Linear

Accelerator Quality Assurance1

Frequency & Tolerance
Daily
Monthly

Procedure Type
SAFETY
Door interlock (beam off)
Door closing safety
Audiovisual monitors
Beam on indicator
Stereotactic interlocks
Radiation area monitor
Laser guard-interlock test
Manufacturers test procedures

Functional
Functional
Functional
Functional
Functional
Functional

MECHANICAL

Functional

Daily

Annually







Functional

Monthly

Annually

General: 2 mm
IMRT: 1.5 mm
SBRT: 1 mm
2 mm

2 mm
SBRT: 1mm

Light/radiation field coincidence

(asymmetric)
Distance check device for lasers compared
with front pointer
Gantry/collimator angle indicators at
cardinal angles (digital only)
Accessory trays

1 mm or 1% on a side

1mm

1 degree

2 mm

Jaw position indicators (symmetric)

2 mm

Jaw position indicators (asymmetric)

1 mm

Cross-hair centering (walkout)

Treatment couch position indicators

Wedge placement accuracy

Compensator placement accuracy

1 mm
2 mm/1 degree
SBRT: 1 mm/0.5 degree
2 mm
1 mm

Laser localization

Optical distance indicator (ODI) at isocenter

Collimator size indicator
Light/radiation field coincidence

2 mm or 1% on a side

Linear Accelerator Quality Assurance1

Frequency & Tolerance
Daily
Monthly

Procedure Type
MECHANICAL

Annually

Latching of wedges, blocking tray

Localizing lasers

Collimator rotation isocenter

Gantry rotation isocenter
Couch rotation isocenter
Electron applicator interlocks
Coincidence of radiation and mechanical
isocenter
Table top sag
Table angle
Table travel maximum range movement in
all directions
Stereotactic accessories, lockouts, etc.

Functional
General: +/- 2 mm
IMRT: +/- 1mm
SBRT: < +/- 1 mm

+/- 1 mm from baseline

+/- 1 mm from baseline
+/- 1 mm from baseline
Functional
+/- 2mm from baseline
SBRT: +/- 1 mm from baseline
2 mm from baseline
1 degree
+/- 2 mm

Functional

DOSIMETRY

Daily

Monthly

Annually

X-ray output constancy (all energies)

Electron output constancy (may be
performed weekly)
Backup monitor chamber constancy
Typical dose rate output constancy

3%
3%

2%
2%

Photon beam profile constancy

Electron beam profile constancy
Electron beam energy constancy
X-ray flatness change from baseline
X-ray symmetry change from baseline
Electron flatness change from baseline

2%
2% at operating dose rate
(IMRT, SBRT)
1%
1%
2% or 2 mm

1%
+/- 1%
1%

Linear Accelerator Quality Assurance1

Frequency & Tolerance
Daily
Monthly

Procedure Type
DOSIMETRY

Annually

Electron symmetry change from baseline

SRS arc rotation mode (range: 0.5-10
MU/degree)

X-ray/electron output calibration

Spot check of field size dependent output
factors for x-ray (2 or more field sizes)
Output factors for electron applicators (spot
check of one applicator/energy)
X-ray beam quality (PDD10 or TMR1020)
Electron beam quality (R50)

+/- 1%
MU set vs. delivered: 1.0MU or
2%, whichever is greater
Gantry arc set vs. delivered: 1
degree or 2%, whichever is
greater
+/- 1% (absolute)
2% for field size <4x4cm2, 1% >
4x4cm2
+/- 2% from baseline

+/- 1% from baseline

+/- 1 mm

MULTILEAF COLLIMATOR
Qualitative test (matched segments, picket
fence)
Setting vs. radiation field for two patterns
(non-IMRT)
Travel speed (IMRT)
Leaf position accuracy (IMRT)

Weekly

Monthly

Annually

Visual inspection for discernable

deviations such as an increase in
interleaf transmission

2 mm

MLC transmission (avg of leaf and interleaf

transmission), all energies
Leaf position repeatability
MLC spoke shot
Coincidence of light field and x-ray field, all
energies
Segmental IMRT (step and shoot) test

Loss of leaf speed >0.5 cm/s

1 mm for leaf positions of an
IMRT field for 4 cardinal gantry
angles

+ 1.0 mm
< 1.0 mm radius
+ 2.0 mm

Moving window IMRT (four cardinal gantry

angles

<0.35 cm max error RMS, 95% of

error counts <0.35 cm
<0.35 cm max error RMS, 95% of
error counts <0.35 cm

+ 0.5% from baseline

Dynamic (Varian)/Universal (Elekta)/Virtual (Siemens) Wedge Quality Assurance1

Procedure Type
Frequency & Tolerance
Daily
Monthly
Annually

Morning check out, run for one angle

Wedge factor for all energies

Functional (Universal)

Check of wedge angle for 60o, full field, and

spot check for intermediate angle, field size

CAX 45o or 60o WF (within 2%)
Virtual: 5% from unity,
otherwise 2%

Check of off-center ratios at 80%
field width @ 10 cm to be within
2%

Respiratory Gating Quality Assurance1
Frequency & Tolerance
Daily
Monthly

Procedure Type

Beam output constancy
Phase, amplitude beam control
In-room respiratory monitoring system
Gating interlock
Beam energy constancy
Temporal accuracy of phase/amplitude gate
on
Calibration of surrogate for respiratory
phase/amplitude
Interlock testing

Annually

2%
Functional
Functional
Functional

2%
100 ms of expected

100 ms of expected

Functional


Procedure Type
PLANAR kV AND MV (EPID)
Collision interlocks
Positioning/repositioning
Imaging and treatment coordinate
coincidence
Scaling

Linear Accelerator Imaging Quality Assurance1

Frequency & Tolerance
Daily
Monthly
Functional
< 2 mm
SBRT: < 1 mm
Single gantry angle:
< 2 mm
SBRT: < 1 mm

Annually

Four cardinal angles:

< 2 mm
SBRT: < 1 mm
< 2 mm
kV SBRT: < 1 mm
Baseline
Baseline
Baseline

Spatial resolution
Contrast
Uniformity and noise
MV: Full range of travel SDD
Imaging dose

kV: Beam quality/energy

CONE-BEAM CT (kV and MV)

Collision interlocks

Functional

Imaging and treatment coordinate

coincidence
Positioning/repositioning

< 2 mm
SBRT: < 1 mm
< 1 mm

Geometric distortion

Spatial resolution

< 2 mm
SBRT: < 1 mm
Baseline

Contrast

Baseline

HU constancy

Baseline

Uniformity and noise

Imaging dose

Baseline

Baseline

< 5 mm
Baseline
Baseline

CT-Based IGRT Systems Quality Assurance2

Frequency & Tolerance
Daily
Monthly (or Upgrade)

Procedure Type
SAFETY
Collision and other interlocks
Warning lights

Laser/image/tx isocenter coincidence -OR-

+ 2 mm
Phantom localization and repositioning with + 2 mm
couch shift

GEOMETRIC

Geometric calibration maps* OR-

Replace/refresh
+ 1 mm
+ 1 mm

SYSTEM OPERATION/ACCURACY

kV/MV/laser alignment
Couch shifts: accuracy of motions

Functional
Functional

Annually

AP/mediolateral/craniocaudal orientations
are maintained (upon upgrade from CT to
IGRT system)

Accurate

IMAGE QUALITY

Scale/distance/orientation accuracy*

Baseline
Baseline
< 2 mm (or < 5 lp/cm)
Baseline
Baseline

DOSE

Imaging dose

Baseline

X-ray generator performance (kV systems

only): tube potential, mA, ms accuracy, and
linearity

Baseline

SYSTEM OPERATION

Long and short term planning of resources

(disk space, manpower, etc.)

Support clinical use and current

imaging policies and procedures

Uniformity/noise*
High contrast spatial resolution*
Low contrast detectability*
CT number accuracy and stability* (if used
for dose calculation)

IMAGING SYSTEM PERFORMANCE

*These tests may be performed on a semiannual basis after stability has been demonstrated, 6-12 months after commissioning

CT Simulator Quality Assurance3

Test Specifications for Radiation and Patient Safety:
PERFORMANCE PARAMETER
TEST OBJECTIVE
FREQUENCY
Shielding survey
Patient dose from CT scan, CTDI

To verify exposure levels around

the CT-scanner room
To verify safe dose delivered
from the scanner

Test Specifications for Electromechanical Components:

PERFORMANCE PARAMETER
TEST OBJECTIVE
Alignment of gantry lasers with the center
of the imaging plane
Orientation of gantry lasers with respect to
the imaging plane

To verify proper identification of

scan plan with gantry lasers
To verify that the gantry lasers
are parallel and orthogonal with
the imaging plane over the full
length of the laser projection
Spacing of lateral wall lasers with respect to To verify that lateral wall lasers
lateral gantry lasers and scan plane
are accurately spaced from the
scan plane. This distance is used
for patient localization marking
Orientation of wall lasers with respect to the To verify that the wall lasers are
imaging plane
parallel and orthogonal with the
imaging plane over the full
length of laser projection
Orientation of the ceiling laser with respect To verify that the ceiling laser is
to the imaging plane
orthogonal with the imaging
plane
Orientation of the CT scanner tabletop with To verify that the CT-scanner
respect to the imaging plane
tabletop is level and orthogonal
with the imaging plane
Table vertical and longitudinal movement
To verify that the table
longitudinal motion according to
digital indicators is accurate and
reproducible
Table indexing and position
To verify table indexing and
position accuracy under scanner
control

Initially

TOLERANCE

Annually or after major CT-

scanner component replacement

NCRP recommendations or
applicable regulatory limits
+ 20% of manufacturer
specifications

FREQUENCY

TOLERANCE

Daily

+ 2 mm

Monthly and after laser

adjustments

+ 2 mm over the length of laser

projection

Monthly and after laser

adjustments

+ 2 mm

Monthly and after laser

adjustments

+ 2 mm over the length of laser

projection

Monthly and after laser

adjustments

+ 2 mm over the length of laser

projection

Monthly or when daily laser QA

tests reveal rotational problems

+ 2 mm over the length and

width of the tabletop

Monthly

+ 1 mm over the range of table

motion

Annually

+ 1 mm over the scan range

CT Simulator Quality Assurance3

Test Specifications for Electromechanical Components:
PERFORMANCE PARAMETER
TEST OBJECTIVE
FREQUENCY

TOLERANCE

Gantry tilt accuracy

Annually

+ 1o over the gantry tilt range

Annually

+ 1o or + 1 mm from nominal
position

Annually

+ 1 mm over the scan range

Annually (this test is optional if

the CTDI accuracy has been
verified)
Semiannually

Manufacturer specifications

After replacement of major

generator component

Manufacturer specifications or
Report No. 39 recommendations

FREQUENCY

TOLERANCE
0 + 5 HU for water


Manufacturer specifications
+ 1 mm

Within 0 + 5 HU

Consistent with commissioning
results and test phantom
manufacturer specifications
Manufacturer specifications
Manufacturer specifications

To verify accuracy of gantry tilt

indicators
To verify that the gantry
accurately returns to nominal
position after tilting
To verify accuracy of scan
localization from pilot images
To verify that the radiation
profile width meets
manufacturer specification
To verify that the sensitivity
profile width meets
manufacturer specifications
To verify proper operation of the
x-ray generator

Gantry tilt position accuracy

Scan localization
Radiation profile width

Sensitivity profile width

Generator tests

Test Specifications for Image Performance Evaluation:

PERFORMANCE PARAMETER
CT number accuracy


Image noise
In-plane spatial integrity

Field uniformity

Electron density to CT number conversion

CT number for water

4-5 different materials
Electron density phantom

x or y direction
Both directions
Most commonly used kVp
Other used kVp settings

Daily
Monthly
Annually
Daily
Daily
Monthly
Monthly
Annually
Annually or after scanner
calibration

Spatial resolution
Contrast resolution

Annually
Annually

+ 1 mm of nominal value

Radiographic Simulator Quality Assurance4

Frequency & Tolerance
Daily
Monthly

Procedure Type

Localizing lasers
Optical distance indicator (ODI)
Field size indicator
Gantry/collimator angle indicators
Crosshair centering
Focal spot-axis indicator
Flouroscopic image quality
Emergency/collision avoidance
Light/radiation field coincidence

2 mm
2 mm

Film processor sensitometry

MECHANICAL

2 mm
1o
2 mm diameter
2 mm
Baseline
Functional
2 mm or 1%

Baseline

Daily

Collimator rotation isocenter

Gantry rotation isocenter
Couch rotation isocenter
Coincidence of collimator, gantry, couch
axes and isocenter
Tabletop sag
Vertical travel of couch
RADIOGRAPHIC CHECKS
Exposure rate
Tabletop exposure with fluoroscopy
kVp and mAs calibration
High- and low-contrast resolution

Annually

Monthly

Annually

2 mm diameter
2 mm diameter
2 mm diameter
2 mm diameter

2 mm
2 mm

Daily

Monthly

Annually
Baseline
Baseline
Baseline
Baseline

Instrument/Device
Ionization chamber and electrometer




Beam scanning systems*
*tests should be performed to evaluate
reliability and constancy of response over
time interval required to make a full set of
measurements

Ancillary equipment**
Phantom positioning devices (rulers, chamber
positioning devices, solid phantom materials)
Thermometers
Barometers
Electronic devices
Relative dose measuring equipment
Diodes, TLDs, film- DO NOT require calibration

Survey Meters

Physics Instruments Quality Assurance5,6

Procedure

Frequency

Submit to ADCL for calibration

At least every 2 years
Compare with reference instrument or an
Twice yearly; Also before and after shipping to
isotope source
reveal damage sustained
Determine stem effect (Kahn pg. 77)
Before initial use

Test for losses due to ionic recombination, for
each beam modality and energy
Perform capacitance test to check constancy of
Before each use
response of system
Verify constancy of response
Upon receipt
Verify system remains waterproof
Upon receipt
Verify leakage current does not change
Upon receipt
significantly or exceed acceptable values
Verify mechanical integrity
Before each use
Test linearity and stem effect
Annually
Verify scanning mechanisms move smoothly and

reliably, and that detector can be positioned
reproducibly
Ensure linearity of positioning and of readout

devices (also for scanning film densitometers)
**Positioning and scanning equipment should be reproducible to within 1mm and should report
detector position to within 1mm accuracy
Inspect for wear and damage
Regularly
Compare with reference instrument
Compare with reference instrument
Compare with reference instrument

Monitor performance and response and apply
corrections as needed
Evaluate behavior that can affect the response of
these devices and apply corrections
Calibrate per NRC or State guidelines
Test battery operation
Verify operation with check/dummy source

Regularly
Aneroid/Electronic: weekly or monthly
Mercury: before first use
Weekly or monthly

Regularly
Before first use
Annually
Before each use
Before each use

IMRT Quality Assurance7

Frequency

Procedure
Individual field and plan verification
Dose to a test point in each IMRT field
Static field v. sliding window field dose
distribution as a function of gantry and
collimator angles
All commissioning procedures:
-Stability of leaf speed, acceleration and
deceleration
-MLC transmission
-Leaf positional accuracy
-Standard plan verification

Tolerance

Before first treatment

Daily
Weekly, Annually

3% (point dose), other per clinical significance

3%
3% in dose delivery

Annually

3% dose delivery, other per clinical significance

MLC Quality Assurance4
Frequency

Procedure
Check of MLC-generated field v. simulator film
(or DRR) before each field treated
Double check of MLC field by therapists for each
fraction
On-line imaging verification for patient on each
infraction
Port film approval before second fraction
Setting v. light field v. radiation field for two
designated patterns
Testing of network system
Check of interlocks
Setting v. light field v. radiation field for patterns
over range of gantry and collimator angles
Water scan of set patterns
Film scans to evaluate interleaf leakage and
abutted leaf transmission
Review of procedures and in-service with
therapists

Tolerance

Patient specific

2 mm

Patient specific

Expected field

Patient specific

Physician discretion

Patient specific
Quarterly

Physician discretion
1 mm

Quarterly
Quarterly
Annually

Expected fields over network

All must be operational
1 mm

Annually
Annually

50% radiation edge within 1 mm

Interleaf leakage <3%
Abutted leakage <25%
All operators must fully understand operation
and procedures

Annually

TPS Quality Assurance8

*Goal: to confirm that the measured data entered into the TPS represents the range of clinical conditions likely to be encountered and that
the computer is able to successfully mimic these situations from the small amount of data provided.

Treatment Planning Computer:
Commissioning~

Ongoing~
(to address major sources of uncertainty)

Understand treatment planning software algorithms and their dependence on measured data
Collection of appropriate data required by TPS and entry of this data
Collection of additional data fully characterizing beams for which treatment planning will be done
and representing a range of clinical situations
Calculation of dose distributions, point doses, and MU or treatment time settings, along with
comparison of these calculations with measured data
Inaccuracies in measured beam and patient-
specific data
Inaccuracies of data entry
Inaccuracies of data output
Algorithm reproducibility and accuracy of
calculations

Check contours weekly, agree within 2 mm

Check no less than annually, agree within 2 mm
or 2% per ICRU guidelines

IMRT:

Commissioning~

Verify the dose predicted by the planning system is accurate to within acceptable limits
Test for single, simple geometry and for cumulative dose from multiple segments.
Ensure leaf and jaw transmission are calculated correctly in the TPS, especially for small MU fields

Patient-specific Dose Verification~

*Per ASTRO/ACR, dose delivery MUST be documented for every IMRT plan by comparing measured
dose in a phantom to planned dose from the TPS
Can be accomplished by measuring: Point or planar dose for a single or composite field

SRS:

Verify accuracy and reproducibility of immobilization and localization systems

Brachytherapy:

Verify accuracy and appropriateness of:

Dose prescription
Consistency
Independent dose check
Homogeneity

Normal structure doses

Duration
Target coverage

Brachytherapy Quality Assurance9

Procedure

Instrument/Device
Applicators:


Radioactive Sources:

Inspected and radiographed

Verify positional accuracy of applicator in
remote-afterloading systems
Clean and inspect for flaws
Careful record keeping is essential
Leak testing

Remote Afterloading Equipment

At Source Change:

Daily QA:

Monthly QA:

Procedure
Radiation safety surveys

Frequency
Prior to initial use

After each use
Routine
Prior to initial use, at least semi-annually (some
cesium sources only tested every 3 years)

Objective

Ensure adequate shielding of source when it is

housed in the head of the treatment unit

Areas adjacent to the treatment room should be
surveyed with the source exposed

In areas where a reading above background is
detected, survey with source retracted as well
Source calibration
Measurement of source activity must be made
before sources are used for patient treatment
All monitors and interlocks should be checked, including door interlocks, emergency off buttons,
treatment interrupt buttons, AV monitors, room radiation monitors, and interlocks that detect
missing or misconnected applicators or transfer tubes should be tested
Treatment unit displays of time, date, and current source strength should be verified for accuracy
Test of source-position accuracy, dwell-time accuracy, and normal termination of treatment should
be performed
Verify mechanical integrity of applicator connections to treatment unit
Verify availability and integrity of emergency response equipment
Verify source positioning accuracy
Verify source activity agrees with calculated activity
Verify timer accuracy and linearity
Verify that source retracts when power supply is interrupted
Integrity of applicators used most often should be checked for mechanical damage, ease of coupling,
kinks and mechanical deformation
Transfer tubes should be inspected and measured to verify they are in proper working condition

References

1. Klein EE, Hanley J, Bayouth J, et al. TG-142: Quality assurance of medical accelerators. Med Phys. 2009;36(9):4197-4212.
http://dx.doi.org/10.1118/1.3190392
2. Bissonnette J-P, Balter PA, Dong L, et al. TG-179: Quality assurance for image-guided radiation therapy utilizing CT-based
technologies. Med Phys. 2012;39(4):1946-1963. http://dx.doi.org/10.1118/1.3690466
3. Mutic S, Palta JR, Butker EK, et al. TG-66: Quality assurance for computed-tomography simulators and the computed-
tomography-simulation process. Med Phys. 2003;30(10):2762-2792. http://dx.doi.org/10.1118/1.1609271
4. Khan FM. Quality assurance. In: The physics of radiation therapy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins;
2010:375-404.
5. Lenards N. Quality assurance: QA of instruments. [SoftChalk]. LaCrosse, WI: UW-L Medical Dosimetry Program, 2015.
6. Khan FM. Measurement of ionizing radiation. In: The physics of radiation therapy. 4th ed. Baltimore, MD: Lippincott Williams
& Wilkins; 2010:70-86.
7. Khan FM. Intensity-modulated radiation therapy. In: The physics of radiation therapy. 4th ed. Baltimore, MD: Lippincott
Williams & Wilkins; 2010:430-452.
8. Vann AM, Lenards N. Quality assurance: QA of TPS, IMRT, SRS. [SoftChalk]. LaCrosse, WI: UW-L Medical Dosimetry Program,
2015.
9. Lenards N. Quality assurance: QA of brachytherapy equipment & sources. [SoftChalk]. LaCrosse, WI: UW-L Medical
Dosimetry Program, 2015.