DOS 542 QA Week 1 discussion

The goal of a quality assurance (QA) program for linear accelerators is to maintain the
accuracy of the treatment machine performance from the original parameters by checking the
equipment and related components periodically with specific recommendations.1 The Internal
Commission of Radiation Units and Measurements (ICRU) recommended an accuracy of 5% of
the prescribed dose delivery.
The linear accelerator I observed for daily QA is a Varian 23IX Linac accelerator (figure
1) with Exac Trac (figure 2) for stereotactic radiosurgery (SRS)/stereotactic body radiation
therapy (SBRT) treatment. The daily test of each machine is performed early in the morning at
one hour prior to the first patient treatment by a morning warm-up radiation therapist with
specific safety training of the relevant procedure and policies. The therapist first turned the
locked backup counter on to warm up the machine. The gas and water temperature, pressure and
water level were checked and recorded in computer system. The overall checking parameters
include safety tests, dosimetric and mechanical means which listed in QA software called Atlas
QA (version 1.5). The therapist performed the series of daily tests by following each step from
the list.
Before starting any tests, the Exac Trac localization accuracy verification must be
performed first. Otherwise, the computer system would not accept any results from the following
tests. The Exac Trac is a small Brain Lab phantom with 5 pointers used for SRS/SBRT treatment.
The isocenter and crosshair centering were checked by aligning ceiling, sagittal and coronal wall
lasers shown in figure 3. Then the therapist left the room to take kV images for calibration and
verification of the isocenter, Winstron-Lutz pointers, and daily check. The images for verification
were taken from right (1) and left (2) tubes respectively seen in figure 4. Each pointer detected
by tube 1 and 2 was visually inspected on the screen if the green crosses match the blue sphere in
the middle cross (see figure 5).
The mechanical check includes laser localization from ceiling, sagittal, and coronal wall
lasers, optical distance indicator (ODI), and collimator size indicator. Whereas the safety tests
include OBI automatic couch positioning test, door sensor and interlock functionality with beam
on and off, audio-visual monitors, dose timer interlock, beam on indicator, pitch/role of couch
manual set to zero, and SRS interlock. For dose timer interlock, the therapist programed 360 MU

at 300 r/min, and then turned the beam on and let timer interlock turn the beam off. The MU1,
MU 2, and the backup counter are also checked with a result of 300 MU within a difference of
8MU. The control console with beam on was also checked to make sure there was no functional
button while the key was turned on. OBI interlocks and alarms were checked to make sure the
one of the touch guards stops all motion. With either kVs or kVD moving, releasing the motion
enables bars on the OBI hand pendant stops all motion.
The dosimetric check is an important daily QA performance for photon and electron
output constancy with all energies with beam types of 3D CRT, IMRT, IGRT, and SBRT/SRS.
The Multileaf collimation (MLC), asymmetric jaws, dynamic and virtual wedges, and electronic
portal imaging devices (EPIDs), cone-beam CT(CBCT), static kilovoltage (kV) and megavoltage
imaging are also checked for this linear accelerator. The electron beam includes 6 MeV, 9 MeV,
12 MeV, 16 MeV, and 20 MeV energies while the photon beam has 6 MV and 16 MV energies.
The output tolerance for daily QA is within 3%, and 2% for monthly and annually checks. Beam
output, beam flatness, field size deviation (X and Y size and shift), and symmetry of the beam
were tested for each energy. The machine warm-up and test acquisition require 80 kV, 100mA,
and 100 mS energy settings. The machine was first warmed up by delivering 200 MU for one
time. The following tests delivered 100 MU at 400 MU/min rate for all energies and 1000
MU/min for SRS mode for 0.3 minute in each delivery. All energies were tested with open beams
for 20 cm x 20 cm field size at 100 cm SSD. Electron energies were tested first with the
accessory mount and block tray in place (figure 6). The results were recorded and transferred to
Atlas QA system (seen in figure1). The Atlas QA system collects and analyzes all the results to
give the therapist fail or pass results. All data are saved in the computer for documentation of the
record of QA and reviewed later by physicists. If the tolerances are exceeding the recommended
limits or any failures happen, an action is required immediately. The machine cannot be used
clinically until the issue had been resolved. The therapist must contact the on duty qualified
medical physicist (QMP) to solve the problem. The radiation engineer is also responsible to
support the QA checks and any failures. On the day, I saw two engineers came to the room to
check what they could help. My clinical site follows the process recommended by AAPM TG142 protocol. However, the therapist told me patients could be treated if the failed tasks do not
affect the safety and accuracy of the treatment. For example, if the electron QA test fails and

patient is treated with photon, the patient can be treated on this machine before the physicist and
engineer solve the problem.
At the end of the daily QA, the therapist checked the backup counter in the locker under
the table to make sure if the delivered MU was the same or within 8 MU to the MU recorded on
the monitor.
References:
1. Klein E, Hanley J, Bayouth J, et al. AAPM TG-142 Report: QA of Medical Accelerators.
Med Phys. September 2009;36(9):4197-4212.

Figures

Figure1: The Varian 23IX Linear accelerator with the calibration reader for photon energy output
QA.

Figure 2: The Brainlab ExacTrac phantom for SRS/SBRT treatment.

Figure 3: The cross-hair verification of ExacTrac localization

Figure 4: The verification of ExacTrac pointers by right and left cameras.

Figure 5: The verification of sphere with images taken by right and left tubes.

Figure 6: The electron energy QA with tray in place