QA LINAC

Daily, Monthly, Annual

Jack Yang, Ph.D., DABR

Institute for Advanced Radiation Oncology
Barnabas Health
Long Branch, NJ 07740
New Technologies in Modern Radiotherapy, Chulabhorn
Research Institute, Bangkok, Thailand, August 22-25, 2012

Outlines

Definition of treatment delivery quality

assurance for LINAC
Assure that the 5% final dose
discrepancy can be achieved with the
site specific QA process
Current QA protocols implemented in
modern radiation oncology clinics with
updated LINAC functionalities

Radiation Oncology Error Management

Clinical experience has shown
that variations of 10% or more
in the delivered dose can
sharply reduce the probability of
local tumor control.
ICRU Report 62 recommends
that radiotherapy be delivered
within 5% of the prescribed
dose to ensure adequate tumor
control.
The global aim is to achieve
the desired tumor control while
maintaining toxicities to normal
tissues to a minimum
Are these endpoints achievable
with current delivery
technology?

Fig., Connor et al, IJROBP 1975

Linac QA
Components:

Dosimetric accuracy
Mechanical Accuracy

Safety
Frequency:

Daily
Monthly

Annually

The Early QA report (1994)

AAPM TG-40 report

Comprehensive QA program
QA of EXRT (External Beam Treatment)
equipment
QA of RTP (Information and IT tools) system

Brachytherapy
Clinical practice

Periodic QA of Linear Accelerator (TG-40)

Frequency
Daily

Monthly

Annually

Procedure
X-ray & electron output constancy
Localization lasers
Safety interlocks (door)
X-ray & Electron output constancy
Light/radiation field coincidence
X-ray flatness and symmetry
Electron flatness and symmetry
X-ray energy
Electron energy
Optical distance indicator
Field size indicators
Gantry angle indicator
Collimator angle indicator
Cross-hair centering
Full calibration
Isocenter shift
Collimator rotation
Gantry rotation
Couch rotation
Couch vertical travel
Tabletop sag

Tolerence ()
3%
2 mm
functional
2%
2 mm
2%
2%
2% in depth dose (2% in ionization ratio)
2 mm in R80 (2 mm in Rp)
2 mm
2 mm
1
1
1 mm
2%
2 mm
2 mm diameter
2 mm diameter
2 mm diameter
2 mm
2 mm

Radiation Isocenter Checks

Collimator 2 mm diameter circle

Treatment table 2 mm diameter circle

Gantry 2 mm diameter circle

Misadministration Definition in US

For external beam (>3 fractions)

No written directive
Wrong patient
Wrong site
Weekly dose exceeds 30%

Total dose exceed 20%

Most of the LINACs are inspected and governed
by the state government !!

Misadministration Definition in US
For Stereotactic radiosurgery/radiotherapy
(<= 3 fractions)
No written directive
Wrong patient

Wrong site
Total dose error exceeds 10%

Background of TG 142
Principles - TG-40 was the International
Commission on Radiation Units and
Measurements (ICRU) recommendation that the
dose delivered to the patient be within 5% of
the prescribed dose.
The goal of a QA program for linear accelerators
is to assure that the machine characteristics do
not deviate significantly from their baseline
values acquired at the time of acceptance and
commissioning.

Rationales for Developing TG 142

New Technology since TG 40 MLC, as
Asymmetric Jaws, Dynamic & virtual
wedges, EPIDs.
Imaging: kV and cone beam,
Respiratory gating..
Clinical procedures not emphasized in
TG 40 with new modalities such SRS,
SBRT, TBI, IMRT
TG50, TG58, TG76 TG106, TG104,
TG100 for various LINAC QAs

TG 142 fro Linear Accelerator QAs

What This Report Doesnt cover (some special techniques)
Describe the techniques for performing QA tests
Accelerator beam data commissioning equipment and procedures
TG-106
QA for TomoTherapy TG-148
QA for Robotic Radiosurgery TG-135
QA for Non-Radiographic Radiotherapy Localization & Positioning
Systems TG-147
Does add Specific Recommendations / Supplements the Work of
Basic Applications of Multileaf Collimators TG-50
Clinical use of electronic portal imaging - TG-58
Management of Respiratory Motion TG-76
Kilovoltage localization in therapy TG-104

MLC QA TG 50 (2001) - Update

EPID QA TG 58 (2001) - Update

TG-142 Testing Standards

Acceptance Testing Procedure (ATP) Standards
Acceptance testing sets the baseline for future
dosimetric measurements for beam performance
constancy, verifies that the equipment is mechanically
functional and operates within certain tolerances from
absolute specified values.
Tolerances and Action Levels
Level 1 Inspection Action
Level 2 Scheduled Action
Level 3 Immediate Action or Stop Treatment
Action or Corrective Action
With these 3 action levels, there is an institutional need to specify
the thresholds associated with Levels 2 and 3. Level 1 threshold isnt
a critical requirement but can lead to improvements in the QA
program.

TG-142 Daily
Procedure

Tolerance (nonIMRT machines)

Tolerance (IMRT
machines)

Tolerance
(Stereotactic
machines)

Dosimetry
X-ray output constancy (all energies)
Electron output constancy (Weekly, except
for machines with unique e- monitoring
requiring daily)

3%

Mechanical
Laser localization

2 mm

1.5 mm

1 mm

Distance indicator (ODI)@ iso

2 mm

2 mm

2 mm

Collimator size indicator

2 mm

2 mm

1 mm

Safety
Door interlock (beam off)

Functional

Door closing safety

Functional

Audiovisual monitor(s)

Functional

Stereotactic interlocks (lockout)

NA

NA

Radiation area monitor (if used)

Functional

Beam on indicator

Functional

Functional

TG-142 Daily (Continued)

Procedure

Tolerance (nonIMRT machines)

Tolerance (IMRT
machines)

Tolerance
(Stereotactic
machines)

Dosimetry
X-ray output constancy (all energies)
Electron output constancy (Weekly, except
for machines with unique e- monitoring
requiring daily)

3%

Mechanical
Laser localization

2 mm

1.5 mm

1 mm

Distance indicator (ODI)@ iso

2 mm

2 mm

2 mm

Collimator size indicator

2 mm

2 mm

1 mm

Safety
Door interlock (beam off)

Functional

Door closing safety

Functional

Audiovisual monitor(s)

Functional

Stereotactic interlocks (lockout)

NA

NA

Radiation area monitor (if used)

Functional

Beam on indicator

Functional

Functional

TG-142: Monthly
Procedure

Tolerance (nonIMRT machines)

Tolerance (IMRT
machines)

Tolerance
Stereotactic machines

Dosimetry
X-ray output constancy
2%

Electron output constancy

Backup monitor chamber constancy
Typical dose rate2 output constancy
Photon beam profile constancy
Electron beam profile constancy
Electron beam energy constancy

NA

2% (@ IMRT dose
rate)
1%
2%/2mm

2% (@ stereo dose
rate, MU)

TG-142 - Monthly (Continued)

Procedure

Tolerance
(non-IMRT
machines)

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 used for lasers/ODI (vs.

front pointer)

1mm

Gantry/collimator angle indicators (@ cardinal

angles) (Digital only)

1.0 deg

Accessory trays (i.e. Port film graticle tray)

2 mm

Jaw position indicators (Symmetric)3

2 mm

Jaw position indicators (Asymmetric)1

1 mm

Cross-hair centering (walk-out)

1 mm

Treatment couch position indicators4

2 mm/1 deg

Wedge placement accuracy

Localizing lasers

1 mm/ 0.5 deg

Functional5
2 mm

1 mm

Respiratory gating
Beam output constancy

2 mm/ 1 deg

Tolerance
Stereotactic
machines

2mm

Latching of wedges, blocking tray5

Tolerance
(IMRT
machines)

2%

Phase, Amplitude beam control

Functional

In room respiratory monitoring system

Functional

Gating interlock

Functional

<1 mm

TG-142 - Monthly (Continued)

Procedure

Tolerance
(non-IMRT
machines)

Tolerance
(IMRT
machines)

Tolerance
Stereotactic
machines

TG-142: Annual
Procedure

Tolerance (nonIMRT machines)

Tolerance (IMRT
machines)

Tolerance
Stereotactic
machines

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

SRS Arc rotation mode (range: 0.5 to 10

MU/deg )

NA

NA

Monitor units set vs.

delivered:1.0 MU or
2% (whichever is
greater)
Gantry arc set vs.
delivered: 1.0 deg or
2% (whichever is
greater)

X-ray/electron output calibration (TG-51)

1%(absolute)

Spot check of field size dependent output

factors for X-ray (2 or more FS)
Output factors for electron applicators
(spot check of 1 applicator/energy)

2% for field size < 4x4 cm2, 1% 4x4 cm2

X-ray beam quality (PDD10, TMR1020)

Electron beam quality (R50)
Transmission factor constancy for all
treatment accessories
Physical wedge transmission factor
constancy

1%

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

TG-142 Annual (Continued)

Procedure
X-ray monitor unit linearity [output .
constancy ]
Electron monitor unit linearity [output .
constancy ]
X-ray output constancy vs dose rate
X-ray output constancy vs gantry angle

Tolerance
(non-IMRT
machines)
2% 5MU

Tolerance
(IMRT
machines)
5% (2-4 MU), 2%
5MU

Tolerance
Stereotactic
machines
5% (2-4), 2%
5MU

2% 5MU
2% from baseline
1% from baseline

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
PDD or TMR and OAF constancy
TBI/TSET Output calibration
TBI/TSET accessories

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

TG-142 Annual (Continued)

Procedure

Tolerance (nonIMRT
machines)

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

Tolerance (IMRT
machines)
1 mm from baseline
1 mm from baseline
1 mm from baseline
Functional

2mm from
baseline

2mm from baseline

Table top sag

2mm from baseline

Table Angle

1 degree

Table travel maximum range movement

in all directions
Stereotactic accessories, lockouts, etc
Safety
Follow manufacturers test procedures
Respiratory gating
Beam energy constancy
Temporal accuracy of Phase/Amplitude
Gate-on
Calibration of surrogate for respiratory
phase/amplitude
Interlock testing

Tolerance
Stereotactic
machines

1mm from baseline

2mm
NA

Functional
Functional
2%
100 ms of expected
100 ms of expected
Functional

Wedge Verification (Not Physical)

Dynamic-incl. EDW (Varian), Virtual (Siemens), Universal (Elekta) Wedge quality assurance
Frequency
Procedure
Tolerance
Dynamic Universal Virtual
Daily

Morning Check-out
run for 1 angle

Functional

Monthly

Wedge factor for

all energies

C.A.
Axis 45
or 60
WF
(within
2%)*

Annual

Check of wedge
angle for 60, full
field & spot check
for intermediate
angle, field size

Check of Off-center ratios @ 80%

field width @ 10cm to be within
2%

* Recommendation to check 45 if angles other than 60 are used.

C.A. Axis
5% from
45 or 60
unity,
WF
otherwise
(within
2%
2%)*

MLC Verification
Multi-leaf collimation quality assurance (with differentiation of IMRT vs. non-IMRT machines)
Frequency

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 trransmission

Setting vs. radiation field for

two patterns (non-IMRT)

2mm

Backup diaphragm settings

(Elekta only)

2mm

Travel speed (IMRT)

Loss of leaf speed > 0.5 cm/sec

Leaf position accuracy (IMRT)

1mm for leaf positions of an

IMRT field for 4 cardinal gantry
angles. (Picket fence test may be
used, test depends on clinical
planning segment size)

Monthly

MLC - Annual Test

MLC Transmission (Average of leaf and

interleaf transmission), All Energies

0.5% from baseline

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

Arc dynamic leaf-speed test

<0.35 cm Max Error RMS, 95% of error

counts <0.35 cm (Varian)

Arc dynamic interlock trip test

Leaf position interlock occurs (Varian)

Arc dynamic typical plan test

<0.35 cm Max Error RMS, 95% of error

counts <0.35 cm (Varian)

Segmental IMRT (Step and Shoot) Test

<0.35 cm Max Error RMS, 95% of error

counts <0.35 cm (Varian)

Moving window imrt (4 cardinal gantry

angles)

<0.35 cm Max Error RMS, 95% of error

counts <0.35 cm (Varian)

Imaging Equipment Test - Daily

Procedure

Non-SRS/SBRT Applications
Tolerances

SRS/SBRT Applications
Tolerances

Daily
MV imaging (EPID)
Collision interlocks

Functional

Functional

Spatial linearity1 (x and y) (single gantry

angle)

< 2 mm

1 mm

Imaging & Treatment coordinate

coincidence (single gantry angle)

< 2 mm

1 mm

Positioning/repositioning

< 2 mm

1 mm

Functional

Functional

Imaging & treatment coordinate

coincidence

< 2 mm

1 mm

Positioning/repositioning

< 2 mm

1 mm

Functional

Functional

< 2 mm

1 mm

KV imaging2
Collision interlocks

Cone-beam CT (kV & MV)

Collision interlocks
Positioning/repositioning

Imaging Equipment Test - Monthly

Procedure

Non-SRS/SBRT
Applications Tolerances

SRS/SBRT Applications
Tolerances

1
MV imaging (EPID)
Imaging & treatment coordinate
coincidence (4 Cardinal angles)

< 2 mm

1 mm

Scaling3

< 2 mm

< 2 mm

Spatial resolution

Baseline

Contrast
Uniformity and noise
kV imaging

Baseline
Baseline

Baseline
Baseline

Imaging & treatment coordinate

coincidence (4 Cardinal angles)

< 2 mm

1 mm

Scaling

< 2 mm

1 mm

Spatial linearity (x and y) (single gantry

angle)

< 2 mm

1 mm

Baseline
Baseline
Baseline

Baseline
Baseline
Baseline

Imaging & treatment coordinate

coincidence

< 1.5 mm

1 mm

Geometric distortion
Spatial resolution
Contrast
HU constancy
Uniformity and noise

< 2 mm
Baseline
Baseline
Baseline
Baseline

1 mm
Baseline
Baseline
Baseline
Baseline

Spatial linearity (x and y) (single gantry

angle)

< 1 mm

1 mm

Spatial resolution
Contrast
Uniformity and noise
Cone-beam CT (kV & MV)

Baseline

Imaging Equipment Test - Annual

Procedure
1

SRS/SBRT Applications
Tolerances

MV imaging (EPID)
Full range of travel SDD

5 mm

5 mm

Baseline

Baseline

Beam quality / energy

kV imaging

Baseline

Baseline

Beam quality / energy

Imaging dose
Cone-beam CT (kV & MV)

Baseline
Baseline

Baseline
Baseline

Baseline

Baseline

Imaging dose5

Imaging dose

Non-SRS/SBRT
Applications Tolerances

Conclusions
LINAC QA protocols have become extensive through
modern LINAC development and implementation.
AAPM TG-40 report still function as the base lines.
AAPM TG-142 has gradually emerging into modern
clinical practice (some of those testing are tedious and
maybe not applicable to a busy clinic).
However, regulatory agencies still have hard time to
follow due to manpower, training and budgeting
constraints.
Annual report should include but not limited to the
following: . (1) Dosimetry, (2) Mechanical, (3) Safety,
(4) Imaging, and (5) Special Devices/Procedures.