AAPM TG198 ImplementationOfTG142-Compressed

Accepted Article
Article type : AAPM Scientific Report
AAPM Task Group 198 Report: An Implementation Guide for TG 142 Quality Assurance of Medical
Accelerators
Joseph Hanley, PhD1, Sean Dresser, MS2, William Simon, MS3, Ryan Flynn, PhD4, Eric E. Klein,
PhD5, Daniel Letourneau, PhD6, Chihray Liu, PhD7, Fang-Fang Yin, PhD8, Bijan Arjomandy, PhD9,
Lijun Ma, PhD10, Francisco Aguirre, MS11, Jimmy Jones, MS12, and John Bayouth, PhD13
1Princeton Radiation Oncology
2Emory University
3Sun Nuclear Corp
4University of Iowa
5Rhode Island Hospital/Warren Alpert Medical
6Princess Margaret Cancer Centre
7University of Florida
8Duke University
9Karmanos Cancer Institute at McLaren-Flint McLaren
10University of California, San Franciscosample
11MD Anderson Cancer Center
12The University of Colorado Health—Poudre Valley
13University of Wisconsin—Madison
Consultants: Todd Holmes (Varian Medical Systems), Carlos Sandin (Elekta)
TG 198 was constituted by the AAPM, Science Council, Therapy Physics Committee, and Quality
Assurance and Outcome Improvement Subcommittee.
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/MP.14992
This article is protected by copyright. All rights reserved
Corresponding Author: Joseph Hanley, Princeton Radiation Oncology, 9 Centre Drive, Monroe, NJ
Accepted Article
08831, USA; phone: 609-655-5755; email: joseph.hanley@asterahealthcare.org
Disclosure Statement
The Chair of the AAPM TG 198 has reviewed the required conflict of interest statement on file for
each member of AAPM TG 198 and determined that disclosure of potential conflicts of interest is an
adequate management plan. Disclosures of potential conflicts of interest for each member of AAPM
TG 198 are found at the close of this document.
Contents
1 Introduction
1.1 Purpose
1.2 Background
2 QA of Medical Accelerators
2.1 General
2.1.1 Clarifications and Deviations From TG 142
2.1.1.1 Test Frequency
2.1.1.2 Daily or Weekly QA
2.1.1.3 Monthly QA
2.1.1.4 Annual QA
2.1.2 Documentation
2.2 Daily
2.2.1 Dosimetry
2.2.1.1 Photon and Electron Output Constancy
2.2.2 Mechanical
2.2.2.1 Laser Localization
2.2.2.2 Optical Distance Indicator (ODI)
2.2.2.3 Collimator Size Indicator
2.2.3 Safety

2.2.3.1 Door Interlock
Accepted Article 2.2.3.2 Door Closing Safety
2.2.3.3 Audiovisual Monitor
2.2.3.4 Stereotactic Interlocks
2.2.3.5 Radiation Area Monitor (If Used)
2.2.3.6 Beam-On Indicator
2.3 Monthly
2.3.1 Dosimetry
2.3.1.2 Backup Monitor Chamber Constancy
2.3.1.3 Typical Dose Rate Output Constancy
2.3.1.4 Photon and Electron Beam Profile Constancy
2.3.1.5 Electron Beam Energy Constancy
2.3.2 Mechanical
2.3.2.1 Light or Radiation Field Coincidence (Symmetric and Asymmetric)
2.3.2.2 Lasers
2.3.2.3 Gantry or Collimator Angle
2.3.2.4 Accessory Trays
2.3.2.5 Jaw Position Indicators
2.3.2.6 Crosshair Centering
2.3.2.7 Treatment Couch Position Indicators
2.3.2.8 Wedge Placement Accuracy
2.3.2.9 Compensator Placement Accuracy
2.3.2.10 Latching of Wedges, Blocking Tray
2.3.3 Safety
2.3.3.1 LaserGuard or Touch Guard—Interlock Test
2.3.4 Respiratory Gating
2.3.4.1 Beam Output Constancy
2.3.4.2 Phase, Displacement Magnitude Beam Control

2.3.4.3 In-Room Respiratory Monitoring System
Accepted Article 2.3.4.4 Gating Interlock
2.3.5 Volumetric Modulated Arc Therapy (VMAT)
2.3.5.1 Test Patient-Specific VMAT QA
2.4 Annual
2.4.1 Dosimetry
2.4.1.1 Photon Flatness and Symmetry
2.4.1.2 Electron Flatness and Symmetry
2.4.1.3 Photon or Electron Output Calibration
2.4.1.4 Output Factors
2.4.1.5 Photon Beam Quality
2.4.1.6 Electron Beam Quality
2.4.1.7 Physical Wedge Transmission Factor
2.4.1.8 MU Linearity
2.4.1.9 Photon Output vs. Dose Rate
2.4.1.10 Output Constancy vs. Gantry Angle
2.4.1.11 Off-Axis Factor Constancy vs. Gantry Angle
2.4.1.12 Arc Mode
2.4.1.13 TBI/TSET Mode
2.4.1.14 TBI/TSET TMR/PDD and OAF Constancy
2.4.1.15 TBI/TSET Output Calibration
2.4.1.16 TBI/TSET Accessories
2.4.2 Mechanical
2.4.2.1 Collimator Rotation Isocenter
2.4.2.2 Gantry Rotation Isocenter
2.4.2.3 Treatment Couch Rotation Isocenter
2.4.2.4 Electron Applicator Interlocks
2.4.2.5 Coincidence of Radiation and Mechanical Isocenter
2.4.2.6 Treatment Couch Top Flex

2.4.2.7 Treatment Couch Angle
Accepted Article 2.4.2.8 Treatment Couch Maximum Range
2.4.2.9 Stereotactic Accessories or Lockouts
2.4.3 Safety
2.4.3.1 Follow Manufacturer’s Test Procedures
2.4.4.1 Beam Energy Constancy
2.4.4.2 Temporal Accuracy of Phase or Displacement Magnitude Gate On
2.4.4.3 Calibration of Surrogate for Respiratory Phase or Displacement Magnitude
2.4.4.4 Interlock Testing
2.4.5.1 Test Patient Specific VMAT QA Constancy
2.4.5.2 Interruption Test
2.5 Dynamic, Virtual, or Universal Wedges
2.5.1 Enhanced Dynamic Wedges
2.5.1.1 Daily Checks
2.5.1.2 Monthly Checks
2.5.1.3 Annual Checks
2.5.2 Universal Wedge
2.5.3 Siemens Virtual Wedge
2.6 Multileaf Collimators (MLCs)
2.6.1 Weekly
2.6.1.1 Qualitative Test (Picket Fence)

2.6.2 Monthly
Accepted Article 2.6.2.1 Leaf Position Accuracy (Non-IMRT)
2.6.2.2 Backup Diaphragm Settings
2.6.2.3 Leaf Travel Speed
2.6.2.4 Leaf Position Accuracy (IMRT)
2.6.3 Annual
2.6.3.1 MLC Transmission
2.6.3.2 Leaf Position Repeatability
2.6.3.3 MLC Spoke Shot
2.6.3.4 Coincidence of Light-Radiation Fields
2.6.3.5 Moving Window IMRT
2.7 Radiographic Imaging
2.7.1 Daily—kV and MV (EPID) Imaging
2.7.1.1 Collision Interlocks
2.7.1.2 Positioning or Repositioning
2.7.1.3 Imaging and Treatment Coordinate Coincidence
2.7.2 Daily—CBCT (kV and MV)
2.7.3 Monthly—Planar MV Imaging (EPID)
2.7.3.2 Scaling
2.7.3.3 Spatial resolution
2.7.3.4 Contrast
2.7.3.5 Uniformity and Noise
2.7.4 Monthly—Planar kV Imaging
2.7.4.2 Scaling

2.7.4.3 Spatial Resolution
Accepted Article 2.7.4.4 Contrast
2.7.5 Monthly—CBCT (kV and MV)
2.7.5.1 Geometric Distortion
2.7.5.2 Spatial Resolution, Contrast, Hounsfield Unit Constancy, Uniformity, and
Noise
2.7.6 Annual—MV Imaging (EPID)
2.7.6.1 Full Range of Travel SDD
2.7.6.2 Imaging Dose
2.7.7 Annual—kV Imaging
2.7.7.1 Beam Quality or Energy
2.7.8 Annual—CBCT (kV and MV)
3 Summary of Recommendations or Implementation Scheme
ABSTRACT
The charges on this task group (TG) were as follows: (1) provide specific procedural guidelines for
performing the tests recommended in TG 142; (2) provide estimate of the range of time, appropriate
personnel, and qualifications necessary to complete the tests in TG 142; (3) provide sample daily,
weekly, monthly, or annual quality assurance (QA) forms. Many of the guidelines in this report are
drawn from the literature and are included in the references. When literature was not available,
specific test methods reflect the experiences of the TG members (for example, a test method for door
interlock is self-evident with no literature necessary). In other cases, the technology is so new that no
literature for test methods was available. Given broad clinical adaptation of volumetric modulated arc
therapy (VMAT), which is not a specific topic of TG 142, several tests and criteria specific to VMAT
were added.
Keywords: accelerator, QA, quality assurance, radiotherapy
1. INTRODUCTION

1.1 Purpose
Accepted Article
The American Association of Physicists in Medicine (AAPM) Task Group (TG) 142 report,1 “Quality
Assurance of Medical Accelerators,” published in 2009, updated table II of TG 402 with respect to
frequency and tolerances of existing procedures. It also added recommendations for quality assurance
(QA) of ancillary devices [asymmetric jaws, multileaf collimators (MLCs), dynamic or virtual
wedges] that were not covered in TG 40. The recommendations made in TG 142 were dependent on
the types of procedures performed on the linear accelerator (linac). Separate tests and tolerances were
recommended based on whether special programs such as stereotactic radiosurgery (SRS), stereotactic
body radiotherapy (SBRT), total body irradiation (TBI)/total skin electron therapy (TSET),
respiratory gating, or intensity modulated radiotherapy (IMRT) were performed on the linac. The
tightest tolerances are reserved for SRS/SBRT treatments, as they are exquisitely sensitive to
treatment machine errors.3–5 For clarification, if no IMRT treatments are delivered on the linac, the
machine falls into the non-IMRT category.
This report, as an extension of TG 142, mainly focuses on C-arm type medical accelerators. However,
many of the recommendations are directly applicable to other types of accelerators, for example, ring-
based gantries or robotic mounted. The reader is also referred to the AAPM guidance documents for
the other types of accelerators.6,7
Many of these recommended tests are new to the medical physics community and, as with TG 40,
there is more than one way to perform the recommended tests. In addition, because of the increasing
complexity of radiation therapy delivery and patient setup verification, there are significantly more
tests that need to be performed. The TG has endeavored to align with previously published AAPM
reports, especially “Medical Physics Practice Guideline 2.a”8 and “Medical Physics Practice
Guideline 8.a.”9 Since the formation of this TG, the AAPM has published TG 100,10 which uses risk
analysis to develop institution-specific quality management programs. The TG feels that there is a
synergy between this report and TG 100 and that this report will help fill the gap as physicists adopt
TG 100 into their clinical practice. As part of a TG 100 quality management program, there will still
be QA that needs to be performed on the linacs. This report will serve as a reference of how to
perform those tests.
As in TG 142, the TG would also like to reiterate that institutional deviations from some of the

recommendations in this report are expected based upon that institution’s policies and procedures.
Accepted Article
The institution must understand and follow local regulations, both on the QA tests themselves and on
the training/qualifications necessary for performing them. Should the institution decide to decrease
the frequency of a particular test, the decision should be validated with an appreciable history of that
test, and it should be based on sound statistical principles. In addition, the TG reiterates that the QA
program should be flexible enough to consider such things as institutional needs, costs, and available
test equipment. However, as in TG 142, we do recommend using the tests and frequencies outlined in
this report until such time as the institution transitions to TG 100.
The purpose of this report is to provide specific examples of how to perform the tests recommended
in TG 142, to provide estimates of the range of time and personnel resources necessary to complete
the tests. Sample QA forms will also be provided.
The recommendations of this TG are not intended to be used as regulations. These recommendations are
guidelines for qualified medical physicists (QMPs) to use and appropriately interpret for their individual
institution and clinical setting. Each institution may have site-specific needs and requirements which may
modify their usage of these recommendations.
1.2 Background
The underlying principle behind TG 40 and TG 142 was the International Commission on Radiation
Units and Measurements’ (ICRU)11 recommendation that the dose delivered to the patient be within
±5% of the prescribed dose.12 Taking into consideration the many steps involved in delivering dose to
a target volume in a patient, each step must be performed with accuracy significantly better than 5%
to achieve this recommendation.
The report of the TG 142 considerably expanded the tests of TG 40. In addition, the report
recommended tolerances that accommodated differences in the intended use of the machine
functionality: non-IMRT, IMRT, and stereotactic delivery. It should be noted that this TG replaced all
references to “x-ray” with “photon” and updated the tolerances for a few of the tests recommended in
TG 142. Furthermore, in the gating sections, all references to amplitude have been replaced with
displacement or displacement magnitude to align with TG 76,13 the management of respiratory motion
in radiation oncology. Volumetric modulated arc therapy (VMAT) QA has also been included in this
report.

As with TG 40, the goal of a QA program for linacs is to ensure that the machine characteristics do
Accepted Article
not deviate significantly from their baseline values acquired at the time of acceptance and
commissioning. As recommended in TG 106,14 the baseline values should be of the highest quality to
avoid the transfer of systematic errors into the QA process. There are several publications that
describe procedures and conditions for acceptance testing and commissioning, and the reader is
referred to these by the following: the International Electrotechnical Commission (IEC),15,16
AAPM,14,17,18 and American College of Medical Physics.19 Many of these baseline values are entered
into treatment planning systems to characterize and/or model the treatment machine and therefore can
directly affect treatment plans calculated for every patient treated on that machine. Deviation from the
baseline values could thus result in suboptimal treatment of patients. Machine parameters can deviate
from their baseline values because of many reasons.20–22 There could be unexpected changes in
machine performance due to machine malfunction, mechanical breakdown, physical accidents, or
component failure. Major component replacement (waveguide, accelerator structure, bending magnet,
etc.) may also alter machine performance from the original parameters. In addition, there could be
gradual changes because of aging of the machine components. These patterns of failure need to be
considered when establishing a periodic QA program.
The advances in medical accelerator design that have enabled both the delivery of complex treatments
and more sophisticated setup verification necessitate a more extensive QA program. While TG 142
itself is considered a comprehensive report that covers the recommendations for linac QA in detail, an
implementation guide to its test procedures is needed to ensure appropriate implementation in routine
clinical settings. While there are several publications that recommend many aspects of QA procedures
for specific components of the tests in TG 142, we feel that the community would be better served by
integrating these guidelines into one updated document. The TG has analyzed the various published
techniques to make recommendations as to which procedure(s) should be used wherever the literature
differs on procedure for a given test. It should be noted that continuing advances in radiotherapy make
even recent reports incomplete. It is therefore incumbent upon the QMP to stay abreast of QA
methodologies on new advances as they appear in the literature as well as improvements on
conventional topics covered in this report. To this end, the TG feels that, as VMAT has been widely
adopted in clinical practice, guidelines for the routine QA of VMAT programs should be included in

this report. The report does not cover commissioning of VMAT programs as they have already been
Accepted Article
covered in the literature.23–25
This report addresses the extra time that is necessary to perform the increased number of tests, with
the aim of educating oncology administrators on the additional demands and time that it could take for
medical physicists to perform such tasks. We recommend the appropriate qualified personnel to
perform the tests and provide ranges of time that the test could require. The time ranges were
estimated from an internal survey of TG members and cover all accelerator manufacturers and a
variety of test techniques. This document contains illustrative pictures of QA devices from various
device manufacturers. These images are intended only as aids to understanding the tests and as
examples of possible tools for performing those tests; they are not intended as an endorsement of any
manufacturer. Ultimately, it is the responsibility of the QMP to determine the method for performing
the test. As additional guidance, this report will provide sample QA forms for daily, monthly, and
annual QA checks.
This report has several recommendations that deviate from TG 142. These deviations are discussed in
detail in the appropriate sections.
2 QA OF MEDICAL ACCELERATORS
2.1 General
Each section begins with the objective, tolerance, and methods and equipment to perform the test and
ends with a summary table documenting the appropriate personnel needed to perform each test and
the required time. As local regulations regarding physicist qualifications and supervision vary, the
institution may need to modify the appropriate personnel for the tests. The personnel fall into three
categories: Registered Radiation Therapy Technologist (RTT) working under the supervision of a
Qualified Medical Physicist (QMP), an individual designated by the QMP and working under the
supervision of the QMP, and a QMP. In this context, we use the AAPM definition of a QMP.26
Linacs have several modes of operation. The two used most are treatment and service. All patients are
treated in treatment mode. Many of the QA tasks recommended in TG 142 can be accomplished in
either mode. If any of the tests are performed in service mode, it is the responsibility of the QMP to
ensure that the result of any test run in service mode is equivalent to the result from treatment mode.
Throughout the report, we reference gantry, collimator, and table angles. The convention used to

describe these angles is the IEC 6121727 coordinate system. For example, gantry zero is defined with
Accepted Article
the gantry head/radiation beam pointing vertically down. The terms for AAPM accredited dosimetry
calibration laboratory (ADCL) and secondary standards dosimetry laboratory (SSDL) are used in
reference to the calibration of ionization chambers and electrometers. Both ADCL and SSDL are
traceable to their corresponding national standards. Throughout the document, we use the term ADCL
which can be equivalently interpreted as SSDL.
The daily QA tests are typically performed by an RTT. The TG recommends a detailed policy and
procedure for daily QA checks to be used as a guide for the RTTs. The competency of the RTTs to
perform the tests should be documented. The procedures should indicate how the tests are performed,
the tolerance of each test, and what corrective action is necessary if any test should fall out of
tolerance. An example corrective action for daily output constancy of photons and electrons is given
here:
If the output measurement performed by the RTT is outside the ±5% tolerance range, do not treat. We
recommend a second person should first repeat the measurement, and if the measurement is still out
of the ±5% tolerance range, a QMP must repeat the measurement as soon as possible.
If the output measurement performed by the RTT is outside the ±3% tolerance range but within ±5%,
treatment may continue, but a second person should repeat the measurement. If the repeated
measurement still indicates out of ±3% tolerance, the cause of the discrepancy should be investigated
at the first opportunity by the QMP.
The procedure should also clearly state that any out-of-tolerance test should be brought to the
attention of the QMP as soon as possible. The QMP should review and sign off on the daily QA tests,
preferably daily but at a minimum of once per week. This frequency has increased since TG 142,
which had recommended a minimum of once per month. More recently, QA management systems are
being used. These systems can be configured to automatically alert the QMP should a daily QA result
exceed tolerance, and the daily sign off is therefore inherent in the system.
The monthly QA tests are typically performed by the QMP, a medical physicist, or physics assistant
working under the supervision of a QMP. These tests can also be performed by medical physics
trainees, such as students or residents, working under the supervision of a QMP. If an individual other
than the QMP performs these tests, competency of the individual should be documented, including

whether he or she can correctly assess and investigate the cause of discrepancies and make proper
Accepted Article
adjustments to bring the system into tolerance. The detailed procedures to perform the tests and the
methods to make necessary corrective actions should be available. In addition, any out-of-tolerance
test should be brought to the attention of the QMP as soon as possible. The QMP should sign off on
the monthly QA tests every month, preferably within 15 days of completion of the tests.
The annual QA tests are typically performed by the QMP.28 The annual tests are usually more
complex and require a greater understanding of the tests, test equipment, and all components of the
linac. The annual report should include a summary section that details the findings of the annual QA.
Upon completion, the report should be checked, signed, and dated by the responsible QMP and should
be kept as a record for inspection for as long as the machine is used for patient treatment.
As recommended in TG 142, this report reiterates that, although the QA program for linacs is a group
effort, the overall responsibility for administering the linac QA program should be assigned to one
individual, the designated QMP.
2.1.1 Clarifications and Deviations From TG 142
2.1.1.1 Test Frequency
This report adopts the test frequencies from TG 142. There is only one frequency change: “The QMP
should review and sign off on the daily QA tests, preferably daily but at a minimum of once per
week.” This frequency has increased since TG 142, which had recommended a minimum of once per
month. This change is based upon the recommendations of the American College of Radiology
(ACR)—“ACR Technical Standard for the Performance of Radiation Oncology Physics for External
Beam Therapy”29—who state that “the medical physicist must review, as soon as possible, all
dosimetric and physics activities that occurred during his/her absence.”
2.1.1.2 Daily or Weekly QA
(1) The tests for positioning or repositioning and imaging and treatment coordinate coincidence for
SRS/SBRT machines were increased to ≤2 from ≤1 mm. The one exception to this increase is for
the clinical situation where image guided radiation therapy (IGRT) is to be used with SRS. Under
that circumstance, it is the recommendation of this TG that the QMP must validate the IGRT
imaging tests to ≤1 mm on the day of SRS treatment. The change was made to align with TG
179.30

(2) For efficiency purposes, the weekly picket fence test for the MLC was reworded so that the test is
Accepted Article
to be performed at a different cardinal gantry angle each week.
(3) The QMP should review and sign off on the daily QA tests, preferably daily but at a minimum of
once per week, as described above.
2.1.1.3 Monthly QA
(1) The tolerance for light radiation coincidence for both asymmetric and symmetric fields was
changed to ±2 mm per jaw to align with “AAPM Medical Physics Practice Guideline 8.a.”9
(2) The tolerance for jaw position indicators was changed to ±2 mm per jaw for symmetric mode and
±1 mm per jaw for asymmetric mode when used for field matching at the central axis to align with
“AAPM Medical Physics Practice Guideline 8.a.”9
(3) An absolute couch position test was added to the relative couch tests in TG 142 to align with
(4) For clarity, the monthly setting vs. radiation field (non-IMRT) was renamed leaf position accuracy
(non-IMRT).
(5) Test patient-specific VMAT constancy QA was added.
2.1.1.4 Annual QA
(1) For efficiency, the SRS arc rotation mode and the arc mode tests were combined into one arc
mode test.
(2) Monitor unit (MU) linearity for photons should be tested for both static (nonsegmented) and
dynamic (segmented) beams as the beam control systems can differ. This was added to align with
(3) For clarification, the photon or electron output constancy and off-axis factor constancy vs. gantry
angle tolerance was reworded to “The measured output should be within 1% of the value acquired
at gantry 0°.”
(4) TBI/TSET measurements specific for energy and profiles were made optional at the extended
treatment distance. The tolerances for measurements taken at the extended distance were adjusted
as follows: TBI TMR/PDD ±5% from baseline, TSET ±3 mm PDD shift, OAF constancy ±5%
from baseline, TBI/TSET output calibration ±3% from baseline.
(5) The tolerance for mechanical and radiation isocenter coincidence was changed to absolute values

as opposed to reference to baseline to align with “AAPM Medical Physics Practice Guideline
Accepted Article
8.a.”9
(6) For clarification and consistency, the tabletop sag test was renamed treatment couch top flex.
(7) For VMAT QA, test patient-specific VMAT constancy QA and an interruption test were added.
2.1.2 Documentation
Documentation of all the tests performed is critical. All results should be documented in either a
permanent electronic or hardcopy format and should be readily available for inspection purposes. For
daily QA, it is recommended that the QMP review and sign off on the reports, preferably daily but at
a minimum of once per week. For monthly QA, the QMP should review and sign off on the reports
within 15 days of completion. Upon completion of the annual measurements, it is recommended that a
comprehensive annual QA report be generated. The report should contain a summary section that
states significant findings based on the recommended table tolerance values. The QA report should be
signed and reviewed by the QMP and filed for future machine maintenance and inspection needs.
This TG has provided sample daily monthly and annual QA forms. The forms were developed in
Microsoft Excel but are distributed as PDF printouts. The original forms use logical tests, dropdown
lists, and other form controls to facilitate data entry. A common theme between all the forms is that
data were entered only in the areas highlighted in yellow. We suggest that the forms be stored
electronically on a departmental network drive. Once the QMP has reviewed the forms, they should
be locked and stored as secure PDFs. If hardcopies are preferred over electronic, it is suggested that
the hardcopies be scanned and stored in digital format for redundancy purposes.
The daily QA form is a single summary sheet. It contains the list of tests to be performed and the
tolerances based on machine type. It has sections to record the results of the dosimetry, mechanical,
safety, wedges, MLCs, and imaging tests. There is also a free text area where comments pertaining to
the tests can be entered. There is a signature area that is to be completed by the therapist performing
the tests and the QMP who reviews the tests.
The monthly QA form is based on an Excel workbook with six tabs: dosimetry, mechanical safety,
respiratory gating, MLC, imaging, and monthly summary. The dosimetry sheet has sections to record:
photon and electron output; EDW, Virtual, or Universal Wedge output; electron energy constancy;
photon and electron beam profile constancy; and respiratory gating beam output constancy. It contains

the list of tests to be performed and the tolerances based on machine type. It has sections to record the
Accepted Article
results of the dosimetry, mechanical, safety, wedges, MLCs, and imaging tests. The dosimetry sheet
can be customized to populate photon and electron energies, dosimetry equipment, calibration dates,
and personnel into the dropdown lists. On the mechanical and safety sheet where tolerances depend
upon the linac usage, for example, treatment couch position indicators, the usage can be picked from
the dropdown list, and the tolerances are adjusted accordingly. In addition, there are selection boxes to
allow users to indicate that certain tests may not be applicable to their linac, for example, graticule
trays. The mechanical and safety sheet also has an area to document the QMP’s review of the daily
QA, the machine logbook, and the service reports. The respiratory gating sheet has a selection box to
allow the QMP to indicate whether respiratory gating is being used on the linac. There is a similar
selection process on the MLC sheet to indicate usage as non-IMRT or IMRT. The imaging sheet has
selection areas for linac usage, which will determine tolerances and imaging usage. For example, a
machine might only have megavoltage (MV) imaging. The imaging tests also contain the baseline
values for each test. The monthly summary sheet uses the same format as the daily summary sheet
with an extra column for the personnel performing the test. Unlike the daily QA, several personnel
may perform the monthly tests for one machine. Similarly, there is also a free text area where
comments pertaining to the tests can be entered. There is also a signature area that is to be completed
by the QMP who reviews the tests.
The annual QA form is based on an Excel workbook with the same six tabs at the monthly form:
dosimetry, mechanical safety, respiratory gating, MLC, imaging, and annual summary. While we
recommend that the QMP continues to use his or her TG 51 forms, the dosimetry sheet has a section
to record the TG 51 results. In addition, there are sections for all the photon and electron dosimetry
tests, TBI/TSET tests, and wedge tests. It contains the list of tests to be performed and the tolerances
based on machine type. It has sections to record the results of the dosimetry, mechanical, safety,
wedges, MLCs, and imaging tests. The mechanical and safety sheet has an area to document the
QMP’s review of the manufacturer’s user and technical manuals, safety guides, safety notices, and
technical bulletins. There is also an area to document the linac QA program annual review. The
respiratory gating, MLC, and imaging sheets have sections for all the annual respiratory gating, MLC,
and imaging tests. The imaging sheet has selection areas for linac usage which will determine

tolerances and imaging usage. For example, a machine might only have MV imaging. The annual
Accepted Article
summary sheet uses the same format as the monthly summary sheet. Similarly, there is also a free text
area where comments pertaining to the tests can be entered. There is one additional section on the
annual summary sheet, summary of findings, where any items that are out of tolerance on the annual
tests can be documented if necessary. Below that section is a signature area that is to be completed by
the QMP who reviews the tests.
2.2 Daily
2.2.1 Dosimetry
The baseline for the daily dose measurement system should be established by performing an
intercomparison with the primary dose measurement system on at least an annual basis.9 Primary
measurement systems are typically performed in a water tank; a secondary measurement system may
be used for monthly QA and a tertiary system for daily QA. Intercomparisons can be quick and easy
and provide high confidence in stability when all available devices are compared during a single
session.
2.2.1.1.1 Objective
Daily verification of photon and electron output is essential for overall confidence that the patient’s
dose during that day’s treatment fraction is constant and nominally accurate to the expected
prescribed dose. These measurements are not a calibration of the beam’s output but serve as
confirmation that the outputs have not changed within a reasonable tolerance.
2.2.1.1.2 Tolerance
The measured output should be within 3% of the established baseline. An institution may choose a
smaller tolerance limit to respond more quickly to a change in output. In addition, an institution can
have operational guidelines such that, if the output measurement performed by the RTT is outside the
±3% tolerance range but within ±5%, treatment may continue, but a second person should repeat the
measurement. If the repeated measurement still indicates out of ±3% tolerance, the cause of the
discrepancy should be investigated at the first opportunity by the QMP.
2.2.1.1.3 Methods and Equipment
Ideally, each treatment vault will have its own dedicated daily measurement system; however, it is not

uncommon to share devices between treatment vaults. The system used to measure daily dose output
Accepted Article
constancy normally, although not always, consists of a phantom embedded with at least five or more
ionization chambers or diodes and electrometers. These devices typically contain sensitive
electronics. Radiation damage to these electronics could cause drifts in the readings; therefore, it is
important that the setup avoids irradiating electronics during measurements. Another common
mistake is to irradiate the electronics during morning warmups; therefore, it is recommended that the
device not be placed on the couch the night before. The important features of the measurement
procedures are the reproducibility in the setup geometry, proper measuring system functionality, data
recording, and analysis. In addition, for electron output, the inherent buildup of the device used for
measurements should not be positioned in the steep distal falloff of the depth dose, a particular
problem for low electron energies. Slight variations in electron energy may cause a false dose
constancy error relative to the dose at depth of clinical interest. Some linacs are designed with
independent photon and electron monitor chambers (e.g., Siemens). It is recommended that each
independent monitor chamber system should be checked daily.
(1) The setup geometry and the beam parameters must be clearly stated in written instructions. These
would include beam energy; dose rate; MU; field size and beam limiters; source-to-surface
distance (SSD); collimator, gantry, or couch angles; position on couch; buildup; and the
orientation of the measurement device.
(2) The repeatability of measuring device setup should be such that it can satisfy the statements in
section II.C.4 of TG 142. It is recommended that the measurement system and procedure
repeatability be such that two standard deviations for three or more repeated consecutive
measurements are less than the tolerance value. This will generally require an ionization chamber-
based system that may be equipped with sensors to correct for temperature and pressure.
Alternatively, diode and metal-oxide-semiconductor field-effect transistor (MOSFET) systems
could be used if their calibration is carefully established. Temperature measurements, if required,
must always be made in the treatment room.
(3) Data and beam parameters should be recorded in a log, either physical or digital. These include all
the measurement results such as offset, final readings, temperature, and pressure. Some devices
with dedicated software may record all the data in a database.

(4) Analysis should include the comparison of the final measurement results with the baseline and an
Accepted Article
indication of a pass (within tolerance) or a fail (out of tolerance).
It should be noted that some daily QA devices could measure other QA items at the same time as
when output constancy are checked. For example, beam symmetry, flatness, and field size may be
measured simultaneously with output with one of these devices.
2.2.2 Mechanical
2.2.2.1 Laser Localization
2.2.2.1.1 Objective
At the time of installation and acceptance, the laser systems on the linac are aligned to the radiation or
mechanical isocenter of the machine. There are typically four lasers units: two on the lateral walls,
one on the ceiling, and one sagittal at the foot of the treatment couch. The lasers on the side walls and
the ceiling laser have orthogonal fan beams, while the laser facing the foot of the treatment couch
only has a vertical fan beam. Lasers may be used for the initial setup of patients before treatment or
acquiring images using in-room imaging systems. Lasers used in radiation oncology have electronic
control systems that can be subject to drift with time. If the lasers are the only means to setup the
patients for treatment, it is crucial to ensure that the positional errors are as small as possible to
deliver the clinical plan accurately to the intended target and to avoid critical structures. In the case of
initial positioning followed by imaging, while the imaging is used for final patient setup, it is still
desirable for the errors in the laser system to be as small as possible so that the patient shifts can be
tracked against a stable baseline.
2.2.2.1.2 Tolerance
The tolerance for non-IMRT is ±2 mm; for IMRT, ±1.5 mm; for SRS/SBRT, ±1 mm.
A variety of commercial test devices are available to verify laser accuracy, such as a cube with
markings on the sides which is positioned at isocenter, typically using the crosshairs and the light
field as a reference point, to determine the accuracy of coincidence of lasers at isocenter. Setting up
the cube is very quick but less rigorous than other methods. For example, the front pointer linac
accessory provides an independent reference point for the mechanical isocenter of the machine, but it
is more time consuming and more fragile than the cube. The choice of the method is dependent upon

the institution’s goals.
Accepted Article
2.2.2.2 Optical Distance Indicator (ODI)
2.2.2.2.1 Objective
The ODI has been a traditional method for setting up SSD for phantom dosimetry measurements and
patient treatment. The purpose and method of using ODI varies from institution to institution. The
ODI is an important redundancy to the coronal lasers and the only setup reference for when the
surface is located away from the machine isocenter. This redundancy may have an important impact
during an SSD setup technique where errors are magnified by an inverse square factor.
2.2.2.2.2 Tolerance
The tolerance is ±2 mm.
The most expedient method is to set the ODI coinciding with crosshairs on a surface at the machine
isocenter (100 cm SAD in most machines) and check that the coronal lasers “graze” the surface
illuminated by the ODI field light. This test assumes that the lasers have already been tested and
coincide with machine or radiation isocenter.
2.2.2.3 Collimator Size Indicator
2.2.2.3.1 Objective
Collimators on the linac are used in conjunction with MLCs or blocks to define the treatment field
edges. The collimator positions are set either through a hand pendant inside the treatment room, the
console, or by the record and verify (R&V) system. The objective is to verify that the collimator
indicators are consistent with the desired setting.
2.2.2.3.2 Tolerance
The tolerance for non-IMRT is ±2 mm per jaw; for IMRT, ± 2 mm per jaw; for SRS/SBRT, ±1 mm
per jaw.
The equipment required to perform this test could be as simple as a piece of graph paper, a template
with predefined rectangular shapes, or the flat surface of the QA device used to measure output
constancy. The test equipment can be illuminated by the light field for visual inspection against the
collimator indicator and should be positioned at isocenter where the collimator setting is defined. In

this method, the light field is a surrogate of the radiation field. Alternatively, the QA device that is
Accepted Article
used to measure the output constancy can often measure radiation field size, and this can be compared
with the collimator settings. If the device is used for this purpose, care should be taken to set the
surface of the device and not the detector plane at isocenter, which would cause an error in the
indicated light field on the equipment surface.
2.2.3 Safety
2.2.3.1 Door Interlock
2.2.3.1.1 Objective
It is important for the safety of personnel to make sure that the beam is turned off when the door is
opened and beam on is prevented when the door is not closed.
2.2.3.1.2 Tolerance
The tolerance is functional.
There are two tests that could be executed to check both failure modes: (1) While the beam is on,
open the treatment room door. The beam should turn off as soon as the door starts to open. This test
should be run during the beam warmup. (2) While the door is open, attempt to turn the beam on. The
beam should remain off. Beam off is indicated on the accelerator console and via the radiation area
monitor. This test can also be used as the test for the beam on indicator (see section 2.2.3.6).
2.2.3.2 Door Closing Safety
2.2.3.2.1 Objective
The treatment room door can weigh as much as 15 tons and may use a large force to close, with the
potential to cause injury. This test should verify that, if the door has emergency stop equipment, the
door will stop closing if personnel are accidently caught in the path.
2.2.3.2.2 Tolerance
With the treatment room door in the open position, press the control to close the door. Stand in a safe
position away from the door-closing path and when the door is halfway closed, activate the
emergency stop equipment. This could be a push bar, proximity sensor, or motion-detection system,

for example. The door should stop closing if the emergency stop is functioning properly.
Accepted Article
2.2.3.3 Audiovisual Monitor
2.2.3.3.1 Objective
The RTTs need to be in constant audio and visual communication with the patient to ensure safe
patient treatments. This is accomplished by installing at least two cameras and a two-way audio
communication system in the treatment room. Systems are tested daily to ensure that they are
functional.
2.2.3.3.2 Tolerance
Turn on the music system, place a sound-producing device on the treatment couch or have a second
person stand near the treatment couch and speak. Exit the treatment room and verify that the device or
person is visually observable on the monitor at the console and sound can be heard. Next, enable the
console side of the two-way communication device and talk into the microphone. Have a second
person or a recording device such as a smartphone verify that sound can be heard or the
communication recorded. Alternatively, listen for the communication sounds coming out of the open
treatment room door.
2.2.3.4 Stereotactic Interlocks
2.2.3.4.1 Objective
Stereotactic interlocks ensure that the devices to be used are interlocked, and the dose rate for a given
modality is only allowed under this condition.
2.2.3.4.2 Tolerance
Attach the stereotactic device to the head of the linac while a nonstereo beam is programmed for
delivery. The linac should indicate an interlock related to this attachment and prevent the operator
from beam delivery. Based on the manufacturer, take the recommended steps to clear the interlock.
Program a stereotactic beam. Deliver a set dose that is designated for QA purposes. Remove the
device and attempt to deliver the same dose. The linac should not be able to deliver the dose when the

interlock is activated. At the QMP’s discretion, the stereotactic interlocks could only be performed on
Accepted Article
days with stereotactic procedures.
2.2.3.5 Radiation Area Monitor (If Used)
2.2.3.5.1 Objective
The treatment room radiation area monitor is connected to a remote indicator located outside of the
treatment room. This is a visual safety check as a backup to the door interlock to prevent personnel
from entering the treatment room while the beam is on. Verify that the area monitor is functional.
2.2.3.5.2 Tolerance
While outside the treatment room entrance and with the treatment room door closed, verify that the
remote radiation area monitor indicates no radiation when the beam is off. With the beam turned on,
the radiation monitor should illuminate to indicate radiation is present in the treatment room.
2.2.3.6 Beam-On Indicator
2.2.3.6.1 Objective
The entrance to the treatment room has indicators for beam off and beam on located close to the
treatment door. These indicators are controlled by the linac to indicate if a radiation beam is on or off
(see Figure 1). Verify that these indicators are functioning properly. There may be separate indicators
for the MV and kilovoltage (kV) systems.
2.2.3.6.2 Tolerance
Close the treatment room door. Visually verify that the beam-on indicator(s) is on when the beam is
on and then beam-on indicator(s) is off when the beam is off.
The time required to perform the daily QA ranges from 20 to 30 min. This will typically include the
daily check of the dynamic, virtual, or universal wedge. Additional time is necessary for the
radiographic imaging daily QA (see Table 6) which can add another 20 to 30 min. Times on the lower
end of the range use commercial systems to combine many of the tests. Note these times include the
time to document the tests.

2.3 Monthly
Accepted Article
2.3.1 Dosimetry
2.3.1.1.1 Objective
The output of a linac is expected to be stable over time. However, changes in output can have
occurred for multiple reasons.31 It is important to verify the output constancy monthly for photon and
electron beams with a calibrated ionization chamber and electrometer under standard testing
conditions. The output constancy check is not an absolute calibration of the machine. The test is to
verify that dose per MU obtained at the time of absolute calibration and those measured at the time of
the test, corrected for temperature and pressure, are within a specific tolerance limit. All available
photon and electron beams should be checked monthly.
2.3.1.1.2 Tolerance
The tolerance for output constancy should be ±2% from the baseline under standard conditions (e.g.,
baseline is 1.000 cGy/MU at dmax, 10 × 10 cm field size, 100.0 cm SSD). As in the tolerance set by
the daily output constancy checks, the institution may choose a different tolerance. If the tolerance is
exceeded, an adjustment should be made to restore the machine to within the tolerance limit.
Note that the need for large adjustments (e.g., >3%) is uncommon.32,33 If a large adjustment is
indicated by initial measurements, a careful review of the measurement setup, all calculations, and the
history of daily output constancy checks should be conducted to verify that the indicated adjustment is
necessary.
Institutions may have several options for measuring the output constancy of the treatment beams. It is
in the best interest of the facility to use the simplest setup to reduce the time required. One may use
either solid materials (e.g., solid water, plastic water) or small water phantoms for the measurements.
It is also suggested to consolidate the depths of measurement to minimize time spent entering the
treatment room. The ionization chamber and electrometer should have a national standards traceable
calibration, usually obtained from an ADCL or SSDL, within the last 2 y or be cross calibrated with
the institution’s traceable equipment. In addition, the calibration of the barometer and thermometer
should be checked annually. Measurements are made at the standard clinical dose rate. Physicists

should be aware that there may be limitations to their electrometer in accumulating charge when the
Accepted Article
beam is rapidly delivered with a high dose rate.34–36 The following procedures may be used for either
a solid or water phantom setup:
(1) Ideally, the solid phantom and ionization chamber should be stored in the treatment room with the
linac at all times to stay in a state of equilibrium with the ambient temperature in the room. If this
is not possible, the phantom and chamber should be placed in the treatment room for a sufficient
period to allow the equipment to reach room temperature. The temperature of the chamber cavity
in the phantom and the barometric pressure should be monitored periodically throughout the
measurements, and appropriate changes should be made to correct the temperature or pressure
factor if necessary. If the electrometer requires a long warmup period—that should be confirmed
from the user manual but is typically 10 to 15 min37—it should be turned on with the appropriate
voltage before any measurements.
(2) The phantom should be placed on the treatment couch or other supportive device at conditions
like those at the time of annual calibration (see Figure 2) per TG 5138 calibration (SSD, SAD,
gantry settings, etc.). If cross-calibrations are performed from water to a solid phantom,
measurement depths should be close to those depths used for TG 51 calibration.
(3) For statistical purposes, three measurements should be obtained for each energy to allow for any
drift that could occur with the linac or electrometer or ionization chamber. Variation between each
reading should not exceed ±0.5%.39
(4) Perform all appropriate corrections to the measurements following the protocol used for the initial
calibration (e.g., TG 51) or alternately using the previously established cross-calibration.
Calculate the result in cGy/MU at the depth indicated by the protocol (e.g., dmax, d = 10 cm, etc.).
(5) Adjustments should be made if the measured output exceeds ±2%. At the discretion of the facility,
adjustments could be made for smaller deviations from expected values. Repeated measurements
should be made after any adjustments to ensure the correct output adjustment was made.
(6) If adjustments are made to the outputs, any devices used for daily QA should be checked. Any
deviation from the new monthly readings should be investigated to determine the cause, and

appropriate action should be taken. Possible causes of a discrepancy are that the output adjustment
Accepted Article
was performed incorrectly or that the daily QA device has drifted. Note that, if the output
adjustment is done correctly and the daily QA device is stable, then the adjustment of the output
back to nominal should result in the readings of the daily QA device also moving back toward the
reference (baseline) values.40,41
(7) All photon and electron beams should be tested at least monthly for output constancy.
(8) The time requirements for monthly output checks can be minimized if the measurements are
compiled to similar settings. This time would increase if recalibration of beam(s) and daily QA
device would be necessary.
2.3.1.2 Backup Monitor Chamber Constancy
2.3.1.2.1 Objective
All modern linacs are required to have a secondary monitor. The backup monitor is intended to
monitor radiation output, flatness, and symmetry in the event of a failure of the primary radiation
monitor chamber. Due to the possibility of such an event, the backup monitor chamber will need to be
calibrated with the same expectations as the primary monitor chamber. Absolute calibrations are
applied to the primary monitor chamber. The backup chamber is either cross calibrated to the primary
or calibrated simultaneously and independently. In addition to the secondary monitor chamber, some
machines may have an independent MU counter located at the control console. The purpose of this
counter is to display the MUs delivered in the event of a power failure during treatment. The delivered
MUs will be displayed until the machine is reset. The backup MU counter should be checked for
accuracy during this test.
2.3.1.2.2 Tolerance
The tolerance for the backup monitor chamber should be the same as the primary monitor chamber
±2%. The tolerance can be more stringent as deemed by the QMP. It should be noted that this
tolerance is insufficient for fields requiring large MU delivery. For example, an Elekta machine may
be limited to fields not exceeding 999 MU yet will be interrupted if the monitor chamber discrepancy
exceeds 10 MU, which is 1%. The backup MU counter should have an identical reading to the
primary monitor chamber.

(1) The secondary monitor chamber constancy should be checked at the same time as the primary
Accepted Article
monitor chamber, using the same setup (see section 2.3.1.1).
(2) Once the primary monitor chamber is calibrated to within tolerance, the secondary backup
monitor chamber is adjusted to give the same reading as the primary. This will bring the backup
monitor chamber within the tolerance of ±2%.
(3) The backup MU counter is visually inspected for consistency with the primary monitor chamber
reading.
2.3.1.3 Typical Dose Rate Output Constancy
2.3.1.3.1 Objective
Dose rates can vary significantly with treatment type, especially with the variety of options available
on most modern machines. Even within the same treatment field, the dose rate can vary from one end
of the range to the other (i.e., IMRT, dynamic wedges). It is important to verify that the machine is
operating correctly at all dose rates used clinically and that the dose per MU is consistent for all dose
rates.
2.3.1.3.2 Tolerance
For non-IMRT machines, dose rate dependence may not be an issue since the dose rate is not meant to
change during treatment. The exception would be for enhanced dynamic wedges where the dose rate
is modulated with jaw movement to deliver the desired wedge-shaped isodose distribution. For IMRT
and stereotactic machines, the dose rate intentionally fluctuates for certain IMRT deliveries. The
tolerance for output constancy should be ±2% from the baseline under standard conditions for all
measurable dose rates. The QMP may implement tighter tolerances at his or her discretion.
(1) The typical dose rate output constancy can be checked at the time that the output calibration of the
machine is being checked using the same setup.
(2) Measurements are made at the standard dose rate that is used clinically. Additional output
measurements are made at dose rates typically used with the types of treatments delivered on the
machine (SRS, IMRT delivery, enhanced dynamic wedges, etc.). For example, if the typical
standard dose rate is 400 MU/min and stereotactic dose rate is 600 MU/min, then the output at
either dose rate setting should be checked and compared with the typical or standard dose rate. If

unflattened beams are used clinically, physicists should be aware that there may be limitations to
Accepted Article
their electrometer in accumulating charge when the beam is rapidly delivered with extremely high
dose rates.34–36
2.3.1.4 Photon and Electron Beam Profile Constancy
2.3.1.4.1 Objective
Photon and electron beam profile constancy is intended to measure any change in flatness or
symmetry that could occur with a machine due to a change in energy, steering failure, or drift in
servos used to direct the beam. Changes in flatness and/or symmetry could result in underdose or
overdose of the patient.
Beam profiles vary with machine type and energy. The baseline values for photon and electron beam
profiles are determined during acceptance testing and commissioning and are verified annually.
Flattening filter-free (FFF) beams are handled in the same manner as flattened beams.42 While there is
much discussion in the literature on the properties of FFF beams,34,42–44 the measured profile is
compared with the baseline profile established for the beams during commissioning. As stated in TG
142, the beam profile constancy test includes flatness and symmetry and is meant to be a
measurement of deviation from baseline values, not an absolute measurement.
All photon and electron beams should be tested for beam profile constancy monthly.45 The photon
profiles should be inspected closely, as deviations could indicate a change in energy.46,47
2.3.1.4.2 Tolerance
The tolerance for photon and electron beam profile constancy is ±1% for all machine types. This
value is a deviation from baseline, not an absolute value.
(1) The device used for daily output monitoring often has the additional ability to measure flatness or
symmetry. The QMP may review the daily measurements made during the daily QA for any
changes in flatness and symmetry. It is up to the QMP if additional monthly measurements are
required. However, it is not specified in TG 142 to measure flatness and symmetry daily.
(2) Equipment used during acceptance testing and commissioning are not always conducive to routine
use. At the time of these measurements, simpler test equipment may be implemented to measure
flatness and symmetry with reference to values obtained at commissioning. This equipment

should be stable over time and have sensitivity that is less than the tolerance limit for profile
Accepted Article
constancy. It should be noted that flatness and symmetry will be unique to the measuring device,
and if a new device is introduced for QA, new baselines must be established.
(3) The specific test equipment used and depth of measurement are the choice of the individual
performing the measurements. There are a variety of array type detectors48 available that can be
used to acquire data for multiple tests at one time. These devices can either be placed on the couch
top or mounted on the gantry. Electronic portal imaging devices (EPIDs) have also been used.33
Whatever measurement geometry is used to establish the baseline value, subsequent routine
measurements should be performed with the same setup and device.
(4) Perform measurements at multiple points along the beam profile in both radial (in-plane) and
transverse (cross-plane) directions. At a minimum, measure a point at the central axis and four
points at the cardinal axes at 80% of the field width defined by the primary jaws.
(5) Apply corrections to all readings that are appropriate for the measurement device (for example,
temperature and pressure corrections for ionization chambers, density vs. dose corrections for
film, dark field and flood field corrections for EPIDs, etc.).
(6) At each individual measurement point, calculate the percent deviation from the baseline off-axis
ratio at that point. For full profiles, such as those from film scans or EPIDs, calculate a percent
difference from the baseline profile.
(7) Repeat for all photon and electron energies.
A simple calculation for the central axis and four points is shown here in Table 2.a.
2.3.1.5 Electron Beam Energy Constancy

2.3.1.5.1 Objective
The objective is to determine if the electron beam energy has changed from original baseline values.
This is done by calculating the ratio of measured ionizations at two depths, usually within the
practical range of electron beam.
2.3.1.5.2 Tolerance
The tolerance is ±2% of the expected ionization ratio or ±2.0 mm of the expected depth.

It is most efficient to perform this test at the same time as the electron output constancy test. Using the
Accepted Article
methods and equipment used in section 2.3.1.1:
(1) Repeat a series of three measurements at a second known depth.
(2) Calculate the ratio of the reading at the second depth to the reading at the depth of calibration.
(3) Compare the result with the baseline values and compare with tolerance values.
Alternatively, one could use an array detector with built-in filters order to discriminate electron
energy.
2.3.2 Mechanical
2.3.2.1 Light or Radiation Field Coincidence (Symmetric and Asymmetric)
2.3.2.1.1 Objective
The radiation light field coincidence is established at acceptance testing and should remain relatively
stable for the life of the machine. Major changes or repairs to devices in the beam path (e.g., mirror,
field light assembly) may result in changes in radiation or light field coincidence.49 This is a concern
for treatment instances where clinical setups are performed using the light field. The result would be
erroneous treatments due to the misconception of treated area to proposed area if radiation or light
fields do not coincide. In contrast to TG 142, while we acknowledge that asymmetric jaws can be
used for beam matching and dynamic or virtual wedge delivery, this TG believes that the tolerances
should be the same for both symmetric and asymmetric jaws. This also aligns with “AAPM Medical
Physics Practice Guideline 8.a.”9 The coincidence of the light fields for all photon energies used for
clinical setups should be tested against the radiation field.
2.3.2.1.2 Tolerance
The tolerance is ±2 mm per jaw. (Note: This is adjusted from TG 142 to align with “AAPM Medical
Physics Practice Guideline 8.a.”9)
(1) Film has long been the choice for this type of measurement, but with the age of digital
radiography, film processors may no longer be available. The ability to differentiate ±1.0 mm on
film can be difficult with the naked eye. Some software suites are available that can quantify the
deviations in light field (usually represented by radiopaque markers on the film) and radiation
field. In the absence of film and/or analyzing software, certain electronic hardware is available to

test light or radiation field coincidence. One could also use MV imaging, if available.
Accepted Article
(2) If film is used (silver halide based or radiochromic film), one could either physically mark the
edge of the light field (score with a pen or pin prick) before the radiation exposure of the film. The
resultant image will show any misalignment between the light field markings and the radiation
field. An alternative to marking the film is to expose a device with radiopaque markers, which are
aligned to the light field.
(3) If an electronic device is used, the commercial software may have the ability to detect field edge
variation. This variation must correspond to the actual light field that is aligned to the detector
edges. Misalignment of the device will give erroneous results. The device or software must also
be able to detect variations smaller than the tolerance limit for this test.
(4) If the linac is used for the test (i.e., using MV imaging), the image analysis must be able to detect
variations smaller than the tolerance limit.
2.3.2.2 Lasers
2.3.2.2.1 Objective
Lasers are conventionally used for the initial setup of a patient regardless of the type of treatment.
With the advent of IGRT, patient setups rely less on the use of lasers and more on the alignment of
internal anatomy or fiducials. However, the lasers can form the basis of many of the QA tests
described in this report. The tolerance on the degree of accuracy of the lasers will depend on the use
of the machine. Machines that are not used for IMRT may have a less stringent tolerance than
machines used for IMRT or stereotactic treatments. Also, the process of determining the laser
alignment as it correlates to the mechanical or radiation isocenter may vary with the machine use (i.e.,
Winston-Lutz test vs. mechanical testing). It should be noted that the QMP can determine which
method to use.
2.3.2.2.2 Tolerance
The tolerance will vary with machine use. Non-IMRT machine laser tolerance is ±2.0 mm, IMRT
machines is ±1.0 mm, and machines used for SRS/SBRT treatments is <1.0 mm deviation. Tolerances
can be made more stringent at the discretion of the QMP.
(1) The methods and equipment will depend on the use of the machine. Less precise methods can be

used for non-IMRT machines. The highest level of precision is required for SRS/SBRT machines.
Accepted Article
(2) The following methods and materials are broken down according to machine use:
(a) Non-IMRT machines:
(i) A determination of the true mechanical isocenter of the machine is required to align the
lasers correctly. The gantry and collimator need to be set in their neutral or standard
position (0° or 180°) and the isocenter verified.
(ii) A possible method is to note the drift or “walk-out” of the sagittal crosshair from the light
field as the gantry is rotated when set at isocenter. Set the approximate isocenter to the
couch surface or device with a crosshair. The sagittal crosshair is either marked or aligned
with the device. The gantry is rotated ±45°, and the projection of the sagittal crosshair is
observed. Movement left or right of the projected crosshair from the original or vertical
position indicates the couch top or device is not at the isocenter. Raise or lower the couch
until the sagittal crosshair no longer drifts left or right as the gantry is rotated. An alternate
method would be to use the mechanical front pointers provided by the manufacturer.
(iii)The collimator must be set at its true neutral position to properly align the lasers. With the
gantry rotated to a side position, a bubble, torpedo, or a digital level can be used to level
the collimator. Caution must be exercised when using a level, as the surface of the
collimator face may not be level. Any inaccuracy in the level itself can be removed by
rotating the level 180° and splitting any discrepancy. An alternate method would be to
place the couch top at an SSD of approximately 130 cm. Set the field size to its largest
setting (40 × 40 cm2). With the gantry at 0°, place a piece of tape on the couch top along
the transverse crosshair as projected by the light field. Rotate the gantry ±45° and mark the
location of the light field central axis on the tape. Set the gantry to 0° using a level and
mark the central axis. Align the collimator with the marks on the tape.
(iv)Once the true mechanical isocenter is determined and all axes are neutral (i.e., gantry at
zero, collimator set to 0° or 180°), a precise laser alignment tool50 can be used. Align the
laser alignment tool with the crosshairs and check all lasers. Alternatively, the lasers can
be aligned to the front pointer as a surrogate for the true mechanical isocenter. The
tolerance will depend on the use of the machine.

(v) It should be noted that, while lasers are typically aligned based on the isocenter plane, the
Accepted Article practical application of using the lasers to align patients using skin marks occurs in a plane
away from the isocenter. Therefore, it is important to verify laser alignment away from the
isocenter plane. There are laser alignment tools and techniques that accomplish this, for
example, the method described by Hwang et al.51
(b) IMRT machines:
(i) The same methodology used for non-IMRT machines can be used for IMRT machines
with the exception of requiring a tighter tolerance.
(c) SRS/SBRT machines:
(i) Machines used for SRS/SBRT may require the tightest tolerance for laser alignment
depending on how the lasers are used. For treatments where the lasers are used to align a
patient to isocenter as the primary means for setup, the laser tolerance will need to be
better than ±1 mm. For SRS/SBRT treatments that are based on imaging for the final
isocenter alignment, better than ±1 mm accuracy of the lasers may not be necessary. The
QMP should determine and set the necessary tolerance.
(ii) If the lasers are the primary method of alignment for patient setup with imaging as a
supplement, the Winston-Lutz method (see Figure 3) is recommended.52,53 The Winston-
Lutz test can use either film or EPIDs for imaging.54–56 The Winston-Lutz test should be
performed over the range of gantry-couch combinations used clinically. The QMP should
determine the number of combinations tested, but the range should include worst-case
scenarios used clinically (gantry-couch combinations with the greatest known error). Also,
if treating with cones, the cones should be used as the collimation during the test.
Likewise, if MLCs are used for treatment, the MLCs should be used for collimation. The
radiation field size chosen (cone size or MLC shape) should be small enough to detect
misalignment with the Winston-Lutz test object. Software can be used to analyze the
resulting images if it can calculate the full width half maximum between the test object
and field edge. Visual inspection of the images can detect obvious misalignments but may
be difficult to quantify the results.
(iii)If lasers are used for initial patient setup with imaging as the final determination of patient

alignment, the preceding methods for IMRT machines may suffice. If the lasers are not the
Accepted Article primary method of aligning a patient for SRS/SBRT, a lesser tolerance for the lasers may
be used at the discretion of the QMP.
2.3.2.3 Gantry or Collimator Angle

2.3.2.3.1 Objective
The objective is to determine the accuracy of the digital readout of gantry and collimator angles. In
many treatment situations, multiple fields are used to treat the target. These fields are delivered at
different gantry angles as well as different collimator angles. To ensure accurate dose delivery to the
target and to spare the sensitive organs, it is necessary to ensure that correct gantry and collimator
angles are set as requested in the clinical plan.
2.3.2.3.2 Tolerance
The tolerance is ±1° regardless of the use of the machine. Tighter tolerances can be used at the
discretion of the QMP.
(1) To verify the collimator angles, the same setup used to align the lasers can be used for this test
[see section 2.3.2.2.3(2)(a)(iii)]. With the couch at 130 cm SSD and using the initial marks used to
set the collimator to true 0°/180°, rotate the collimator ±90°. Align the crosshairs with the same
marks on the tape at each angle. Record each digital readout. Alternatively, one can use a level for
this test. The level can be tested on a known flat surface. Rotate the gantry to 90° or 270°. Set a
level on a flat spot on the collimator housing. Rotate the level ±180° to correct for any error in the
level itself. Caution should be used when using a level for this test. As a true flat spot may be
difficult to find on the collimator housing, the projection of jaws or the crosshairs can be
compared with a plumb line on a vertical surface, on a wall or something attached to the table, for
example. Check the digital readout for the indicated collimator angles.
(2) To measure the gantry angles, place a level on the interface mount or on the accessory mount and
obtain the true angle for the four orthogonal gantry angles. Rotate the level ±180° to offset any
error in the level itself. Check the digital readout.
(3) For machines used to treat patients at extended distances, e.g., 130 cm, a 0.5° gantry misalignment

will appear as a 3 mm translation of the isocenter (30 cm × tan 0.5°). The calibration of the gantry
Accepted Article
angle at 0° and 180° should be more stringent, when possible, for these machines.
(4) For machines used to treat TBI/TSET patients at extended distances, the calibration of the gantry
at the treatment angle, typically 90° or 270°, should also be more stringent when possible.
2.3.2.4 Accessory Trays
2.3.2.4.1 Objective
The objective is to determine the positioning of the accessory tray with respect to isocenter at the four
cardinal gantry angles. Accessory trays are used to hold beam-shaping blocks at a fixed position with
reference to isocenter. The trays are slid into an accessory slot on the linac head. The trays are locked
into place by a latch. If the latch does not function as intended, the tray could become dislodged,
presenting a safety concern. In addition, any deviation from the intended position as the gantry rotates
can cause a misalignment of the treatment portal with respect to isocenter. If there are no patients
being treated clinically with blocks, then this test can be omitted.
2.3.2.4.2 Tolerance
Latching is functional, deviation of block position from zero gantry angle position within ±2 mm.
Rotate gantry to 0°. Insert accessory tray with custom blocking into the accessory slot on the linac
head and ensure tray latches. Measure deviation of accessory tray central axis (usually scribed on
tray) from the machine crosshairs. Rotate gantry to 90°, 180°, and 270° and measure the deviation at
each angle. The collimator should be rotated such that the latch is placed toward the floor at gantry
angles 90° and 270°.
2.3.2.5 Jaw Position Indicators
2.3.2.5.1 Objective
Jaw positions are important for setting the field edges. For asymmetric jaws, there should be
additional scrutiny for beam matching and the accuracy of dynamic or virtual wedge delivery which
depends strongly on jaw positioning accuracy.
2.3.2.5.2 Tolerance
The tolerance for symmetric is ±2 mm per jaw, asymmetric ±1 mm per jaw when used for field
matching at the central axis.

Accepted Article
Align graph paper or template with predefined rectangular shapes with the crosshairs at collimator
angle = 0°, 100 cm from the source. Adjust the collimators to match several field sizes covering the
clinical range. Record the digital readout. Do this for the upper and lower jaws (in symmetric and
asymmetric modes). Asymmetric jaws should be checked at settings of 0.0 (central axis) and 10.0 cm.
2.3.2.6 Crosshair Centering
2.3.2.6.1 Objective
The centering of the crosshairs as the collimator rotates reflects the accuracy of the mechanical
alignment of the collimator. For treatments involving the rotation of the collimator from neutral
position, the alignment is important, as the MLCs or compensators can be shifted.
2.3.2.6.2 Tolerance
Crosshair centering or walk-out should have a radius of ≤1.0 mm for all machines. More stringent
tolerances are up to the site QMP.
Set field size = 10 × 10 cm2. Align graph paper or template with predefined rectangular shapes and
crosshairs with the collimators at collimator angle = 0°, 100 cm from the source. Record the radius of
the smallest circle, which includes all the crosshair central axis projections at collimator angles of 0°,
90°, and 270°.
2.3.2.7 Treatment Couch Position Indicators
2.3.2.7.1 Objective
Digital treatment couch position indicators are used to both verify that day-to-day treatment setups are
occurring in a reproducible manner and that shifts for patient alignment are implemented accurately.
The treatment couch position indicators include longitudinal, lateral, vertical, and rotational digital
readouts. In the case of SRS/SBRT treatments, if the linac digital readout has a scale of zero, it is up
to the QMP to determine an alternate method to perform the couch rotation test.
2.3.2.7.2 Tolerance
The tolerance for non-IMRT is ±2 mm/±1°, IMRT ±2 mm/±1°, SRS/SBRT ±1 mm/±0.5°.
(1) For longitudinal verification, place the gantry and collimator at a neutral position (at zero angles).

Set graph paper or a ruler at 100 cm SSD on the couch and draw lines that are aligned with the
Accepted Article
crosshairs. Note the current digital longitudinal reading. Shift the table longitudinally toward and
away from the gantry by a set distance (e.g., 15 cm from the initial position) by using the marks
on the graph paper or ruler and the center of the crosshairs. Note the actual digital reading at each
location and record the difference.
(2) For lateral displacement, the same setup for the longitudinal verification can be used, instead
shifting the couch laterally and noting the digital lateral position indicators.
(3) To test the rotational digital readouts, there are several methods that one can use. If the
mechanical readout on the floor has been deemed accurate, one can simply rotate the couch ±90°
and record the digital readings. If the mechanical readings are not reliable or are nonexistent, the
crosshairs can be used as a reference. The collimator must be at the true neutral position if it is to
be used for this test. With the graph paper or ruler aligned to the sagittal crosshair, unlock the
couch longitudinal brake and run the couch first toward the gantry and then toward the foot of the
couch. Observe the sagittal crosshair as it aligns with the graph paper or ruler. If the sagittal
crosshair does not track parallel to the line on the graph paper or the edge of the ruler, rotate the
couch slightly until the sagittal crosshair runs parallel as the table is driven in and out. Record the
digital angle. For ±90°, the transverse crosshair is used.
(4) For the vertical digital table readout, the ODI and/or front pointer can be used. Set the couch top
to 100.0 cm SSD using the ODI and verify with the mechanical front pointer. Record the digital
vertical couch reading. Raise and lower the couch a known amount (e.g., ±10.0 cm) using the ODI
and verifying with the mechanical front pointer. Alternatively use the wall lasers and a ruler held
vertically.
(5) In addition to the relative couch position tests suggested in TG 142, we propose an absolute couch
test. We suggest one clinically relevant point, for example, couch vertical reading at 100 cm SSD
to the couch surface. This is typically couch vertical equal to zero.
(6) All these tests can be performed using phantoms of known dimensions. There are also
commercially available devices with known distances scribed on them.
2.3.2.8 Wedge Placement Accuracy
2.3.2.8.1 Objective

The objective is to verify the position of the external hard wedge or internal dynamic hard wedge with
Accepted Article
respect to the treatment isocenter. Misalignment of either will cause undesired shifts in isodose lines
with respect to the isocenter.
2.3.2.8.2 Tolerance
For visual inspection, the tolerance is ±2 mm for all machines. The dosimetric comparison of the
central axis wedge factor should be within ±2%. Tighter tolerances can be set by the site QMP if
desired.
Alignment of the wedge can be checked visually on some machines, or it can be performed
dosimetrically with reference to baseline readings taken at commissioning. For visual verification of
external hard wedges, the light field must be visible. Simply inserting the wedge is not an acceptable
surrogate for this test. The wedge will obstruct the light unless the collimator can be opened outside
the boundaries of the wedge. The shadow of the edge of the wedge can be measured and compared
with baseline readings with reference to the central axis. If visual inspection of the wedge is not
possible, dosimetric alignment of the wedge can be used with chamber measurements or with an array
type device. Readings at the central axis or off-axis are compared with baseline readings. It is
important to obtain readings by rotating the wedge or collimator for internal wedge ±180° to ensure
the mechanical wedge central axis coincides with the photon central axis. A similar central axis dose
should be measured in both orientations, and the average of the two readings should be compared
with the baseline. It is recommended to use the largest wedge (i.e., 60° wedge) for this test.
2.3.2.9 Compensator Placement Accuracy
2.3.2.9.1 Objective
Solid compensators are used with machines without MLCs or in situations where compensators
produce a better plan. As with MLC positioning for IMRT plans, compensators should be aligned
with similar precision to produce satisfactory dosimetric results.
2.3.2.9.2 Tolerance
Compensator placement accuracy should be ±1 mm at the isocenter.
Compensators are mounted on trays which slide into the accessory mount on the machine. Alignment

can be checked visually with a blank tray and compared with the crosshairs or dosimetrically against a
Accepted Article
known isodose distribution. The dosimetric evaluation can be performed either with a chamber placed
at the central axis and compared with a baseline reading or with a detector array, film, or MV imager
(EPID).
2.3.2.10 Latching of Wedges, Blocking Tray
2.3.2.10.1 Objective
The objective is to determine the functionality of the accessory tray and wedge latching mechanisms
at all collimator or gantry angle combinations that places the latch toward the floor. Accessory trays
are used to hold beam-shaping blocks at a fixed position with reference to isocenter. The trays are slid
into an accessory slot on the linac head. The trays are locked into place by a latch. Similarly, the
physical wedges are held in place by a latch. If the latch does not function properly, the tray or wedge
could become dislodged, presenting a safety concern.
2.3.2.10.2 Tolerance
Rotate linac to a collimator and gantry angle combination that places the latch toward the floor. Insert
wedge into the appropriate slot in the treatment head. Confirm that the wedge is latched securely.
Repeat for all wedges and the blocking tray.
2.3.3 Safety
As part of the monthly safety tests recommended in TG 142, the TG recommends that the monthly
QA form be used to document the QMP’s signoff on the daily QA, machine logbook, and machine
service reports. Daily QA is preferably signed daily but at a minimum of once per week by the QMP.
This frequency has increased since TG 142, which had recommended a minimum of once per month.
As discussed in section 2.1, more recently, QA management systems are being used. These systems
can be configured to automatically alert the QMP should a daily QA result exceed tolerance, and the
daily signoff is therefore inherent in the system. Machine logbooks and service reports are usually
signed upon completion of service.
2.3.3.1 LaserGuard or Touch Guard—Interlock Test
2.3.3.1.1 Objective

The objective is to test the functionality of the LaserGuard or touch guard systems. LaserGuard or
Accepted Article
touch guards are integrated patient and equipment collision detection systems. The LaserGuard
system uses an infrared laser scanning device that monitors the region between the collimator face
and the patient. This area is defined as the protection zone. If an object enters the protection zone, the
system inhibits motion before a potential collision. Touch guard systems consist of physical pressure
switches. If a switch is depressed, the appropriate motion, gantry, collimator, or table is prevented.
2.3.3.1.2 Tolerance
The tolerance is functional, activating all motion stop if an object breaks the zone of protection or
touch guard switch is depressed.
Turn on the LaserGuard system. Place a phantom on the treatment couch (see Figure 4). Place the
couch under the gantry in a typical treatment position but relatively close (e.g., 10 cm if that is the
boundary) to the collimator. Rotate the gantry as if it were to collide with the couch. The LaserGuard
should activate the motion stop and prevent the collision. To test the touch guard system, ensure that
there is sufficient clearance and begin to rotate the gantry. Depress one of the touch guard switches;
gantry motion should be inhibited. With the switch activated, attempt to move the collimator and
treatment couch. Motion should be prevented. Repeat for all touch guard switches.

All the tests in this section can be accomplished with the same QA patient in the respiratory gating
software. The QA patient is typically created by recording the respiratory trace of a QA device or
reciprocating phantom and setting the appropriate phases and/or displacement magnitude thresholds.
It should be noted that, in contrast to TG 142, all references to amplitude have been replaced with
displacement or displacement magnitude to align with TG 76, “The Management of Respiratory
Motion in Radiation Oncology.”13 Respiratory monitoring systems require QA to ensure that they are
responding consistently to breathing motion in the form of thoracic motion, abdominal motion, or
inhalation volume. The Varian Real-Time Position Management (RPM) system57 uses a charge-
coupled device camera to detect the motion of infrared reflecting markers embedded in a marker
block (breathing surrogate). To test the system functionality, place the marker block on the vendor-

supplied reciprocating phantom (see Figure 5). Open a patient in the RPM software. Select a new
Accepted Article
treatment field and create a reference session. If the system is functioning properly, the software
should display the breathing pattern of the surrogate device. The Anzai respiratory monitoring
system58 is a belt-based system that uses a strain gauge to measure respiratory phase. Functionality of
the Anzai respiratory monitoring system can be accomplished by applying a “load cell” of known
mass to the strain gauge. The strain gauge is contained in a plastic button with a 3 cm diameter and a
1 cm height. The load cell is a cylinder that fits around the button, with a metal central weight that
applies a known pressure to the strain gauge. The Anzai control system is started, a QA “patient” is
loaded, and the operator determines if the pressure applied to the strain gauge results in the same
simulated breathing percentage displacement magnitude position, for example, 50%. If a large
deviation from the displacement magnitude of, for example, 10% is noted, the strain gauge may be
damaged and require replacement, or the overall system may require recalibration. Another popular
system is the Active Breathing Coordinator system.59 It uses a spirometer to track the patient’s lung
volume. The system uses a balloon valve to prevent airflow through the spirometer when the patient is
in breath hold. The balloon valve is controlled by the patient via a patient control switch. Daily QA
consists of a check of system conductivity, functionality of the patient control switch button, and
system calibration with a 3.0 L calibrated syringe.
2.3.4.1 Beam Output Constancy

2.3.4.1.1 Objective
The objective is to check the gated beam output against the nominal beam output.60–62
2.3.4.1.2 Tolerance
Output for a gated beam should be ±2% as compared with measurements from a static, nongated
beam. Tighter constraints can be applied per the QMP.
Open the QA patient in the gating software. Use the same setup as the monthly beam output
constancy (section 2.3.1.1). This can be done by irradiating a QA device with the standard (nongated)
radiation beam to a known dose, then irradiating the same device with a gated beam to the same dose.
The readings for nongated and gated beams should be within ±2%.

2.3.4.2 Phase, Displacement Magnitude Beam Control
Accepted Article 2.3.4.2.1 Objective
The objective is to verify that phase and displacement magnitude controls hold the beam as indicated.
It is necessary for the beam control system to gate the radiation beam at the appropriate phases and/or
displacement magnitudes during the treatment. Otherwise, the target may not be within the planning
target volume when the beam is turned on.
2.3.4.2.2 Tolerance
The tolerance is functional, creating a beam hold within the desired settings of the phase or
displacement magnitude.
Observe the gated beam output constancy test beam delivery. Verify that the appropriate beam holds
are activated.
2.3.4.3 In-Room Respiratory Monitoring System
2.3.4.3.1 Objective
The objective is to check the in-room respiratory monitoring system for proper functionality. The
computer system should monitor the respiratory motion appropriately, with the ability to adjust the
settings used for phase and displacement magnitude control.
2.3.4.3.2 Tolerance
The device used to monitor the respiratory motion and generate the gating signal should be functional.
Start the respiratory gating software. Open the QA patient and deliver the gated beam for the output
constancy test. If the beam can be delivered, the system is functioning properly.
2.3.4.4 Gating Interlock
2.3.4.4.1 Objective
The objective is to test the interlock for preventing a patient prescribed a gated radiation delivery from
being treated in a nongated treatment mode.
2.3.4.4.2 Tolerance
Gating interlock is functional.

Open the QA patient and deliver the gated beam for the output constancy test. Turn off the respiratory
Accepted Article
motion measurement system. Attempt to deliver the gated beam. An interlock should be triggered that
prevents the beam from turning on.
VMAT is an extension of IMRT that synchronizes dynamic MLC position, dose rate, and gantry
speed as the gantry rotates around the patient to deliver the prescribed treatment. The routine linac
QA and IMRT QA described in this report are prerequisites for VMAT.
2.3.5.1 Test Patient-Specific VMAT QA
2.3.5.1.1 Objective
The objective is to ensure the linac can deliver VMAT plans that pass VMAT QA criteria.
2.3.5.1.2 Tolerance
The tolerance is institutional VMAT QA passing criteria based on TG 21863 guidelines.
Patient-specific VMAT QA is performed for every patient prior to treatment. There are many ways to
perform VMAT QA64–70 using commercially available phantoms, film, or EPIDs. Typically, the
patient’s treatment plan is transferred to the phantom setup in the treatment planning system and the
dose calculated. The DICOM dose is exported for comparison with the measured dose. The treatment
plan is exported to the R&V system for delivery on the treatment unit. The QMP or designee then
delivers the treatment to the QA phantom. The measured dose is compared with the treatment
planning system dose using TG 21863 guidelines.
At least one patient-specific VMAT QA plan should be evaluated per month on a linac that is used for
clinical VMAT delivery. In the unlikely event there are no VMAT patients on treatment, the plan for
a patient scheduled to start treatment, or a plan used for the annual patient-specific VMAT QA
(section 2.4.5.1) is acceptable for this test.
The time required for monthly QA will vary widely with the machine capabilities and energy choices.
For single energy machines with limited imaging capabilities (i.e., MV only), a full monthly QA may
take 1–1.5 h. High performance machines with multiple energies, photon and electron, imaging,
MLCs, stereotactic capabilities, etc., may require more than 6.5 h for data acquisition and analysis.
Commercial software suites may shorten the time spent assessing data and help to trend data.

Phantoms that measure several parameters with single tests can also decrease time spent performing
Accepted Article
monthly QA. These time estimates do not include any adjustments that may occur (output corrections,
MLC calibration, etc.).
2.4 Annual
The first annual QA performed on the machine after acceptance and commissioning is the most
critical for the treatment unit. A full series of tests, closely resembling commissioning, should be
performed. This amount of detailed testing has the potential to identify any systematic problems that
may have occurred during the commissioning process. Subsequent versions of the annual QA can be
less comprehensive while still being detailed enough to monitor machine performance with respect to
baseline. For example, during the first annual QA, it is recommended that, for photon flatness and
symmetry, a minimum number of field sizes for measurements is four (5 × 5, 10 × 10, 20 × 20, and 40
× 40 cm2, or maximum field size available). In subsequent years, a single field can be used. The
justification for this is that, for photon beams, it has been shown that beam quality is sensitive to beam
profile changes139-141. Therefore, percentage depth dose measurements for a single field are sufficient
if they are accompanied by corresponding profile checks for a field size of at least 30 × 30 cm2.
Similarly, for the first annual QA for electrons, the recommended number of applicator sizes for
flatness, symmetry, and percentage depth dose measurements is two (10 × 10 and 25 × 25 cm2, or
what was specified at the time of acceptance). Subsequently, flatness, symmetry, and percentage
depth doses for electron beams can be adequately assessed by using only the largest available
applicator.
2.4.1 Dosimetry
2.4.1.1 Photon Flatness and Symmetry
2.4.1.1.1 Objective
The flatness and symmetry of the treatment beams need to be consistent to enable accurate and
reproducible dose delivery. The flatness and symmetry of all energies used for treatment should be
checked against the data acquired during commissioning to confirm the delivered dose is consistent
with the dose calculated by the treatment planning system. The flatness and symmetry values should
be determined by measuring the largest available field size, using 80% of field width. FFF beams are
handled in the same manner as flattened beams.42 All photon beams should be tested for flatness and

symmetry annually.
Accepted Article 2.4.1.1.2 Tolerance
The tolerance for photon flatness is ±1% deviation from baseline, and the tolerance for photon
symmetry is ±1% deviation from baseline.
It is recommended to measure the flatness and symmetry in a water tank using a suitable ionization
chamber with high spatial resolution. However, film dosimetry as well as two-dimensional (2D)
ionization chamber or diode arrays may be used if a baseline was established using the same devices
during the commission procedures or if a baseline is established when the linac is demonstrated to be
in a dosimetrically equivalent state as when it was commissioned. The beam profile measurements
should be performed for multiple depths and field sizes per energy. The recommended minimum
number of field sizes for measurements is two, with sizes of 10 × 10 and 40 × 40 cm2, or the
maximum field size available. The recommended measurement depths are dmax and a depth of 10 cm,
or wherever the vendor specifies flatness and symmetry at the time of acceptance. Flatness and
symmetry should be calculated using the same formula that was used for commissioning. Compare
these values with the baseline values and verify that they are within the stated tolerances.
2.4.1.2 Electron Flatness and Symmetry
2.4.1.2.1 Objective
As with photons, the flatness and symmetry of the treatment beams need to be consistent to enable
accurate and reproducible dose delivery. The flatness and symmetry of all electron energies used for
treatment should be checked against the treatment planning system data acquired during
commissioning to ensure the calculated dose is consistent with the intended dose. It is recommended
to use the largest available cone for each electron energy. The flatness and symmetry values should be
measured using the center 80% of the field along the in-plane and cross-plane directions. All electron
energies should be tested for flatness and symmetry annually.
2.4.1.2.2 Tolerance
The tolerance for electron flatness is ±1% deviation from baseline, and the tolerance for electron
symmetry is ±1% from baseline.

It is recommended to measure the flatness and symmetry in a water tank using a suitable ionization
Accepted Article
chamber with a high spatial resolution. However, film dosimetry as well as 2D ionization chamber or
diode arrays may be used if a baseline was established using the same devices during the commission
procedures or if a baseline is established when the linac is demonstrated to be in a dosimetrically
equivalent state as when it was commissioned. Perform beam profile measurements for a single depth
and one applicator size per energy. The recommended applicator size is the largest electron applicator
available. The recommended depth is at the reference depth or the depth measured at time of
commissioning. Flatness and symmetry should be calculated using the same formula that was used at
the time of commissioning. Compare these values with the baseline values and verify that they are
within the stated tolerances.
2.4.1.3 Photon or Electron Output Calibration
2.4.1.3.1 Objective
The output of linac beams do not tend to change rapidly over time.40 However, changes in output can
occur from multiple sources such as major component replacement, failure or drift of monitoring
devices (i.e., circuit boards), or inadvertent adjustment. Absolute calibration of the linac should be
performed with a valid ADCL calibrated ionization chamber and electrometer under controlled
conditions, specifically those outlined by TG 51.71,72 All available photon and electron beams should
be checked on an annual basis. Note that any changes detected in energy, either from flatness and
symmetry or beam quality measurements, should be addressed before output calibration.
2.4.1.3.2 Tolerance
The tolerance for output constancy should be within ±1% of the dose calculated using the TG 51
protocol measured in water under standard conditions (e.g., baseline is 1.000 cGy/MU at dmax, 10 × 10
cm2 field size, 100.0 cm SSD). As in the tolerance set by the monthly output constancy, the institution
may choose a smaller tolerance. If the tolerance is exceeded, adjustments should be made to bring the
machine within tolerance.
Note that the need for large adjustments (e.g., >3%) is extremely rare. If a large adjustment is
indicated by initial measurements, carefully review the measurement setup, all calculations, and the
history of monthly output constancy to verify that the indicated adjustment is necessary.

Absolute calibration of high-energy photons and electrons is outlined in TG 51. Absolute calibration
Accepted Article
must be performed in a water tank with a calibrated ionization chamber and electrometer. The
calibration equipment shall have a National Institute of Standards and Technology (NIST) traceable
calibration performed within the last 2 y. Once the output has been established in water,
intercomparisons should be made with the secondary measurement system used for monthly QA and
the tertiary system for daily QA to reestablish baselines for those systems.
2.4.1.4 Output Factors
2.4.1.4.1 Objective
Output factors are required by all treatment planning systems to determine dose. Output factors for all
beams used for patients’ treatment should be checked against the commissioning data or treatment
planning system baseline established during commissioning to ensure the calculated dose is consistent
with the intended dose. At the time of commissioning, it is common to obtain a large set of output
factors to obtain more accurate dose calculations. It is not essential to duplicate these efforts; a
smaller subset of output factors will suffice to verify constancy. The recommended fields for photons
are the smallest field size used clinically, the reference field size, the largest field size used clinically,
and one additional field size intermediate of the former two, for example, 2 × 2, 10 × 10, 20 × 20, and
40 × 40 cm2. The measurement depth for each field size should replicate the commissioning data or
treatment planning system baseline. Appropriate detectors should be used for small field geometries
to obtain accurate measurements.14,73–75,76 Small volume ionization chambers, diodes, or scintillators
are more appropriate choices under these conditions. The recommended fields for electrons are the
smallest applicator used clinically, the reference applicator (usually 10 × 10 cm2), and the largest
applicator used clinically.
2.4.1.4.2 Tolerance
The tolerance for photon fields smaller than 4 × 4 cm2 and electron applicators is ±2% deviation from
the output factors established at the time of commissioning due to potential setup uncertainty. For
photon fields larger than or equal to 4 × 4 cm2, the tolerance is a ±1% deviation.
There are many options on how to measure output factors as well as conditions under which to
measure them. The most common methods are with an ionization chamber in either water or in solid

water. Most treatment planning system vendors will specify the setup conditions of the system they
Accepted Article
require for commissioning. It is important that the setup conditions used at the time of commissioning
are replicated at the time of constancy checks. Regardless of the setup conditions, the typical
workflow is similar and outlined below:
(1) Set up the phantom (water or solid water) and ionization chamber on the treatment couch or
appropriate support device. Replicate the conditions used at the time of commissioning (SSD,
SAD, ionization chamber depth, etc.).
(2) Acquire measurements for a 10 × 10cm2 open field. This is the reference field that all other values
for the same energy will be normalized to. Three measurements should be obtained to allow for
any drift that can occur. Variation between each reading should not exceed ±0.5%.
(3) Acquire a set of measurements at the recommended field sizes.
(4) Divide the acquired readings by the reference reading for the same energy. These values should be
within the tolerances listed above relative to the output factors obtained at the time of
commissioning.
(5) Repeat this procedure for each photon energy.
(6) Repeat this procedure for each electron energy. The reference conditions for electrons are
different than those used for photon measurements. It is common to acquire output factors for
electrons at dmax rather than the standard depth of 5 or 10 cm for photons. Additionally, some
clinics elect to normalize their readings to an applicator other than the 10 × 10 cm2 applicator. It is
important to verify the conditions that were used at the time of commissioning and duplicate those
for output constancy checks.
2.4.1.5 Photon Beam Quality
2.4.1.5.1 Objective
Precise determination of beam quality or energy is essential to accurately calculate doses in patients
and to generate models for treatment planning. Beam quality for a linac is typically very stable. The
possibility of mechanical failure, drift in electronic stability, or positioning of the target and/or
flattening filter exists on a linac, and therefore, it is vital to verify beam quality on an annual basis.
2.4.1.5.2 Tolerance
The tolerance for the photon beam quality is within ±1% of the baseline value.

Accepted Article
(1) Water tank scanning systems are most often used to obtain the commissioning data that serve as
the baseline. It is recommended to measure the photon beam quality in a water tank using a
suitable ionization chamber with high spatial resolution. Beam flatness has been shown to be
sensitive to changes in the photon beam quality.46,47 If film dosimetry or ionization chamber
arrays were used during the commissioning process to establish the baseline flatness as a surrogate
for photon beam quality, then the same device can be used to measure beam quality on an annual
basis.
(2) Depending on how the machine was calibrated, it is recommended to obtain beam quality
measurements (PDD or TMR) at a minimum of one field size for each photon energy used
clinically. The recommended field size is the calibration field size, usually 10 × 10 cm2.
(3) Set up the water tank, field ionization chamber, reference ionization chamber, and electrometer
per vendor specifications.
(4) Acquire depth dose scans at the recommended field sizes.
(5) Compare the acquired raw data with the baseline values obtained during commissioning.
(6) Verify that the acquired scans are within stated tolerances of the baseline values, namely PDD10 or
TMR20:10.
2.4.1.6 Electron Beam Quality
2.4.1.6.1 Objective
Like photon beam quality, precise determination of electron beam quality is essential to ensure
accurate beam modeling and dose delivery.
2.4.1.6.2 Tolerance
The tolerance for the electron beam quality is within ±1 mm of the baseline value.
(1) The setup for electron beam quality is the same as for photon beam quality. It is recommended
that at least two applicator sizes are used for measurement 10 × 10 and 25 × 25 cm2.
(2) Acquire depth dose measurements for the recommended applicator field sizes.
(3) Compare the measured R50 value with the baseline value and verify that it is within the specified
tolerance. It is important to note that R50, and not I50, is the recommended metric for evaluating

electron beam quality.
Accepted Article
2.4.1.7 Physical Wedge Transmission Factor
2.4.1.7.1 Objective
Physical wedges are subject to mechanical abuse over time. The measurement of physical wedge
transmission factors helps to ensure the integrity of the wedge is not changed. All wedge angles that
are used clinically should be checked. A single field size is recommended for each wedge angle.
2.4.1.7.2 Tolerance
The tolerance for the physical wedge transmission factor is within ±2% of the baseline value.
It is most efficient to perform this test at the same time as the output factor test, using the methods and
equipment used in section 2.4.1.5.
(1) Repeat a series of three open field measurements under reference conditions.
(2) Acquire readings with each physical wedge in place. When obtaining output factors for wedges,
measurements should be made with the wedge in two opposing orientations. Doing so will help
verify that the wedge is centrally placed along the beam axis.
(3) Calculate the ratio of the reading with the wedge in place to the reference open field value.
(4) Compare the result with the known transmission factor and verify that they are within tolerance
values.
2.4.1.8 MU Linearity
2.4.1.8.1 Objective
Testing of MU linearity is important due to the advent of dynamic or segmented field dose delivery.
This delivery uses numerous segments that can range from a high number of MUs to as few as 2 MU.
It is vital to ensure MU linearity in these situations so that precise dose is delivered.
2.4.1.8.2 Tolerance
Electron delivery tolerance is ±2% when five or more MUs are delivered. Photon tolerances vary
depending on the type of treatment being delivered. For all types of delivery, if more than 5 MU are
delivered, the tolerance is ±2%. During IMRT and SRS/SBRT delivery, it is common to have fewer
than 5 MU delivered for a particular segment or beam. In that scenario, the tolerance is ±5% for 2 to 4
MU delivered.

Accepted Article
(1) MU linearity should be tested over the range of MUs used clinically on the treatment machine.
(2) For photons, MU linearity should be tested for both static (nonsegmented) and dynamic
(segmented) beams, as the beam control systems can differ. One simple way to test the beam in
segmented beam mode is to deliver a beam with a 10 × 10 field size but program the MLC leaf
furthest from the central axis to move during treatment delivery.
(3) MU linearity can be performed in a water tank or in solid water with an ionization chamber and an
electrometer. Typical setup is 10 × 10 field size at 100 SSD.
(4) Setup the phantom and the ionization chamber such that the ionization chamber is along the
central axis of the beam.
(5) Deliver 400 MU with a clinically relevant dose rate and record the measurement. Take a total of
three readings and calculate the average.
(6) Using the same setup conditions, deliver 100 MU with the same dose rate. Take a total of three
readings and calculate the average.
(7) Verify that the average result is one-fourth of the 400 MU average reading to within tolerance.
(8) Deliver 2 MU for photons, or 50 MU for electrons, with the same dose rate and setup conditions.
Take a total of three readings and calculate the average.
(9) Verify that the average result is one-fiftieth for photons, or one-half for electrons, of the 100 MU
average reading to within tolerance.
(10) Repeat for all photon and electron energies. For electrons use 50 MU or another value
representative of the range used clinically.
2.4.1.9 Photon Output vs. Dose Rate
2.4.1.9.1 Objective
The objective is to verify that clinical output does not vary with dose rate. It is common for
institutions to incorporate different dose rates depending on the type of treatment being performed.
Additionally, the advent of modulated therapy that uses various dose rates throughout delivery has
made the verification of output vs. dose rate a critical assessment to ensure proper delivery of dose to
patients.
2.4.1.9.2 Tolerance

The measured values at each dose rate should be within ±2% of the most used clinical dose rate for
Accepted Article
each energy.
It is most efficient to perform this test at the same time as the MU linearity test, using the methods
and equipment used in section 2.4.1.8.
(1) Using the same setup to determine MU linearity, deliver a set number of MUs with at least two
other clinically relevant dose rates.
(2) Verify that each reading is the same to within the specified tolerance.
(3) Repeat for all photon energies.
2.4.1.10 Output Constancy vs. Gantry Angle
The objective is to verify that clinical output does not vary with gantry angle. As a clarification to TG
142, and to align with “Medical Physics Practice Guideline 8.a”9, output constancy vs. gantry angle
and off-axis factor constancy vs. gantry angle reading obtained at nonzero gantry angles are compared
with the readings obtained at gantry zero.
The measured output should be within ±1% of the value acquired at gantry 0°.
(1) Institutions may have several options for measuring output at various gantry angles, for example,
daily QA device mounted to the gantry, ion chamber in air at isocenter, ion chamber or film in
solid water, cylindrical phantoms with assigned chambers, and/or commercially available
cylindrical devices.
(2) It is recommended that output is checked at the four cardinal gantry angles at a minimum.
(3) Verify that the difference in the measurements is within the stated tolerance.
2.4.1.11 Off-Axis Factor Constancy vs. Gantry Angle
The objective is to verify that the off-axis factors do not vary with gantry rotation or position.

The measured off-axis factors should be within ±1% of the value acquired at gantry 0°.
Accepted Article 2.4.1.11.3 Methods and Equipment
Measurements can be accomplished in several ways. Radiographic or radiochromic film can be
supported at isocenter on phantom material with appropriate build up. Alternatively, a diode or ion
chamber array can either be mounted to the gantry and rotated with the linac or supported on the
treatment couch with phantom material. If the latter setup is used, then measurements with the gantry
at 180° can pose a challenge, as the beam will be attenuated by the couch. One solution is to
creatively support the measurement device over the end of treatment couch. If this cannot be
accomplished safely, then we suggest the reading at gantry 180° be eliminated.
(1) Acquire measurements with the gantry at 0° and determine the output at various points off-axis. A
minimum of two points along the x and y axes is recommended.
(2) Acquire additional measurements at the other cardinal gantry angles.
(3) Verify that the dose at the same off-axis distances matches the values obtained with the gantry at
0° to within tolerance.
2.4.1.12 Arc Mode
The objective is to verify that the MUs delivered and the degree of rotation traversed through a
standard or SRS arc treatment (constant field size, constant gantry rotation speed, and constant MU/°
value) matches those which were prescribed. If SRS arcs are used clinically, then SRS dose rates must
be evaluated.
For non-SRS arcs, the MUs delivered and the actual degrees of rotation traversed should be within
±1% of the prescribed values. For SRS arcs, the tolerance is a ±1 MU discrepancy between the MUs
prescribed and those delivered (or 2%, whichever is greater). The tolerance for gantry motion is ±1°
discrepancy between what was prescribed and what was delivered (or 2%, whichever is greater).
(1) Deliver arc treatments, non-SRS and SRS, as appropriate, covering the range of parameters for
which the linac is used clinically. The arcs should encompass the range of known MUs, degrees of

rotation, and MUs per degree.
Accepted Article
(2) Verify that the delivered MUs and gantry angle motion match the prescribed values to within
stated tolerances. This can be accomplished by reading the MUs delivered and the start/stop of the
gantry from the treatment console or through analysis of the trajectory logs on a Varian linac, if
equipped.
(3) This test should be repeated for all energies that are used for the delivery of standard arcs
clinically.
2.4.1.13 TBI/TSET Mode
Bone marrow or stem cell transplant protocols have specific parameters for TBI which typically
include dose rate. Similarly, TSET can also have specific parameters for irradiation. If the linac has a
user-selectable mode that is used for TBI or TSET, the functionality of this mode should be tested as
described below.
TBI/TSET mode on the linac is functional.
Enter clinical mode on the accelerator and program up TBI/TSET treatment. Ensure that all interlocks
are cleared and that you can deliver the treatment. Alternatively, enter R&V mode and send a test
TBI/TSET patient to the linac control console. Ensure that all interlocks are cleared and that you can
deliver the treatment. Note that this test is not performed separately, as it is inherently included in the
next three tests.
2.4.1.14 TBI/TSET TMR/PDD and OAF Constancy
The objective is to independently verify the TMR/PDD and off-axis factor constancy for TBI/TSET
treatments. However, if the accelerator has demonstrated constancy regarding energy
(PDD/TMR/flatness) and profiles, there is no fundamental unique delivery modality (such as the case
with Siemens low dose rate mode), and the room conditions and ancillary devices are the same, then
the TBI/TSET measurements specific for energy and profiles are optional at the extended treatment
distance. If TBI/TSET TMR/PDD and off-axis factors are to be measured at the extended treatment

distance, the tolerances will be increased due to the possible variability in reproducing the baseline
Accepted Article
measurements.
The tolerance for TBI TMR/PDD is ±5% from baseline measured at the extended treatment distance,
TSET ±3 mm PDD shift, OAF constancy ±5% from baseline measured at the extended treatment
distance.
To perform TMR measurements for TBI treatments, set up a full scatter phantom, usually solid water,
in treatment position with the ionization chamber at the treatment distance. Open the jaws to the
treatment field size. Select the treatment energy, TBI dose rate, deliver the field, and record the
reading. Without moving the ionization chamber, incrementally add build up to a total of 25 cm at 5
cm increments in front of the chamber. Deliver the same MU each time and record the electrometer
readings. Compute TMRs. Compare the results with the baseline TMRs measured when the program
was commissioned. Repeat for all energies used for treatment. To verify the TMR measurements,
calculate the MUs to deliver 100 cGy to the phantom midline. Measure the delivered dose. Repeat the
measurements for two relevant depths, as additional verification compares the measured with the
expected doses.
For TSET, depth dose data can be acquired with a parallel-plate ionization chamber overlaid with
varying thicknesses of phantom material. A small amount of phantom material surrounding the
chamber suffices for this measurement and is described in detail in TG 30’s report “Total Skin
Electron Therapy: Technique and Dosimetry.”77 The results should be compared with the baseline
PDDs measured when the program was commissioned.
To perform off-axis factor constancy for TBI/TSET,77,78 use the same technique used during
commissioning and compare the results with the baseline. These measurements are often performed
by translating ion chambers in phantom material along the principal axes of the field and acquiring a
series of readings under treatment conditions. Alternative methods include the use of film or diode
arrays to acquire data at multiple locations within the treatment field.
2.4.1.15 TBI/TSET Output Calibration

The objective is to independently verify the machine output for TBI/TSET treatments. However, if the
Accepted Article
accelerator has demonstrated constancy regarding energy (PDD/TMR/flatness) and profiles, there is
no fundamental unique delivery modality (such as the case with Siemens low dose rate mode which
requires independent calibration), and neither the room conditions nor any devices in the beam path
changed, then the TBI measurements specific for energy and profiles are optional at the extended
treatment distance.
The tolerance for the TBI/TSET output calibration is ±3% from baseline measured at the extended
treatment distance when the program was commissioned.
Perform calibration for all energies according to the standard department protocol using an ionization
chamber or electrometer system with a current NIST traceable calibration (see section 2.3.1.1).
(1) TBI: Set up a full scatter phantom in treatment position with the ionization chamber at the
extended treatment distance. The source-to-chamber distance (SCD) is equal to the treatment
distance plus dmax. Set the jaws to treatment field size used at commissioning and the gantry to the
treatment angles. In addition, any treatment accessories should be placed in the beam path, for
example, blocking tray or beam spoiler or screen. Deliver the exposure at the treatment dose rate
and compute the average of at least three electrometer readings. The TBI output is then calculated
by multiplying the standard TG 51 output by the ratio of the readings at the treatment distance
divided by readings at the calibration distance scaled for MU. Compare the result with the
baseline measured when the program was commissioned.
(2) TSET: A detailed description of the output calibration for TSET is given in section 6.5 of TG 30’s
report “Total Skin Electron Therapy: Technique and Dosimetry.”77
(3) To confirm that the output is invariant with dose rate, repeat these measurements for all linac dose
rates used for TBI/TSET treatment.
(4) It should be noted that, in some instances, a polarity effect has been observed for TBI/TSET
measurements77,78. The QMP should verify the polarity effect of their measurement system.
2.4.1.16 TBI/TSET Accessories

TBI/TSET treatments are delivered using special setups unique to those treatments. As such, there are
Accepted Article
many accessories associated with the treatments. These can range from diodes for in vivo dose
measurements to rice bags and compensators used to ensure a uniform dose is delivered to the whole
patient’s body.
The tolerance for all accessories is ±2% from baseline.
For TBI/TSET treatments, accessories are often used to make the dose delivered to the patient
uniform. Some accessories such as blocking trays and beam spoilers are of a fixed thickness, whereas
others such as compensators and rice bags vary from treatment to treatment. To measure accessory
transmission, set up an ionization chamber at depth 5 cm, for example, in a phantom under treatment
conditions appropriate for the modality, and take a series of three measurements. For those
accessories that vary in thickness, place various thicknesses of the accessory material at the treatment
location and take a series of three measurements for each thickness. Calculate the accessory
transmission factor and compare with the baseline measured when the program was commissioned.
Repeat for all energies used for TBI treatments.
Diodes are often used to verify TBI/TSET treatments. These diodes should be calibrated under
treatment conditions. Set up the TBI/TSET phantom and deliver a known dose under TBI/TSET
conditions. As diode performance can drift over time, a new dose calibration file should be made for
each energy used for treatment. To verify the new calibration, deliver known doses to the TBI/TSET
phantom and simulate several patients’ separations.
2.4.2 Mechanical
2.4.2.1 Collimator Rotation Isocenter
2.4.2.1.1 Objective
The objective is to make sure that the deviation of collimator mechanical isocenter remains within
tolerance of the established baseline.
2.4.2.1.2 Tolerance
The tolerance is ±1 mm from baseline.

The most common technique to check and verify the isocentricity of the collimator is to use the
Accepted Article
vendor-supplied mechanical front pointer calibrated at time of machine commissioning. The position
of the front pointer should represent the location of the mechanical and radiation isocenters within the
acceptance specification for the machine. With the gantry set to 0°, the front pointer assembly is
mounted to the head and the calibrated pointer inserted. A piece of paper is secured to the top of the
couch which is then raised to almost touch the front pointer. The collimator rotation isocentricity can
be checked by marking the tip of the pointer on the paper every 30° to 45° over the full range of
rotation of the collimator. The marked locations should be enclosed in a circle with diameter less than
the tolerance for the machine. The center of the circle is the collimator rotation isocenter. The front
pointer should be left in place for the next test.
2.4.2.2 Gantry Rotation Isocenter
2.4.2.2.1 Objective
The objective is to make sure that the deviation of gantry mechanical isocenter remains within
2.4.2.2.2 Tolerance
The front pointer remains in place from the previous test. A second pointer with a fine tip is secured
horizontally off the end of the tabletop so that its tip is near the collimator rotation isocenter defined
by the front pointer. The gantry is rotated through 360°, and the deviation of the front pointer is
monitored against the stationary pointer. The deviations should be enclosed in a circle with diameter
less than the tolerance for the machine. The center of the circle is the gantry rotation isocenter. The
front pointer should be left in place for the next test.
2.4.2.3 Treatment Couch Rotation Isocenter
2.4.2.3.1 Objective
The objective is to make sure that the deviation of couch mechanical isocenter remains within
2.4.2.3.2 Tolerance

Accepted Article
This test should be performed directly after the collimator rotation isocenter test. With the front
pointer and paper still in place, translate the couch longitudinally so a clean section of the paper is
under the front pointer. The treatment couch is rotated through 180°, and the position of the end of the
pointer is marked every 45° on the paper. The marked locations should be enclosed in a circle with
diameter less than the tolerance for the machine. The center of the circle is the treatment couch
rotation isocenter. If the gantry collimator and couch isocenters are all within tolerance, then the
position of the front pointer at gantry zero, collimator zero can be used to represent the mechanical
isocenter of the machine. Frequently, the lasers would be aligned to mechanical isocenter at this point
in the process.
2.4.2.4 Electron Applicator Interlocks
2.4.2.4.1 Objective
The electron interlock is a safety feature that is required for delivery of electron beams. This interlock
should be examined for proper operation to ensure (1) that an electron beam cannot be delivered if the
applicator is not inserted in the head of machine and (2) no photon beam treatment is allowed when
the applicator is inserted in the head of the machine.
2.4.2.4.2 Tolerance
Insert applicator in the head of the machine, select an electron beam, and prepare to deliver dose.
Ensure that the correct applicator and field size is displayed on the treatment console. Remove the
applicator before delivery and try to turn the beam on. The machine should not be able to deliver any
dose, and an interlock should have been activated. Insert the applicator in the head of the machine to
clear the interlock and select a photon beam. The machine interlock should not allow the user to
choose any photon beam while the electron applicator is in position.
2.4.2.5 Coincidence of Radiation and Mechanical Isocenter
2.4.2.5.1 Objective
The objective is to determine the coincidence of the radiation and mechanical isocenter.
2.4.2.5.2 Tolerance

The tolerance is ±2 mm for non-IMRT and IMRT machines, ±1 mm for stereotactic machines. Note
Accepted Article
these are absolute values as opposed to a deviation from baseline recommended in TG 142.
The radiation isocentricity for each axis (collimator, gantry, and treatment couch) is commonly
checked using the Starshot technique.79 The coincidence of the radiation and mechanical isocenter can
then be checked. For each axis, place a film (radiographic or radiochromic) between two slabs of
plastic water. Orient the film, using the lasers as a surrogate for mechanical isocenter, such that it is in
the plane of the mechanical isocenter and the film center is close to mechanical isocenter. Mark the
position of the mechanical isocenter, as determined by the lasers, on the film. Open the jaws (oriented
such that it is perpendicular to the plane of film) by ±2 mm symmetrically from central axis. Use low
energy photons to deliver the appropriate MU for the film at different angles (every 30°–45°). Use
either commercially available software to analyze the results or draw lines in the centers of exposed
band on films. The intersection of the lines should be enclosed within a circle within tolerance for the
machine. More recently, the Winston-Lutz test has been used to measure all three axes in one
test,54,80,81 and this is the preferred method. The typical method places a radiopaque ball (5–6 mm) at
the mechanical isocenter defined by the lasers from the previous tests. Images of the ball are acquired
with film or an EPID with a predefined small square field (for example, 2 × 2 cm) or cone (1 cm cone,
for example) at various gantry, collimator, and couch angles. The displacement of the radiopaque ball
center from the radiation field center is calculated either manually or via dedicated software. Du et
al.54 concluded that eight images, the four cardinal gantry angles with two opposing collimator angles
for each, were sufficient to reduce the isocenter localization error with respect to gantry and
collimator to less than 0.2 mm. An additional two images at couch angles 90° and 270° can be used to
complete the test with respect to the couch. As the gantry rotation isocenter has both a mechanical
(gantry sag) and energy-specific component (beam steering) the Winston-Lutz test should be repeated
for all energies used for stereotactic treatments.
2.4.2.6 Treatment Couch Top Flex
2.4.2.6.1 Objective
The objective is to examine the rigidity and the integrity of the treatment couch when a heavy object
(or patient) is positioned on its top. This test was called tabletop sag in TG 142.

2.4.2.6.2 Tolerance
Accepted Article
With the couch fully extended, mark the position of the horizontal laser near isocenter (one can use a
marker block or a piece of tape attached the side of the couch). Next, place a heavy weight (about
100–150 lb) evenly distributed on the couch top. Measure the flex of the couch top relative to the
laser projections determined without the weight. Alternatively, the flex can be measured using the
front pointer set.
2.4.2.7 Treatment Couch Angle
2.4.2.7.1 Objective
The objective is to verify the couch rotational accuracy against the digital readout. In many clinical
situations, the digital readout is used to set up the patient for a specific field of treatment. This is like
the monthly couch angle test (section 2.3.2.7.3), except measurements are taken at additional couch
angles.
2.4.2.7.2 Tolerance
Note tolerances have changed from TG 142 and are aligned with “AAPM-RSS Medical Physics
Practice Guideline 9.a”82: non-IMRT ±1°, IMRT ±1°, SRS/SBRT ±0.5°.
Place a piece of graph paper or rectilinear grid at 100 cm SSD at isocenter. Rotate the couch 45° using
the crosshairs and the grid. Record the couch angle readout. Repeat every 45°.
2.4.2.8 Treatment Couch Maximum Range
2.4.2.8.1 Objective
The objective is to examine the accuracy of the treatment couch travel over the whole range in all
three axes. In clinical treatment situations the couch is sometimes moved to a new position to treat a
different isocenter, i.e., match fields. The test should also ensure that the couch movement is linear
and accurate.
2.4.2.8.2 Tolerance

Position the treatment couch at the level of isocenter location. Place and secure (using tape) a tape
Accepted Article
measure such that the couch can move along the ruler length for the whole range of travel along each
axis. Record the couch position on the machine console in the direction of motion before any
movement. Project the crosshair on the ruler and move the couch in periodic intervals. Record and
compare the readout from the machine console and the ruler. In addition, record the maximum extent
of the couch travel. These procedures should be repeated for each axis (lateral, longitudinal, and
vertical). The difference between the console readout and the measurement should be within specified
tolerance.
2.4.2.9 Stereotactic Accessories or Lockouts
2.4.2.9.1 Objective
Stereotactic interlocks (see Figure 6) ensure that the devices to be used are interlocked and the dose
rate for a given modality is only allowed under this condition.
2.4.2.9.2 Tolerance
Attach the stereotactic device to the head of the linac. The linac should indicate an interlock related to
this attachment and prevent you from beam delivery. Based on the manufacturer, take the
recommended steps to clear the interlock. Program a stereotactic beam. If the stereotactic device is
coded for the machine, check that the machine code and associated jaw settings are correct. Repeat for
all coded accessories. Deliver a set dose that is designated for QA purposes. Remove the device and
attempt to deliver the same dose. The linac should not be able to deliver the dose when the interlock is
activated. Test all the motor motion disable functionality if available on the machine.
2.4.3 Safety
2.4.3.1 Follow Manufacturer’s Test Procedures
2.4.3.1.1 Objective
The objective is to follow the manufacturer’s recommended safety procedures.
2.4.3.1.2 Tolerance
The tolerance is as per manufacturer’s tolerances.

Accepted Article
Review the manufacturer’s user manuals for the linac and ancillary devices. Determine which tests
can be performed by a physicist or service personnel. If the tests are to be performed by the service
personnel as part of the preventive maintenance program, it is the responsibility of the physicist to
ensure that they have been completed on an annual basis.
In addition, carefully read and understand all safety-related information in the documents provided by
the manufacturer. These documents may include user manuals, safety guides, technical manuals, etc.
Safety-related information will generally be identified as warnings or cautions within these
documents. Additional safety-related information may be communicated via letters, such as technical
bulletins or safety notifications. Be sure to fully understand all safety-related information and contact
the manufacturer with questions. The QMP should review the manufacturer recommendations and
determine which tests are appropriate for the user’s clinic. In addition, the QMP should periodically
review the quality control procedures to ensure that they properly address all potential safety issues.
Technical bulletins or safety notifications should be signed and dated by the QMP documenting any
corrective action taken.
2.4.4.1 Beam Energy Constancy
2.4.4.1.1 Objective
The objective is to determine if the photon beam energy in the gated mode does not differ
significantly from the nongated mode. Photon beam energy may not reach the nominal value when
beam-on times are short, which has been reported to occur during free-breathing respiratory gating if
temporal gating windows are allowed below 500 ms.60,83–85
2.4.4.1.2 Tolerance
The tolerance is the percentage depth dose ±2% from that of the beam in nongated mode.
Beam energy constancy for the gated beam can be quantified with a pair of ionization chambers at 10
and 20 cm depths or alternatively dmax and 10 cm in liquid or solid water. The gated beam is used to
deliver a predetermined dose to the chambers, and the ratio of the two readings is compared with that
for the beam in a nongated mode.

2.4.4.2 Temporal Accuracy of Phase or Displacement Magnitude Gate On
Accepted Article 2.4.4.2.1 Objective
The objective of this test is to quantify the time delay that occurs between the moment when the gated
radiation beam is expected to turn on or off and the moment when it is actually turned on or off as
triggered by the gating system. The trigger may be based on direct motion measurement (ExacTrac)
or motion measurement using a respiratory motion surrogate (Varian RPM, Anzai strain gauge,
VisionRT patient surface motion, C-Rad patient surface motion).
2.4.4.2.2 Tolerance
The time delay should be within ±100 ms of the expected value measured as baseline.
A phantom capable of exhibiting predictable periodic motion of a radiopaque object and/or film can
be used for this measurement. A technique for determining gated time delay from a pattern delivered
to a film undergoing a known motion pattern has been described by Chang et al.85,86 A small, known
radiation field is delivered to a moving film, and the ends of the profile in the direction of motion are
then determined by measuring half-local-maximum positions (80% to 20% of local maximum of both
ends) and compared with the expected profile ends. The time delay can then be calculated based on
the difference between delivered and expected profile lengths, which is straightforward when the
motion pattern is sinusoidal and of known displacement magnitude. An EPID could also be used to do
these measurements if a radiopaque point object is moved by the phantom and imaged over the gated
period. Woods and Rong57 used both the MV and kV imagers to measure the positional displacement
between triggered and static images for a range of motion speeds.
2.4.4.3 Calibration of Surrogate for Respiratory Phase or Displacement Magnitude
2.4.4.3.1 Objective
Several different types of surrogates of respiratory pattern may be used clinically, e.g., optical, strain-
gauge belts with pressure sensors, and spirometry. The objectives of this test are to verify that the
phase and displacement magnitude indicated by the respiratory surrogate motion measurement system
accurately indicate the actual motion phase.
2.4.4.3.2 Tolerance
The actual and measured motion traces should be within ±100 ms of each other.

Accepted Article
An example test for a pressure sensor is placing a series of fixed weights on the sensor and
determining the gain and offset values that produce a desired displacement magnitude, e.g., 50%. For
optical systems, this can be accomplished by placing a fiducially marked block surrogate at a series of
fixed known locations within the field of view and comparing the reported displacements with the
known values. Once spatial accuracy is confirmed, phase confirmation can be established with a
periodic motion phantom. As described by Chang et al.,86 a phantom capable of periodic motion of
known displacement magnitude and period can be monitored using the surrogate system, and their
motion traces can then be overlaid and compared. Woods and Rong57 compared the motion trace
caption by the gating system with the surrogate motion to determine deviations in surrogate position.
To determine deviations in surrogate timing, they compared set duty cycle with the cycle period
recorded by the gating system.
2.4.4.4 Interlock Testing
2.4.4.4.1 Objective
An interlock should be in place to prevent a patient prescribed a gated radiation delivery from being
treated in a nongated treatment mode. Such an occurrence could result in the dose to the planning
target volume being lower than planned, and the dose to the surrounding normal tissue being greater
than planned.
2.4.4.4.2 Tolerance
The gating interlock is either functional or nonfunctional.
The same test defined in monthly QA can be done for annual QA to verify functionality of the gating
interlock (see section 2.3.4.4).
2.4.5.1 Test Patient Specific VMAT QA Constancy
2.4.5.1.1 Objective
The objective is to test the year-to-year constancy of VMAT delivery.
2.4.5.1.2 Tolerance
The tolerance is the pass rate greater than or equal to the baseline pass rate minus 2% and plan passes

institutional VMAT QA criteria (section 2.3.5.1.2.) using the baseline tolerance.
Accepted Article 2.4.5.1.3 Methods and Equipment
See section 2.3.5.1.3. The baseline passing rate should be acquired at the time of VMAT
commissioning or the previous annual QA. If the VMAT QA fails tolerance and all other annual QA
tests pass, repeating the vendor acceptance testing process for VMAT may be an effective approach
for bringing the VMAT QA passing rates back within tolerance.
2.4.5.2 Interruption Test
2.4.5.2.1 Objective
The objective is to test the accuracy of VMAT delivery when the treatment is interrupted and
restarted.
2.4.5.2.2 Tolerance
The tolerance is ±1% deviation from uninterrupted passing rate.
Set up the QA phantom for clinical measurements. Deliver the test VMAT field. Analyze results.
Repeat delivery of the test VMAT field and interrupt the beam during delivery. Resume treatment.
Compare the interrupted delivery QA passing rate with uninterrupted delivery QA passing rate.
The annual linac QA described in this section would require 30–45 person-hours. However, one
should be aware that the number of person-hours depends on the machine as well as availability of the
appropriate equipment that facilitates these QA procedures. This time also includes analysis of the
data, comparison with the baseline data, and report generation.
2.5 Dynamic, Virtual, or Universal Wedges
2.5.1 Enhanced Dynamic Wedges
2.5.1.1.1 Objective
The objective is to ensure that the enhanced dynamic wedge software and enhanced dynamic jaw
positioning are working as expected.
2.5.1.1.2 Tolerance
As this is simply a software check, whereby a self-monitoring system looks at collimator position
referencing MUs to be delivered, tolerances are set by the manufacturer, in this case, Varian, to be on

the order of 1 mm. This does allow for the jaw speed to change. This test ensures that the dynamic
Accepted Article
wedge is functional.87
2.5.1.1.3 Method and Equipment
This can be performed by either engineers or physicists, although more likely RTTs. Any error
messages should be propagated to either engineering or physics. One enhanced dynamic wedge field
should be programmed as part of the morning warmup and delivered. The result should be
documented in the morning QA log and should be reviewed by the engineers or physicists.
2.5.1.2.1 Objective
The objective is to ensure that the central axis dose delivered by the enhanced dynamic wedge is
constant for all energies.
2.5.1.2.2 Tolerance
The calculated wedge factor should be within ±2% of baseline.
This test can be performed with the same setup as the monthly photon output constancy (largest field
size at a depth where the wedge angle is defined typically, 10 cm, see section 2.3.1.1). We
recommend that tests be performed for the 60° wedge angle. The wedge transmission factor is
calculated as the ratio of the dynamic wedge field to the open field.87–91 The calculated wedge factor
is compared with baseline. Repeat for all photon energies.
2.5.1.3.1 Objective
The objective is to ensure that the enhanced dynamic wedge delivery is functioning as expected for all
wedge angles.
2.5.1.3.2 Tolerance
Off-axis ratios should be within ±2% of baseline for the central 80% of the field width at a depth of
10 cm.
The profile for the enhanced dynamic wedges should be measured at one gantry angle. Profiles can be
measured with film, ionization chamber, or diode.87–97 As with the monthly review, it should be

performed at the depth at which the wedge angle is defined, typically 10 cm. Profiles should be
Accepted Article
measured for the 60° angle for the largest field size and one other intermediate wedge angle with a 10
× 10 cm2 field size. The measured profiles are compared with the baseline profiles. Repeat for all
photon energies.
2.5.2 Universal Wedge
2.5.2.1.1 Objective
The objective is to ensure that the universal wedge, particular to Elekta machines, is functioning. In
contrast to the enhanced dynamic wedge, the universal wedge is static and in place for certain
percentage of the total MUs.98,99
2.5.2.1.2 Tolerance
The universal wedge is functional.
See section 2.5.1.1.3.
2.5.2.2.1 Objective
The objective is to ensure that the central axis dose delivered by the universal wedge is constant for
all energies.
2.5.2.2.2 Tolerance
The calculated wedge factor should be within ±2% of baseline.
2.5.2.3.1 Objective
The objective is to ensure that the universal wedge delivery is functioning as expected for all wedge
angles.
2.5.2.3.2 Tolerance
Off-axis ratios should be within ±2% of baseline for the central 80% of the field width at a depth of
10 cm.

Accepted Article
2.5.3 Siemens Virtual Wedge
2.5.3.1.1 Objective
The objective is to ensure that the virtual wedge software and dynamic jaw positioning are working as
expected.
2.5.3.1.2 Tolerance
Virtual wedge field is functioning and deliverable without error.
2.5.3.2.1 Objective
The objective is to ensure virtual wedge delivery is exactly as expected.
2.5.3.2.2 Tolerance
The tolerance is to ensure that the wedge factor for a given wedge angle and field size is within ±5%
from unity. For other wedges of different field sizes, ensure that the wedge factor is within ±2%.
2.5.3.3.1 Objective
The objective is to ensure that the virtual wedge delivery is functioning as expected for all wedge
angles.
2.5.3.3.2 Tolerance
Off-axis ratios or off-center ratios should be within ±2% of baseline for the central 80% of the field
width at a depth of 10 cm.
The time required for daily QA is 1–2 min and is simply delivering one field. Monthly QA may take

15–20 min, which includes approximately 10 min for setup and 5 min per energy. Annual QA takes
Accepted Article
approximately twice as long as an additional wedge angle is checked. The times quoted include time
for analysis and documentation.
2.6 Multileaf Collimators (MLCs)
2.6.1 Weekly
2.6.1.1 Qualitative Test (Picket Fence)
2.6.1.1.1 Objective
The objective of this test is to assess variation in leaf position accuracy and interleaf leakage
transmission by visually inspecting the 2D dose distribution at the junction of abutting fields defined
by the MLC leaves. The pattern created by these abutting fields is referred to as the picket fence
pattern.100 Examples of passing and failing MLC leaf patterns can be found in the literature.100 Leaf
gap width in dynamic MLC mode can also be assessed with a different version of the picket fence
pattern.101,102
2.6.1.1.2 Tolerance
The tolerance is ±2 mm. A well-calibrated MLC should generate a regular pattern at the location of
the abutting fields. The Elekta MLC models103 will generate a fairly homogenous dose at the junction
of the abutting fields as the leaves are calibrated based on the radiation field edge location. For the
Varian MLC, the dose at the junction should appear slightly higher than the surrounding dose
distribution as the leaves are calibrated based on the physical location of the leaf tips.104–106 Leaves
out of alignment with their neighbors will break the regular pattern at the location of field junctions,
and displacement ≥1 mm should be detectable. For a given leaf pair, difference in leaf position
between the opposed leaves will create a lower or higher dose at the location of the field junctions,
and an error of ≥1 mm should be visually detectable. This test does not verify the leaf position
accuracy with respect to the radiation isocenter but will indicate leaf misalignment.
The morning therapist is mostly likely to perform this test after the machine has been properly
warmed up. The results should be reviewed by a physicist. The abutting beams used to generate the
picket fence pattern should include all MLC leaves and cover the entire MLC leaf travel range. For
example, eight fields of 5 × 40 cm2 spaced every 5 cm can be used. The 2D dose distribution

produced with the picket fence beams can be measured with a radiographic film of sufficient
Accepted Article
dimensions placed at treatment unit isocenter (100 cm). An equal number of MUs should be used for
each beam of the picket fence pattern. Radiochromic films can replace radiographic films, but their
limited dimensions might require more than one film or to limit the test to a smaller field size (limited
number of leaves and leaf travel). Alternatively, the film can be moved closer to the target, and an
appropriate magnification factor can be used. Megavoltage EPIDs can also be used as a replacement
for radiographic film.107
For Varian accelerators, a dynamic MLC beam designed to produce a 1 mm irradiation strip every 2
cm can be used to assess dynamic leaf gap width consistency.100 This test is appropriate for Varian
accelerators as the minimum dynamic leaf gap for different manufacturers and MLC models can limit
the application of this test.
To assess impact of gravity on MLC leaf position accuracy, it is recommended that a different
cardinal gantry angle is used each week, so that all four cardinal angles are covered during the month.
This fulfills the gantry angle dependence requirement that was proposed in the monthly section in TG
142.
2.6.2 Monthly
2.6.2.1 Leaf Position Accuracy (Non-IMRT)
2.6.2.1.1 Objective
The objective of this test is to assess leaf position accuracy with respect to the radiation isocenter
location. It differs from the weekly picket fence test as it involves a quantitative assessment of leaf
positioning accuracy instead of the weekly visual inspection.
2.6.2.1.2 Tolerance
The tolerance is ±1 mm per leaf, ±2 mm on field width.
First, determine that the crosshairs represent the radiation isocenter. This should have already been
performed during the annual QA and checked monthly. Align large graph paper or template that has
millimeter resolution with the crosshairs at collimator angle 0°, gantry angle 0°, 100 cm from the
source. Program the MLC to move to several field sizes covering the clinical range. Record the
position of the light field relative to isocenter and compare with the programmed MLC field. Do this

for both MLC leaf banks.
Accepted Article
2.6.2.2 Backup Diaphragm Settings
2.6.2.2.1 Objective
The objective of this test is to assess backup diaphragm position accuracy with respect to the radiation
isocenter location. Some linacs, Elekta Infinity, for example, use backup diaphragms that are partial-
attenuation jaws that overlap with the MLC leaf banks to increase their attenuation and move in the
same direction as the MLC leaves. The backup diaphragms are typically calibrated to be located about
1 mm behind the leaves. This distance will vary due to linearity of calibration, but the field edge
should always be defined by the most retracted leaves across the given field sizes.
2.6.2.2.2 Tolerance
The tolerance is ±1 mm on each individual backup diaphragm position, ±2 mm on backup diaphragm
opening.
Using film, radiographic or radiochromic, or an EPID, acquire an image of two regular beams limited
by the backup diaphragm and measure the diaphragm position with respect to the radiation isocenter.
This test is usually performed in service mode using stored beams which allow the backup diaphragm
to extend beyond the MLC leaves. The MLC leaves should be retracted at least 1 cm behind the
backup diaphragm for this test. Fields of 5 × 20 and 20 × 20 cm2 can be used to assess the backup
diaphragm position accuracy. The backup diaphragm position should correspond to the 50%
penumbra point position for each diaphragm. The normalization point (100%) can be selected as the
maximum intensity in the open field. Detect the location of the radiation isocenter. This can be done
by placing a fiducial marker based on light field. The radiation isocenter can also be determined based
on the location of the field center for different collimator angles. Appropriate image analysis software
can be used to analyze this test.
2.6.2.3 Leaf Travel Speed
2.6.2.3.1 Objective
The objective of this test is to identify lag in leaf motion and suboptimum leaf speed. Leaves
exhibiting slower leaf motion will generate undesirable holdoffs in clinical dynamic beam deliveries.
A reduction in leaf speed might also indicate that the corresponding MLC motor is approaching its

end of life.
Accepted Article 2.6.2.3.2 Tolerance
Max leaf speed for Varian Millennium, Elekta MLCi, Elekta Agility, and Siemens are 2.5, 2.0, 3.5,
and 4.0 cm/s. Leaf speed should be within ±0.5 cm/s of the maximum leaf speed set for the dynamic
MLC QA beam. For example, for a Varian Millennium MLC test, leaf speed should be 2.5 cm/s, and
the measured leaf speed should be greater than 2.0 cm/s.
This test can be performed by analyzing the treatment unit log file for a particular beam delivery.
Deliver a dynamic MLC beam with a 1 × 40 cm2 aperture that travels 15 cm in the right-to-left
direction (±7.5 cm each side of the isocenter). The travel distance can be increased if the MLC model
supports a longer travel for a given leaf carriage position. The total number of MUs to be used for this
dynamic MLC beam to be delivered at max leaf speed is given by
MU = [MLC travel (cm) × dose rate (MU/s)]/max MLC speed (cm/s).
Retrieve the log file corresponding to the beam delivery. The MLC speed can be calculated using the
MLC position and the timestamps in the log file.108 Kaurin et al.107 uses the same equation without the
use of a log file to determine the maximum MLC speed for a dynamic MLC delivery.
This test can also be performed using the EPID. In this approach, deliver a dynamic MLC beam with
a 1 × 20 cm2 aperture that travels 15 cm in the right-to-left direction (±7.5 cm each side of the
isocenter) and acquire a movie of the MLC delivery using the EPID. Detect leaf positions on each
frame of the EPID movie and calculate the MLC speed using the EPID frame rate. The EPID field of
view is not sufficient to detect all MLC leaves, and the test must be repeated at least twice to verify all
leaves.109
2.6.2.4 Leaf Position Accuracy (IMRT)
2.6.2.4.1 Objective
The objective of this test is to assess leaf position accuracy with respect to the radiation isocenter
location. This test is like the leaf position accuracy (non-IMRT) test but has a more stringent tolerance
and can be performed either radiographically or by visual inspection.
2.6.2.4.2 Tolerance
The tolerance is ±1 mm on each individual leaf position for linacs used for IMRT delivery.

Accepted Article
Fields of 5 × 40 and 20 × 40 cm2 can be used to assess leaf position accuracy. Take an image of an
MLC-defined beam and measure the leaf position, as defined by the 50% penumbra point, with
respect to the radiation isocenter. The normalization point (100%) can be selected as the maximum
intensity in the open field. The location of the radiation isocenter can be determined using the
projection of the light crosshair as a surrogate and placing a fiducial marker at that location. Use of
the light field crosshair as well as the accuracy of placement of the fiducial marker will introduce
additional uncertainty in the test results and might make the test more user dependent. The location of
the radiation isocenter can be determined by averaging the location of the radiation field center at
different collimator angles for a regular beam such as a square field. Radiographic or radiochromic
films as well as megavoltage EPID110–116 can be used with the appropriate image analysis software to
perform this test. Perform for one photon energy per month and cycle through all photon energies.
Alternatively, this test can be performed using the method in section 2.6.2.1.3, if the penumbra
location can be resolved to better than the tolerance, 1 mm.
2.6.3 Annual
2.6.3.1 MLC Transmission
2.6.3.1.1 Objective
The objective of this test is to ensure that the average inter- and intra-MLC leaf transmission for all
photon energies does not change over time and that it remains consistent with the original data for
treatment planning system beam modeling.101,117–125
2.6.3.1.2 Tolerance
The tolerance is ±0.5% from baseline, example baseline = 1.5%, tolerance range = 1%–2%.
Setup a small volume ionization chamber in a solid water phantom on the central axis at 5 cm depth
with the phantom surface at 100 cm SSD. The long axis of the chamber should be perpendicular to the
leaf travel to measure both interleaf and intraleaf transmission. Deliver 100 MU with a 10 × 10 cm2
field and record the ionization chamber reading as the open field reading. Close the field using the
MLC and repeat the ionization chamber measurement with 1000 MU, ensuring leaf gap is not directly
over the chamber. Determine the ionization chamber reading (R) per MU for the closed and open

fields (R/MU)closed and (R/MU)open. The average MLC transmission is the ratio of ionization chamber
Accepted Article
R per MU for closed and opened fields. Alternatively, this test can be expanded by using film or a 2D
detector array126 to measure transmission for more leaf pairs. Repeat all steps for each photon energy
available.
2.6.3.2 Leaf Position Repeatability
2.6.3.2.1 Objective
The objective of this test is to assess the MLC leaf positioning reproducibility in the context of an
IMRT delivery.
2.6.3.2.2 Tolerance
The tolerance is ±1 mm maximum difference between repeat leaf position measurements.
If this test is performed using the EPID, the procedure for the monthly leaf position accuracy test
(IMRT) can be repeated 5–10 times without moving the EPID to determine the leaf position
repeatability. The procedure for the monthly test can be simplified, as the location of the radiation
isocenter is not required for the assessing leaf position repeatability. This test can also be performed
using the light field. In this case, set the gantry, collimator, and couch angles at 0°. Set the tabletop at
100 cm SSD and align a piece of millimeter scale graph paper with the light field crosshair. Toggle
the MLC between two fields (e.g., 10 × 40 and 5 × 40 cm2) 5–10 times and mark on paper the
variation in leaf positions for at least one of the two fields.
The light-field-based approach is faster than the EPID method. It should be noted that, while the light-
field-based approach is acceptable, it is less accurate than the EPID approach. In addition, because of
the EPID field-of-view limitation, additional images must be acquired to cover all MLC leaves.
2.6.3.3 MLC Spoke Shot
2.6.3.3.1 Objective
The objective of this test is to determine the alignment of the MLC with respect to the radiation
isocenter and the collimator mechanical axis of rotation.
2.6.3.3.2 Tolerance
The tolerance is ≤1 mm radius.

As a prerequisite for this test, the MLC should be symmetrical around the radiation isocenter. This
Accepted Article
can be checked by irradiating a film with a half-beam block field at 0° and 180° of collimator angle
and making sure that the field edges are well aligned. Set the gantry, collimator, and couch angles to
0°. Place a radiographic or radiochromic film at depth of maximum dose (dmax) in a solid water
phantom with the phantom surface at 100 cm SSD. Mark the location of the light field crosshair using
a pin prick or fine tip pen before covering the film with the solid water. Irradiate film with a narrow
MLC-defined field (e.g., 0.4 × 20 cm2) at intervals of 30° of collimator angles to create a star pattern.
Use sufficient dose per irradiation to darken the film. Determine the centerline of each narrow field.
The intersection of all field centerlines should be within a circle of 1 mm radius. The distance
between the pin prick or pen mark and the center of the circle that contains all field centerline
intersections should be within 1 mm. The analysis can be done manually, but the use of dedicated film
analysis software usually helps obtaining a more accurate estimation. The EPID can be used to
replace the film; however, a radiopaque marker must be used on the EPID to mark the location of the
light field crosshair.
2.6.3.4 Coincidence of Light-Radiation Fields
2.6.3.4.1 Objective
The objective of this test is to verify the coincidence between light and radiation fields as defined by
the MLC and ensure that the light field is an acceptable surrogate for the radiation field. If the light
field is not used to set up patients, this test can be omitted. Note that this test could be performed at
the same time as test 2.6.2.1 or 2.6.2.4.
2.6.3.4.2 Tolerance
The tolerance is ±2 mm per MLC bank.
Setup the gantry and the collimator angle at 0°. Place a radiographic or radiochromic film on the
surface of a flat phantom. Load a field (e.g., 20 × 20 cm2). Mark the location of the light crosshairs as
well as the light field edge using the pressure from a pen or pin prick. Cover the film with sufficient
buildup. Radiopaque markers can also be used to mark the location of the light field crosshair and the
field edges. Place these markers on the top of the buildup. Expose the film with sufficient dose to
darken the film and process it. The coincidence can be assessed determining the location of 50%

radiation penumbra location on each field edge using a point densitometer and measuring the distance
Accepted Article
between the radiation and light field edges. Alternatively, film dosimetry software can be used to
analyze the scanned film and determine the distance between the light and radiation field edges. The
EPID can be used to replace the film; however, radiopaque markers must be used to mark the light
field, and dedicated software is required. Repeat for all photon energies.
2.6.3.5 Moving Window IMRT
2.6.3.5.1 Objective
The objective of this test is to assess the agreement between the delivered and planned leaf positions
for a moving window IMRT test pattern. Note the test for segmental IMRT (step and shoot) was not
applicable and has been removed.
2.6.3.5.2 Tolerance
The mean positioning deviation from the planned position [defined with the root-mean-square (RMS)
of leaf positioning error] <0.35 cm for all leaves. In addition, ≥95% of the leaf positioning deviations
should be <0.35 cm.
Deliver a moving-window IMRT test pattern on the linac. The test pattern should exercise all MLC
leaves and should cover the maximum leaf travel range. A sweeping gap IMRT pattern can be used
for this test. Retrieve the linac delivery log file and analyze the positioning deviations between
planned and delivered MLC leaf positions using dedicated software.108 Positioning deviations are
assessed per leaf and for the entire MLC. The test pattern should be delivered at the four cardinal
gantry angles. An additional method for this using the EPID is described by Agnew et al.127
The time required for weekly QA is 5–15 min, with the lower times corresponding to EPID
acquisition. Frequency may be reduced following a history of past results. Monthly QA may take 12–
15 min for non-IMRT and approximately 50–100 min for IMRT, where the high end would be for
film-based QA. Tests for the backup diaphragm in Elekta could add 20–30 min. Assuming 2–3 beam
energies for MLC transmission with an ionization chamber, annual QA takes approximately 80 min
using a combination EPID and light field, or up to 130 min with film. The times quoted include time
for analysis and documentation.
2.7 Radiographic Imaging

A summary of the time, staffing, and equipment requirements for imaging QA is contained in Table 6.
Accepted Article
The times for each task are estimated based on the assumption that each task is carried out
independently. As tools are commercially available to address multiple tasks with a single image
acquisition, the overall time required to accomplish several tasks in the same category, such as planar
kV imaging, can substantially speed up the QA process. Significant time savings can also be realized
by using a standard test patient in the R&V system. The test patient can be set up to contain fields for
all the MV, kV, and cone beam computed tomography (CBCT) image acquisitions. In addition, the
R&V system can be used to document and store the images. If necessary, the images can be exported
for further review and analysis.
It should be noted that the recommendations for the tolerances for the daily QA tests for positioning
or repositioning and imaging and treatment coordinate coincidence provided in TG 142 have been
modified. This report aligns with TG 179,30 “QA for Image-Guided Radiation Therapy Utilizing CT-
Based Technologies,” and “AAPM Medical Physics Practice Guideline 2.a”8 in recommending the
tolerance for these tests for SRS/SBRT machines be increased to ≤2 from ≤1 mm. The rationale
behind these changes is that these daily tasks typically must be performed rapidly, and as a result,
there is a reduction in test precision. The one exception to this increase is for the clinical situation
where IGRT is to be used with SRS. Under that circumstance, it is the recommendation of this TG
that the QMP must validate the IGRT imaging tests to ≤1 mm on the day of SRS treatment. The
tolerance for the monthly imaging and treatment coordinate coincidence tests remains unchanged.
It should be noted that there are some differences between this TG’s recommendations and “AAPM
Medical Physics Practice Guideline 2.a”8 with respect to frequency of testing. Medical physics
practice guidelines recommend a minimum subset of tests. As such “Medical Physics Practice
Guideline 2.a” recommends image quality be tested annually as opposed to this TG, which
recommends monthly.
2.7.1 Daily—kV and MV (EPID) Imaging
2.7.1.1.1 Objective
There is potential for MV and kV detectors (KVDs), and the kV source, to collide with the patient
and/or the treatment couch. These devices are equipped with collision detectors which, when

depressed, will halt all mechanical movements of the treatment unit. The proper functioning of these
Accepted Article
interlocks is essential for patient safety. The objective of this test is to check the functionality of all
the collision detectors.
2.7.1.1.2 Tolerance
The tolerance is all interlocks functional.
The collision interlocks for the megavoltage detector, kilovoltage detector, and kilovoltage source can
be tested by physically pressing the corresponding collision detectors sequentially and ensuring that
all mechanical movements are halted.
2.7.1.2.1 Objective
The objective of this test is to ensure that the EPID-based planar imaging system can be used to detect
patient positioning errors and accurately correct for them.
2.7.1.2.2 Tolerance
The tolerance is ≤2 mm for non-SRS/SBRT and ≤2 mm for SRS/SBRT, ≤1 mm day of SRS. Note this
was adjusted from TG 142. The change was made to align with TG 179.30
There are many commercially available cube phantoms containing radiopaque markers that can be
used to perform the test128 (for example, see Figure 7). The phantom is placed on the couch in a
predefined manner using the room lasers and/or light field crosshairs, shifted away from the target
position by a known three-dimensional (3D) vector (usually defined by marks on the phantom),
imaged, and shifted back to its nominal target position using the imaging registration tools. The
displacement between the laser positions on the phantom after the final shift and the marks on the
phantom used for the initial phantom setup are reported as the position or repositioning accuracy for
the daily test.
2.7.1.3.1 Objective
The objective of this test is to ensure that the same isocenter is shared by the planar imaging and
treatment systems, within tolerance.

2.7.1.3.2 Tolerance
Accepted Article
was adjusted from TG 142.
The imaging and treatment coordinate coincidence can be measured using a cube phantom containing
radiopaque markers. There are many commercially available cube phantoms that can be used for this
test. The phantom is leveled and positioned on the treatment couch using the room lasers. The system
is imaged at the four cardinal angles (270°, 0°, 90°, and 180°), and the deviation between the
appropriate markers and electronic crosshairs on each rent image there represents the deviation
between the imaging and treatment coordinates128. This test assumes that the crosshairs, which could
be either electronic or using a graticule, are aligned to the radiation isocenter.
An alternative technique for this test is to perform the daily CBCT test first, which involves applying
the corresponding table shifts and verifying that the appropriate shifts are within the appropriate
tolerance relative to the known shifts. After the CBCT test, an orthogonal pair of 2D images (one kV
and one MV image) of the phantom is acquired, and the residual shifts from the 2D images are
calculated based on the electronic crosshairs and/or graticule. If the residual shifts are within the
tolerance, the test passes.
2.7.2 Daily—CBCT (kV and MV)
See section 2.7.1.1.
2.7.2.2.1 Objective
The objective of this test is to ensure that the cone beam imaging system can be used to detect patient
positioning errors and accurately correct for them.
2.7.2.2.2 Tolerance
The tolerance is ≤2 mm for non-SRS/SBRT and ≤2 mm for SRS/SBRT, ≤1 mm day of SRS.

2.7.2.3.1 Objective
Accepted Article
To ensure that the same isocenter is shared by the CBCT imaging and treatment systems, within
tolerance.
2.7.2.3.2 Tolerance
was adjusted from TG 142.
Ideally, the phantom used for these tests contains multiple radiopaque targets to facilitate quick and
easy 3D image registration between reference CT and CBCT images. A cube phantom containing
radiopaque markers, for example, the one used for kV and MV planar imaging, could be used for this
test. Note that, as this phantom typically has an asymmetric marker configuration, it can also be used
to test for coordinate flips. The phantom is leveled and positioned on the treatment couch using the
room lasers as a surrogate of radiation isocenter. The phantom is imaged and registered with the
reference CT. The deviation between the CBCT and reference isocenters represents the deviation
between the imaging and treatment coordinates.128 This test assumes that the crosshairs, which could
be either electronic or using a graticule, are aligned to the radiation isocenter. An alternative method
to perform the test is described by Chang et al.128
2.7.3 Monthly—Planar MV Imaging (EPID)
2.7.3.1.1 Objective
The objective is to ensure that the same isocenter is shared by the planar MV imaging and treatment
systems, within tolerance.
2.7.3.1.2 Tolerance
The tolerance is ≤2 mm for non-SRS/SBRT and ≤1 mm for SRS/SBRT.
The same test used for daily QA can be used, although action is often taken during the monthly QA
process if the imaging and treatment coordinate coincidence can be improved. Winston-Lutz tests
using commercially available automated image processing can be especially useful to guide the
process of applying modifications to bring the imaging and treatment isocenters to within tolerance.

Linac vendors also provide equipment and software to perform this test.129
Accepted Article
2.7.3.2 Scaling
2.7.3.2.1 Objective
The position of the MV imager is variable. For image comparison purposes, the dimensions of the
images are scaled to isocenter. The purpose of this test is to ensure that 2D planar MV images scale
correctly.
2.7.3.2.2 Tolerance
With the gantry at 0°, a device containing at least five radiopaque markers is placed on the treatment
couch, with one marker along the central axis of the beam and the others peripheral to the central
marker at known distances and in the plane perpendicular to the central axis of the beam. The QA
device is placed at a known SSD, and a pair of planar MV and kV images is then taken. The distance
between the central marker and the peripheral markers can be measured and compared with the
known distance (Chang et al.128).
Automated, commercially available techniques also exist to do the scaling, spatial resolution, contrast,
and uniformity and noise QA based on single kV and MV images. These techniques that use a
combination of software and hardware can result in a considerable time saving for these imaging tests.
2.7.3.3.1 Objective
The objective is to ensure that the spatial resolution of the EPID has not degraded with time.
2.7.3.3.2 Tolerance
The tolerance is better than or equal to baseline measured during acceptance.
Each linac vendor typically supplies a spatial resolution test phantom. These phantoms can be imaged
to verify that the MV imaging system’s spatial resolution has not fallen below baseline. The phantom
images contain bar patterns or hole patterns that can be visually analyzed. Typical bar patterns have
spatial frequencies between 0.1 and 0.8 line pairs per millimeter. Typical hole patterns contain holes
of diameters ranging from 0.5 to 15 mm. More sophisticated analysis, such as modulation transfer

function, can be applied using commercially available software. An example image of such a phantom
Accepted Article
is shown in Figure 8.
2.7.3.4 Contrast
2.7.3.4.1 Objective
The objective is to ensure that the contrast resolution of the EPID has not degraded with time.
2.7.3.4.2 Tolerance
Contrast should be better than or equal to baseline measured during acceptance.
A QA device such as the Las Vegas phantom can be imaged to verify that the MV imaging system’s
contrast has not fallen below baseline. The Las Vegas phantom is a square aluminum phantom with
28 circular holes with different diameters and depths shown in Figure 9. When imaged, the visibility
of these holes is a measure of the contrast resolution of the MV EPID. Distribution and number of
visible holes is visually compared with baseline. More sophisticated phantoms are available
commercially, and they can be analyzed automatically using the accompanying software.

2.7.3.5.1 Objective
The objective is to ensure that the performance of the EPID with respect to uniformity and noise has
not degraded with time.
2.7.3.5.2 Tolerance
Uniformity and noise should be better than or equal to baseline measured during acceptance.
A stack of 5-cm thick, 30 × 30 cm, build-up material is placed on a uniform treatment couch top
between the radiation source and the detector (Chang et al.128). A planar MV image is then taken at
the most used clinical settings. Image uniformity and noise can be quantified by measuring the
average pixel intensity in 1 × 1 cm square regions of interest placed at the image center and 7.5 cm
off-center left, right, top, bottom. The measured values of center, left, right, top, and bottom should
agree with the baseline values. To quantify image noise, a 5 × 5 cm square ROI is placed at the center
of the radiation field. The mean image intensity and the standard deviation of the intensity within the

ROI are calculated. Fractional deviation (expressed as the ratio of standard deviation to the mean)
Accepted Article
should agree with baseline values. The image noise and uniformity calculation processes can be
automated using commercially available phantoms and software.
2.7.4 Monthly—Planar kV Imaging
2.7.4.1.1 Objective
The objective is to ensure that the same isocenter is shared by the planar kV imaging and treatment
systems, within tolerance.
2.7.4.1.2 Tolerance
The same test used for daily QA can be used, although action is often taken if the imaging and
treatment coordinate coincidence can be improved. Linac vendors also provide equipment and
software to perform this test.129
2.7.4.2 Scaling
2.7.4.2.1 Objective
For image comparison purposes, the dimensions of the images are scaled to isocenter. The purpose of
this test is to ensure that 2D planar kV images scale correctly.
2.7.4.2.2 Tolerance
2.7.4.3.1 Objective
The objective is to ensure that the spatial resolution of the kV imager has not degraded with time.
2.7.4.3.2 Tolerance
The tolerance is better than or equal to baseline measured during acceptance.
A QA device such as the Leeds phantom, shown in Figure 10, can be imaged to verify that the kV

imaging system’s contrast has not fallen below baseline. The Leeds Phantom (TOR 18FG) is placed
Accepted Article
on the cover of the KVD with the KVD positioned at a known distance. The collimators are set to the
manufacturer recommended field size, and the 1-mm copper plate is inserted over the phantom. The
same x-ray techniques (kVp, mA, ms) used at commissioning are used for image acquisition. The
images are visually inspected to determine the smallest discernable group of bars visible in the
images, which corresponds to a certain line pair per millimeter values. This value is compared with
baseline.
2.7.4.4 Contrast
2.7.4.4.1 Objective
If kV imager is not functioning properly or if an inappropriate filter is applied to the acquired images,
the images may have poor contrast, which can compromise patient setup effectiveness due especially
to inability to differentiate between tissues.
2.7.4.4.2 Tolerance
Contrast should be better than or equal to baseline measured during acceptance.
A QA device such as the Leeds phantom can be imaged to verify that the kV imaging system’s
contrast resolution has not fallen below baseline (see Figure 11). The same image acquired in section
2.7.4.3.3 can be used for this test. Inspect the images visually to determine the lowest contrast disk
visible in the images. This value is compared with baseline. It should be noted that there are several
commercially available software packages that will perform the analysis of these imaging tests
automatically.
2.7.4.5.1 Objective
The objective is to ensure that the performance of the kV imager with respect to uniformity and noise
has not degraded with time.
2.7.4.5.2 Tolerance
Uniformity and noise should be better than or equal to baseline measured during acceptance.

The same process as used for MV imaging can be applied for kV imaging. It should be noted that
Accepted Article
there are additional quantitative image evaluation methods for spatial resolution, contrast, uniformity,
and noise.130,131 These tests can be very sensitive to deterioration in image quality, most commonly
caused by subpanel artifacts. The use of local noise power spectrum and wavelet analysis is described
by Lee et al.132
2.7.5 Monthly—CBCT (kV and MV)
2.7.5.1 Geometric Distortion
2.7.5.1.1 Objective
The objective of this test is to ensure that point-to-point distances inside objects are preserved within
images of the objects.
2.7.5.1.2 Tolerance
Geometric distortion of the CBCT system can be measured using a phantom containing inserts or
beads with known geometrical positions, the locations of which can be measured on the images
acquired from a geometrically calibrated spiral CT scanner or from the manufacturer’s specifications.
Measurement should be made in both the X and Y directions. Any image quality phantom with a
combination of CT-visible inserts or beads can be used for this task. For kV-CBCT, the Catphan (The
Phantom Laboratory, Salem, NY), shown in Figure 12, is one example of a phantom appropriate for
this test (different versions supplied by Varian and Elekta). For MV-CBCT, the CBCT image quality
phantom (EMMA; supplied by Siemens) is another example of a phantom that can be used.133
2.7.5.2 Spatial Resolution, Contrast, Hounsfield Unit Constancy, Uniformity, and Noise
2.7.5.2.1 Objective
If an EPID or KV imager is not functioning properly or if an inappropriate filter is applied to the
acquired images, the images used clinically may appear blurred, have poor contrast, have time-
dependent Hounsfield units (HUs) for the same imaged object, appear nonuniform when the imaged
object is uniform, or have high noise. All these problems can make images difficult to interpret, result
in artifact, and/or obscure important details that are needed for patient setup. The objective of this test
is to ensure imaging system performance has not degraded with time.

2.7.5.2.2 Tolerance
Accepted Article
Spatial resolution, contrast, uniformity, and noise should be better than or equal to baseline measured
during acceptance. HU constancy = ±40 HU.
These tests can be performed with any image quality phantom that has appropriate high-resolution
and low-contrast test objects, in addition to a uniformity section and HU material samples. It is
important to use the same CBCT technique for each monthly QA. For example, spatial resolution for
kV-CBCT and MV-CBCT can be measured using Catphan and EMMA, respectively. The Catphan
high resolution module is shown in Figure 13. Appropriate phantoms contain bar patterns that can be
visually inspected or used for quantitative modulation transfer function analysis in the spatial
resolution measurement, high- and low-contrast inserts, and slices with uniform density for uniformity
and noise measurements, shown in Figure 14. The Catphan module for low contrast analysis is shown
in Figure 15. The Catphan module with slice width, HU constancy, and spatial linearity measurement
capability is shown in Figure 16.
2.7.6 Annual—MV Imaging (EPID)

2.7.6.1 Full Range of Travel SDD
2.7.6.1.1 Objective
The objective of this test is to ensure that the mechanical flat panel positioners can position the EPID
at a source-to-detector distance that is within tolerance. This test is not applicable for Elekta linacs
with EPIDs that do not have adjustable SDDs.
2.7.6.1.2 Tolerance
The flat panel detector is extended and made to travel along its full range, and at the end of each
range, the distance between the face of the flat panel and a point on the gantry head, such as the
accessory tray, is measured. The measurements are compared with baseline and must agree to within
5 mm for the test to pass.

2.7.6.2.1 Objective
Accepted Article
The objective is to ensure that patients are receiving the appropriate imaging doses during IGRT
procedures.
2.7.6.2.2 Tolerance
The tolerance is ±5% of the baseline imaging dose per MU.
Megavoltage imaging dose can be measured in the same manner as radiation dose for the treatment
beams.
2.7.7 Annual—kV Imaging
2.7.7.1 Beam Quality or Energy
2.7.7.1.1 Objective
Ensuring beam quality prevents beam hardening or softening from affecting image quality.
2.7.7.1.2 Tolerance
The tolerance is ±5% baseline energy.
Beam quality for keV-range beams can be assessed using the Raysafe Xi or X2 system. The Raysafe
X2 device is straightforward to use and, when irradiated with a keV-range beam, provides beam
quality in units of millimeters of aluminum as well as other relevant beam parameters, such as kV,
mA, mAs, dose, dose rate, and pulse rate, within a matter of seconds. The user can read the data off
the device’s display or export time-dependent data on a millisecond scale (for example) for many of
these parameters for analysis and postprocessing if desired. An example of a readout obtained with
the system is shown in Figure 17.
2.7.7.2.1 Objective
procedures.
2.7.7.2.2 Tolerance
The tolerance is ±20% of the baseline dose.

Dose for keV-range beams can be assessed using the Raysafe Xi or X2 system or similar. Alternate
Accepted Article
methods are described by Amer et al.134 and Osei et al.135 Amer et al. used CT Dose Index (CTDI)
phantoms and 10 cm CT pencil chambers to measure CBCT imaging dose on an Elekta accelerator.
Osei et al. used a 0.6 cc Farmer chamber in phantom and compared measurements with a 10 cm CT
chamber.
2.7.8 Annual—CBCT (kV and MV)
2.7.8.1.1 Objective
procedures.
2.7.8.1.2 Tolerance
For the kV-CBCT imaging dose, the tolerance dose is recommended to be ±20% of the baseline dose.
For the MV-CBCT imaging dose, the tolerance dose is recommended to be ±5% of the baseline
imaging dose per MU. The tolerance for the MV-CBCT imaging dose is a lower percentage than for
kV-CBCT since the MV-CBCT imaging dose is far greater (about a factor of 10) than the kV-CBCT
imaging dose for a given site and is easily adjustable using the same parameters as the treatment
beam.
TG 75136 “The Management of Imaging Dose During Image-Guided Radiotherapy” provides an
overview of IGRT techniques, the associated radiation doses, and techniques to measure them. For
MV-CBCT, the imaging dose per MU can be measured for a fixed beam delivered in cone beam
imaging mode using an ionization chamber during the same process used for measuring photon beam
outputs. For kV-CBCT, the Raysafe Xi or X2 system can be used to measure the imaging dose using
human-representative head and body phantoms. A CTDI chamber is inserted into each phantom for
the measurements and scanned using kV-CBCT.128 The dose can be reported as the integrated dose-
length value and established as baseline at acceptance or commissioning of the linac. An example of a
readout obtained with the system is shown in Figure 18. It is recommended that users measure the
dose for at least the minimum and maximum dose CBCT protocols for a centrally located ion
chamber annually to determine if the range of CBCT doses has remained constant. Once the baseline

dose has been measured, an additional method for kV-CBCT dose constancy would be to use an
Accepted Article
ionization chamber in air.137,138
The times for each task are estimated based on the assumption that each task is carried out
independently. As tools are commercially available to address multiple tasks with a single image
acquisition, the overall time required to accomplish several tasks in the same category, such as planar
kV imaging, can substantially speed up the QA process.
3 SUMMARY OF RECOMMENDATIONS OR IMPLEMENTATION SCHEME
QA of linacs is just a subset of the departmental QA program. We reiterate the recommendation of
TG 142 that every department should have a QA committee that oversees and monitors all the
departmental QA. With the increasing complexity of treatments delivered in a radiation oncology
department, it has become more and more important to have detailed policies and procedures. These
policies and procedures should be readily available to all members of the departmental QA team. The
policy should establish the roles and responsibilities of involved QA personnel, and this TG makes
recommendations on the appropriate personnel to perform the specific QA tasks. These
recommendations are documented in Tables 1–6. In general, the daily QA tasks may be carried out by
a radiation therapist. The monthly QA tasks should be performed by an individual designated by the
QMP and working under the supervision of the QMP. The annual measurements should be performed
by a QMP with proper involvement of the entire QA team.
The TG would also like to provide some guidance on the interpretation of frequency and timing of the
QA program. We recommend that the daily QA is performed before any patient treatment that day.
For monthly QA, we recommend following calendar months plus or minus 1 wk. Similarly, for annual
QA, we recommend that the maximum time spent between annuals is not more than 13 months.
A QMP should lead or play a central role in the QA team. For the QA of linacs, the personnel fall into
three categories: Registered RTT working under the supervision of a QMP, an individual designated
by the QMP and working under the supervision of the QMP, and a QMP. The QMP should provide
adequate training of the other team members, so that they clearly understand and follow policies and
procedures. All team members are required to be trained on the operation of the appropriate QA
equipment to perform the specific QA tasks. They should be trained to interpret the measured data
and what to do when tolerance levels are exceeded. It is recommended that the QMP should be

notified as soon as possible in the case tolerances are exceeded. The QMP should document the
Accepted Article
competency of the QA team members to perform the specific tests. These competencies should be
reviewed on an annual basis.
The foundations of the TG 142 QA tests are the institution-specific baseline and absolute reference
values for all QA measurements. Whenever a new piece of equipment is accepted and commissioned
into clinical use, it is especially important to take great care in establishing these baseline values.
These values should meet or preferably exceed the manufacturer’s tolerance. Although TG 142 did
not make specific recommendations regarding independent acceptance tests for a new machine until
TG 210 (acceptance testing of linacs) provides recommendations, we reiterate the use of annual QA
tests as a general guide when reviewing vendor-specific acceptance tests and tolerance values. The
QA team needs to monitor the measurement results against the established values on a daily, monthly,
and annual basis to ensure the machine performance and to prevent any clinically significant dose
deviations from the treatment planning calculations. During the annual QA review, absolute machine
output should be calibrated as per the TG 51 calibration protocol71 using an ionization chamber with a
NIST traceable calibration factor. Once the machine output has been calibrated, all secondary QA
dosimeters, including the daily QA and the monthly QA devices, should be cross-checked against
such calibrations. If necessary, this reestablishes baselines for the daily and monthly QA to account
for any drift with these secondary measurement devices.
This report addresses the extra time that is necessary to perform the increased number of tests. We
expect that this will provide guidelines to oncology administrators on the additional demands and time
that it takes for medical physicists to perform such tasks. The ranges of time to perform all the tasks
recommended by TG 142 are given in Tables 1 through 6. The total time required for the annual QA
is estimated to be in the range of 40–60 person-hours. Each table has a summary with
recommendations for time saving. For example, for the daily and monthly imaging QA, test patients
with predefined fields could be set up in the departmental R&V system. It is worth noting that the
times also include analysis of the data, comparison with the baseline data, and report generation.
There are many commercial hardware and software products that can produce significant time
savings. There will be a tradeoff between the costs of the equipment and the cost of the labor to
perform the tests. In addition, there will be methods to improve the testing efficiency and accuracy for

modern linacs. One approach is to automatically run test fields that are programmed or loaded in the
Accepted Article
machine with automatic change of setup parameters for each field. Some of these approaches have
been provided by vendors for machine performance testing. However, the equivalence of the machine
performance checks with the machine QA activities should be carefully examined by the QMP.
As clearly described in section 1.2, the recommendations of this TG are not intended to be used as
regulations. These recommendations are guidelines for QMPs to use and appropriately interpret for
their individual institution and clinical setting. Each institution may have site-specific needs and
requirements which may modify their usage of these recommendations.
Disclosure Statement
1. The members of AAPM TG 198 listed below attest that they have no potential conflicts of interest
related to the subject matter or materials presented in this document: Joseph Hanley, Sean Dresser,
William Simon, Ryan Flynn, Eric Klein, Daniel Létourneau, Chihray Liu, Fang-Fang Yin, Bijan
Arjomandy, Lijun Ma, Francisco Aguirre, Jimmy Jones.
2. The members of AAPM TG 198 listed below disclose the following potential conflict(s) of interest
related to subject matter or materials presented in this document: John Bayouth has ownership interest
in MR Guidance, LLC, which provides commissioning consulting services for MRI guided radiation
therapy. Todd Holmes is an employee and shareholder of Varian Medical Systems. Carlos Sandin is
an employee of Elekta LTD.
REFERENCES
1. Klein EE, Hanley J, Bayouth J, et al. Task Group 142 report: quality assurance of medical
accelerators. Med Phys. 2009;36:4197.
2. Kutcher GJ, Coia L, Gillin M, et al. Comprehensive QA for radiation oncology: report of
AAPM Radiation Therapy Committee Task Group 40. Med Phys. 1994;21:581–618.
3. Fought AM, Trager M, Yin FF, Kirkpatrick J, Adamson J. Re-examining TG-142
recommendations in light of modern techniques for linear accelerator based radiosurgery. Med Phys.
2016;43:5437.
4. Al-Hallaq HA, Chmura S, Salama JK, et al. Rationale of technical requirements for NRG-

BR001: the first NCI-sponsored trial of SBRT for the treatment of multiple metastases. Pract Radiat
Accepted Article
Oncol. 2016;6:e291–e298.
5. Roper J, Chanyavanich V, Betzel G, Switchenko J, Dhabaan A. Single-isocenter multiple-
target stereotactic radiosurgery: risk of compromised coverage. Int J Radiat Oncol Biol Phys.
2015;93:540–546.
6. Langen KM, Papanikolaou N, Balog J, et al. QA for helical tomotherapy: report of the AAPM
Task Group 148. Med Phys. 2010;37:4817–4853.
7. Dieterich S, Cavedon C, Chuang CF, et al. Report of AAPM TG 135: quality assurance for
robotic radiosurgery. Med Phys 2011;38:2914–2936.
8. Fontenot JD, Alkhatib H, Garrett JA, et al. AAPM medical physics practice guideline 2.a:
commissioning and quality assurance of x-ray-based image-guided radiotherapy systems. J Appl Clin
Med Phys. 2014;15:4528.
9. Smith K, Balter P, Duhon J, et al. AAPM medical physics practice guideline 8.a.: linear
accelerator performance tests. J Appl Clin Med Phys. 2017;XX:XXXX.
10. Huq MS, Fraass BA, Dunscombe PB, et al. The report of Task Group 100 of the AAPM:
application of risk analysis methods to radiation therapy quality management. Med Phys.
2016;43:4209.
11. Determination of absorbed dose in a patient irradiated by beams of x- or gamma-rays in
radiotherapy procedures. ICRU Report 24. Bethesda, MD; 1976.
12. ICRU Report 24. Bethesda, MD; 1976.
13. Keall PJ, Mageras GS, Balter JM, et al. The management of respiratory motion in radiation
oncology: report of AAPM Task Group 76. Med Phys. 2006;33:3874–3900.
14. Das I, Cheng JC, Watts RJ, et al. Accelerator beam data commissioning equipment and
procedures: report of the TG 106 of the Therapy Physics Committee of the AAPM. Med Phys.
2008;35:4186–4215.
15. Medical electron accelerators-functional performance characteristics. IEC Publication 976.
Geneva, Switzerland; 1989.
16. Medical electron accelerators in the range 1 MeV-50 MeV-guidelines for functional
performance characteristics. IEC Publication 977. Geneva, Switzerland; 1989.

17. Nath R, Biggs PJ, Bova FJ, et al. AAPM code of practice for radiotherapy accelerators: report
Accepted Article
of AAPM Radiation Therapy Task Group No. 45. Med Phys. 1994;21:1093–1121.
18. Physical aspects of quality assurance in radiation therapy. AAPM Task Group Report 13.
American Institute of Physics. New York, NY; 1984.
19. Radiation control and quality assurance in radiation oncology: a suggested protocol. American
College of Medical Physics Rep. Ser. No. 2. City, ST; 1986.
20. Pawlicki T, Whitaker M, Boyer AL. Statistical process control for radiotherapy quality
assurance. Med Phys. 2005;32:2777–2786.
21. Klein EE, Low DA, Maag D, Purdy JA. A quality assurance program for ancillary high
technology devices on a dual-energy accelerator. Radiother Oncol. 1996;38:51–60.
22. Rassow J, Klieber E. Quality assurance procedures in radiotherapy—IEC specifications for
equipment. Strahlenther Onkol. 1986;162:496–502.
23. KD GL, SL E, ME I, Saikanth M. VMAT testing for an Elekta accelerator. J Appl Clin Med
Phys. 2012;13:55–72.
24. Bedford JL, Warrington AP. Commissioning of volumetric modulated arc therapy (VMAT).
Int J Radiat Oncol Biol Phys. 2009;73:537–545.
25. Ling CC, Zhang P, Archambault Y, Bocanek J, Tang G, LoSasso T. Commissioning and
quality assurance of RapidArc radiotherapy delivery system. Int J Radiat Oncol Biol Phys.
2008;72:575–581.
26. Policy Number PP 1-H. Definition of a qualified medical physicist. AAPM. 2011.
27. Radiotherapy equipment—coordinates, movements and scales ed 2.0. IEC 61217. 2011.
28. Clements JB, Baird CT, de Boer SF, et al. AAPM medical physics practice guideline 10.a.:
scope of practice for clinical medical physics. J Appl Clin Med Phys. 2018;19:11–25.
29. American College of Radiology. ACR technical standard for the performance of radiation
oncology physics for external beam therapy. RES 52. 2015.
30. Bissonnette JP, Balter PA, Dong L, et al. Quality assurance for image-guided radiation therapy
utilizing CT-based technologies: a report of the AAPM TG-179. Med Phys. 2012;39:1946–1963.
31. Davis MG, Nyerick CE, Horton JL, Hogstrom KR. Use of routine quality assurance
procedures to detect the loss of a linear accelerator primary scattering foil. Med Phys. 1996;23:521–

522.
Accepted Article
32. Partridge M, Evans PM, Mosleh-Shirazi MA. Linear accelerator output variations and their
consequences for megavoltage imaging. Med Phys. 1998;25:1443–1452.
33. Budgell GJ, Zhang R, Mackay RI. Daily monitoring of linear accelerator beam parameters
using an amorphous silicon EPID. Phys Med Biol. 2007;52:1721–1733.
34. Budgell G, Brown K, Cashmore J, et al. IPEM topical report 1: guidance on implementing
flattening filter free (FFF) radiotherapy. Phys Med Biol. 2016;61:8360–8394.
35. Corns RA, Huang VW, Thomas SD. Pion effects in flattening filter-free radiation beams. J
Appl Clin Med Phys. 2015;16:376–385.
36. Fogliata A, Garcia R, Knoos T, et al. Definition of parameters for quality assurance of
flattening filter free (FFF) photon beams in radiation therapy. Med Phys. 2012;39:6455–6464.
37. Chao KSC, Apisarnthanarax S, Ozyigit G. Practical Essentials of Intensity Modulated
Radiation Therapy, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
38. Almond PR. AAPM’s TG-51 protocol for clinical reference dosimetry of high-energy photon
and electron beams. Med Phys. 1999;26:1847–1870.
39. Klein EE, Hanley J, Bayouth J, et al. Task Group 142 report: quality assurance of medical
accelerators. Med Phys. 2009;36:4197–4212.
40. Hossain M. Output trends, characteristics, and measurements of three megavoltage
radiotherapy linear accelerators. J Appl Clin Med Phys. 2014;15:4783.
41. Chan MF, Li Q, Tang C, et al. Visual analysis of the daily QA results of photon and electron
beams of a Trilogy Linac over a five-year period. Int J Med Phys Clin Eng Radiat Oncol.
2015;4:290–299.
42. Xiao Y, Kry SF, Popple R, et al. Flattening filter-free accelerators: a report from the AAPM
Therapy Emerging Technology Assessment Work Group. J Appl Clin Med Phys. 2015;16:5219.
43. Ponisch F, Titt U, Vassiliev ON, Kry SF, Mohan R. Properties of unflattened photon beams
shaped by a multileaf collimator. Med Phys.2006;33:1738–1746.
44. F A, G R, K T, N G, C A, V E, K C, C L. Definition of parameters for quality assurance of
flattening filter free (FFF) photon beams in radiation therapy. Med Phys. 2012;39:6455–6464.
45. Ritter TA, Gallagher I, Roberson PL. Using a 2D detector array for meaningful and efficient

linear accelerator beam property validations. J Appl Clin Med Phys. 2014;15:4749.
Accepted Article
46. Gao S, Balter PA, Rose M, Simon WE. Measurement of changes in linear accelerator photon
energy through flatness variation using an ion chamber array. Med Phys. 2013;40:042101.
47. Gao S, Balter PA, Rose M, Simon WE. A comparison of methods for monitoring photon beam
energy constancy. J Appl Clin Med Phys. 2016;17:242–253.
48. Watts RJ. Evaluation of a diode detector array for use as a linear accelerator QC device. Med
Phys. 1998;25:247–250.
49. Luchka K, Chen D, Shalev S, Gluhchev G, Rajapakshe R. Assessing radiation and light field
congruence with a video based electronic portal imaging device. Med Phys. 1996;23:1245–1252.
50. Brezovich IA, Jordan S, A device for precision positioning and alignment of room lasers to
diminish their contribution to patient setup errors. J Appl Clin Med Phys. 2007;8:2398.
51. Hwang UJ, Jo K, Lim YK, et al. A new method and device of aligning patient setup lasers in
radiation therapy. J Appl Clin Med Phys. 2016;17:49–61.
52. Lutz W, Winston KR, Maleki N. A system for stereotactic radiosurgery with a linear
accelerator. Int J Radiat Oncol Biol Phys. 1988;14:373–381.
53. Podgorsak EB, Pike GB, Pla M, Olivier A, Souhami L. Radiosurgery with photon beams:
physical aspects and adequacy of linear accelerators. Radiother Oncol. 1990;17:349–358.
54. Du W, Johnson JL, Jiang W, Kudchadker RJ. On the selection of gantry and collimator angles
for isocenter localization using Winston-Lutz tests. J Appl Clin Med Phys. 2016;17:5792.
55. Rowshanfarzad P, Sabet M, O’Connor DJ, Greer PB. Isocenter verification for linac-based
stereotactic radiation therapy: review of principles and techniques. J Appl Clin Med Phys.
2011;12:3645.
56. Liu G, van Doorn T, Bezak E. The linear accelerator mechanical and radiation isocentre
assessment with an electronic portal imaging device (EPID). Australas Phys Eng Sci Med.
004;27:111–117.
57. Woods K, Rong Y. Technical report: TG-142 compliant and comprehensive quality assurance
tests for respiratory gating. Med Phys. 2015;42:6488–6497.
58. Li XA, Stepaniak C, Gore E. Technical and dosimetric aspects of respiratory gating using a
pressure-sensor motion monitoring system. Med Phys. 2006;33:145–154.

59. Wong JW, Sharpe MB, Jaffray DA, et al. The use of active breathing control (ABC) to reduce
Accepted Article
margin for breathing motion. Int J Radiat Oncol Biol Phys. 1999;44:911–919.
60. Cui G, Housley DJ, Chen F, Mehta VK, Shepard DM. Delivery efficiency of an Elekta linac
under gated operation. J Appl Clin Med Phys. 2014;15:4713.
61. Kubo HD, Hill BC. Respiration gated radiotherapy treatment: a technical study. Phys Med
Biol. 1996;41:83.
62. Ramsey CR, Cordrey IL, Oliver AL. A comparison of beam characteristics for gated and
nongated clinical x-ray beams. Med Phys. 1999;26:2086–2091.
63. Miften M, Olch A, Mihailidis D, et al. Tolerance limits and methodologies for IMRT
measurement-based verification QA: recommendations of AAPM Task Group No. 218. Med Phys.
2018;45:e53–e83.
64. Schreibmann E, Dhabaan A, Elder E, Fox T. Patient-specific quality assurance method for
VMAT treatment delivery. Med Phys. 2009;36:4530–4535.
65. Bakhtiari M, Kumaraswamy L, Bailey DW, de Boer S, Malhotra HK, Podgorsak MB. Using
an EPID for patient-specific VMAT quality assurance. Med Phys. 2011;38:1366–1373.
66. Feygelman V, Zhang G, Stevens C, Nelms BE. Evaluation of a new VMAT QA device, or the
“X” and “O” array geometries. J Appl Clin Med Phys. 2011;12:3346.
67. Hussein M, Rowshanfarzad P, Ebert MA, Nisbet A, Clark CH. A comparison of the gamma
index analysis in various commercial IMRT/VMAT QA systems. Radiother Oncol. 2013;109:370–
376.
68. Bedford JL, Lee YK, Wai P, South CP, Warrington AP. Evaluation of the Delta4 phantom for
IMRT and VMAT verification. Phys Med Biol. 2009;54:N167–176.
69. Chandraraj V, Stathakis S, Manickam R, Esquivel C, Supe SS, Papanikolaou N. Comparison
of four commercial devices for RapidArc and sliding window IMRT QA. J Appl Clin Med Phys.
2011;12:3367.
70. Li G, Zhang Y, Jiang X, et al. Evaluation of the ArcCHECK QA system for IMRT and VMAT
verification. Phys Med. 2013;29:295–303.
71. Almond PR, Biggs PJ, Coursey BM, et al. AAPM’s TG-51 protocol for clinical reference
dosimetry of high-energy photon and electron beams. Med Phys. 1999;26:1847–1870.

72. McEwen M, DeWerd L, Ibbott G, et al. Addendum to the AAPM’s TG-51 protocol for clinical
Accepted Article
reference dosimetry of high-energy photon beams. Med Phys. 2014;41:041501.
73. Das IJ, Ding GX, Ahnesjo A. Small fields: nonequilibrium radiation dosimetry. Med Phys.
2008;35:206–215.
74. Cheng CW, Das IJ, Huq MS. Lateral loss and dose discrepancies of multileaf collimator
segments in intensity modulated radiation therapy. Med Phys. 2003;30:2959–2968.
75. Leybovich LB, Sethi A, Dogan N. Comparison of ionization chambers of various volumes for
IMRT absolute dose verification. Med Phys. 2003;30:119–123.
76. Benedict SH, Yenice KM, Followill D, et al. Stereotactic body radiation therapy: the report of
AAPM Task Group 101. Med Phys. 2010;37:4078–4101.
77. Karzmark CJ, Anderson J, Buffa A, et al. Total skin electron therapy: technique and
dosimetry. AAPM Report No. 23. Report of Task Group 30. Radiation Therapy Committee, AAPM.
1987.
78. Van Dyk J, Galvin JM, Glasgow GP, Podgorsak EB. The physical aspects of total and half
body photon irradiation. AAPM Report No. 17. A Report of Task Group 29 Radiation Therapy
Committee American Association of Physicists in Medicine. 1986.
79. Wootton PA, PR, Holt JG, Jones D, Karzmark CJ, Schulz RJ. Code of practice for x-ray
therapy linear accelerators. Med Phys. 1975;2:110–121.
80. Ravindran PB. A study of Winston-Lutz test on two different electronic portal imaging
devices and with low energy imaging. Australas Phys Eng Sci Med. 2016;39:677–685.
81. Rowshanfarzad P, Sabet M, Barnes MP, O’Connor DJ, Greer PB. EPID-based verification of
the MLC performance for dynamic IMRT and VMAT. Med Phys. 2012;39:6192–6207.
82. Halvorsen PH, Cirino E, Das IJ, et al. AAPM-RSS medical physics practice guideline 9.a. for
SRS-SBRT. J Appl Clin Med Phys. 2017;18:10–21.
83. Bayouth JE, Sample J, Waldron T, Sioch IR. Evaluation of 4DRT: CT acquisition and gated
delivery system. Med Phys. 2006;33:2188.
84. Cardenas A, Fontenot J, Forster KM, Stevens CW, Starkschall G. Quality assurance
evaluation of delivery of respiratory-gated treatments. J Appl Clin Med Phys. 2004;5:55–61.
85. Chang Z, Liu T, Cai J, Chen Q, Wang Z, Yin FF. Evaluation of integrated respiratory gating

systems on a Novalis Tx system. J Appl Clin Med Phys. 2011;12:3495.
Accepted Article
86. Chang Z, Liu T, Cai J, Chen Q, Wang Z, Yin FF. Evaluation of integrated respiratory gating
systems on a Novalis Tx system. J Appl Clin Med Phys. 2011;12:71–79.
87. Klein EE, Gerber R, Zhu XR, Oehmke F, Purdy JA. Multiple machine implementation of
enhanced dynamic wedge. Int J Radiat Oncol Biol Phys. 1998;40:977–985.
88. Klein EE, Low DA, Meigooni AS, Purdy JA. Dosimetry and clinical implementation of
dynamic wedge. Int J Radiat Oncol Biol Phys. 1995;31:583–592.
89. Liu C, Kim S, Kahler DL, Palta JR. Generalized monitor unit calculation for the Varian
enhanced dynamic wedge field. Med Phys. 2003;30:1891–1896.
90. Liu C, Li Z, Palta JR. Characterizing output for the Varian enhanced dynamic wedge field.
Med Phys. 1998;25:64–70.
91. Liu C, Zhu TC, Palta JR. Characterizing output for dynamic wedges. Med Phys.
1996;23:1213–1218.
92. Alaei P, Higgins PD. Performance evaluation and quality assurance of Varian enhanced
dynamic wedges. J Appl Clin Med Phys. 2006;7:14–20.
93. Avadhani JS, Pradhan AS, Sankar A, Viswanathan PS. Dosimetric aspects of physical and
dynamic wedge of Clinac 2100C linear accelerator. Strahlenther Onkol. 1997;173:524–528.
94. Beavis AW, Weston SJ, Whitton VJ. Implementation of the Varian EDW into a commercial
RTP system. Phys Med Biol. 1996;41:1691–1704.
95. Bidmead AM, Garton AJ, Childs PJ. Beam data measurements for dynamic wedges on Varian
600C (6 MV) and 2100C (6 and 10 MV) linear accelerators. Phys Med Biol. 1995;40:393–411.
96. Gossman MS, Robertson MA, Lawson RC. Correlation between detector array measurements
and a computer algorithm for enhanced dynamic wedge profiles. Med Dosim. 2007;32:211–215.
97. Zhu TC, Ding L, Liu CR, Palta JR, Simon WE, Shi J. Performance evaluation of a diode array
for enhanced dynamic wedge dosimetry. Med Phys. 1997;24:1173–1180.
98. Shackford H, Bjarngard BE, Vadash P. Dynamic universal wedge. Med Phys. 1995;22:1735–
1741.
99. Mutic S, Esthappan J, Klein EE. Peripheral dose distributions for a linear accelerator equipped
with a secondary multileaf collimator and universal wedge. J Appl Clin Med Phys. 2002;3:302–309.

100. Chui CS, Spirou S, LoSasso T. Testing of dynamic multileaf collimation. Med Phys.
Accepted Article
1996;23:635–641.
101. LoSasso T. IMRT delivery performance with a varian multileaf collimator. Int J Radiat Oncol
Biol Phys. 2008;71:S85–88.
102. Bayouth JE, Wendt D, Morrill SM. MLC quality assurance techniques for IMRT applications.
Med Phys. 2003;30:743–750.
103. Jordan TJ, Williams PC. The design and performance characteristics of a multileaf collimator.
Phys Med Biol. 1994;39:231–251.
104. Boyer A, Biggs P, Galvin J, et al. Basic applications of multileaf collimators. AAPM Report
No. 72. Report of Task Group No. 50 Radiation Therapy Committee. 2001.
105. Boyer AL, Li S. Geometric analysis of light-field position of a multileaf collimator with
curved ends. Med Phys. 1997;24:757–762.
106. Mubata CD, Childs P, Bidmead AM. A quality assurance procedure for the Varian multi-leaf
collimator. Phys Med Biol. 1997;42:423–431.
107. Kaurin DG, Sweeney LE, Marshall EI, Mahendra S. VMAT testing for an Elekta accelerator.
J Appl Clin Med Phys. 2012;13:3725.
108. Stell AM, Li JG, Zeidan OA, Dempsey JF. An extensive log-file analysis of step-and-shoot
intensity modulated radiation therapy segment delivery errors. Med Phys. 2004;31:1593–1602.
109. Sonke JJ, Ploeger LS, Brand B, Smitsmans MH, van Herk M. Leaf trajectory verification
during dynamic intensity modulated radiotherapy using an amorphous silicon flat panel imager. Med
Phys. 2004;31:389–395.
110. Baker SJ, Budgell GJ, MacKay RI. Use of an amorphous silicon electronic portal imaging
device for multileaf collimator quality control and calibration. Phys Med Biol. 2005;50:1377–1392.
111. Chang J, Obcemea CH, Sillanpaa J, Mechalakos J, Burman C. Use of EPID for leaf position
accuracy QA of dynamic multi-leaf collimator (DMLC) treatment. Med Phys. 2004;31:2091–2096.
112. Mamalui-Hunter M, Li H, Low DA. MLC quality assurance using EPID: a fitting technique
with subpixel precision. Med Phys. 2008;35:2347–2355.
113. Parent L, Seco J, Evans PM, Dance DR, Fielding A. Evaluation of two methods of predicting
MLC leaf positions using EPID measurements. Med Phys. 2006;33:3174–3182.

114. Partridge M, Evans PM, van Herk M, Ploeger LS, Budgell GJ, James HV. Leaf position
Accepted Article
verification during dynamic beam delivery: a comparison of three applications using electronic portal
imaging. Med Phys. 2000;27:1601–1609.
115. Samant SS, Zheng W, Parra NA, et al. Verification of multileaf collimator leaf positions using
an electronic portal imaging device. Med Phys. 2002;29:2900–2912.
116. Vieira SC, Dirkx ML, Pasma KL, Heijmen BJ. Fast and accurate leaf verification for dynamic
multileaf collimation using an electronic portal imaging device. Med Phys. 2002;29:2034–2040.
117. Bayouth JE, Morrill SM. MLC dosimetric characteristics for small field and IMRT
applications. Med Phys. 2003;30:2545–2552.
118. Burman C, Chui CS, Kutcher G, et al. Planning, delivery, and quality assurance of intensity-
modulated radiotherapy using dynamic multileaf collimator: a strategy for large-scale implementation
for the treatment of carcinoma of the prostate. Int J Radiat Oncol Biol Phys. 1997;39:863–873.
119. Galvin JM, Smith AR, Lally B. Characterization of a multi-leaf collimator system. Int J Radiat
Oncol Biol Phys. 1993;25:181–192.
120. Klein EE, Harms WB, Low DA, Willcut V, Purdy JA. Clinical implementation of a
commercial multileaf collimator: dosimetry, networking, simulation, and quality assurance. Int J
Radiat Oncol Biol Phys. 1995;33:1195–1208.
121. Klein EE, Low DA. Interleaf leakage for 5 and 10 mm dynamic multileaf collimation systems
incorporating patient motion. Med Phys. 2001;28:1703–1710.
122. Low DA, Sohn JW, Klein EE, Markman J, Mutic S, Dempsey JF. Characterization of a
commercial multileaf collimator used for intensity modulated radiation therapy. Med Phys.
2001;28:752–756.
123. Pasquino M, Borca VC, Catuzzo P, Ozzello F, Tofani S. Transmission, penumbra and leaf
positional accuracy in commissioning and quality assurance program of a multileaf collimator for
step-and-shoot IMRT treatments. Tumori. 2006;92:511–516.
124. Sontag MR, Steinberg TH. Performance and beam characteristics of the Siemens Primus linear
accelerator. Med Phys. 1999;26:734–736.
125. Venencia CD, Besa P. Commissioning and quality assurance for intensity modulated
radiotherapy with dynamic multileaf collimator: experience of the Pontificia Universidad Católica de

Chile. J Appl Clin Med Phys. 2004;5:XX.
Accepted Article
126. Letourneau D, Gulam M, Yan D, Oldham M, Wong JW. Evaluation of a 2D diode array for
IMRT quality assurance. Radiother Oncol. 2004;70:199–206.
127. Agnew A, Agnew CE, Grattan MW, Hounsell AR, McGarry CK. Monitoring daily MLC
positional errors using trajectory log files and EPID measurements for IMRT and VMAT deliveries.
Phys Med Biol. 2014;59:N49–63.
128. Chang Z, Bowsher J, Cai J, et al. Imaging system QA of a medical accelerator, Novalis Tx, for
IGRT per TG 142: our 1 year experience. J Appl Clin Med Phys. 2012;13:3754.
129. Glide-Hurst C, Bellon M, Foster R, et al. Commissioning of the Varian TrueBeam linear
accelerator: a multi-institutional study. Med Phys. 2013;40:XX.
130. Dolly S, Chen HC, Anastasio M, Mutic S, Li H. Practical considerations for noise power
spectra estimation for clinical CT scanners. J Appl Clin Med Phys. 2016;17:392–407.
131. Nakahara S, Tachibana M, Watanabe Y. One-year analysis of Elekta CBCT image quality
using NPS and MTF. J Appl Clin Med Phys. 2016;17:211–222.
132. Lee S, Yan G, Bassett P, Gopal A, Samant S. Use of local noise power spectrum and wavelet
analysis in quantitative image quality assurance for EPIDs. Med Phys. 2016;43:4996.
133. Gayou O, Miften M. Commissioning and clinical implementation of a mega-voltage cone
beam CT system for treatment localization. Med Phys. 2007;34:3183–3192.
134. Amer A, Marchant T, Sykes J, Czajka J, Moore C. Imaging doses from the Elekta Synergy x-
ray cone beam CT system. Br J Radiol. 2007;80:476–482.
135. Osei EK, Schaly B, Fleck A, Charland P, Barnett R. Dose assessment from an online
kilovoltage imaging system in radiation therapy. J Radiol Prot. 2009;29:37–50.
136. Murphy MJ, Balter J, Balter S, et al. The management of imaging dose during image-guided
radiotherapy: report of the AAPM Task Group 75. Med Phys. 2007;34:4041–4063.
137. Hioki K, Araki F, Ohno T, Nakaguchi Y, Tomiyama Y. Absorbed dose measurements for kV-
cone beam computed tomography in image-guided radiation therapy. Phys Med Biol. 2014;59:7297–
7313.
138. Scandurra D, Lawford CE. A dosimetry technique for measuring kilovoltage cone-beam CT
dose on a linear accelerator using radiotherapy equipment. J Appl Clin Med Phys. 2014;15:4658.

139. M. Hossain, J. Rhoades, "On beam quality and flatness of radiotherapy megavoltage photon
Accepted Article
beams," Australas Phys Eng Sci Med 39, 135-145 (2016)
140. S. Goodall, N. Harding, J. Simpson, L. Alexander, S. Morgan, "Clinical implementation of
photon beam flatness measurements to verify beam quality," J Appl Clin Med Phys 16, 340-345
(2015).
141. S. Gao, P.A. Balter, M. Rose, W.E. Simon, "Measurement of changes in linear accelerator
photon energy through flatness variation using an ion chamber array," Med Phys 40, 042101 (2013).
FIGURE LEGENDS
Figure 1. Beam-on indicator and x-ray-in-use lights outside a treatment vault.
Figure 2. Solid water setup for monthly output measurements.
Figure 3. Winston-Lutz setup with cone and film holder.
Figure 4. LaserGuard collision test setup. Object is set up on couch such that it will enter the
protection zone of the LaserGuard system. Once in protection zone, all motion should be inhibited.
Figure 5. Reciprocating phantom with marker block for respiratory gating tests for the Varian RPM
system.
Figure 6. Stereotactic motion lockouts on a Varian linac.
Figure 7. Planar kV images of a cube phantom used for positioning or repositioning tests. A central
target BB, along with 2 setup BBs are visible. The blue crosshairs are the digital graticule.
Figure 8. Planar MV image of an image quality phantom for monthly QA. The bar patterns or line
pairs along the central axis can be used to determine spatial resolution.
Figure 9. Las Vegas phantom for MV planar image QA. The number of visible holes in the image
should be consistent with the number visible during acceptance testing.
Figure 10. Leeds phantom for kV QA.

Figure 11. Leeds phantom image (left) and contrast sensitivity table (right).
Figure 12. Catphan phantom (a) photograph, (b) sagittal plane, and (c) CTP404 slice geometry and
sensitometry module.
Figure 13. Catphan high resolution module with line pair frequency (left), line pair design diagram

(middle), and kV-CBCT image (right).
Accepted Article
Figure 14. Catphan image uniformity module with regions of interest used for analysis is shown.
Figure 15. (a) Catphan low contrast module. (b) Transaxial image of Catphan low contrast model
with analysis regions for the 1% supraslice targets.
Figure 16. (a) Catphan module with slice width, HU constancy, and pixel size measurement
capability. Table of expected HU is shown. (b) Transaxial image of Catphan low contrast model with
analysis regions for HU constancy (circles) and slice width (rectangle).
Figure 17. Display of RaySafe X2 device indicating measured kV parameters using the X2 R/F
sensor.
Figure 18. Display of Raysafe X2 device indicating measured CBCT parameters using the CT sensor.

Accepted Article
Procedure Tolerance
Non-IMRT/IMRT/SRS
Typical Measuring
Device
Time Required
(range)
Personnel
Dosimetry
Photon & Electron ±3% Ionization chamber, 10-20 min RTT
Output Constancy Diode/MOSFET system
Mechanical
Laser Location ±2mm/±1.5mm/±1mm Front pointer, reference marks 2 min RTT
Distance Indicator ±2mm Front pointer, jig 2 min RTT
Collimator Size Indicator ±2mm/±2mm/±1mm Graph paper, ruler, jig 3 min RTT
Safety
Door Interlock Functional NA 1 min RTT
Door Closing Safety Functional NA 1 min RTT
Audiovisual Monitors Functional NA 1 min RTT
Stereotactic interlocks NA/NA/ Functional NA 1 min RTT
Radiation Area Monitors Functional NA 1 min RTT
Beam-on Indicator Functional NA 1 min RTT
Table 1. Time/Staffing/Equipment requirements for daily QA
NA = not applicable.

Accepted Article
Table 2.a. Profile constancy calculation example
Profile Constancy Measurements C T G L R
Baseline measurement values 100.5 102.1 102.7 102.5 102.6

Monthly measurement values 100.2 101.2 102.5 102.5 102.1
Profile Constancy Analysis T/C G/C L/C R/C
Baseline 1.016 1.022 1.020 1.021

Monthly 1.010 1.023 1.023 1.019
Task - Base (Tolerance ±1%) -0.6% 0.1% 0.3% -0.2%
Pass/Fail Pass Pass Pass Pass
C= central axis, T = target point, G = gun point, L = left point, R = right point.

Accepted Article
Table 2.b. Time/Staffing/Equipment requirements for Monthly QA
Procedure Tolerance Typical Measuring Device Time Personnel
Non-IMRT/IMRT/SRS Required(range)
Dosimetry
Photon and Electron Output ±2% ADCL Calibrated Ionization 45-60 min. QMP or
Constancy per beam Chamber/Electrometer or Designee
Chamber/Electrometer cross-calibrated with
ADCL Chamber/Electrometer, solid phantom
or water phantom
Backup Monitor Chamber ±2% ADCL Calibrated Ionization Included above QMP or
Constancy Chamber/Electrometer or Designee
or water phantom
Typical Dose Rate Output NA/±2%/±2% ADCL Calibrated Ionization 10-15 min. QMP or
Constancy Chamber/Electrometer or Designee
or water phantom
Photon and Electron Beam ±1% Array, film, portal imager 10-60 min. QMP or
Profile Constancy Designee
Electron Beam Energy ±2%/± 2 mm ADCL Calibrated Ionization 20-30 min. QMP or
Constancy Chamber/Electrometer, solid phantom or Designee
water phantom
Mechanical
Light / Radiation Field ±2.0 mm per Jaw Film or EPID 30 min. (Film) QMP or
Coincidence (Symmetric & 15 min. (EPID) Designee
Asymmetric)
±2mm/ ±1 mm/ ≤ 1mm Front pointer/Winston-Lutz test equipment 5 min. QMP or
Lasers
deviation Designee
Gantry / Collimator Angle ±1° Level 5 min. QMP or
Indicators (@ cardinal angles, Designee
digital only)
Accessory Trays (i.e., port film ±2 mm NA 1 min. QMP or
graticule tray) Designee
Jaw Position Indicators ±2 mm per Jaw Graph paper, template 15 min. QMP or
(Symmetric) Designee
±2.0mm or ±1 mm per Graph paper, template 15 min. (can be QMP or
Jaw Position Indicators jaw when used for done simultaneously Designee
(Asymmetric) field matching at the with Symmetric)
central axis
Cross-Hair Centering ≤1 mm Graph paper, template 15 min. QMP or
(Walkout) Designee
Treatment Couch Position ±2 mm, ±1°/ ±2 mm, Graph paper, ruler 15 min. QMP or

Indicators ±1°/± 1 mm, ±0.5° Designee
Accepted Article visual
±2mm
inspection: Graph paper, ruler
Ion chamber or device array
15 min. QMP or
Designee
Wedge Placement Accuracy
Dosimetric
Comparison: ±2%
Compensator Placement ±1mm Graph paper, ruler 15 min. QMP or
Accuracy Designee
Latching of Wedges, Blocking Functional NA 5 min. QMP or
Tray Designee
Safety
Laser guard-interlock test Functional NA 1 min. QMP or
Designee
Respiratory Gating
Beam output constancy ± 2% ADCL Calibrated Ionization 15 min. (using same QMP or
Chamber/Electrometer or setup as output Designee
Chamber/Electrometer cross-calibrated with constancy)
or water phantom
Phase, displacement Functional NA 1 min. QMP or
magnitude beam control Designee
In-room respiratory monitoring Functional NA 1 min QMP or
system Designee
Gating interlock Functional NA 1-2 min. QMP or
Designee
VMAT
Patient Specific VMAT QA Institutional VMAT QA VMAT QA phantom 20-30 min QMP or
passing criteria based Designee
on TG-218 guidelines

Accepted Article
Table 3. Time, staffing, and equipment requirements for annual QA
Procedure Tolerance Typical Measuring Device Time Required Personnel
Non-IMRT/IMRT/SRS (range)
Dosimetry
Photon Flatness Change from Large water tank 60-120 min. QMP
±1%
Baseline
Photon Symmetry Change from Large water tank 60-120 min. QMP
±1%
Baseline
Electron Flatness Change from Large water tank 60-120 min. QMP
±1%
Baseline
Electron Symmetry Change from Large water tank 60-120 min. QMP
±1%
Baseline
± 1% (Absolute) Small/large water tank. ADCL 120-180 min. QMP
Photon / Electron Output Calibration 71 Calibrated Ionization
Chamber/Electrometer
±2% for field sizes < 4 Ionization Chamber/Electrometer, 30-60 min. QMP
Spot Check of Field-Size Dependent 2
× 4 cm ; solid phantom or water phantom
Output Factors for Photon (2 or more
±1% for field sizes ≥ 4
field sizes)
× 4 cm2
Output Factors for Electron Applicators Ionization Chamber/Electrometer, 60-90 min. QMP
± 2% from baseline
(spot check of one applicator / energy) solid phantom or water phantom
Photon Beam Quality (PDD10 or Large water tank 30-60 min. QMP
± 1% from baseline
TMR20:10)
Electron Beam Quality (R50) ± 1 mm Large water tank 60-90 min. QMP
Physical Wedge Transmission Factor Ionization Chamber/Electrometer, 30-60 min. QMP
± 2%
constancy solid phantom or water phantom
± 2% ≥ 5 MU Ionization Chamber/Electrometer, 30-60 min. QMP
± 5% (2- 4) MU, ± 2% ≥ solid phantom or water phantom
Photon Monitor Unit Linearity (Output
5 MU
Constancy)
± 5% (2- 4) MU, ± 2% ≥
5 MU
Electron Monitor Unit Linearity (Output Ionization Chamber/Electrometer, 30-60 min. QMP
± 2% ≥ 5 MU
Constancy) solid phantom or water phantom
Photon Output Constancy vs Dose- ± 2% from clinical Ionization Chamber/Electrometer, 30-60 min. QMP
Rate dose rate solid phantom or water phantom
Photon Output Constancy vs Gantry ± 1% of the value Ionization Chamber/Electrometer. 30-90 min. QMP
Angle acquired at gantry 0 2D/3-D Diode array
Electron Output Constancy vs Gantry ± 1% of the value Ionization Chamber/Electrometer. 60-120 min. QMP
Angle acquired at gantry 0 2D/3-D Diode array
Electron and Photon Off-Axis Factor ± 1% of the value Ionization Chamber/Electrometer. 60-120 min. QMP
Constancy vs Gantry Angle acquired at gantry 0 2D/3-D Diode array
± 1% from baseline NA 15 min. QMP
Arc Mode (expected MU, degrees) SRS Mode (±1 MU or
±2%) and (±1° or

±2%)
Accepted Article
TBI / TSET Mode Functional
TBI TMR/PDD ±5%
NA
Ionization Chamber/Electrometer,
5 min.
90-120 min.
QMP
QMP
from baseline TBI/TSET phantom.
PDD or TMR and OAF Constancy
TSET ±3 mm PDD
measured at extended treatment
shift,
distance
OAF Constancy ±5%
from baseline
± 3% from baseline at Ionization Chamber/Electrometer, 90-120 min. QMP
TBI / TSET Output Calibration
extended distance TBI/TSET phantom.
TBI / TSET Accessories ± 2% from baseline Various. 90-120 min. QMP
Mechanical
Collimator Rotation Isocenter ± 1 mm from baseline Front pointer set. 10-15 min. QMP
Gantry Rotation Isocenter ± 1 mm from baseline Front pointer set. 15-30 min. QMP
Couch Rotation Isocenter ± 1 mm from baseline Front pointer set. 10-15 min. QMP
Electron Applicator Interlocks Functional NA 10-15 min. QMP
Coincidence of Radiation and ±2/ ±2/ ±1 mm Front pointer set. Film/ GafChromic 30-60 min. QMP
Mechanical Isocenter film/EPID.
Couch Top Sag ± 2 mm from baseline Front pointer set. Lasers and ruler. 10-15 min QMP
Couch Angle ±1°/ ±1°/ ±0.5° Graph paper. 10-15 min QMP
Couch Travel Maximum Range Graph paper. Ruler. 10-15 min QMP
± 2 mm
Movement in All Directions
Stereotactic Accessories, Lockouts, NA/ NA/ Functional NA 10-15 min QMP
etc.
Safety
Follow Manufacturer's Test Functional NA 30-45 min. QMP
Procedures
Respiratory Gating
Beam Energy Constancy ± 2% of non-gated Ionization Chamber/Electrometer, 15-30 min QMP
beam solid phantom or water phantom
Temporal accuracy of ±100 ms of expected Motion phantom. Film. GafChromic 60-120 min QMP
phase/displacement magnitude gate film. EPID
on
Calibration of surrogate for ±100 ms of expected Motion phantom. 60-120 min QMP
phase/displacement magnitude
Interlock testing Functional NA 5-10 min QMP
VMAT
Test Patient Specific VMAT QA Plan passes QA at a VMAT QA phantom 20-30 min QMP
constancy pass rate ≥ baseline
pass rate minus 2%
AND Plan passes
institutional VMAT QA
criteria
Interruption test ± 1% deviation from VMAT QA phantom 10-15 min QMP
uninterrupted passing

rate
Accepted Article
NA = not applicable

Accepted Article
Table 4. Time/Staffing/Equipment requirements for Dynamic/Virtual/Universal QA
Daily
Morning check-out run for one Functional NA 1-2 min. RTT
angle
Monthly
Wedge factor for all energies ±2% Ionization chamber, Array, 15 - 20min. QMP or
film, portal imager Designee
Annual
Check of wedge angle for 60°, Check of off- Array, film, portal imager 20 - 30 min. QMP
full field and spot check for center ratios @
intermediate angle, field size 80% field width @
10 cm depth to be
within ±2%
NA = not applicable

Accepted Article
Table 5. Time/Staffing/Equipment requirements for MLC QA
Weekly
Qualitative test - “picket fence” ±2mm Array, film, portal imager Film: 12-15 min RTT deliver,
EPID: 5 min QMP or
Designee
review
Monthly
Leaf position accuracy (non- ±2mm Graph paper, template. 12-15 min QMP or
IMRT) Designee
Backup diaphragm settings ±2mm Film or EPID and radio- Film: 30-35 min QMP or
(Elekta only) opaque markers if the light EPID: 15-20 min Designee
field crosshair is used as a
surrogate for the radiation
isocenter.
Leaf Travel speed (IMRT) leaf speed within Log-file analysis software or Log file method: QMP or
±0.5 cm/s EPID and corresponding 10-12 min Designee
analysis software EPID method:
15-20 min
Leaf position accuracy (IMRT) ±1mm Films or EPID and software Film: 25-40min QMP or
analysis application EPID: 15-25 min Designee
Graph paper, template Light Field: 10-15
min
Annual
MLC transmission (average of ±0.5% from Ionization chamber and Obj. 1: 20-30 QMP
leaf and interleaf baseline water equivalent scattering min for one
transmission), all energies material. energy. 10 min
per additional
energies
Leaf position repeatability ±1mm EPID or graph paper for the 30-40 min with QMP
light field-based approach EPID. 15 min
with the light-field
approach

≤1.0 mm radius
Accepted Article
MLC spoke shot Film or EPID and software
analysis application
Film: 30-35 min
EPID: 15-20 min
QMP
Coincidence of light field and ±2mm per MLC Film or EPID and software Film: 25-25 min QMP
Photon field (all energies) bank analysis application EPID: 10-15 min
(for one energy)
Moving window IMRT RMS of leaf Delivery log file analysis 10-20 min QMP
positioning error <
software tool
0.35 cm for all leaves

Accepted Article
Table 6. Time/Staffing/Equipment requirements for Imaging QA
Procedure Tolerance Typical Measuring Time Required Personnel
Non-SRS/SBRT SRS/SBRT Device (range)
Daily
Planar kV and MV (EPID)
imaging
Collision interlocks Functional NA 5 min. RTT
Positioning/repositioning ≤2 mm / ≤2 mm/ Phantom containing 10-15 min. RTT
≤1 mm day of SRS radiopaque markers.
Imaging and treatment ≤2 mm / ≤2 mm/ Phantom containing Included above. RTT
coordinate coincidence ≤1 mm day of SRS radiopaque markers.
Cone-beam CT (kV & MV)
Collision interlocks Functional NA 5 min. RTT
Positioning/repositioning ≤2 mm / ≤2 mm/ Phantom containing 10-15 min. RTT
≤1 mm day of SRS radiopaque markers.
Imaging and treatment ≤2 mm / ≤2 mm/ Phantom containing Included above. RTT
coordinate coincidence ≤1 mm day of SRS radiopaque markers.
Monthly
Planar MV imaging (EPID)
Imaging and treatment ≤2 mm / ≤1 mm Phantom containing 15-20 min. QMP or
Designee
coordinate coincidence radiopaque markers.
Scaling ≤2 mm / ≤1 mm Object of known 5 min. QMP or
Designee
dimensions
Spatial resolution ≥ Baseline Manufacturer supplied 5-10 min. QMP or
Designee
test phantom
Contrast ≥ Baseline Manufacturer supplied 5-10 min. QMP or
Designee
test phantom
Uniformity and noise ≥ Baseline Manufacturer supplied 5-10 min. QMP or
Designee
test phantom
Planar kV imaging
Imaging and treatment ≤2 mm / ≤1 mm Phantom containing 15-20 min. QMP or
Designee
coordinate coincidence radiopaque markers.
Scaling ≤2 mm / ≤1 mm Object of known 5 min. QMP or
Designee
dimensions
Spatial resolution ≥ Baseline Manufacturer supplied 5-10 min. QMP or
Designee
test phantom

≥ Baseline QMP or
Accepted Article
Contrast Manufacturer supplied
test phantom
5-10 min.
Designee

Designee
test phantom
Geometric distortion ≤2 mm / ≤1 mm phantom of known and 15-20 min. QMP or
Designee
dimensions
Spatial resolution ≥ Baseline Object of known 5 min. QMP or
Designee
dimensions
Contrast ≥ Baseline Manufacturer supplied 5-10 min. QMP or
Designee
test phantom
HU constancy ± 40 HU from baseline Manufacturer supplied 5-10 min. QMP or
Designee
test phantom
Designee
test phantom
Annual
Planar MV imaging (EPID)
Full range of travel SDD ±5 mm Tape measure 5-10 min. QMP
Imaging dose ± 5% of the baseline Radiographic dosimetry 15-30 min. QMP
imaging dose per system

monitor unit
Planar kV imaging
Beam quality/energy ± 5% Baseline energy Radiographic dosimetry 15-30 min. QMP
system
Imaging dose ± 20% of the baseline Radiographic dosimetry 15-30 min. QMP
dose system
Imaging dose Baseline ± 20% for kV- Radiographic dosimetry 15-30 min. QMP
CBCT, Baseline ± 5% system

for MV-CBCT

Accepted Article
mp_14992_f1.jpg

Accepted Article
mp_14992_f2.jpg

Accepted Article
mp_14992_f3.jpg

Accepted Article
mp_14992_f4.jpg

Accepted Article
mp_14992_f5.jpg

Accepted Article
mp_14992_f6.jpg

Accepted Article
mp_14992_f7.jpg

Accepted Article
mp_14992_f8.jpg

Accepted Article
mp_14992_f9.jpg

Accepted Article
mp_14992_f10.jpg

Accepted Article
mp_14992_f11.jpg

Accepted Article
mp_14992_f12.jpg

Accepted Article
mp_14992_f13.jpg

Accepted Article
mp_14992_f14.jpg

Accepted Article

Accepted Article
mp_14992_f16.jpg

Accepted Article
mp_14992_f17.jpg

Accepted Article
mp_14992_f18.jpg

AAPM TG198 ImplementationOfTG142-Compressed

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

AAPM TG198 ImplementationOfTG142-Compressed

Uploaded by

Copyright:

Available Formats

Accepted Article

Article type : AAPM Scientific Report

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

2.3.1.5 Electron Beam Energy Constancy

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

2.3.2.3 Gantry or Collimator Angle

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

2.3.4 Respiratory Gating

This article is protected by copyright. All rights reserved

2.3.4.1 Beam Output Constancy

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved

This article is protected by copyright. All rights reserved