Linear Accelerator QA Tolerances - Daily

Tolerance
Non-IMRT IMRT

X-ray Output Constancy (all Energies) 3%

Electron Output Constancy 3%

Laser Localization 2 mm 1.5 mm

Optical Distance Indicator (ODI) @ ISO 2 mm 2 mm
Collimator size indicator 2 mm 2 mm

Door Interlock (beam off) Functional: Y/N?

Door closing Safety Functional: Y/N?
Audio-visual Monitor(s) Functional: Y/N?
Stereotactic interlocks (lockout) N/A N/A
Radiation Area Monitor (if used) Functional: Y/N?
Beam on indicator Functional: Y/N?

Source: Klein EE, Hanley J, Bayouth J, et al. Task group 142 Report: Quality assurance of medical accelerators. Med Phys. 200
 SRS/SBRT

1 mm
2 mm
1 mm

Functional?

cal accelerators. Med Phys. 2009; 36(9)4197-4212

Linear Accelerator QA Tolerances - Monthly

non-IMRT

Dosimetry
X-ray Output Constancy
Electron Output Constancy
Backup Monitor Chamber Constancy
Typical Dose Rate Output Constancy N/A
Photon Beam Profile Constancy
Electron Beam Profile Constancy
Electron Beam Energy Constancy

Safety
Emergency off Switches
Laser guard-interlock test
Latching of wedges, blocking tray

Mechanical
Light / Radiation field Coincidence
Light / Radiation field Coincidence (Asymmetric)
Distance Check device for lasers compared with front pointer
Gantry / Collimator Angle Indicators (digital only)
Accessory Trays (i.e., port film graticule tray) position
Jaw Position indicators (symmetric)
Jaw Position indicators (asymmetric)
Cross-hair centering (walkout)
Treatment couch position indicators 2mm / 1 degree
Wedge placement accuracy
Compensator placement accuracy
Localizing Lasers 2 mm

Respiratory gating
Beam Output Constancy
Phase, amplitude beam control
in-room respiratory monitoring system
Gating interlock
Source: Klein EE, Hanley J, Bayouth J, et al. Task group 142 Report: Quality assurance of medical accelerators. Med Phys. 200
 Tolerance
IMRT SRS/SBRT

2%
2%
2%
2% (@ IMRT dose rate) 2% (@ SRS dose rate)
1%
1%
2%, 2mm

Functional: Y/N?
Functional: Y/N?
Functional: Y/N?

2 mm, or 1% on a side
1 mm, or 1% on a side
1 mm
1 degree
2 mm
2 mm
1 mm
1 mm
2mm / 1 degree 1mm / 0.5 degree
2 mm
1 mm
1 mm < 1mm

2%
Functional: Y/N?
Functional: Y/N?
Functional: Y/N?
ce of medical accelerators. Med Phys. 2009; 36(9)4197-4212
Linear Accelerator QA Tolerances - Annual

non-IMRT

Dosimetry
X-ray flatness change from baseline
X-ray symmetry change from baseline
Electron flatness change from baseline
Electron symmetry change from baseline

SRS arc rotation mode (range: 0.5-10 MU/deg) N/A

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

Spot check of field size dependent output factors for x-rays (for two
or more field sizes)

Output factors for electron applicators (spot check of one

applicator/energy)
X-ray beam quality (PDD10 or TMR20/10)
Electrom beam quality (R50)
Physical Wedge transmission factor constancy

X-ray monitor unit linearity (output constancy) 2% for > 5MU

Electron monitor unit linearity (output constancy)
X-ray output constancy vs dose rate
X-ray/ electron output constancy vs Gantry angle
X-ray/ electron 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
 Mechanical
Collimator rotation isocenter
Gantry rotation isocenter
Couch rotation isocenter
Electron applicator interlocks
2 mm from
Coincidence of radiation and mechanical isocenter baseline
Table top sag
Table Angle
Table travel maximum range in all directions
Stereotactic accessories, lockouts, etc N/A

Safety
Follow manufacturer's test procedures

Respiratory gating
Beam Energy Constancy
Temporal accuracy of Phase/amplitude gate on
Calibration of surrogate for respiratory phase/amplitude
Gating interlock testing

Source: Klein EE, Hanley J, Bayouth J, et al. Task group 142 Report: Quality assurance of medical accelerators. Med Phys. 200
 Tolerance
IMRT SRS/SBRT

1%
1%
1%
1%
MU set vs delivered: 1.0
MU or 2% (whichever is
greater)
N/A

Gantry arc set vs

delivered: 1.0 MU or 2%
(whichever is greater)

1% (absolute)

2% for FS < 4 x 4 cm; 1% for > 4

x 4 cm

2% from baseline
1% from baseline
1 mm
2%
5% for 2-4 MU; 2% for > 5% for 2-4 MU; 2%
5MU for > 5MU
2% for > 5MU
2% from baseline
1% from baseline
1% from baseline
1% from baseline
Functional: Y/N?

1% (TBI) or 1mm PDD shift

(TSET) from baseline
2% from baseline
2% from baseline
 1 mm from baseline
1 mm from baseline
1 mm from baseline
Functional: Y/N?

2 mm from baseline 1 mm from baseline

2 mm from baseline
1 degree
2 mm
N/A Functional: Y/N?

Functional: Y/N?

2%
100 ms of expected
100 ms of expected
Functional: Y/N?

of medical accelerators. Med Phys. 2009; 36(9)4197-4212

Linear Accelerator QA Tolerances - Imaging
Daily

Planar kV and MV (EPID) imaging

Collision interlocks
Positioning/repositioning
Imaging and treatment coordinate coincidence (single gantry angle)

Cone-beam CT (kV and MV)

Collision interlocks
Positioning/repositioning
Imaging and treatment coordinate coincidence (single gantry angle)

Monthly

Planar MV (EPID) imaging

Imaging and treatment coordinate coincidence (4 cardinal angles)
Scaling
Spatial Resolution
Contrast
Uniformity and Noise

Planar kV imaging
Imaging and treatment coordinate coincidence (4 cardinal angles)
Scaling
Spatial Resolution
Contrast
Uniformity and Noise

Cone-beam CT (kV and MV)

Geometric distortion
Spatial Resolution
Contrast
HU constancy
Uniformity and Noise
 Annual

Planar MV (EPID) imaging

Full range of travel SDD
Imaging dose

Planar kV imaging
Beam quality/energy
Imaging dose

Cone-beam CT (kV and MV)

Imaging dose

Source: Klein EE, Hanley J, Bayouth J, et al. Task group 142 Report: Quality assurance of medical accelerators. Med Phys. 200


Tolerance
non-SRS/SBRT SRS/SBRT

Functional: Y/N? Functional: Y/N?

< 2 mm < 1 mm
< 2 mm < 1 mm

Functional: Y/N? Functional: Y/N?

< 1 mm < 1 mm
< 2 mm < 1 mm

Tolerance
non-SRS/SBRT SRS/SBRT

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

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

< 2 mm < 1 mm
Baseline Baseline
Baseline Baseline
Baseline Baseline
Baseline Baseline
 Tolerance
non-SRS/SBRT SRS/SBRT

5 mm 5 mm
Baseline Baseline

Baseline Baseline
Baseline Baseline

Baseline Baseline

assurance of medical accelerators. Med Phys. 2009; 36(9)4197-4212

Treatment Planning System QA Tolerances

Frequency Test Tolerance

At Commissioning and after

Software updates
Understand Algorithm Functional
Single field or source isodose 2% or 2mm
distributions
MU Calculations 2%
Test cases 2% or 2mm
I/O system 1 mm

Daily
I/O devices 1 mm

Monthly
Checksum No change
Subset of reference QA test set 2% or 2mm
(when checksums not available)
I/O system 1 mm

Annual
MU Calculations 2%
Reference QA test set 2% or 2mm
I/O system 1 mm

Source: 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.
Periodic RTP Process QA Check

Recommended
Frequency Item

Daily Error Log

Change log

Weekly Digitizer

Hardcopy output

Computer Files

Review clinical planning

Monthly CT data input into RTP

system

Problem Review

RTP System Review

Annual Dose Calculations

Data and I/O devices

 Critical software tools

Variable Beam parameterization

Software Changes
including Operating
System

Fraass B, Doppke K, Hunt M, et al. American Association of Physicists in Medicine Radiation Therapy Committee T
Quality assurance for clinical radiotherapy treatment planning. Med Phys. 1998;25(10):1773-1828.
Source: https://doi.org/10.1118/1.598373.
 Comments/Details

Review report log listing system failures, error messages, hardware

malfunctions, and other problems. Triage list and remedy any serious
problems that occur during the day.

Keep log of hardware/software changes

Review digitizer accuracy

Review all hardcopy output, including scaling for plotter and other
graphics-type output.

Verify integrity of all RTP system data files and executables using
checksums or other simple software checks. Checking software
should be provided by the vendor.

Review clinical treatment planning activity. Discuss errors,

problems, complications, difficulties. Resolve problems.

Review the CT data within the planning system for geometrical

accuracy, CT number consistency ~also dependent on the QA and use
of the scanner!, and derived electron density.

Review all RTP problems ~both for RTP system and clinical
treatment planning! and prioritize problems to be resolved.

Review current configuration and status of all RTP system software,

hardware, and data files.

Annual checks. Review acceptability of agreement between

measured and calculated doses for each beam/source.

Review functioning and accuracy of digitizer tablet, video/laser

digitizer, CT input, MR input, printers, plotters, and other imaging
output devices.
 Review BEV/DRR generation and plot accuracy, CT geometry,
density conversions, DVH calculations, other critical tools,
machine-specific conversions, data files, and other critical data.

Checks and/or recommissioning may be required due to machine

changes or problems.

Checks and/or recommissioning may be required due to changes in

the RTP software, any support/additional software such as image
transfer software, or the operating system.

can Association of Physicists in Medicine Radiation Therapy Committee Task Group 53:
py treatment planning. Med Phys. 1998;25(10):1773-1828.
CT Simulator: Test Specifications QA for Electromechanical Components

Performance parameter Frequency

Alignment of gantry lasers with the center

Daily
of imaging plane
Orientation of gantry lasers with respect to
Monthly
the imaging plane

Spacing of lateral wall lasers with respect

Monthly and after laser adjustments
to lateral gantry lasers and scan plane

Orientation of wall lasers with respect to

Monthly and after laser adjustments
the imaging plane
Orientation of ceiling lasers with respect
Monthly and after laser adjustments
to the imaging plane

Orientation of tabletop with respect to Monthly or when daily laser QA tests

imaging plane fail

Table vertical and longitudinal motion Monthly

Table indexing and position Annually
Gantry tilt accuracy Annually
Gantry title position accuracy Annually
Scan localization Annually
Radiation profile width Annually
Sensitivity profile width Semiannually

After replacement of major generator

Generator tests
component

CT Simulator: Test Specifications QA for Image Performance Evaluation

Performance parameter Frequency

CT number accuracy Daily

Monthly: 4-5 diff. materials
Annually: Electron density phantom
Image noise Daily
In-plane spatial integrity Daily: x or y axis
 Monthly: both directions
Field uniformity Monthly: most common kVP setting
Annually: Other kVP settings

Electron density to CT number conversion Annually

Spatial resolution Annually
Contrast resolution Annually

Source: Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkin
ponents

Tolerance limits

+/- 2mm

+/- 2mm over the length of laser

projection

+/- 2mm

+/- 2mm over the length of laser

projection
+/- 2mm over the length of laser
projection

+/- 2mm over the width of the tabletop

+/- 1mm over the range of table motion

+/- 1mm over the scan range
+/- 1 over gantry tilt range
+/- 1 or +/- 1mm from nominal position
+/- 1mm over the scan range
Manufacturer specifications
+/- 1mm of nominal value

Manufacturer specifications

luation

Tolerance limits

For water, 0 +/- 5HU

Manufacturer specification
+/- 1mm
 Within +/- 5HU

Consistent with commissioning results &

test phantom manufacturer specs
Manufacturer specs
Manufacturer specs

lphia, PA: Lippincott Williams & Wilkins; 2014:396-398.

Periodic QA of Radiographic Simulators

Daily
Procedure Tolerance
Localizing lasers 2 mm
Distance Indicators 2 mm

Monthly
Procedure Tolerance
Field size Indicator 2 mm
Gantry/Collimator angle Indicators 1 degree
Cross-hair Centering 2 mm diameter
Focal Spot Axis Indicator 2 mm
Fluoroscopic Image Quality baseline
Emergency/Collision Avoidance Functional
Light/RadiationField Coincidence 2 mm or 1%
Film Processor Sensitometry Baseline

Annually
Procedure Tolerance

Mechanical Checks
Collimator rotation isocenter 2 mm diameter
Gantry rotation isocenter 2 mm diameter
Couch rotation isocenter 2 mm diameter
Coincidence of radiation and mechanical isocenter 2 mm diameter
Table top sag 2 mm
Vertical travel of Couch 2 mm

Radiographic Checks
Exposure rate Baseline
Table-top Exposure with Fluoroscopy Baseline
kVp and mAs Calibration Baseline
High & Low Contrast Resolution Baseline
 Khan FM, Gibbons JP. Khans The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014:396-398.
Source:

Multileaf Collimation QA

Frequency Test

Patient specific Check of MLC generated field vs. simulator film

(or DRR) before each field is treated

Double check of MLC field by therapists for each

fraction

One-line imaging verification for patient on each

infraction

Portfilm approval before second fraction

Quarterly Setting vs. light field vs. radiation field for two
designated patterns

Testing of network system

Check of Interlocks

Annually Setting vs. light vs. radiation field for patterns

over range of gantry and collimator angles

Water scan of set patterns

Film scans to evaluate interleaf leakage and

abutted leaf transmission

Review of procedures and in-service with

therapists

Source: Khan FM, Gibbons JP. Khan's The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2014:396-398.
 Tolerance

2 mm

Expected Field

Physician's discretion

Physician's discretion

1 mm

Expected fields over

network

All must be operational

1 mm

50% radiation edge within 1

mm

Interleaf leakage < 3%;

Abutted leakage < 25%

All operators must fully

understand operation and
procedures

h ed. Philadelphia, PA: Lippincott Williams

Intracavitary Source and Applicator QA

Procedure End-point

Evaluate dimensions/ serial Source identity; Physical length and diameter

number

Superposition of auto- and Active source length and uniformity, capsule

transmission radiographs thickness Accuracy of source construction

Source leak test Capsule Integrity

Source calibration Source Strength

Dosimetric evaluation of Magnitude and geometric characteristics of

applicator shielding effect

Orthogonal radiographs of Correct source position, mechanical integrity,

internal shield positioning coincidence of
applicators dummy and radioactive source

Measure applicator Correct diameter and length, correct diameter

dimensions of all colpostat caps and cylinder segments

Source inventory Correct source number

Source preparation area

survey Safety of brachytherapy personnel

Interstitial Source and Applicator QA

Procedure End-point
 Evaluate spacing and Ribbon geometry and seed quantity
number of seeds/ ribbon

Source calibration Source strength

Strength per seed, or Source strength uniformity

strength per unit length

Varies; Metal needles: sharpness and

Applicator integrity straightness; Templates: 0-ring integrity and
hole locations

Evaluate dummy ribbon

Coincidence of dummy and radioactive sources
geometry

Source leak test Capsule integrity

Source inventory Correct source number

Source preparation area Safety of brachytherapy personnel

survey

Nath R, Anderson LL, Meli JA, et al. Code of practice for brachytherapy physics: Report of the AAPM
Source: Radiation Therapy Committee Task Group No. 56. Med Phys. 1997;24(10):1557-1598.
https://doi.org/10.1118/1.597966.
Frequency

Initially

Initially

NRC requires leak

testing, generally at 6
month intervals

Initially, Annually

Initially

Initially, Annually

Initially, Annually

Quarterly

As needed

Frequency
 Initially

Initially; each use

Initially

Initially, Annually

Initially, Annually

Quarterly

Quarterly

Quarterly

apy physics: Report of the AAPM

24(10):1557-1598.
Brachytherapy Source QA

Type of Source Test Frequency

Long half-life: Physical/chemical form Initial purchase

Description
Source encapsulation Initial purchase

Radionuclide distribution Initial purchase

and source uniformity

Location of radionuclide Initial purchase

Long half-life: Mean of batch Initial purchase

Calibration

Deviation from mean Initial purchase

Calibration verification Every use

Short half-life: Physical/chemical form Initial purchase

Description

Source encapsulation Initial purchase

Short half-life: Mean of batch Every use

Calibration

Deviation from mean Every use

Radionuclide distribution Every use

and source uniformity

A* Visual check of source color code or measurement in a calibrator.

V** Visual check, autoradiograph, or ionometric check

 Nath R, Anderson LL, Meli JA, et al. Code of practice for brachytherapy physics: Report of the
Source: AAPM Radiation Therapy Committee Task Group No. 56. Med Phys. 1997;24(10):1557-1598.
https://doi.org/10.1118/1.597966.

Remote Afterloading Brachytherapy Unit QA

Test Frequency

Room safety door interlocks, lights, and alarms Each treatment day

Console functions, switches, batteries, printer

Visual inspection of source guides

Verify accuracy of ribbon preparation

Accuracy of source and dummy loading

(dummies used for spacing and/or Weekly
simulation/verification)

Source positioning

Calibration
At each source change
or quarterly

Timer Function

Source: 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.
 Tolerance

Documented

Documented

Documented

1 mm

3%

5%, Documented

A*

Documented

Documented

3%

5%

V**
rapy physics: Report of the
s. 1997;24(10):1557-1598.

Tolerance

Functional

Functional

Free of kinks and

firmly attached

Autoradiograph

1 mm

1 mm

3%

1%

n Oncology. AAPM Report No.

8/1.597316.
Dynamic/ Universal/ Virtual Wedge QA ***

Frequency Procedure Dynamic Universal

Daily Morning check-out run for

one angle Functional

Monthly C.A. axis 45 or 60 WF C.A. axis 45 or 60 WF

Wedge factor for all energies (within 2%) (within 2%)

Check of off-center Check of off-center

Annually Check of wedge angle for 60, ratios @ 80% field ratios @ 80% field
full field and spot check for width @ 10 cm to be width @ 10 cm to be
intermediate angle, field size within 2% within 2%

***Dynamic-including EDW (Varian), virtual (Siemens), universal (Elekta) wedge quality as

Source: Klein EE, Hanley J, Bayouth J, et al. Task group 142 Report: Quality assurance of medical accelerators. Me
 Virtual

5% from unity,
otherwise 2%

Check of off-center
ratios @ 80% field
width @ 10 cm to be
within 2%

a) wedge quality assurance.

dical accelerators. Med Phys. 2009; 36(9)4197-4212