Linear Accelerator QA1,2

Tolerance
Frequency Procedure Non-IMRT IMRT SRS/SBRT
Dosimetry
x-ray output constancy 3%

D Electron output constancy (machines with

unique e-monitoring)
3%

A
Mechanical
Laser localization 2 mm 1.5 mm 1 mm

I Distance indicator (ODI) @ isocenter

Collimator size indicator
2 mm
2 mm
2 mm
2 mm
2 mm
1 mm
Safety
L Door interlock Functional

Y Door closing safety

Audiovisual monitor
Functional
Functional
Stereotactic interlocks N/A N/A Functional
Radiation area monitor (if used) Functional
Beam on indicator Functional
MLCs/Wedges .
Qualitative test i.e. picket fence (weekly) Visual inspection for discernable deviations such as an
increase in interleaf transmission
Morning check-out run for one EDW Functional
Dosimetry
x-ray output constancy 2%
Electron output constancy 2%
Backup monitor chamber constancy 2%
Typical dose rate output constancy N/A 2% 2%
Photon beam profile constancy 1%
Electron beam profile constancy 1%
Electron beam energy constancy 2%/2mm

M Mechanical

Light/radiation field coincidence 2 mm or 1% on a side

O Light/radiation field coincidence (asymmetric) 1 mm or 1% on a side
Distance check device for lasers compared 1 mm
N with front pointer
Gantry/collimator angle indicators 1.0
T Accessory trays 2 mm
Jaw position indicators (symmetric) 2 mm
H Jaw position indicators (asymmetric) 1 mm

L
Cross-hair centering 1 mm
Treatment couch position indicators 2 mm/1 2 mm/1 1 mm/0.5

Y
Wedge placement accuracy 2 mm
Compensator placement accuracy 1 mm
Latching of wedges, blocking tray Functional
Localizing lasers 2 mm 1 mm <1 mm
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
 Tolerance
Frequency Procedure Non-IMRT IMRT SRS/SBRT
M MLCs/Wedges
O MLCs: Setting vs radiation field for two patterns (non-IMRT) 2 mm N/A N/A
N MLCs: Backup diaphragm settings (Elekta only) 2 mm
T MLCs: Travel speed (IMRT) N/A Loss of speed Loss of speed
>0.5cm/s >0.5cm/s
H
MLCs: Leaf position accuracy (IMRT) N/A 1 mm for 4 cardinal 1 mm for 4 cardinal
L angles angles
Y Wedge factor for all energies EDW & universal = 2% / Virtual = 5% from unity or 2%
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 1%
SRS are rotation mode (range: 0.5-10MU/degree)
Monitor units set vs. delivered: N/A N/A 1.0 MU or 2%
(whichever is
greater)
Gantry are set vs. delivered: N/A N/A 1.0 or 2%
(whichever is
greater)
x-ray/electron output calibration (TG-51) 1% (absolute)
Spot check of field size dependent output factors for x-
A
2% for field size <4 x 4 cm2
ray (two or more FSs) 1% 4 x 4 cm2
Output factor for electron applicators 2% from baseline
N X-ray beam quality
Electron beam quality
1% from baseline
1mm
N Physical wedge transmission factor constancy
x-ray monitor unit linearity 2% 5MU
2%
5%(2-4MU), 5%(2-4MU),
U Electron monitor unit linearity
2% 5MU
2% 5MU
2% 5MU

A x-ray output constancy vs. dose rate

x-ray output constancy vs. gantry angle
2% from baseline
1% from baseline

L Electron output constancy vs. gantry angle

Electron and x-ray off axis factor constancy vs. gantry
1% from baseline
1% from baseline
angle
Arc mode (excepted MU/degrees) 1% from baseline
TBI/TSET mode Functional
PDD or TMR and OAF constancy 1% (TBI) or 1 mm PDD shift (TSET) from baseline
TBI/TSET output calibration 2% from baseline
TBI/TSET accessories 2% from baseline
Mechanical
Collimator rotation isocenter 1 mm from baseline
Gantry rotation isocenter 1 mm from baseline
Couch rotation isocenter 1 mm from baseline
Electron applicator interlocks Functional
Coincidence of radiation and mechanical isocenter 2 mm from 2 mm from 1 mm from
baseline baseline baseline
Table top sag 2 mm from baseline
Table angle 1
Table travel maximum range movement in all directions 2 mm
Stereotactic accessories, lockouts, etc. N/A N/A Functional
Safety
Follow manufacturers test procedures Functional
Respiratory gating
Beam energy constancy 2%
Temporal accuracy of phase/amplitude gate on 100 ms of expected
Calibration of surrogate for respiratory 100 ms of expected
phase/amplitude
Interlock testing Functional
 MLCs/Wedges
MLCs: transmission (average of leaf and interleaf), all 0.5% from baseline
energies
MLCs: Leaf position repeatability 1.0 mm
MLCs: MLC spoke shot 1.0 mm radius
MLCs: Coincidence of light field and x-ray field (all energies) 2.0 mm
MLCs: Segmental IMRT (step and shoot) test <0.35 cm max. error RMS, 95% of error counts <0.35 cm
MLCs: Moving window IMRT (four cardinal gantry angles) <0.35 cm max. error RMS, 95% of error counts <0.35 cm
Check of wedge angle for 60, full field and spot check for Check of off-center ratios @ 80% field width @ 10 cm to
intermediate angle, field size be within 2%

Imaging QA2
Tolerance
Frequency Procedure Non-SRS/SBRT SRS/SBRT
Planar kV and MV (EPID) imaging
D Collison interlocks Functional Functional
Positioning/repositioning 2 mm 1mm
A Imaging and treatment coordinate coincidence (single 2 mm 1 mm
I gantry angle)
Cone-beam CT (kV and MV)
L Collison interlocks Functional Functional
Y Imaging and treatment coordinate coincidence
Positioning/repositioning
2 mm
1 mm
1mm
1 mm

Planar MV imaging (EPID)

Imaging and treatment coordinate coincidence (four 2 mm 1 mm
cardinal angles)
Scaling 2 mm 2 mm
M Spatial resolution Baseline Baseline
O Contrast Baseline Baseline
Uniformity and noise Baseline Baseline
N Planar kV imaging
T Imaging and treatment coordinate coincidence (four 2 mm 1 mm
cardinal angles)
H Scaling 2 mm 1 mm
L Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Y 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
A Planar MV imaging (EPID)
Full range of travel SDD 5 mm 5 mm
N Imaging Dose Baseline Baseline
N Planar kV imaging
U Beam quality/energy Baseline Baseline
Imaging Dose Baseline Baseline
A Cone-beam CT (kV and MV)
L Imaging Dose Baseline Baseline
 CT Simulator QA3
Frequency Procedure Test objective Tolerance Limits

D Alignment of gantry lasers with

Electromechanical
To verify proper identification of scan plane 2mm
A the center of imaging plane with gantry lasers
Image performance
I CT number accuracy CT number for water 0 5 HU
Image Noise Manufacturer
L specifications
In plane spatial integrity (x or 1 mm
Y y direction)
Electromechanical
Orientation of gantry lasers To verify that the gantry lasers are parallel and 2 mm over the
with respect to the imaging orthogonal with the imaging plane over the full length of laser
plane length of laser projection projection
M Spacing of lateral wall lasers with
respect to lateral gantry lasers
To verify that the lateral wall lasers are
accurately spaced from the scan plane
2 mm

O and scan plane

Orientation of wall lasers
N with respect to the imaging
plane
To verify that wall lasers are parallel and 2 mm over the
orthogonal with the imaging plane over full
length of laser projection
length of laser
projection

T Orientation of ceiling laser

with respect to the imaging
To verify that the ceiling laser is orthogonal
with the imaging plane
2 mm over length of
laser projection

H Orientation of CT-scanner
tabletop with respect to imaging
To verify that the CT-scanner tabletop is level
and orthogonal with the imaging plane
2 mm over the
length and width of
plane table top
L Table vertical and To verify the table longitudinal motion 1 mm over the range
longitudinal motion according to digital indicators is accurate and of table motion
Y reproducible
Image performance
CT number accuracy Test 4-5 different materials 5 HU
In plane spatial integrity (both x 1 mm
and y directions)
Field uniformity (most 5 HU
common used kVp)
Electromechanical
Table indexing and position To verify table indexing & position accuracy 1 mm over the scan
under scanner control range
Gantry tilt accuracy To verify accuracy of gantry tilt indicators 1 degree over the
A Gantry tilt position accuracy To verify that the gantry accurately returns to
gantry tilt range
1 degree or 1 mm
N Scan localization
nominal position after tilting
To verify accuracy of scan localization from
from nominal position
1 mm over the scan
N Radiation profile width
pilot images
To verify that the radiation profile width
range
Manufacturer

U meets manufacturer specifications

Image performance
specifications

A CT number accuracy
Field uniformity (other used
Electron density phantom 5 HU
5 HU

L kVp settings)
Electron density to CT Consistent with
number conversion commissioning results
and test phantom
manufacturer
specifications
 Spatial Resolution Manufacturer
specifications
Contrast resolution Manufacturer
specifications
SEMI- Electromechanical
ANNUAL Sensitivity profile width To verify that the radiation profile width 1mm of nominal
meets manufacturer specs value

Measurement Equipment QA4

Instrument Type Procedure Frequency Tolerancea
ADCL calibration 2yc Documented and correction applied
Linearity 2yc 0.5%
Venting 2yc Documented and correction applied
Extra-cameral signal Initial use
0.5%
Local Standardb (stem effect)
Leakage Each use 0.1%
Redundancy checkd Each use 2%
Recombination Initial use Documented and correction applied
Collecting potential Each use Documented and correction applied
Local std. comparison 2y 1%
Linearity 2y Documented and correction applied
Venting 2y Documented and correction applied
Field instruments Extra-cameral signal 2y Documented and correction applied
Leakage Each use 1%
Recombination Initial use Documented and correction applied
Collecting potential Each use Documented and correction applied
Output check Local std. comparison monthly 1%
Relative dose Calibration Each use Documented and correction applied
TLD Linearity Initial use Documented and correction applied
Each batch or box at
Dose response Documented and correction applied
appropriate energy
Densitometer linearity 1y Documented and correction applied
Film
Processor
Each use Documented and correction applied
uniformity/reproducibility
Linearity 1y Documented and correction applied
Ion Chamber
Extra-cameral signal Initial use 1%
Energy dependence Initial use Documented and correction applied
Diodes Extra-cameral signal Initial use Documented and correction applied
Linearity Initial use Documented and correction applied
Accuracy Each use 2 mm
Positioning
Hysteresis Each use 2 mm
Mechanical Initial use 2 mm
Positional accuracy Each use 1 mm
Collecting potential of
Each use Documented and correction applied
Automated Scanners detector
Detector linearity Initial use 0.5%
Extra-cameral signal Initial use 0.5%
Detector leakage Each use 0.5%
 Accuracy of data analysis Initial use 1%
Accuracy of printouts Initial use 1 mm
Thermometer Calibration Initial use 0.1 degree/C
Accessories Barometer calibration 3 mo 1 mm/Hg
Linear rule calibration Initial use 0.3%
a = Percent values are the deviation of the parameter with respect to the nominal, and distances are referred to the
isocenter or nominal SSD.
b = Local standard instrument has a calibration directly traceable to NIST and should be reserved for calibration of radiation
beams, field instruments, and intercomparisons
c = Two years required by NRC. Without a redundancy program, this may be inadequate; with a redundancy program,
dosimetry systems maintain calibration factors for significantly longer periods of time.
d = With a radionuclide (e.g. SR-90) or chamber intercomparison.

Brachytherapy Source QA5

Type of source Test Frequency Tolerance
Physical/chemical form Initial purchase Documented
Long half-life: Source encapsulation Initial purchase Documented
description Radionuclide distribution and source Initial purchase Documented
Location of radionuclide Initial purchase 1 mm
Long half-life: Mean of batch Initial purchase 3%
Calibration Deviation from mean Initial purchase 5%, Documented
Calibration verification Every use Visual check of source color
code or measurement in a
calibrator
Short half-life: Physical/chemical form Initial purchase Documented
description Source encapsulation Initial purchase Documented
Short half-life: Mean of batch Every use 3%
Calibration Deviation from mean Every use 5%
Radionuclide distribution and source Every use Visual check,
uniformity autoradiograph, or
ionometric check

Intracavitary source and applicator QA5

Procedure Endpoint Frequency
evaluate dimensions/serial number source identity physical length and diameter Initially
superposition of auto and transmission active source length and uniformity, capsule thickness Initially
radiographs accuracy of source construction
source leak test capsule integrity 6 month intervals
source calibration source strength Initially, annually
dosimetric evaluation of applicator magnitude and geometric characteristics of shielding Initially
effect
orthogonal radiographs of applicators correct source position, mechanical integrity, internal Initially, annually
shield positioning coincidence of dummy and
radioactive source
measure applicator dimensions correct diameter and length, correct diameter of all Initially, annually
colpostat caps and cylinder segments
source inventory correct source number Quarterly
Source preparation area survey Safety of brachytherapy personnel As needed
 Interstitial source and applicator QA5
Procedure
evaluate spacing and no. seeds/ribbon
source calibration
strength per seed or strength per unit
length
applicator integrity
evaluate dummy ribbon geometry
source leak test
source inventory
Source preparation area survey
Endpoint Frequency
ribbon geometry and seed quantity Initially
source strength Initially, each use
source strength uniformity Initially
Varies: metal needles: sharpness and straightness; Initially, annually
templates: o-ring integrity and hole locations
coincidence of dummy and radioactive sources Initially, annually
capsule integrity 6 month intervals
correct source number Quarterly
Safety of brachytherapy personnel As needed

Remote afterloading facility QA5

Frequency Test endpoint Test methodology System type
dose delivery Verify date, time and source strength in treatment unit and planning all
accuracy t
Verify source strength and timer accuracy against a tertiary standard HDR/PDR
Run system through a complete cycle of simulated treatment: programming, all
overall source ejection, source retraction at end of timer countdown.
system Verify treatment status indicator lights and critical source control functions all
function

D
Correct function of dedicated fluoroscopy/imaging system if present HDR
Correct function: door interlock HDR/PDR

A
Correct function: area radiation monitor HDR/PDR
Correct function: Audio/visual system communication HDR/PDR
patient/public
/staff safety Correct function: Portable survey meter all

I Correct function: audible/visual error and alarm condition indicators

Safety equipment available: emergency instructions, emergency equipment
(forceps, emergency safe, surgical supplies), operators manual, survey meter
all
all

L Measure hourly/weekly radiation levels after patient loaded and portable

shields positioned
primary positional accuracy test for a single catheter, deviation of ion chamber
PDR/LDR

all

Y verify
positional
response placed near a programmed dwell position, multiple-channel
autoradiograph of every active dwell position used in the patient treatment
and compare programmed position to expected, visually check that relative
position of source tip in a ruled catheter reproduces from day-to-day.
accuracy
within 1 mm Autoradiograph patient-specific configuration of sources loaded into All fixed and
intermediate safe of device programmable
source-train units
time duration of source ejected light, perform a spot check of radiation HDR/PDR
output for a timed interval using tertiary calibration standard jig, compare
temporal source arrival and departure times on printed treatment documentation with a
accuracy clock or stop watch
subtract treatment interruptions from overall treatment time and compare to LDR (optional)
programmed time
 Remote afterloading facility QA (continued)5
Frequency General endpoint Specific tests/endpoints System type
Personnel safety Head/machine survey with source retracted all
Important interlocks and emergency response systems function: all
obstructed applicator, missing applicator, door, unlocked indexer
Patient safety ring, displacement, power/air pressure loss, backup battery system.
Emergency source handling tools, shielded storage container, and all
supplies for emergency applicator removal available and functioning.

Q
Calibration of optical and
pneumatic source
position/status detection As specified by vendor all
systems; any other

U
preventive maintenance
or inspections
correct operation of all Examine all dummies for kinks or bends that may shorten their axial all

A
applicators, transfer displacement through applicator assembly. Check integrity of all
tubes and source transfer tube-applicator interfaces
localization dummies
Verify that radioactive source position agrees with dummy marker

R positional accuracy:
within 0.5 mm previously tested against dwell position markers used
in simulation
Confirm check cable operation All HDR/PDR

T
single stepping source Obtain multiple channel autoradiograph with unique dwell sequence single stepping
in each channel: verify that dwell position spacing, assignment of source devices
dwell sequence to programmed channel, and relative indexer length
to dwell 1 are correct within 1 mm.

E Confirm accuracy of daily positional test protocol

Transfer tube length (if stability through time is not confirmed and
positional accuracy is influenced by tube length).

R Device positions source train in specified treatment location all

Source trains delivered to programmed channels within 1 mm of all
positional accuracy:
intended location

L
multiple-source Source trains correctly sorted and composed Programmable
machines source train
Source inventory correct all

Y
Source trains stored in correct locations in user accessible storage Fixed source
location train devices
source calibration Measure source air kerma strength using a secondary standard HDR/PDR
Difference between measured and vendor-specified air kerma
redundant source strength is within expected margin
calibration checks Use tertiary source strength standard (e.g., daily/monthly output HDR/PDR
checking system) to confirm primary calibration within 5%. Different
electrometer and detector to be used
spot check of absolute Various techniques available All LDR
timer accuracy
timer accuracy and Various techniques available HDR/PDR
linearity measurement
Update source strength in treatment planning computer initialization all
miscellaneous file, treatment unit and quarterly inventory
Have a second physicist independently review the quarterly report HDR/PDR
 Remote afterloading facility QA (continued)5
Frequency Test endpoint Test methodology System type
Personnel and Review workload and annualized unrestricted area/personnel exposures all
public safety Perform facility survey if occupancy/building structure revised. all
Intercompare secondary standard used for quarterly calibration against HDR/PDR
dose delivery another departmental substandard. Obtain new calibration from ADCL if
accuracy calibration more than two years old. Perform Table III tests for re-entrant
chamber if used.

A
Verify air kerma strength calibration and other annual Table I checks. LDR
Verify accuracy of any jigs or autoradiography cassettes used for all
daily/monthly positional accuracy verification

N positional
accuracy
Verify construction/spacing of all simulation markers (dummy sources)
Verify position of simulation markers agrees with radioactive source for all
applicator types. Verify simulation source localization procedure
all
all

N Apply Table I/II tests to all intracavitary/interstitial applicators

If positional accuracy assumes fixed transfer tube length, verify
length/uniformity if not checked quarterly
all
all

U temporal
accuracy
Verify timer linearity and absolute accuracy
Verify transit dose/source velocity
all
all

A
Verify pulse sequencing PDR
Additional Verify that unit detects simulated detached source capsule HDR/PDR
interlock/ Verify emergency retraction buttons in room and manual source retraction HDR/PDR

L emergency crank function

response tests Verify that source retracts and emergency retraction motor activates when
excessive friction/applicator obstruction encountered by source
all

Check that treatment unit correctly decays source strengths and corrects all
dwell times for decay

miscellaneous Review accuracy of all standard treatment configurations stored in treatment all
unit
Review quality assurance manual and update if necessary all

Review compliance with personnel training requirements all

 IMRT QA1
Frequency Procedure Tolerance
Prior to first treatment Field/plan verification 3%
Daily Dose to test point in each field 3%
Static vs. IMRT dose distribution as function of
Weekly, Annually 3% in dose delivery
gantry and collimator angles
Stability of leaf speed
Leaf acceleration/deceleration
3% in dose delivery, other
Annually Multileaf collimator transmission
per clinical significance
Leaf positional accuracy
Standard plan verification

SRS QA6
Guidelines to follow
Linear Accelerator
Follow guidelines from AAPM TG-42 Stereotactic Radiosurgery from 1995
Gamma Knife
Follow guidelines from AAPM TG-42 Stereotactic Radiosurgery from 1995
Cyberknife
Follow guidelines from AAPM TG-135 QA for Robotic Radiosurgery from 2011

References
1. Khan FM. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
Chapter 17.
2. Klein EE, Hanley J, Bayouth J, et al. Task group 142 report: quality assurance of medical accelerators. Med Phys.
2009;36(9):4197-4212. http://dx.doi.org/10.1118/1.3190392.
3. Muntic S, Palta J, Butker EK, et al. Quality assurance for computed-tomography simulators and the computed-
tomography-simulator process: Report of the AAPM Radiation Therapy Committee Task Group No. 66. Med
Phys.2003;30(10):2762-2792. https://doi.org/10.1118/1.1609271.
4. Kutcher GJ. Comprehensive QA for radiation oncology: Report of AAPM Radiation Therapy Committee Task
Group 40. Med Phys. 2009;21:581618.
5. Nath R, Anderson LL, Meli JA, Olch AJ, Stitt JA, Williamson JF. Code of practice for brachytherapy physics: report
of the AAPM Radiation Therapy Committee Task Group No. 56. American Association of Physicists in Medicine.
Med Phys. 1997;24(10):1557-98.
6. Thomason C, Vann AM, Lenards N. QA Brachytherapy. [SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry
Program; 2017.