Quality Assurance in External Beam

Radiation Therapy
Goran K. Svensson, Ph.D.

Editor’s Note:
This is the fifth of a series of articles on Radiation Treatment Planning based on the Basic
Physics Symposium of the American Association of Physicists in Medicine that was presented at
the 73rd Annual meeting of the RSNA.

Introduction Dose computation demands measure-

ments of beam data. It also requires the use of
It is the purpose of this article to discuss computational methods, computer programs
quality assurance in external beam radiation and hardware.
therapy. Treatment requires the availability of ac-
It is well known that the steep dose me- curate treatment equipment and the use of
sponse relations demand a high degree of ac- treatment aids and immobilization devices.
curacy and precision throughout the entire Treatment verification can be imple-
therapy process. Therefore, the quality assun- mented by the use of portal and verification
ance program must encompass both clinical nadiognaphs and in vivo dosimetry. Patient
and physical components. Steep dose me- charts and equipment log books are also im-
sponse relations were illustrated in an earlier portant elements in treatment verification.
article (9) for carcinoma of the lung and other Quality assurance is required in all these
tumor sites. Similar steep dose response mela- areas although the main emphasis in this dis-
tions have been observed by several other in- cussion is the quality assurance of the treat-
vestigators, notably Stewart and Jackson, and ment itself. Such a discussion requires that we
Shukowski (15, 16) deriving their conclusions focus on some of the uncertainties in the treat-
from the results of the treatment of the larynx. ment process that cause errors in the treat-
On the basis of the steepness, they have con- ment results.
cluded that 3-5% uncertainty in the dose to a First, however, let me make a digression to
patient is acceptable, while Wambemsie and explain that the uncertainties are the result of
others have stated that the uncertainty must two types of errors in the treatment process.
be less than 7% (10). These errors can be described as those of pre-
The complexity of a radiation therapy pro- cision and those of accuracy. Figure 1 illus-
gram is evident from a brief description of the trates these concepts. Precision is a measure
whole therapy process. of how reproducible a result is. When we make
Patient data acquisition involves the use measurements of a quantity, some observa-
of many diagnostic procedures, such as con- tions will be too large and some too small. A
ventional radiography, scintigraphy, CT, so- pattern or a distribution will emerge from our
nography and, recently, MRI technology. observations. The width of the distribution de-
Treatment decision requires a synthesis of scribes the expected uncertainty associated
diagnostic data for the determination of the with one observation. This is a measure of pre-
target volume; contouring and simulator cision and is expressed in standard deviations.
equipment will facilitate the decision. For a gaussian distribution, 68% of the observa-

Address reprint requests to G.K. Svensson. Ph.D., Joint Center for Radiation Therapy and Department of Radiation
Therapy, Harvard Medical School, 50 Binney St., Boston, MA 02115

Volume 9, Number I January,

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Radiation Therapy: Quality Assurance Svensson

I 70 RadioGraphics January,
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Svonsson Radiation Therapy: Quality Assurance

can be facilitated by the following consider- tional intercompamisons are therefore neces-
ations (1). samy. Theme are various ways of performing
All chambers used for therapy beam cali- constancy checks. In those institutions with Co-
brations must have a calibration factor trace- 60 machines, one can make use of the inher-
able to the National Bureau of Standards ently reproducible Co beam and, as shown in
(NBS). This can be accomplished either by hay- Figure 2, one can build a fixed jig for position-
ing the hospital standard instrument calibrated ing the dosimeter in a reproducible manner.
by NBS directly, or by having the instrument
calibrated by one of the five AAPM accredited As seen in Figure 3, such a setup has pro-
calibration laboratories. The hospital standard duced interesting constancy check results,
instrument will then be used within the hospital here demonstrated on a Baldwin-Farmer ion-
for the calibration of field instruments. These ization chamber. The variations of this cham-
field instruments are used for the calibration of ben lie within ±1%. Seasonal variations of the
the therapy beams. This procedure assures chamber response can be seen, however. This
that all radiation equipment has its output nor- suggests that the reproducibility of these mea-
malized to the national calibration laboratory. surements is better than I % and that the vamia-
Specific state or NRC regulations may apply to tions are due to changing environmental con-
calibration procedures. ditions in the calibration room. Somewhat less
The accuracy of a dosimetry system is sub- precise, but still adequate in most situations, is
ject to change without obvious indications. In- a special check source containing Sm-90 (see
stitutional constancy checks or multiinstitu- Figure 4) into which the chamber is inserted.

Figure 3
Results of constancy checks versus
time, using the setup shown in Figure 2.
I I I I I I I I I I I I I

Constancy Checks
BF 2505 I 3 Serialal56
1.01 60Co Therapy Machine

U)
C 00 0
0
0.
U)
1.00 0 08 : 00 0:0

V
a)
N

D
E 0.99
0
z

0.98

0.97

O.Ji:_1:c1 , I I I ‘ I ,

OCT.’85 DEC. FEB. APR. JUN. AUG. OCT. DEC.

0.0 NOV. JAN.’86 MAR. MAY JUL. SEP. NOV.

Time

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 ...,.‘

I 72 RadloGraphics January,
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Svensson Radiation Therapy: Quality Assurance

Prior to machine calibration, the dosimeter dose, i.e. 5 cm, to avoid the effect of spurious
,

must be accurately positioned in the beam beam contamination and to be at a depth

(Figure o). The source to axis distance must be that is representative of the treatment situa-
well controlled and the calibration depth tion.
should be greater than the depth of maximum

Source

The positioning of the dosimeter

in the radiation beam to be
calibrated must be done with great
care. The calibration depth should
be greater than the depth of dose
maximum.

Figure 6
Typical calibration geometry for high energy x-ray beams

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Radiation Therapy: Quality Assurance Svensson

The monitor system of a treatment ma- CENTRAL AXIS DOSE CALIBRATIONS

chine is far from infallible. Constancy checks of
a monitor chamber must be performed with The next area of concern in a Quality As-
great came and frequency. An interesting and sumance program is the central axis dose cali-
relatively common type of failure occurs when bmation (4, 13). This includes the dose per moni-
a sealed monitor chamber opens up to the at- ton unit on time, the central axis depth dose
mospheme and is subjected to temperature and constancy checks. The dose per monitor
changes as well as humidity changes. Figure 7 unit on time needs to be determined using the
shows the results of daily calibrations. Because measurement equipment previously discussed.
of an unsealed monitor chamber, large output As mentioned before, the fairly involved Quali-
variations corresponding to a standard devi- ty Assurance program for such equipment is to
ation of 1.8% are observed. A sealed chamber assume that the result of the machine calibma-
was installed and continued daily checks tion is traceable to the National Bureau of
showed a standard deviation of 0.6%. Standards. It has been determined (11) that
Finally, all of the auxiliary equipment, such the overall uncertainty in a dose calibration,
as thermometers and barometers, that is nec- taking all steps into account, is between 4-
essamy for calibration measurements must be 5%. This figure corresponds to the 95% confi-
of good quality and must be checked against dence limit.
standard instruments. The next consideration pertains to off-axis
dose determinations. Treatment field unifommi-
ty is often expressed in terms of flatness and
symmetry. On modern linear accelerators,
these characteristics can change unexpect-
edly because of shifts on changes in flattening
filters, beam steering and beam energy. The
The monitor syst#{149}m(or tim#{149}r)
skewed curve in Figure 8 indicates such a shift.
of a machina Is fallibla.
Constancy ch.cks must be p.rform.d.

Field uniformity, beamsteering

, [Jthamber
. OpentoAir and/or alignment of flattening filter.
Sept.9Oct.1O,1983
:i Sealed Chamber
- Octl8-Dec2O,1983
,.. I

_%. . . - ., -.

.-_J :

! ..Y.’.’;’

2-, ,
0-
L #{149} I #{149} I #{149}
-4 -2 0 2 4
DAILY CHANG’E(%I CENTRAL AXIS
x
Figure 7 Figure 8
Variations of x-ray beam calibrations The Flatness and symmetry changes owing to a shift in
broaden distribution represents a situation in which the flattening filter on beam steering
the normally sealed monitor chamber was open to
atmospheric temperature and pressure variations.

I 74 RadioGraphics January,
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Svensson Radiation Therapy: Quality Assurance

The beam uniformity should be monitored fre- It is very important that action levels be es-
quently. There are several commercial and tablished for the Quality Assurance personnel.
home built instruments that can be used to de- Without action levels, it is likely that errors
temmine the dose at off-axis points. Beam uni- found during the Quality Assurance tasks me-
formity can then be calculated. A generic ap- main unconnected. Such levels can be deter-
proach to off-axis dose determination is illus- mined within each department. As an exam-
trated in Figure 9, which shows five detectors pie, one can specify that if the central axis
embedded in a plastic block. The detectors constancy checks deviate from a posted val-
are lined up to measure dose at off-axis points ue by less than ±5%, no action is needed by
as well as the central axis value. Detectors the technologist (the physicist will have tighter
numbers I and 5 should be at least 25 cm action levels). If the deviation is greaten than
apart. This will permit monitoring the beam ±5% but less than ±10%, a physicist on engi-
neem should be notified immediately. Treat-
ments may continue for the nest of that day,
however. If the deviation exceeds ±10%, the
treatments must stop immediately, and a
physicist on engineer must be notified.

Table I shows a summary of those tests

that are normally required in a well implement-
Detector ed Quality Assurance program. Note that a
Array central axis calibration need not be done fme-
quently, provided that frequent and precise
constancy checks are performed.

The overall uncertainty in the dose to a

patient is difficult to assess. In the previous dis-
cussion, the uncertainty in the central axis
dose calibration was estimated to be 5%. As-
sume an additional 3% (95% confidence limit)
620 600 608 598 622 uncertainty in patient dose related to dose dis-
tnibution calculations (except tissue hetemoge-
neities) and the use of treatment aids. It may
(622 - 608)xlOO/608 = + 2.3 % then be reasonable to estimate the overall un-
Flatness certainty in patient dose to be
(598 - 608)x1001608 = - 1.6 %

Figure 9 AO/
U /0.

An example of beam uniformity check procedure

Hence, one can conclude that under the con-
ditions of a carefully implemented Quality As-
sumance program of all dosimetnic equipment
and of procedures used for beam calibrations
and treatment planning, the achievable un-
“wings” the portions of the beam that are
,
certainty of about 6% is of the same magni-
particularly sensitive to variations in beam con- tude as the clinically acceptable uncertainty.
ditions. The numerical example shows the cal-
culation of beam uniformity by taking the dif-
ference between the responses of detectors 5
and 3 and dividing the difference by the me-
sponse of detector 3, which is on the central
axis. The central axis value is also a constancy
check of machine output.

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Radiation Therapy: Quality Assurance Svensson

TABLE I

Summary of tests for Frequency Tolerance

external beam calibrations

Central axis dose calibration

Xrays and Co6O Annual

Constancy checks:
1 Dose/monitor
. unit,
X-rays Daily +1-3%
2. Dose/mm, Co6O Monthly +/-3%
3. Depth dose Monthly +/-2%
4. Beam uniformity Weekly +/-3%
5. Dose monitor or
timer constancy Annual Not Applic.

Spatial Uncertainties as outlined by the cross hair. Figure 10 shows

that the locations of the clips are distributed
PATIENT AND ORGAN MOTION
around their mean location X with a standard
deviation of 3.5-4 mm. The V and Z directions
Let us now move on to discuss spatial un-
showed similar distributions. The X-axis is the
certainties associated with radiation therapy.
transverse (might-left) axis of the patient, the Y-
The two areas of concern are equipment
axis is the longitudinal axis of the patient and
alignment and setup precision, and organ and
the Z-axis is the antemopostemiom patient direc-
patient motion. What is needed in geometric
tion.
accuracy? To answer that question, we need
to examine how well patients are positioned Another study was performed on patients
for their treatments. What is the setup accura- treated for Hodgkin’s disease. Treatment-to-
cy and precision, and how large is the organ treatment variations for patients treated with
motion? a mantle field were determined using portal
One group of patients was studied on a radiogmaphs. Treatment-to-treatment vamia-
radiation therapy simulator (17). The patients tions of the field size, the location of the canina
had undergone surgery, and in each case the and the chest wall separation were analyzed.
tumor or tumor bed was marked with clips. The The results, shown in Figure 1 1 indicate
, that
patients were set up on the simulator for an- the daily variation in the field size is about 2
temoposteniom and lateral madiogmaphs. Align- mm; the daily variation of the location of the
ment lasers were used against external marks. canina is about 3.2 mm; and the daily variation
The clips were easily identified on the radio- of the chest wall separation, where breathing
graphs. The location of each clip was mea- is a large factor, is about 5.5 mm. These figures
sumed relative to the isocenter of the x-ray field correspond to one standard deviation.

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Svensson Radiation Therapy: Quality Assurance

Figure 10 #MEASUREMENTS
Distribution of surgically implanted
clips around the mean location (X)
-ii
SET UP C8mm
BREATHING
OTHER MOTION

10

I I I

_7-::5 _3 -101 3 5 7

(X-Ajrnm

MANTLE STUDY

(I)

(I)

o\o
4
D/STANCE(rnrn)
Figure 1 1
Treatment-to-treatment variations for patients treated with a mantle
field The data were derived from daily portal nadiographs taken before
and after the treatments. The figure illustrates the percent of observations
that exceed a certain deviation from the expected value.

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Radiation Therapy: Quality Assurance Svensson

Information on setup precision is scarce. ion during a treatment on from treatment to

Summarizing available data (14, 18), including treatment. In this case, the motion is assumed
results from these studies, one can state that: to be 4 mm (one standard deviation). Note
(a) Immobilization in special treatment that the effect always causes the organs out-
procedures results in <2 mm setup side the field edge to receive a higher dose
precision corresponding to one stan- than calculated and those organs inside the
dand deviation. field edge, that is the target, to receive a low-
(b) Normal radiation therapy procedures em dose. The beam penumbra width thus in-
have a setup precision of 3-5 mm. creases with increasing position uncertainty as
The effect of these random spatial errors shown in Figure 13. A 5-6 mm random motion
can be seen in Figure 12, showing the field throughout the treatment results in appmoxi-
edge of an 8 MV x-ray beam. The solid edge is mately doubling the width of the beam edge
the stationary field measured in a water phan- in the case of 8 MV x rays. The effect of these
tom. The dashed curve shows the widening of random errors needs to be accounted for in
the dose distribution across the field edge, if the determination of the target volume.
the patient on organ moved in a random fash-

BEAM PROFILE. SINGLE FIELD 8MV X-RAYS

10cm x 10cm, DEPTH =10cm

Cl)
0

a)
>

a)

Distance from Central Axis, cm

Figure 12
The edge widening effect of a random setup error of 4 mm ( 1 SD)

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Svensson Radiation Therapy: Quality Assurance

PENUMBRA WIDTH, 80% to 20% gantry axis with the isocenter, (c) stability of
SINGLE FIELD,8MV X-RAYS the gantry arm under rotation, (d) couch mo-
10cm x iOcm,DEPTH=lOcm
tion, and (e) focal spot position.

A routine test method for these character-

istics is based on the observation that any mis-
1.5 A
alignment will cause two opposing fields to be
E 1.4 - ,/(G.O.8.Pa 1.47) displaced relative to one another in the plane
C)

1.3h I of the isocentem (12). Figure 14, redrawn from

0.
Lutz et al. (12), illustrates this effect under the
‘C 1.2L / conditions of jaw asymmetry. The two oppos-
1.1 ing fields are then displaced in the cross plane
1 .0
direction. Special test equipment can be
bought on built addressing these alignment
E 0.9 ( =O.4.P= 0.95)
, 0-:
tests. Figure 15 is a beam’s eye view of a set of
C
0
0. 0.8 lead blocks mounted on two plastic plates.
The blocks are so positioned as to shield the
0.7
edges of a 10 x 10 field. A film is inserted be-
0.6 CQ-. .o.= 0.56) tween the plastic plates. One field exposes
0.5 the film from one side oven the open area. The

0 0.5 1.0

Position Uncertainty em Jaw asymmetry

Figure 13
Electron beam
The apparent width of a field edge versus setup pre-
cision

A B
Collimator
ALIGNMENT AIDS

One also needs to consider methods of me- Rotational aXIS

ducing setup errors. For that purpose, we have of collimators
positioning aids, such as alignment lasers, field
light and distance indicators. These alignment
aids require approximately weekly checks,
and the tolerances are of the order of ±2 mm.
The light field is an important positioning
aid. The light field/radiation field coincidence Gantry axis of rotation
(out of page)
must, therefore, be checked frequently. Film is
an effective medium for rapid checks of light A
field/radiation field coincidence.

THERAPY MACHINE ALIGNMENT

Electron beam
The machine itself needs to have its me- Figure 14
chanical characteristics checked for proper The effect of jaw asymmetry on the alignment accu-
alignment at regular but not very frequent in- racyof two opposing fields
temvals. Those in question are: (a) jaw symme-
try, (b) coincidence of collimator (jaw) and

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Radiation Therapy: Quality Assurance Svensson

shows that the left and might edges are not in

alignment. Since this shift can be symptomatic
of several mechanical problems, one cannot
draw specific conclusions from this test about
the origin of the misalignment. Further tests
are, therefore, necessary to identify the exact
reason for the problem. These tests are dis-
cussed in references 2, 3, 5, 7, and 10.
With respect to spatial uncertainties, one
can conclude that patient positioning errors
Figure 15 can and should be reduced by immobilization
Beam’s eye view of the lead techniques. Remaining patient positioning em-
block test device intended momsshould be known and accounted for when
for alignment tests (12) deciding on adequate margins for the target
volume. Uncertainties resulting from equip-
ment misalignment may be additive and regu-
lam tests and adjustments are necessary. A rea-
opposing field exposes the same film from the sonable objective is that misalignment errors
other side over the area that was shielded by should be less than unavoidable patient posi-
blocks from the first field. Figure 16 shows an tioning errors.
example of the results. The dank, double ex-
posed central region can be ignored. Consid-
em only the exposed edges. For a properly
aligned machine, all of the edges from the op-
posing fields should be aligned. This is shown in
the left part of Figure 16. For the incorrectly
aligned machine, the might part of Figure 16

Gantry Gantry

‘A
Figure 16
The double exposed film resulting from the lead block test device (12)

I 80 RadioGraphics January,
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Svensson Radiation Therapy: Quality Assurance

Treatment Planning, Treatment Aids TREATMENT VERIFICATION

and Treatment Verification
Treatment verification is an important
Quality Assurance task. For this purpose, one
uses portal and verification madlographs (6)
TREATMENT PLANNING
and on occasion In vivo dosimetry. The portal
and verification radiographs allow confirma-
Treatment planning has many compo-
tion of field delineation and tumor coverage.
nents requiring quality control. The first step in
All radiographs taken for this purpose must be
treatment planning is Patient Data Acquisition.
evaluated and signed by the radiation oncolo-
Many different diagnostic methods may be
gist or his or hem designee. The frequency of
used, such as radiographic techniques, scintig-
portal radiographs must be established and
maphy, CT, sonogmaphy, MRI and simulation.
special intensifying screens must be used for
These techniques are normally subjected to
high energy photon beams (6).
Quality Assurance of their imaging charactenis-
The patient’s chart is an extremely impor-
tics. For radiation therapy application, howev-
tant document for verification of the radiation
em, additional assurance of the geometric ac-
treatment. In this document, the treatment in-
cumacy of these tools is often needed. Another
tent, patient positioning and treatment aids
step in treatment planning is the Treatment
must be recorded. Redundant checks of all
Decision, involving diagnostic patient data
dose calculations and summations must be
synthesis for the determination of target vol-
performed. The treatment chart should be
umes, critical organs and contours. Contouring
treated as a legal document.
and simulator equipment facilitates the treat-
Another document of significance is the
ment decision. The simulator is a complex
equipment logbook, which should be avail-
piece of equipment requiring mechanical
able at all machine consoles. Calibrations and
quality control similar to a linear accelerator. In
constancy checks should be recorded in such
addition, simulators equipped with fluomoscopy
a logbook. Maintenance problems should be
units need to have a program assuring ade-
documented and records of repair and pre-
quate image quality. The third component of
ventive maintenance should be kept.
treatment planning is Dose Computation.
Computational methods, computer hardware
and programs need to be carefully evaluated.
Much work needs to be done to evaluate the Conclusion
accuracy of these tools. Institutionally mea-
suned bench mark cases can be recommend- A comprehensive Quality Assurance pro-
ed as a method for checking computer calcu- gram should not focus on the analysis of a nan-
lations. row set of treatment variables, but rather,
should attempt to understand the cumulative
errors of the complete treatment process.
TREATMENT AIDS
Thus, the Quality Assurance program has clini-
cal and physical components. Its implementa-
Commonly used treatment aids include,
tion requires team work and must involve all
but are not limited to, immobilization devices,
key personnel in the radiation therapy depart-
shielding blocks, wedges and compensators.
ment.
Treatment aids need to be checked for align-
ment and mounting accuracy. The mechani-
cal integrity, proper identification labels and
accurate dose modifying factors must be as-
sumed. The devices must be mechanically safe
and, in the event that material toxicity is of
concern, proper working conditions must be
established.

Volume 9, Number I January,

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Radiation Therapy: Quality Assurance Svsnsson

References

1. American Association of Physicists In Medicine Task surements. Determination of absorbed dose In a pa-
Group 2 1 . Physical aspects of quality assurance in ra- tient Irradiated by beams of x-ray and gamma radla-
diatlon therapy. Report 13. New York: American Insti- tion In radiotherapy procedures. Report 24. WashIng-
tute of Physics. 1984. ton, DC: International Commission on Radiation Units
2. WrIght AE, Boyer AL, eds. Advance in radiation treat- and Measurements, 1980.
ment planning. American Association of Physicists In I I . Johanson KA. Studies of different methods of ab-
Medicine Medical Physics Monograph no. 9. New York: sorbed dose determination and a doslmetrlc Inter-
American Institute of Physics. 1983: 244-268. comparison at the Nordic Radiotherapy centers. The-
3. Starkschall G. ed. Proceedings of a symposium of qual- sis. Goteborg, Sweden, 1982.
Ity assurance of radiation therapy equipment. Kansas 12. Lutz WR, Larsen RD. Bjamgard BE. Beam alignment
City, Mo: American Association of Physicists In MedI- tests for therapy accelerators. Int J Radlat Oncol Biol
cine, 1982. Phys 1981; 7:1727-1731.
4. American Association of Physicists In Medicine Task 13. DosImetry of x-ray and gamma-ray beams for radla-
Group 21 . A protocol for the determination of ab- tion therapy In the energy range of 10 key to 50 MeV.
sorbed dose from high energy photon and electron NCRP report no 69. Bethesda, Md: National council on
beams. Med Phys 1983; 10:741-77 1. Radiation Protection and Measurements, 1981.
5. American Association of Physicists In Medicine. Code 14. Rablnowltz I, Broomberg J, Goltein M, McCarthy K,
of practice for x-ray linear accelerators. Med Phys Leong J. Accuracy of radiation field alignment In dm1-
1975; 2:110-121. cal practice. nt J Radlat Oncol BIoI Phys 1985;
6. AmerIcan Association of Physicists in Medicine and BI- I 1:1857-1867.
ology Task Group 28. Radiotherapy portal Image qual- 15. Shukovsky U. Dose, time, volume relationshIps In squa-
Ity. Report 24. New York: American Institute of Physics. mous cell carcinoma of the supraglottic larynx. AJR
1987. 1970; 108:27-29.

7. Wlzenberg MJ. ed. Quality assurance In radiation ther- 16. Stewart JG, Jackson AW. The steepness of the dose
apy: A manual for technologists. Chicago. American response curve both for tumor cure and normal tissue
College of Radiology. 1982. injury. Laryngoscope 1975; 85:1107-1111.
8. CommIttee for Radiation Oncology Studies. Report to 17. Svensson GK. Quality assurance In radiation therapy:
the Director of the National Cancer Institute on criteria Physics efforts. Int J Radlat Oncol Biol Phys 1984;
for radiation oncology in multidisciplinary cancer man- 1O(suppl 1):23-29.
agement: The blue book. 1981. 18. verhay LV, Goltemn M, McNulty P. Munzenrlder JE, Suit
9. Hendrickson FR. Radiation treatment planning: The HD. Precise positioning of patients for radiation thera-
physician’s role. RadioGraphics 1988; 8:987-991. py. Int J Radiaf Oncol Blol Phys 1982; 8:289-294.
10. International Commission on Radiation Units and Mea-

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