Table 1: Daily Linac QA

Daily Linac QA
Machine-Type Tolerance
Non- IMRT IMRT SRS/SBRT
Dosimetry
X-ray output - Photon (All Energies) 3%
X-ray output - Electron (All Energies) 3%
X-ray output - EDW (6x and 10x) 3%

Mechanical
Laser Localization 2mm 1.5mm 1mm
Distance Indicator (ODI) @iso 2mm 2mm 2mm
Collimator Size Indicator 2mm 2mm 1mm

Safety
Door Interlock (Beam Off) Functional
Door Closing Safety Functional
A/V Monitors Functional
Stereotactic Interlocks (Lockout) N/A N/A Functional
Radiation Area Monitor Functional
Beam On Indicator Functional

Table 2: Monthly Linac QA

Monthly Linac QA
Machine-Type
Tolerance
Non- SRS/SBR
IMRT IMRT T
Dosimetry
X-ray output - Photon (All Energies) 2%
X-ray output - Electron (All Energies) 2%
Backup Monitor Chamber 2%
Typical Dose Rate (for each type) N/A 2% 2%
Photon Beam Profile 1%
Electron Beam Profile 1%
Electron Beam Energy 1%
Mechanical
Light/Radiation Field Coincidence 2mm or 1% on a side
Light/Radiation Field Coincidence
(asymmetric) 1mm or 1% on a side
Distance Check Device for Lasers Compared
with Front Pointer 1mm
Gantry/Collimator Angle Indicators 1.0
Accessory Trays 2mm
Jaw Position Indicators (Symmetric) 2mm
Jaw Position Indicators (Asymmetric) 1mm
Cross-Hair Centering (Walkout) 1mm
1mm/0.5
Treatment Couch Position Indicators 2mm/1 2mm/1
Wedge Placement Accuracy 2mm
Compensator Placement Accuracy 1mm
Latching of Wedges, Blocking Tray Functional
Localizing Lasers 2mm 1mm <2mm

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

Table 3: Annual Linac QA

Annual Linac QA
Machine-Type Tolerance
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 1%
from Baseline
SRS Arc Rotation Mode
(Range: .5-10 MU/deg)
Monitor Units Set vs. Delivered N/A N/A 1 MU or 2%
and Gantry Arc Set
vs. Delivered
X-ray/Electron Output
Calibration (TG-51) 1% (Absolute)
Spot Check of FS Dependent 2% for FS < 4x4 cm2, 1%
Output Factors 4x4 cm2
Output Factors for Electron
Applicators 2% from Baseline
X-ray Beam Quality (PDD10 or
TMR20/10) 1% from Baseline
Electron Beam Quality (R50) 1mm
Physical Wedge Transmission 2%
5% (2-4
MU),2% 5
X-ray MU Linearity 2% 5 MU 5% (2-4 MU),2% 5 MU MU
Electron MU Linearity 2% 5 MU
X-ray Output vs. Dose Rate 2% from Baseline
X-ray Output vs. Gantry Angle 1% from Baseline
Electron Output vs. Gantry
Angle 1% from Baseline
Electron and X-ray off-axis
1% from Baseline
Factor vs. Gantry Angle
Arc Mode (Expected MU,
Degrees) 1% from Baseline
TBI/TSET mode Functional
PDD or TMR and OAF 1% (TBI) or 1mm PDD Shift
Constancy (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 2mm from 1mm from
Mechanical Isocenter Baseline 2mm from Baseline Baseline
Table Top Sag 2mm from Baseline
Table Angle 1.0
Table Travel Maximum Range
2mm
Movement in All Directions
Stereotactic Accessories,
Lockouts, etc. N/A N/A Functional

Safety
Follow Manufacturer's Test
Procedures Functional

Respiratory Gating
Beam Energy Constancy 2%
Temporal Accuracy of
Phase/Amplitude Gate On 100ms of expected
Calibration of Surrogate for
100ms of expected
Respiratory Phase/Amplitude
Interlock Testing Functional

Table 4: CT Simulator QA

CT Simulator QA
Frequency Tolerance Limits
Radiation and Patient Safety
Shielding Survey Initially NCRP Guidelines
Anually or after major component 20% of manufacturer
Patient Dose from CT-scan, CTDI
change specs

Electromechanical Components
Alignment of gantry lasers with
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
Daily 2 mm
2 mm over the length
Monthly and after laser asdjustments
of laser projection
Monthly and after laser asdjustments 2 mm
2 mm over the length
Monthly and after laser asdjustments
of laser projection
2 mm over the length
Monthly and after laser asdjustments
of laser projection
2 mm over the length
Monthly or when daily laser QA tests
and width of the
reveal rotational problems
tabletop
Table vertical and longitudinal 1 mm over the range of
Monthly
motion table motion
1 mm over the scan
Table indexing and position Annually
range
1 or 1 mm from
Gantry Tilt Accuracy Annually
nominal position
1 mm over the scan
Scan localization Annually
range
Annually (optional if CTDI accuracy
Radiation Profile Width Manufacturer specs
verified)
Sensitivity Profile Width Semiannually 1 mm of nominal value
After replacement of major generator Manufacturer specs or
Generator tests
component Report No. 39

Imaging Performance
Daily- for water
CT Number accuracy Monthly- 4 to 5 materials For water, 05 HU
Annually- Electron density phantom
Image Noise Daily Manufacturer specs
In plane spacial integrity Daily- x or y directions
1 mm
Monthly- both directions
Monthly- most common kVp
Field uniformity within 5 HU
Annually- other used kVp settings
consistent with
Electron density to CT number
Annually or after scanner calibration commissioning results
conversion
and test phantom
Spatial Resolution Annually Manufacturer specs
Contrast Resolution Annually Manufacturer specs

Table 5: CT Based IGRT QA

CT- Based IGRT QA

Quality Check Tolerance
Daily
Collision and other interlock, warning
Safety Functional
lights
laser/image/treatment isocentre
2 mm
coincidence
System operation and accuracy
Phantom localization and repositioning
2 mm
with couch

Monthly (or by upgrade)

geometric calibration maps Replace/Refresh
Geometric kV/MV/laser alignment 1 mm
Couch shifts: accuracy of motions 1 mm
 scale, distance, and orientation accuracy Baseline
Uniformity and noise Baseline
Image Quality 2 mm (or
High contrast spatial resolution
5lp/cm)
Low contrast detectability Baseline
Image Quality (If used for dose
CT number accuracy and stability Baseline
calculation)

Annual
Dose Imaging dose Baseline
Imaging system performance X-ray generator performance Baseline
AP, mediolateral and craniocaudal
Geometric Accurate
orientations
support clinical
Long and short term planning of
System operation use and current
rescources (disk space, manpower, etc.)
policies

Table 6: QA of Imaging Equipment

QA of Imaging Systems
Frequency Procedure non-SRS/SBRT SRS/SBRT

Planar kV and MV imaging

Collision interlocks Functional Functional
positioning/repositioning 2 mm 1 mm
imaging and treatment coordinate coincidence 2 mm 1 mm
Daily
Cone-beam CT (kV and MV)
Collision interlocks Functional Functional
Imaging and treatment coordinate coincindence 2 mm 1 mm
positioning/repositioning 1 mm 1 mm

Planar MV imaging
Imaging and treatment coordinate coincidence 2 mm 1 mm
Scaling 2 mm 2 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Monthly Uniformity and noise Baseline Baseline

Planar kV imaging
Imaging and treatment coordinate coincidence 2 mm 1 mm
Scaling 2 mm 1 mm
Spatial resolution Baseline Baseline
 Contrast Baseline Baseline
Uniformity and noise 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

Planar MV imaging
Full range of travel SDD 5 mm 5 mm
Imaging dose Baseline Baseline

Planar kV imaging
Annual
Beam quality/energy Baseline Baseline
Imaging dose Baseline Baseline

Cone-beam CT (kV and MV)

Imaging dose Baseline Baseline

Table 7: QA of TPS and MU Calculations

QA of TPS and MU Calculations

Frequency Test Tolerance
Understand Algorithm Functional
Single field or source isodose
2% or 2mm
Commisioning and following distribution
software update MU Calculations 2%
Test Cases 2% or 2mm
I/O System 1mm

Daily I/O devices 1mm

Checksum No change
Monthly Subset of reference QA test set 2% or 2mm
I/O System 1mm

MU Calculations 2%
Annual Reference QA test set 2% or 2mm
I/O System 1mm
Table 8: MLC QA

MLC QA
Frequency Test Tolerance
Check of MLC-generated field vs.
simulator film before each field 2mm
treated
Double check of MLC field by
Expected field
Patient Specific therapists for each fraction
On-line imaging verification for
Physician discretion
patient on each infraction
Port film approval before second
Physician discretion
fraction

Setting vs. light field vs. radiation

1mm
field for two designated patterns
Quarterly
Testing of network system Expected fields over network
Check of interlocks All must be operational

Setting vs. light vs. radiation field

for patterns over range of gantry
and collimator angles
Water scan of set patterns
Annually Film scans to evaluate interleaf
leakage and abutted leaf
transmission
Review of procedures and in-
service with therapists
1mm
50% radiation edge within 1mm
Interleaf leakage <3%, abutted leakage <25%
All operators must fully understand operation
and procedures
Table 9: Dynamic Wedge QA

Dynamic/Universal/Virtual Wedge QA
Frequency Procedure Dynamic Universal Virtual
Morning checkout run
Daily Functional
for one angle
wedge factor for all C.A. axis 45 or 60 C.A. axis 45 or 60 5% from unity,
Monthly
energies WF (within 2%) WF (within 2%) otherwise 2%
check for wedge
Check of offcenter Check of offcenter Check of offcenter
angle for 60, full field
ratios @80% field ratios @80% field ratios @80% field
Annual and spot check for
width @10cm to be width @10cm to be width @10cm to be
intermediate angle,
within 2% within 2% within 2%
field size

Table 10: QA for Brachytherapy Sources

QA for Brachytherapy Sources

Type of Source Test Frequency Tolerance
physical/chemical form Initial purchase Documented
source encapsulation Initial purchase Documented
Long half-life: Description radionuclide distribution
Initial purchase Documented
and source uniformity
location of radionuclide Initial purchase 1 mm

mean of batch Initial purchase 3%

deviation from mean Initial purchase 5%
Long half-life: Calibration visual check of color
calibration verification Every Use code or measurement in
a calibrator

Physical/chemical form Initial purchase Documented

Short half-life: Description
Source encapsulation Initial purchase Documented

Mean of batch Every Use 3%

Deviation from mean Every Use 5%
Short half-life: Calibration Visual check,
Radionuclide distribution
Every Use autoradiograph, or
and source uniformity
ionometric check
Table 11: Remote Afterloader QA

Remote Afterloader QA
Frequency Test Tolerance
room safety door
Functional
interlocks, lights, alarms
console functions,
Functional
switches, batteries, printer
Each treatment day
visual inspection of source
Free of kinks and firmly attached
guides
verify accuracy of ribbon
Autoradiograph
preparation

accuracy of source and

1mm
Weekly dummy loading
source positioning 1mm

calibration 3%
timer function 1%
At each source change or quarterly check accuracy of source
1mm
guides and connectors
mechanical integrity of
Functional
applicators

dose calculation algorithm 3%, 1mm

simulate emergency
Annual Perform
conditions
verify source inventory Perform
 Reference

1. Klein E, Hanley J, Baymouth J. Task Group 142 report: Quality assurance of medical
accelerators. Med. Phys. 2009;36(9):4197-4212. http://dx.doi.org/10.1118/1.3190392.
2. Mutic S, Palta J, Butker EK, et al. Quality assurance for computed-tomography
simulators and thecomputed-tomography-simulation process: report of the AAPM
radiation therapy committee task group No. 66. Med Phys. 2003; 30(10): 2762-2792. doi:
10.1118/1.16092715.
3. Bissonnette J, Balter P, 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. http://dx.doi.org/10.1118/1.3690466.
4. Thompson C, Vann AM, Hilsendager L. QA of Imaging systems [Softchalk]. La Crosse, WI: UW-L
Medical Dosimetry Program; 2017.
5. Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014:396-398.
6. 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.
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.