Daily QA

Procedure
Dosimetry

Non-IMRT
3%

X ray output constancy (all energies)

Mechanical
Laser Localization
ODI @ Iso
Collimator Size Indicator

2mm
2mm
2mm

Safety
Door Interlock (beam off)
Door closing safety
Audiovisual monitor(s)
Sterotactic Interlocks
Radiation area monitor (if used)
Beam on indicator

N/A

Monthly QA
Procedure
Dosimetry

Non-IMRT

X ray output constancy

Electron output constancy
Backup monitor chamber constancy
typical dose rate output constancy
Photon beam profile constancy
Electron beam profile constancy
Electron beam energy constancy

N/A

Mechanical
Light/radiation field coincidence
Light/radiation field coincidence (asymmetric)
Distance check device for lasers compared with front pointer
Gantry/collimator angle indicators (@cardinal angles; digital only)
Accessory trays
Jaw position indicators (symmetric)
Jaw position indicators (asymmetric)
Cross-hair centering (walkout)

Treatment couch position indicators

Wedge placement accuracy
Compensator placement accuracy
Latching of wedges, blocking tray
local laxers

2mm/1

2mm/1

Safety
Laser guard-interlock test

Respiratory gating
Beam output constancy

Phase, amplitude beam control

In-room respiratory monitoring system
Gating interlock

CT Simulator QA (From TG 66)

Performace parameter

Frequency

Central Alignment of gantry lasers

Daily
CT number accuracy
Daily
Gantry laser orientation with imaging plane monthly and after adjustments
Spacing of lateral wall lasers with respect tomonthly and after adjustments
Orientation of wall lasers with respect to im monthly and after adjustments
Orientation of ceiling laser with respect to monthly and after adjustments
Orientation of CT tabletop with respect to i monthly or daily
Table vertical and longitudinal motion
monthly
Table indexing and position
annually
Gantry tilt accuracy
annually
Gantry tilt position accuracy
annually
Scan localization
annually
Radiation profile width
annually
Sensitivity profile width
semianually
Generator tests

after major generator component

IMRT

SRS/SBRT
3%

1.5mm
2mm
2mm

1mm
2mm
1mm

functional
functional
functional
N/A
functional
functional

functional

IMRT

SRS/SBRT

2%
2% (@ IMRT DR)

2% (@ Stereo DR, MU)

1%
1%

2%/2mm
2mm or 1% on a side
1mm or 1% on a side
1mm or 1% on a side
1.
2mm
1mm
1mm
1mm

2mm/1
2mm
1mm

1mm/.5

functional
1mm

<1mm

functional
2%

functional
functional
functional

om TG 66)
Tolerance Limits
within 2mm
for water within 5 HU
within 2mm
within 2mm
within 2mm
within 2mm
within 2mm over L & W of tabletop
within 1 mm over range of motion
within 1mm over scan range
within 1 degree over tilt range
within 1 degree or 1 mm from nominal position
within 1mm over scan range
Manufacture specifications
within 1 mm of nominal value
manufactures specifications or report No. 39

Yearly QA
Procedure
Dosimetry

Non-IMRT

X ray flatness change from baseline

X ray symmetry change from baseline
Electron flatness change from baseline
Electron symmetry change from baseline
SRS are rotation mode (range .5-10MU/deg)
X ray/electron output calibration (TG-51)
Spot check of field size dependent output factors for x rays (two or more FSs
Output factors for electron applicators (spot check of one applicator/energy
X ray beam quality (PDD10 or TMR20/10)
Electron beam quality (R50)
Physical wedge transmission factor constancy
X ray monitor unit linearity (output constancy)
Electron monitor unit linearity (output constancy)
X ray output constancy vs. dose rate

2%>=5MU

X ray output constancy vs gantry angle

Electron output constancy vs. gantry angle
Electron and x-ray off axix factor constancy vs. gantry angle
Arc mode (expected MU, Degrees)
TBI/TSET mode
PDD or TMR and oAF constancy
TBI/TSET output calibration
TBI/TSET accessories

Mechanical
Collimator rotatoin isocenter
Gantry rotation isocenter
Couch rotation isocenter
Electron applicator interlocks
Coincidence of radiation and mechanical isocenter

2mm from base

Table top sag

Table angle
Table travel max range movement in all directions
Sterotactic Accessories, lockouts etc

2mm from baseline

1
2mm
N/A

Safety
Follow manufacturer's test procedures

Respiratory Gating

Beam energy constancy

Temporal accuracy of phase/amplitude gate on
Callibration of surrogate for respiratory phase/amplitude
Interlock testing

References:

1. Kahn FM, Gibbons JP. Kahns The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lipp

2. Klein EE, Hanley J, Bayouth J, et al. Task Group 142

report: quality assurance of medical accelerators. Med
Phys. 2009;36(9):4197-212.
http://dx.doi.org/10.1118/1.3190392
3.1. 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):1773-829. http://dx.doi.org/10.1118/1.598373

IGRT QA
Procedure/Modality

Frequency

KV and MV EPID
Collision interlocks

Daily

Positioning/repositioning
Imaging and Tx coordinate coincidence
Imaging and Tx coordinate coincidence
Scaling b
Spatial resolution
Contrast
Uniformity and Noise
Full range of travel SSD (FOR KV)
Imaging Dose
Beam quality/energy (FOR MV)
CBCT (KV & MV)

Daily
Daily
Monthly
Monthly
Monthly
Monthly
Monthly
Annual
Annual
Annual

collision interlocks

Daily

Imaging and Tx coordinate coincidence

positioning/repositioning
Imaging and Tx coordinate coincidence
Scaling b
Spatial resolution
Contrast
HU Constncy
Uniformity and Noise
Imaging Dose

Daily
Daily
Monthly
Monthly
Monthly
Monthly
Monthly
Monthly
Annual

arly QA
IMRT

SRS/SBRT
1%

1%
1%
1%
N/A

MU set vs delivered: 1MU or 2% (whichever is greater)

Gantry are set vs. delivered: 1 or 2% (Whichever is greater)

1% absolute
2% for field size<4x4cm^2; 1%>= 4x4cm^2
2% from baseline
1% from baseline
1mm
2%
5%(2-4MU); 2%>=5MU
2%>=5MU
2% from baseline

5%(2-4MU); 2%>=5MU

1% from baseline
1% from baseline
1% from baseline
1% from baseline
functional
1%TBI or 1mm PDD shift (TSET) from baseline
2% from baseline
2% from baseline

1mm from baseline

1mm from baseline
1mm from baseline
2mm from baseline

1mm from baseline

om baseline

N/A
functional

functional

2%
100ms of expected
100ms of expected
functional

h ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014

RT QA
Tolerance
Functional
<=2mm
<=2mm
<=2mm
<=2mm
Baseline
Baseline
Baseline
within 5mm
Baseline
Baseline
Functional

<=1mm
<=1mm
<=2mm
Baseline
Baseline
Baseline
Baseline
Baseline
Baseline

hichever is greater)
2% (Whichever is greater)

TPS
Procedure
Acceptance Tests
CT Input
Anatomical descriptions
Beam description
Photon beam dose calcs
Electron beam dose calc
Brachytherapy dose calcs
Dose display, DVH
Hardcopy

Image Input Tests

Topic
Image Geometry
Geometric location and orientation of scan
Text info
Imaging data
Image unwraping

Anatomical S
Topic
Structure attributes
Relative e- density definition
Display characteristics
Auto-segmentation parameters
Structure created from contours
Stucture constructed from non-axial contours
Capping (how end of structure is based from
Structure Definition

Conto
Topic
Manual contour acquisition
Digitization process
Contouring on 2D images
Autotracking contours
Bifurcated structures

Contours on projected DRR or BEV

Extracting contours from surfaces

Density Des
Topic
Relative e- density representation
CT number conversion
Editing
Meansurement tools

Bolu
Topic
e- density within bolus
Density measurement tools
Automated bolus design
Beam assignment
Dose Calc
Monitor unit calc
Output and graphic display

Image Use an
Topic
Grayscale window level
Creation and use of reformatted images
Removal of imaging table
Gemetrical accuracy of slices associated with
Region of interest analysis
Positional measurements
3D object rendering
Multiple window display use

Beam Confi

Topic
Machine library
Machine/beam accessories
Parameter limitations
Beam names and numbers
Readouts
Beam technique tools
Wedges
Compensators

System Readout Conventions

Topic
General system conventions
Internal consistency
Readouts
Test frequency
Multi-user environment

Field Sha
Block type
Block transmission
MLC leaf fits
Electron applicators
Hardcopy output

Manual Apert
Film mag factors
Special drawing aids
Number of points in aperture definition
Editing apertures
Defining apertures on BEV/DRR displays
3D projections

Wedg
Orientation and angle specifications
2D display
3D display
Orientation and field size limits
Autowedges
Dynamic wedge

Beam Geomet
Axial beam divergence
Non-axial divergence
BEV/DRR displays
3D displays
Patient and beam lables

Methodology and
Regions to be calculated
Calculation grid definition
Status of density corrections
Reading saved plan info
Calculation validity logic

Dose Dis
Dose points
Interactive point doses
Consistency
Dose grids
2D dose displays
Isodose surfaces
Beam display

DVH
Volume ROI identification
Structure ID
Voxel dose interpolation
Structure Volume
Histogram bins and limits
DVH calcs
DVH types
DVH plotting and output
Plan and DVH normalization
Dose and VROI grid effects
Use of DVHs from different cases

Non-Dosimetric B
Source input and geometrical accuracy
Source display
Optimization and evaluation

TPS QA
Function
Acceptance Tests
Create anatomical description based on a standard of CT scans provided by vendor.

Create a patient model based on the standard CT data discussed above. Contour external sur
verify that all beam technique functions work, using standard beam descriptions provided by
Perfrom standard photon dose calcs. Include multiple SSDs, MLC shapes, inhomogeneity, wed
A set of standard e- dose calcs. Various field variety as mentioned above

Perform dose calcs for single sources of each type, as well as multi-source implant techniques
Display dose calc results. Use standard distribution provided by vendor to verify the DVH code
Print out all hardcopy docs for a given series of plans and confirm graph and text info is correc

Image Input Tests

Tests
Document and verify parameters used to determine geometric discription of each image
Document and verify parameters of geo location of each image
Verify that all text info is correctly transferred
verify accuracy of grayscale values; conversion of CT# to e- density
Test all features, including the doc tools which assure that the original and modified image

Anatomical Structure Tests

Tests
verify contour capabilities are dependant on that type
Verify correct definition for relative e- density. 1-assign bulk density everywhere in side st
check color, rendering and type of contours to be drawn when displaying structure
check parameters for autocontouring and other type of autostructure
Resolve bookeeping, algorithm and expansion issues
Verify bookkeeping of definitions. Test for creation of structures and contour orientation
Verify all methods of capping performed coreectly. Document default cappings.
verify basic surface generation functinoality using simple contours. Run test situations

Contour Tests
Tests
Define standard procedures. Check and document separation and SSDs to AP and lats. Ch
Digitize standard contours weekly. Verify geometric accuracy of digitizer of entire digitizer
Verify 3D location, accuracy, and algorithm. Tests: contouring structures on phantom, gra
verify proper response of tracking algorithm. Test may involved phantoms or grayscale. Pa
Resolve issues such as: can system maintain more than 1 contour per slice? Dose it form

Check points defined on projection of images, contours on projection correct, Incorrect handlin
Determine limitations and functionality.

Density Description Tests

Tests
verify that the system reates the correct e- density; verified maintained when contours ar
Verify that the CT number to HU number conversions are correct
Verify the proper operation of functions used to edit the relative e- density
verify display tools used to measure e- density

Bolus Tests
Tests
Verify density in bolused region is set to assigned value
verify that tools read the correct density values within the bolus
Verify bolus design is correct, info is correctly exported
Confirm whether bolus is associated w a single beam or entire plan
Verify that bolus is accounted for in dose calc
Confirm the proper method to calc MU when bolus is used
Verify bolus is displayed properly and properly documented

Image Use and Display Tests

Tests
Verify functinoality, determine correct window range
Verify accuracy of grayscale location and geometric location. Check consistency between
verify capability to removve unwanted imaging information
verify accuracy of location with respect to rest of anatomy
verify mean, min and max CT number inside ROI for a range of situations
verify point coordinates, distances and angles in each coordinate system for each display
Confirm color and other rendering functions
Verify each panel of amultiple window display is kept current as the planning session proc

Beam Configuration Tests

Tests
Verify library of machines and beams is correct
Verify that availability of machine and beam--specific accessories are correct
verify limitations are correct for jaws, MLC, fs, wedges, compensators e- applicators etc
Verifgy correct use and display of user-defined names and numbers
Verify correct display of angle and linear motion readouts
Verify correct functionality of tools such as those to move isocenters or set SSDs
Verify that wedge characterizations such as coding, directions fs limitations and avilibility
Verify correct use and display

System Readout Conventions and Motion Descriptions Testing

Tests
verify that the TPS conventions agree w system documentation and are used consistently
Examine machine settings and 2D/3D displayed orientation of the beam for a variety of gan
Verify TPS agrees with actual machine settings
Verify the accuracy of info at commissioning of the RTP system and each major update
Establish a procedure to ensure consistent beam information in multi-user and network e

Field Shape Design

Verify system distinguishes between blocks
verify correct specification of transmission or block thickness for full/partial trans blocks
Document/test all methods used to fit MLC leaves to desired shapes
verify availability and size of e- applicators
Check all output showing beam apertures and/or used for beam aperture fabrication for a

Manual Aperture Entry Tests

confirm film magnification is correct for film
check geometrical accuracy
eval the effects of any limitation on # of defining points
Evaluate how the algorithm handles aperture editing
Confirm geometry
confirm 3D projections of anatomical information in BEV and DRR displays

Wedge Tests
Confirm wedge orientation and angles are consistent
Check display of wedges in 2D planes; for various collimator, gantry etc angles
Check display of wedges in 3D view as described above
Verify that wedge orientations and fs not allowed by the Tx machine are not allowed
Confirm that division of a field into fractional open and wedged fields agrees in the RTP
Verify that implementation has same capabilities, limitations, orientations and naming c

Beam Geometry Display Tests

Test intersection of divergent beams and aperture edges with axial slices
Test intersection of divergent beam and aperture edges with sagittal coronal and oblique s
Verify projection of contours/structures defined on axial slices into BEV- type displays. C
Verify 2D prjoections correctly projected in 3D and relations. Verify edges are correct
Verify orientation with respect to beam annotations both 2D/3D displays

Methodology and Algorithm Use Test

Eval and confirm the correct functioning of methods used to identify regions to be calced
Eval and verify proper functioning: grid zie, grid spacing, interpolation between grid poin
verify correct bookkeeping for status corrections. Determine how status corrections are
Verify functionallity; reading stored anatomical, beam, dose and source info
Eval System rules for recalc of dose distribution when changes are made in anatomy, bea

Dose Display Tests

Verify: point is defined at 3D position and coordinates. Dose at point is correct
Verify: point coordinates correctly correspond to cursor position. Dose at point correctly di
Verify: dose intersecting planes are consistent. Dose displayed w different techniques are
verify that dose is correctly interpolated between dose points
Verify that IDLs are correctly located. Colorwash lines come up correctly and agrees with I
Verify: surfaces are displayed correctly and are consistent with isodose lines on planes
Verify: positions and fs are correct, wedges shown w correct orientation, beam edges/aper

DVH Tests
Test creation of the voxel VROI description used to create DVHs against structure descript
Test Boolean operators and how voxels of multiple structures act
verify accuracy of dose interpolated into each voxel
Test accuracy of volume determination with irreguarly shaped objects
verify that appropriate istogram bins and limits are used
Test DVH calc algorithm with known distributions
Verify that standard differential and cummulative histograms are all correct
Test DVH plotting and output using known values
Verify relationship of plan normalization values to DVH results
Review and understand relationship of dose and VROI grids
Test correct use of DVHs from different cases with different DVH bin sizes, dose grids etc

Non-Dosimetric Brachytherapy Tests

Checks should be made of the data entry software, film acquisition process, source ID and
Verify accuracy of : 2D views and reconstructed images and arbitrary planes, 3D views,
test automated brachy tools such as automatic determination of dwell positions and times t

external surface, internal anatomy, etc

provided by vendor
ogeneity, wedges, etc

nt techniques. Standard implant techniques; tandem and ovoids, two plane breast implant
the DVH code works as described
info is correct

Reasons
Conventions can cause specific geometrical errors when converted to rtp system
conventions can cause specific geometrical errors when converted to rtp system
Incorrect name or scan sequence identification could cause misuse or misinterpretation of sca
Wrong grayscale data may cause incorrect anatomy ID or density corrections for beams
Methodologies may leave incorrect imaging information data

Reasons
incorrect attributes may cause incorrect usage of the stucture
Relative e densities depend on choice of method for definition
display errors cmay cause planning errors due to misinterpretation

Incorrect parameters can lead to incorrect sturcture definition

PTV are often defined by expansion from CTV. Errors could result in target erros
Difficulties can arise dependent on the underlying 3D data structures and esign code
Cap[ing can affect dose calc results, target shapes, BEV display and DRR generation. Effects o
Test should convince the user that the algorithm generally works correctly

Reasons
Incorporate standard checks into the acquisition of manual contours to prevent systematic or
geometrical accuracy of digitization device and often be user dependant. Many suffer from po

Errors in contouring coordinates or display can lead to incorret anatomy being used for planni
Partial volum misunderstandings may lead to improper contours. Gradient range can affect co
Algorithm for creating stuctures may affect the calc volumes

orrect handling of contours on projection images can lead to misinterpretation of plan idsplays
provides one of the best ways to quantitatively check the 3D description of anatomical struct

Reasons
Incorrect relative e- density info may result in incorrect dose calcs
can cause incorrect result for density-corrected calcs

image grayscale might be altered due to the precense of contrast or image artifacts leading t
Incorrect info may lead to errors in planning

Reasons
If incorrect will lead to incorrect dose calcs
Error reading density values makes verification of correct behavior difficult
will lead to wrong design or usage of bolus
Possible incorrect calcs
possible incorrect calcs
Potential incorrect MU calc or pt set up
potential set up error

Reasons
Affects data interpretation
Use all 3 planes for tx planning
Exclude material that will not be used while pateitn is under Tx
Inaccuracies ingeometry can lead to errors in 3D visualiation and planning
CT # and e- densities are important when evaluation accuracy of calcs
Measurements are often used for important planning and evaluating the accuracy of dose cal
Incorrect rendering my misrepresent the gemetrical situation
inconsistencies coul lead to incorrect plan decisions

Reasons
Incorrect beam choice leads to wrong dose calcs and MU
Wrong accessorie lead to plans that are not usable incorrect or misleading
Exceeding limits lead to plans that are not deliverable
incorrect 3/names can lead to incorrect tx due to confusing docs
Lack of agreement between system and machine leads to machine Tx errors
Incorrect functioning of these features will lead to internal mistakes in planning
Incorrect functining of these will lead to internal mistakes in planning
May cause important dosimetric errors

ting

Reasons
Problems cause systematic Tx errors
Problems cause systematic planning system errors
Errors may cause isolated but systematic Tx errors
Systematic errors might be missed at new releases unless checks are made
users might interfere with each other's plans, or access to the machine database or similar p

could lead to incorrect identification of blocked or irradiated areas

Incorrect TF leads to incorrect dose under blocks
Extra or missing dose to some targets/Ors
Can lead to plans which cannot be used
Ipoor documentation may lead to incorrect fabrication of aperture or inappropriate QA checks

incorrect block shape could be used in plan

Could lead to incorrect margins during aperture design
Could lead to incorrect aperture shape
Could lead to incorrect aperture shape
Could lead to incorrect interpretation of planned aperture
May lead to incorrect aperture design or choice of beam direction

Wedge labeling or orientation conventions which do not agree with RTP system can cause con
Visual orientation checks are most effective way to prevent wrong wedge orientation in plan o
Incorrect wedge orientation leads to large dose differences
May lead to plans which cannot be delivered
Could lead to incorrect dose distribution and Mus
Incorrect wedge choice possible

Incorrect
Incorrect
Incorrect
Incorrect
Incorrect

divergence leads to selection of wrong fs or aperture shape

divergence leads to wrong fs or aperture shapes
projections lead to selection of wrong apeture shape
projections lead to selection of wrong apeture shape
labeling can mislead treatment therapists or physicians

Must calculate dose to regions which are important

Incorrect grid use can result in dose in incorrect places, miscalculation, incorrect display misa
Misleading dose distributions, incorrect MU's possible
just as important as doing the OG dose calc correctly
Will either: 1-waste time and resources 2-leave an invalid dosecalc for incorrect interpretation

Point displays used for critical structure doses and for investigating dose distrubution behavio
problems would affect results of plan optimization
Inconsistency demonstrates algorithm limitations or problems. Makes evaluations impossible
Interpolations will give wrong reslults especially in penumbra areas
Throw off plan evaluations
Might lead to use of plans with too much or too little coverage
must be aligned correctly with dose distribution or entire plan should be doubted

Mis ID of VROI leads to incorrect DVH

Incorrect complex VROI leads to incorrect DVH
interpolation from one 3D grid to another could lead to grid-based inaccuracies
Volume may be directly used in physician plan evaluation
Inappropriate bins and/or limits to DVH can lead to misleading DVH
basic calcs must be sound, else incorrect clinical decisions about plan evaluation may result
Each type of DVH display is useful in different situations
Hardcopy output must be correct for physician decision making
Normalization is critical to the dose axis of the DVH
Grid-based artifacts can cause errors in volume, dose, DVH and evaluation of the plan
Comparison of DVHs from different plans depends critically on bin sizes

Dose calculations for brachytherapy are very sensitive to exact source positions
Accurate display of source position is crucial to plan development and optimization
Incorrect functioning of optimiazation and eval tools can result in sub-optimal or incorrect Tx

t implant

p system

isinterpretation of scans

tions for beams

d esign code
R generation. Effects of lung densities and etc

prevent systematic or patient specific errors

t. Many suffer from position-dependent distortions.

being used for planning

nt range can affect contour size and location

plan idsplays
n of anatomical structures

age artifacts leading to incorrect derived relative e- densities

accuracy of dose calc results

database or similar problems

ppropriate QA checks

system can cause confusion and possible incorrect Tx

e orientation in plan or Tx

ncorrect display misalignment of dose and beam

correct interpretation

e distrubution behavior

valuations impossible

doubted

valuation may result

on of the plan

ptimization
timal or incorrect Tx