Quality assurance procedures and

equipment for implementing a new

Linac-based SRS program
Zeynep Karakas

Overview
Remember SRS
Delivery options
Phases of implementing a new SRS
program
Picking the right dosimeter
Picking the right phantom
Relevant QA tests

What is SRS?
SRS = stereotactic radiosurgery
Its a single-fraction radiation therapy
procedure for treating brain lesions
Concentrates dose to the target and spares as
much brain tissue as possible

It uses stereotactic frame + 3D imaging

(CT/MRI) to localize the lesion and
plan/deliver treatment
Uses small field, circular beams delivered
by rotating gantry around targets isocenter

SRS delivery options

Phases of implementing a new SRS

program
1. research relevant protocols and practice
guidelines
2. commission the treatment planning system
for radiotherapy device and SRS techniques **
3. verify commissioning data
4. vendor training of TPS-specific hardware and
software
5. phantom studies **
N
A
C
E
6. documentation development
E
W
R
*
*
SU
A
7. mock procedures
E

Commissioning phase
picking the right dosimeter

Commissioning for SRS

techniques
Involves accurately collecting photon beam data
of small fields (as small as 0.4 cm x 0.4 cm)
The three SRS dosimetric quantities of interest:
1. central axis depth dose
2. cross-beam profiles
3. output factors

Note: getting accurate measurements of these

quantities can be difficult for small fields and
can be a major source of treatment error
.lack of charged particle equilibrium
.dosimeters can only be so small

Picking the right dosimeter

Limitations of small field SRS measurements
can be overcome by:
using small sized dosimeters (smallest: TLDs/diodes)
dosimeters with high spatial resolution (highest:
film)

AAPM TG-42 recommends:

depth dose and beam profiles be measured with film
SRS output factors be measured with an ionization
chamber with a diameter less than or equal to 3 mm
(most precise)

Phases of implementing a new SRS

program
1. research relevant protocols and practice
guidelines
2. commission the treatment planning system
for radiotherapy device and SRS techniques **
3. verify commissioning data
4. vendor training of TPS-specific hardware and
software
5. phantom studies **
N
A
C
E
6. documentation development
E
W
R
*
*
SU
A
7. mock procedures
E

Phantom studies
picking the right phantom

SRS phantom studies

SRS phantom studies encompass end-to-end
quality assurance (QA) testing of:
CT/MRI scans
contouring
image fusion
treatment planning
target localization
dose delivery

AAPM TG-42 states possible phantoms include:

polysterene, anthromorphic phantoms, water
and water-equivalent phantoms

Picking the right phantom

Because SRS uses rotating fields,
spherical phantoms can be used for QA
tests
There are many 3D phantoms that,
while not necessarily spherical in
spherical in shape, can be used for SRS
QA
Only three possible SRS phantoms will
be discussed here

Lucy 3D QA Phantom by
Standard Imaging

Lucy 3D QA Phantom
Spherically shaped acrylic with a central square
cavity that accommodates dosimetry and
imaging QA inserts
Dosimetry inserts:
used to obtain absolute dose measurements at the
isocenter and for exact positions off the isocenter
ionization chamber at geometric center, 3 in x 3 in
film, TLD detectors (spaced 1 mm or 3 mm apart)

Imaging inserts:
contain volumes of known geometries and densities
specific to MRI or CT
check imaging integrity when moving from one
imaging system to another

Lucy 3D QA Phantom
Capable of achieving unrivaled 0.1
mm accuracy of end-to-end QA
tests
So, can be used to measure
cumulative uncertainties of:
imaging
planning and dose delivery
mechanical and geometric alignment

QUASAR Verification
Phantom by ModusQA

QUASAR Verification Phantom

Cylindrically shaped acrylic with a
central rectangular cavity that
accommodates 25 cm x 15 cm film
Can also accommodate an ionization
chamber that can be placed every 2.5
cm along the diameter of the cylinder
Does not provide a means of checking
imaging accuracy; limited to dose
delivery checks

ArcCHECK by Sun Nuclear

ArcCHECK
Cylindrically shaped diode array with 1386 silicon
diodes embedded in acrylic (spaced 1 cm apart)
Checks fields as small as 1.5 cm x 1.5 cm
Has a central cylindrical cavity that can
accommodate an ionization chamber that can
measure isocentric dose
Without the ionization chamber, the diode array
measures the entrance and exit dose of the beam
Can be used for treatment alignment and patientspecific dosimetric QA checks (only truly 3D
detector we can use to do this)

Which phantom is best?

Lucy 3D QA Phantom
pros: high spatial accuracy (0.1 mm)
cons: maybe cumbersome to change inserts

QUASAR Verification Phantom

pros: simultaneous film and ionization chamber dose
measurements
cons: cannot be used to conduct all SRS QA tests

ArcCHECK
pros: only truly 3D dose/position verification phantom
cons: cannot verify fields smaller than 1.5 cm x 1.5
cm

ArcCHECK by Sun Nuclear

Relevant SRS QA tests

Two categories of QA tests:
Periodic tests
Mechanical tests

Periodic tests:
Check for whether the targets isocenter and
Linacs isocenter agree to 1 mm

Mechanical tests:
Needed for radiation therapy devices not used
solely for SRS treatment, i.e. Linacs at UTMC
Check for the alignment of the radiation beam
with patients coordinate system or lasers in
the treatment room

Summary
Remember SRS = stereotactic radiosurgery
Delivery options: charged particles, Co-60, xrays
Phases of SRS implementation that we can
measure: commissioning and phantom studies
Picking the right dosimeter: small size, high
resolution
Picking the right phantom: end-to-end testing
and ease of use
Relevant tests: periodic and mechanical