 2%
Backup monitor chamber constancy
Typical dose rate output constancy NA 2% (@IMRT dose rate) 2% (@ stereo dose rate, MU)
Photon beam profile constancy
1%
Electron beam profile constancy
Electron beam energy constancy 2%/2mm

Mechanical
Light/ radiation field coincidence 2 mm or 1% on a side
Light/ radiation field coincidence (asymmetric) 1 mm or 1% on a side
Distance check device for lasers compared with front pointer
1 mm
Gantry/ collimator angle indicators (@cardinal angles) (digital
1°
only)
Accessory trays
2 mm
Jaw position indicators (Symmetric)
Jaw position indicators (Symmetric)
1 mm
Cross-hair centering (walkout)
Treatment couch position indicators 2 mm/ 1° 1 mm/ 0.5°
Wedge placement accuracy 2 mm
Compensator placement accuracy 1 mm
Latching of wedges, blocking tray Functional
Localizing lasers ±2 mm ± 1 mm ≤ ± 1mm

Safety
Laser guard-interlock test Functional

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

Table 3. Linear Accelerator Quality Assurance: Annual1

Machine-type tolerance
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) Monitor units set vs delivered: 1.0 MU or 2% (whichever is
greater)
NA
Gantry arc set vs delivered:
1.0° or 2% (whichever is greater)
X-ray/ electron output calibration (TG-51) ±1% (absolute)
Spot check of field size dependent output factor for x-ray
2% for field size < 4x4 cm2, 1% ≥ 4x4 cm2

Output factors for electron applicators ±2% from baseline

X-ray beam quality ±1% from baseline
Electron beam quality ±1 mm
Physical wedge transmission factor constancy ±2%
X-ray monitor unit linearity (output constancy) ± 2% ≥ 5 MU 5% (2-4 MU), ±2% ≥ 5 MU

Electron monitor unit linearity (output constancy) ± 2% ≥ 5 MU 5% (2-4 MU), ±2% ≥ 5 MU

X-ray output constancy vs dose rate ±2% from baseline

X-ray output constancy vs gantry angle
Electron output constancy vs gantry angle
±1% from baseline
Electron and x-ray off-axis factor constancy vs gantry angle
Arc mode (expected MU, degrees)
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

Mechanical
Collimator rotation isocenter
Gantry rotation isocenter ±1 mm from baseline
Couch rotation isocenter
Electron applicator interlock Functional
Coincidence of radiation and mechanical isocenter ±2 mm from baseline ±1 mm from baseline
Table top sag 2 mm from sagline
Table angle 1º
Table travel maximum range movement in all direction ±2 mm
Stereotactic accessories, lockouts, etc NA Functional

Safety
Follow manufacturer’s test procedures Functional

Respiratory Gating
Beam energy constancy 2%
Temporary accuracy of phase/ amplitude gate on
100 ms of expected
Calibration of surrogate for respiratory phase/ amplitude
Interlock testing Functional

Table 4. Imaging1
Procedure Non-SRS/SBRT SRS/SBRT
Daily
Planar kV and MV (EPID) imaging
Collision interlocks Functional
Positioning/ repositioning ≤2 mm ≤1 mm
Imaging and treatment coordinate coincidence (single gantry ≤2 mm ≤1 mm
angle)

Cone-beam CT (kV and MV)

Collision interlocks Functional
Imaging and treatment coordinate coincidence ≤2 mm ≤1 mm
Positioning/ repositioning ≤1 mm

Monthly
Planar MV imaging (EPID)
Imaging and treatment coordinate coincidence (four cardinal ≤2 mm ≤1 mm
angles)
Scaling ≤2 mm
Spatial resolution
Contrast Baseline
Uniformity and noise

Planar kV imaging
Imaging and treatment coordinate coincidence (four cardinal ≤2 mm ≤1 mm
angles)
Scaling ≤2 mm ≤1 mm
Spatial resolution
Contrast Baseline
Uniformity and noise

Cone-beam CT (kV and MV)

Geometric distortion ≤2 mm ≤1 mm
Spatial resolution
Contrast
Baseline
HU constancy
Uniformity and noise

Annual
Planar MV imaging (EPID)
Full range of travel SSD ±5 mm
Imaging dose Baseline

Planar kV imaging
Beam quality/ energy
Baseline
Imaging dose
Cone-beam CT (kV and MV)
Imaging dose Baseline

Table 5. Computed-Tomography Simulators1

Electromechanical Components
Performance parameters Tolerance limits
Daily
Alignment of gantry lasers with the center of imaging plane ±2 mm

Monthly
Orientation of gantry lasers with respect to the imaging plane ±2 mm over the length of laser projection

Spacing of lateral wall lasers with respect to lateral gantry ±2 mm

lasers and scan plane
Orientation of wall lasers with respect to the imaging plane
Orientation of the ceiling laser with respect to the imaging ±2 mm over the length of laser projection
plane
Orientation of the CT-scanner tabletop with respect to the ±2 mm over the length and width of the table top
imaging plane
Table vertical and longitudinal motion ±1 mm over the range of table motion

Annual
Table indexing and position ±1 mm over the scan range
Gantry tilt accuracy ±1 mm over the gantry tilt range
Gantry tilt position accuracy ±1° or ±1 mm from nominal position
Scan localization ±1 mm over the scan range

Image Performance Evaluation

Performance parameters Tolerance limits
Daily
CT number accuracy (water) 0±5 HU
Image noise Manufacturer specification
In plane spatial integrity (x or y direction) ±1 mm

Monthly
CT number accuracy (4 to 5 different materials) Baseline
In plane spatial integrity (x and y direction) ±1 mm
Field uniformity (most commonly used kVp) Within ±5 HU

Annual
CT number accuracy (electron density phantom) Baseline
Field uniformity (other used kVp settings) Within ±5 HU
Electron density to CT number conversion Consistent with commissioning results and test phantom
manufacturer specifications
Spatial resolution
Manufacturer specification
Contrast resolution

Table 6. Image-Guided Radiation Therapy Quality Control1

Daily
Collision and other interlocks
Functional
Warning lights
Laser/ image/ treatment isocenter coincidence OR
±2 mm
Phantom localization and repositioning with couch shift

Monthly
Geometric calibration maps OR Replace/ refresh
kV/ MV/ laser alignment
±1 mm
Couch shift: accuracy of motions
Scale, distance, and orientation accuracy
Baseline
Uniformity, noise
High contrast spatial resolution ≤2 mm (or ≤5 lp/cm)
Low contrast detectability Baseline

Annual
CT number accuracy and stability
Imaging dose
Baseline
X-ray generator performance (kV system only): tube
potential, mA, ms accuracy, and linearity
Anteroposterior, mediolateral, and craniocaudal orientations
Accurate
are maintained (upon upgrade from CT to IGRT system)
Long and short term planning of resources (disk spaces, Support clinical use and current imaging policies and procedures
manpower, etc)

Table 7. TPS QA2

TPS QA
Proceedure Objectives/Tasks Involved Frequency Tolerance
Comissioning Understanding TPS Software algorithims
Collection entry of appropriate data charecterizing beams and
representing range of clinical situations Initially, post-updates
Calculation and comparison of dose distributions, point doses,
MU/time setting

Address Areas of Uncertainty Innacuracies in measured data (beam and patient specific) Ongoing
Innacuracies of data entry: digitizer accuracy Weekly ± 2 mm
Innacuracies of data output Weekly

Test of reproducibility
Algorithm Inaccuracy Annually, post-updates ± 2% or ± 2mm in regionsof high dose gradients
Test evaluating calculation accuracy

Function Checks Image registration, autocontouring, deformable registration, etc. Initially, ongoing

Pre-treatment Physics Checks Independent MU check Each Plan

IMRT QA Individual patient measurements Each Plan

Table 8. Multileaf collimation (with differentiation of IMRT vs non-IMRT machines)1

Procedure Tolerance
Weekly (IMRT machines)
Qualitative test (i.e., matched segments, aka “picket fence’) Visual inspection for discernable deviations such as an increase in
interleaf transmission

Monthly
Setting vs radiation field for two patterns (non-IMRT)
2 mm
Backup diaphragm setting (Elekta only)
Travel speed (IMRT) Loss of leaf speed > 0.5 cm/s
Leaf position accuracy (IMRT) 1 mm for leaf positions of an IMRT field for four cardinal gantry
angles. (Picket fence test may be used, test depends on clinical
planning-segment size)

Annually
MLC transmission (average of leaf and interleaf ±0.5% from baseline
transmission), all energies
Leaf position repeatability ±1.0 mm
MLC spoke shot ≤1.0 mm radius
Coincidence of light field and x-ray field (all energies) ±2.0 mm
Segmental IMRT (step and shoot) test
<0.35 cm max. error RMS, 95% of error counts <0.35 cm
Moving window IMRT (four cardinal gantry angles)

Table 9. Brachytherapy pretreatment QA checks. For routine applications, these tests can be performed by the radiation therapists or source curator.3
System tested Test end point Test methodology
Reusable applicators, e.g., intracavitary applicators All applicator components, caps, cylinder segments, clamps,
tools, and other accessories available. Plastic components not
Completeness, operable condition, and structural integrity
cracked or abraded and fit tightly over metal tubes. Applicator
appropriately sterilized.
Single-use interstitial and transluminal applicators Identity Correct diameter and length
Buttons, connectors, etc, fit on applicators. Applicators not
Correct function
kinked. If indicated, perform simulated treatment on machine
Completeness All accessories present
If active source positioning requires fixed length, sound each
Positional accuracy
applicator
Templates and other custom devices Correct function Correct hole diameter
Identity Review spacing, dimensions, etc., with physician or physicist
Waiting room readiness All required equipment and medical resources available Arrangement in advance. Verify on day of procedure
Remote afterloader Correct function of device and safety accessories Execute daily QA protocol the morning of the procedure

Table 10. IMRT QA1

IMRT QA
Proceedure Frequency Tolerance
Field/Plan Verification Prior to first treatment 3%
Dose to test point in each field Daily 3%
Static vs. IMRT dose distribution as function of gantry and
collimator angles Weekly, Annually 3% in dose delivery
Stability of leaf speed
Leaf acceleration/deceleration
Multileaf collimator transmission
Annually 3% in dose delivery, other per clinical significance
Leaf positional accuracy
Standard plan verification

1. Khan F, Gibbons J. Quality Assurance In: Khan F, Gibbons, eds. Khan’s The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2014: 371-403.
2. Thomason C, Vann AM, Lenards N. QA TPS, IMRT and SRS. [SoftChalk]. La Crosse, WI
3. Kubo HD, Glasgow GP, Pethel TD, et al. High-dose rate brachytherapy treatment delivery: Report of the AAPM radiation therapy committee task group no. 59. Med Phys. 1998;(25):375-403.