RPAD/ACC/QA/04

ACCEPTANCE/QUALITY ASSURANCE TESTS FOR

MEDICAL LINEAR ACCELERATOR

Medical Physics & Safety Section

Radiological Physics & Advisory Division
Bhabha Atomic Research Centre
CT & CRS Building, Anushaktinagar,
Mumbai – 400 094
 Acceptance/Quality Assurance Tests for Medical Linear Accelerator

1. Identification
1.1 Name of the institution :
1.2 Address with Pin code :

1.3 Telephone/ telex number :

1.4 Head of the institution :
1.5 Name and qualification of :
the radiotherapist(s)

1.6 Name and qualification of :

the physicist(s)

1.7 Unit model & number :

1.8 Head number :
1.9 Couch number :
1.10 Beam type : Photon / Photon & Electron
(Tick as appropriate)
1.11 Dual photon energies? : Yes/No
1.12 Nominal beam energies : Photon(s): ______________ MV
(As specified by the manufacturer) Electron(s): ___________________ MeV
1.13 Target
Material(s) :
Dimensions :
1.14 Photon beam flattening filter
Material(s) :
Dimensions :
1.15 Electron beam scattering foil(s)
Material(s) :
Dimensions :
1.16 Asymmetric jaw motions provided? : Yes/No
1.17 Multi-leaf collimator available? : Yes/No
1.18 Universal wedge filter provided? : Yes/No
1.19 Motorised wedge filter available? : Yes/No
1.20 Dynamic wedge filter available? : Yes/No
1.21 Dose rate ranges provided :
1.22 Calibration dose rate? : ________________ cGy/MU
1.23 Output for 10 cm x 10 cm field at : ________________ cGy/min
isocentre?
1.24 Installation plan
Approved by : BARC/Other (if other then provide details)
Date :
1.25 Accelerator
Installed by :
Date :
1.26 Any other specific information :

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2. Mechanical Tests

2.1 Physical characteristics

2.1.1 Couch

2.1.1.1 Level above floor : , cm

2.1.1.2 Horizontal motion : from , cm to , cm
2.1.1.3 Vertical motion : from , cm to , cm
2.1.1.4 Lateral motion : from , cm to , cm
2.1.1.5 Rotational motion : from , deg to , deg
2.1.1.6 Speed : max. , cm/sec Limit: 5cm/sec
: min. ,cm/sec Limit.: 1cm/sec

2.1.2 Collimator

2.1.2.1 Level above floor : , cm

2.1.2.2 Rotation : from , deg to , deg
2.1.2.3 Angular scale test : Tolerance: 0.5°
2.1.2.4 Distance from isocentre : , cm
2.1.2.5 Optical & collimator axes : , mm Tolerance: 1 mm
coincidence

(a) Conventional jaws - Symmetric and asymmetric motion

2.1.2.6 Jaw size

Lower jaw : from , cm to , cm
Upper jaw : from , cm to , cm
2.1.2.7 Parallelism of the jaws : Lower :
Upper :
Tolerance: 1°
2.1.2.8 Orthogonality of the : Tolerance: 90° ± 1°
adjacent jaws
2.1.2.9 Symmetry of the jaws : Tolerance: ± 1 mm
2.1.2.10 Asymmetric jaw over-travel : , cm
distance

Note: Check for complete gantry rotation, at the gantry positions: 0°, 90°, 180°, & 270°.

(b) Multileaf collimator (MLC) jaws

2.1.2.11 MLC type : X – Jaws, Y – Jaws, Tertiary (tick)

2.1.2.12 No. of leaf pairs :
2.1.2.13 Leaf width at isocentre : , mm
2.1.2.14 Leaf thickness : , cm
2.1.2.15 Leaf over-travel distance : , cm
2.1.2.16 Inter-leaf spacing : , mm
2.1.2.17 Intra-leaf spacing : , mm
2.1.2.18 Speed of leaves : , cm /sec

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2.1.2.19 Abutting of leaves on and :
off the field central axis
2.1.2.20 Reproducibility of leaf : , mm Tolerance: 1 mm
positions
2.1.2.21 Interlocks for leaf : Yes / No Tolerance: functional
2.1.2.22 Jaw position interlocks : Yes / No Tolerance: functional
2.1.2.23 Alignment of MLC axes and : Yes / No Tolerance: 1 mm
secondary collimator axes
2.1.2.24 Collimator centring

Use a field size of 10 cm x 10 cm and place a graph paper at isocentre with collimator at
0°. Record the maximum deviations of the upper and lower jaws for combinations of gantry and
collimator angles at 0°, 90°, 180°, and 270°. Repeat the observations for MLC leaf ends and
sides.
Maximum difference
(a) between jaws : , mm
(b) leaves : , mm
Tolerance: 2 mm
2.1.2.25 Correspondence between : Acceptable / Not acceptable
MLC irregular fields & shapes
and BEV target cross-section
Tolerance: 2 mm

2.2.1 Field light centring

The centring of the light source with collimator rotation shall be checked by using an
object having a right angle at one corner, suspended close to cross-wires. The radial and
transverse shifts in shadow of the object measured at the collimator angles of 90° and 270° can
be used to calculate the centring of the light source. Tolerance: I mm shift

Angle
Test 90° 270°
Radial shift, mm
Transverse shift, mm

2.2.2 Cross-wire centring vs. collimator rotation

The projection of the cross-wires is marked at collimator angles 0°, 90°, 180° and 270°
at 100 cm NTD. Measure the diameter of the smallest circle that includes all the cross-wire
projections at the isocentre.

Diameter of the circle : , mm Tolerance: 2 mm φ Circle

2.2.3 Cross-wire centring vs. gantry rotation

The projection of the cross-wires with respect to the horizontal front pointer shall be
recorded at various gantry angles through 360° by placing a graph sheet just behind the
pointer.
Cross-wire projections at : , mm Tolerance: 2 mm φ Circle
different gantry positions

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2.3 Gantry

2.3.1 Rotation speed (.1 to 1 RPM) : Tolerance: 0 1%

2.3.2 Angular scale test : Tolerance: 0.5°

2.4 Isocentre

(a) Mechanical

2.4.1 Collimator rotation isocentre : , mm

2.4.2 Gantry rotation isocentre : , mm
2.4.3 Couch rotation isocentre : , mm
2.4.4 Coincidence of collimator, gantry : , mm
and couch axes with isocentre

(b) Radiation

2.4.5 Radiation isocentre : , mm

2.4.6 Coincidence between radiation and : , mm

mechanical isocentre
Tolerance: ≤ 2 mm diameter sphere

2.5 Head swivel : from ° to °

2.6 Readout accuracy

Stated Measured

2.6.1 SSD / SAD verification : , cm ; , cm

2.6.2 Mechanical front pointer :
value verification
Tolerance: 2 mm

2.6.3 Optical distance indicator

Use a solid phantom and adjust its top surface at 100 cm. Raise the phantom by 30 cm
in steps of 1 cm and record ODI readings. Bring back the phantom to NTD and lower it by 20
cm in steps of 1 cm and record the corresponding ODI readings. All the readings must lie within
the given tolerance. This procedure will enable testing of ODI Scale in the range of 80 – 130
cm.
Optical distance indicator scale verification
Couch Position Optical distance indicator, readings Tolerance
NTD

NTD - 20 cm to NTD + 20 cm ± 1.5 mm

in steps of 1 cm

Note: NTD (normal treatment distance) corresponds to 0 cm position of the couch, i.e.,
SAD / SSD = 100 cm.

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2.6.4 Laser beam indicator

Check positions of 100 cm lasers with respect to mechanical isocentre. Check the
levelness (tolerance: 1 mm) and plumb (tolerance: 0.3°) using a level (horizontal & vertical
lasers) or a plumb (vertical lasers). Tolerance is met if displacement 20 cm from the isocentre is
less than 1 mm. Co-linearity of the lasers in the transverse direction should also be within 1
mm. Sagittal laser should pass through the mechanical isocentre. Ceiling laser position is
measured with respect to the mechanical isocentre. Check the co-linearity with respect to the
lateral and sagittal lasers. Enclose the results of the measurements for evaluation.

Tolerance: ± 1.0 mm.

2.7 Field size (Fs) defined at 100 cm SAD by Light Field

2.7.1 Upper and lower jaws

Align graph paper with cross-wires at collimator angle 0° and SAD = 100 cm. Adjust the
collimators to match several field sizes covering the clinical range. Verify that the field sizes
defined by upper and lower jaws respectively matches with the readings on the graph paper.
Record the observations for both symmetric and asymmetric motion of the jaws. Analyse the
data to ensure that the results are within the tolerance limits.

Tolerance: 2 mm or 1% of field width at isocentre for symmetric motion of the jaws

2 mm on any side at isocentre for asymmetric motion of the jaws

2.7.2 Multi-leaf collimator (MLC)

For MLC, use the manufacturer provided leaf position table in auto-cycle mode. Record
the leaf positions observed on the graph paper and verify that the measured leaf position
matches with the specifications within the tolerance limits. Tabulate and submit the
observations for evaluation and record.

Tolerance: 1 mm

2.7.3 Symmetric Jaws and Square Fields

Set optical field size, Measured optical field size, cm x cm Tolerance

cm x cm at Gantry Position
0° 90° 180° 270°
5x5 For Fs ≤
10 x 10 10 cm x 10 cm
15 x 15 ± 1 mm
20 x 20
25 x 25 &
30 x 30 For Fs >
35 x 35 10 cm x10 cm
40 x 40 ≤ 2 mm

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2.8 Wedge position reproducibility : , mm Tolerance: 2 mm

2.9 Tray position reproducibility : , mm Tolerance: 2 mm

2.10 Applicator position : , mm Tolerance: 2 mm

2.11 Latching of wedges & blocking tray: Tolerance: Functional

2.12 Table top sag : , mm Tolerance: 2 mm

2.13 Table vertical travel : , mm Tolerance: 2 mm

2.14 Field light intensity : Tolerance: Functional

2.15 Audio-visual monitor : Tolerance: Functional

3. Electrical Tests

3.1 Treatment room door

3.1.1 Electrical interlock

Provided? : Yes / No
Working? : Yes / No

3.2 Emergency cut - off

3.2.1 Emergency stop push buttons to cut-off all electrical supply to the area in which the
accelerator is situated
Provided? : Yes / No
Working? : Yes / No
3.2.2 Emergency stop button to interrupt the irradiation
Provided? : Yes / No
Working? : Yes / No

3.3 Anti-collision system

Provided? : Yes / No
Working? : Yes / No

3.4 End-course cut - off

Provided? : Yes / No
Working? : Yes / No

3.5 Hand control box

Provided? : Yes / No
Working? : Yes / No
3.5.1 Can all movements of the table and accelerator be
controlled using the buttons on the box? : Yes / No

3.6 Control console

3.6.1 Are all operating parameters displayed on the console? : Yes / No

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3.6.2 Are all operating parameter push buttons functional? : Yes / No
3.6.3 Are safety switches operable from control console? : Yes / No
3.6.4 Is arc / rotation switch start / terminate the rotation at the
pre-assigned angle? : Yes / No
3.6.5 Is mode selection switch provided? : Yes / No
3.6.6 Does alteration of the mode during the irradiation cuts - off
the beam? : Yes / No
3.6.7 Are the range selection switches adjacent to each other? : Yes / No
3.6.8 Does changing of the range switch terminate irradiation? : Yes / No
3.6.9 Are dose monitor switches adjacent to each other and
close to the system used for preselection of monitor units?: Yes / No
3.6.10 Do the readings of the two monitor systems agree to
within 10% ? : Yes / No
3.6.11 Is irradiation possible only after having pre-selected
monitor units on the control console ? : Yes / No
3.6.12 Is the number of monitor units continued to be displayed
until reset to zero ? : Yes / No
3.6.13 Are residual monitor units displayed (at least for 20 mins.)
even after accidental or intentional power cut off ? : Yes / No
3.6.14 Do dose monitor systems function independently ? : Yes / No
3.6.15 Is each monitor system capable of terminating the
irradiation independently ? : Yes / No
3.6.16 Is independent timer provided? : Yes / No
3.6.17 Does the timer start and stop simultaneously with the
irradiation ? : Yes / No
3.6.18 Is wedge filter integrated into unit head with only one
possible mode of insertion and interlocked with console? : Yes / No
3.6.19 Are characteristics of the wedge filter displayed during use?: Yes / No
3.6.20 Is compensator interlocked with the console? : Yes / No
3.6.21 Is shielding tray interlock provided? : Yes / No
3.6.22 Is shielding tray interlock operational? : Yes / No

3.7 Switch selection

3.7.1 Can irradiation be given without selecting the same

parameters on the hand control box and control panel? : Yes / No
3.7.2 Is irradiation feasible without mode selection? : Yes / No
3.7.3 Is it possible to prevent irradiation in photon mode, if
accessories of electron mode are in use and vice-versa? : Yes / No
3.7.4 Is radiation type displayed on control panel before, during
and after irradiation? : Yes / No
3.7.5 Is range of X - & electron energies displayed on panel? : Yes / No
3.7.6 Is irradiation possible by bypassing range selection? : Yes / No
3.7.7 Is range selection displayed on panel during and after
irradiation? : Yes / No
3.7.8 Can irradiation be given without wedge filter selection on
control panel? : Yes / No

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4. Photon Beam Characteristics
For accelerators capable of emitting photons of different energies, the following checks
shall be carried out, for each nominal beam energy:

4.1 Congruence between optical and radiation fields++

The congruence between optical and radiation fields must be assessed at the depth of
the reference plane - which is usually at SSD + dmax or with the reference plane placed at the
isocentre of the accelerator - for square fields of 5 cm x 5 cm, 10 cm x 10 cm and 30 cm x 30
cm or for a field of maximum dimension, available on the unit, at the level of the reference plane
and for gantry positions of 0°, 90°, 180° and 270° for each nominal photon energy (MV). In all
cases, the separation between optical field edge and the 50% isodose line shall not
exceed 2 mm.

4.1.1 Light Field and Radiation Field Congruence

a) L – R vs Field Size (each photon energy)

Place film at 100 cm SFD on a levelled surface. Set fields using specified collimator
settings. Measure 50% edge and distance between corresponding cross-wires. Insert graticule
tray. Deliver 70 MU (no build-up). Set 30 cm x 30 cm field, give 10 MU. Compare the
congruence between set optical and radiation fields.

b) L – R vs Collimator Angle (one photon energy)

Set field size to 10 x 10 cm, SSD to 100 cm. Score field edges and cross-wires. Deliver
70 MU (no build-up). Repeat for collimator angles of 90° and 270°.

c) L – R vs SSD (one photon energy only)

Set field size to 10 x 10 cm, SSD to 130 cm. Score field edges and cross-wires. Deliver
100 MU (no build-up). Establish that the differences between optical and radiation fields with
changing SSD are within the tolerance limits.

d) MLC (one photon energy only)

Set jaws to 26 x 40 cm. Place film at 100 cm SFD on a levelled surface. Use 4 L – R
fields from the MLC “QA” file. Measure 50% edge and with between corresponding cross-wires.
Deliver 70 MU (no build-up) for each field. Compare the results. Retract MLC jaws. Set jaw to
30 x 30 cm and give 10 MU. Compare the deviations.

Tolerance: Light and radiation field coincidence: greater than 2 mm or 1%.

4.1.2 Coincidence between parallel opposed fields

Using a suitable phantom, determine the maximum of X – jaw non-coincidence between

parallel opposed fields. Align the phantom with the sagittal and lateral lasers (100 cm SSD).
Insert Kodak X-omat V film. Set 10 x 10 cm field size. Rotate the gantry to 90° and then to 270°.
Deliver 30 MU at each angle. Rotate the collimator 90°. Repeat for Y-jaw. Repeat for each
energy. Repeat for the MLC for one energy. Tolerance: 3 mm

9
4.2 Field Flatness and Symmetry ++

Beam flatness and symmetry can be measured with any of the following methods:

(a) With an ion chamber in a water tank

(b) With film inserted at reference depth in a phantom
(c) With the beam profiler (diode array)

Record the average unflatness and asymmetry over 80% of the field. Compare the
results with the data obtained at the time of commissioning.

It is important that field flatness and symmetry are tested over a range of available field
sizes and beam energies at the clinically relevant depths (e.g., dmax, & 10 cm) for at least four
cardinal gantry orientations of 0°, 90°, 180° and 270°. However, at least three field sizes,
namely, 5 cm x 5 cm, 10 cm x 10 cm and 30 cm x 30 cm should be covered during each QA
test.

4.2.1 Flatness

Along X - axis :
Along Y - axis : Tolerance: ± 3% **
Along Diagonal :

** To determine field flatness, obtain transverse beam profiles, at the depths of dmax and 10
cm, along the two orthogonal axes and diagonal axis of the beam. Obtain maximum (Vmax ) and
minimum (Vmin ) values of dose in the central 80% region of the respective beam profiles.
Calculate the required field flatness parameter, V, using the following equation:

V = (Vmax - Vmin) / (Vmax + Vmin) * 100

for the respective beam axes. V values should lie within ± 3%. In addition, field flatness should
be evaluated at all other clinically relevant depths and for each nominal photon beam energy.

4.2.2 Stability of flatness with gantry rotation

Gantry angle Measured Flatness Tolerance

0°
90° ≤ 3% ***
180°
270°

*** Deviation between the doses at lateral points and the radiation beam axis must
remain within .97 and 1.03. It should be ensured that the stability of the flatness with gantry
rotation is checked at the reference depth. This check should be repeated for a range of field
sizes and all nominal beam energies.

10
4.2.3 Symmetry

With regard to symmetry, the ratio between measured values for each pair of
symmetrical points (with respect to beam axis) for a range of field sizes and gantry orientations
must lie between .98 and 1.02 within the central 80% flattened beam area.

4.2.3.1 Symmetry vs Gantry angle

Place a Kodak X-Omat V film at a depth of dmax with SAD: 100 cm, field size 25 x 25 cm
and collimator at 0°. Irradiate the films at 0°, 90°, 180°, 270° gantry angles and compare the
asymmetry at different gantry angles. Alternatively, mount the Profiler to the head of the
machine and determine the asymmetry at different gantry angles.
Tolerance: 2%

++ Please attach transverse beam profiles and check films for evaluation of optical and
radiation beam congruence, field flatness and symmetry of the radiation field. The data
will be retained by the Division for records.

4.2.4 Beam contamination check

Ratio between maximum dose and :

dose at the depth of dose maximum Tolerance: ≤ 1.07
on radiation beam axis

4.3 Radiation field penumbra

Specified by manufacturer Measured

(lateral distance between 80% & 20% isodose line)
mm mm

4.4(a) Output calibration

Following a standard dosimetry formalism (e.g., IAEA Protocol 398), check the output
calibration of the accelerator for all available beam energies – photon as well as electron
beams. Apply the end correction factor, if relevant. Record information about the equipment
used and any current calibration factors. Take al least three output readings for each beam
energy at dmax. Record the MU1, MU2, time, and mechanical backup counter. Calculate the
dose per MU.

Tolerances: Dose Output: ± 2%

MU2 and mechanical backup: 2% agreement with MU1

4.4(b) Calibration check of Morning Output checker

Place the output checker in the beam as per morning set up procedure. Verify the
calibration by normalising the readings with the reference calibration field size (10 x 10 cm) and
compare with the tolerance values for each beam.
Tolerance: 1%

11
4.4(c) Output vs Gantry angle

Measure the output at isocentre for gantry angles of 0°, 90°, 180°, and 270° for each
beam. Calculate the ratio of the outputs at 90°, 180°, and 270° to that at 0°. Compare with the
baseline value.
Tolerance: 2%
4.4(d) Output factor constancy

Measure the output of the machine for different field sizes by placing an ion chamber on
the central axis in a phantom at the depth of SSD + dmax. Normalise the values with respect to
the reference field size of 10 x 10 cm. Compare the measured output factors with the baseline
values. Output factor constancy should be checked for each beam energy. Use a small ion
chamber for field sizes less than 6 x 6 cm. Use gantry angle: 0° and collimator angle: 0° for all
measurements.
Tolerance: 2%

4.4(e) Head and Phantom Scatter Constancy

Place an ion chamber in a midi-phantom so that electronic equilibrium condition is

satisfied for the beam energy under consideration. Set the phantom at SAD (or at a large
distance for field sizes ≤ 6 x 6 cm ) and ensure that active volume of the chamber is not in dose
gradient region. Take measurements for different field sizes and calculate the head scatter
factor by normalising the measured values to reference field size (10 x 10 cm). Calculate
phantom scatter factors by dividing output factor with the corresponding head scatter factor.
Compare the results with the baseline values established at the time of commissioning.
Tolerance: 2%
4.4(f) Output vs Collimator jaws exchange

Set the phantom at normal SSD and place an ion chamber at SSD + dmax. Measure the
outputs for different field sizes defined by exchanging collimator jaws (e.g., 10 x 15 cm & 15 x
10 cm). If the difference between output values obtained from exchanged jaw fields is 2% or
less then take the mean value for output factor calculations. However, for differences greater
than 2% calculate output factors for each jaw separately for use in treatment planning
calculations. Establish the constancy of output factors as discussed above.

4.4(g) Output for field sizes defined by asymmetric jaws, MLC, and DMLC

Set the phantom at normal SSD and place the ion chamber at SSD + dmax along axis of
the beam. Measure the output for different field sizes defined by the asymmetric jaws, MLC and
DMLC jaws and compare the results with 3D TPS calculated values and baseline values
established at the time of the commissioning.
Tolerance: 2%

4.5 Depth dose characteristics

The following measurements shall be carried out for a field size of 10 cm x 10 cm

defined at a source to surface distance of 100 cm and the radiation beam incident normally on a
homogeneous phantom having a flat surface. If the depth of dose maximum (dm) and %DD at
10 cm depth correspond to the values given in the Table 1, then these values can be used for
characterising the photon beam energy in MV.

12
 TABLE 1
Specifications for photon beam energy determination
Energy, MV Dm, cm %DD, at 10 cm depth

4 1.0 ± 0.2 62.5% ± 1.5%

5 1.3 ± 0.2 65.3% ± 1.0%
6 1.5 ± 0.2 67.1% ± 1.5%
8 2.0 ± 0.2 70.2% ± 1.5%
10 2.4 ± 0.2 73.5% ± 1.5%
15 3.0 ± 0.2 77.3% ± 2.0%
18 3.3 ± 0.2 80.0% ± 1.0%

4.5.1 Percent surface dose(Ds) :

(with respect to maximum axial dose)
4.5.2 Depth of dose maximum(dm) : , cm
4.5.3 % DD at 10 cm depth :

4.6 Quality index (QI)

The ratio of the ionisation (J20 / J10) measured at 20 cm and 10 cm depths respectively
for a field size of 10 cm x 10 cm at the detector level and with a constant source - detector
distance (e.g., 100 cm) is called Quality index (QI). Quality index is also termed as Tissue -
phantom Ratio (TPR). QI is always less than 1 and tends to 1 with increasing photon beam
energy. Hence, QI is defined as
J20
QI = ⎯⎯
J10

Under condition of infinite SSD, ionisation and absorbed dose ratios are identical. Table
2 presents QI values for a few selected beam energies. Values for intermediate energies can be
obtained by interpolation.

TABLE - 2
Quality Index for a few Photon Beam Energies
Nominal Energy Quality Index
4 MV 0.629 ± 0.015
6 MV 0.676 ± 0.009
9 MV 0.716 ± 0.012
12 MV 0.740 ± 0.001
18 MV 0.771 ± 0.005
23 MV 0.781 ± 0.001

4.7 Energy stability verification

Measuring the quality index periodically and comparing it with the corresponding base
line value check energy stability. This check assures that the beam energy has not changed
over the test interval.

13
 Variation in quality index (J20 / J10) :
with time Tolerance: ± 1%

4.8 Variation of dm and Ds with field size

Since there is considerable variation in the values of dm and Ds with field size, it should
be carefully measured and documented for planning calculations.

Variation of Ds and dm with Field Size (Fs)

Test Fs, cm x cm
5x5 10x10 15x15 20x20 25x25 30x30 40x40
Dm, cm

%Ds

Note: The variation of Ds and dm with Fs must be determined for each nominal beam energy.
Please enclose central axis depth dose profiles for above fields for our records.

4.9 Wedge Factors

Wedge factor measurement should be done at the depth of dose maximum along the
radiation beam axis at 0° & 180° collimator position for all wedge fields and wedge angles
supplied with the accelerator. However, if motorised / dynamic / or auto-wedge filter is being
used for the treatment, then respective wedge factor should be measured at the depth of dose
maximum. Wherever the aforementioned wedge angles are not appropriate, the wedge angles
in use should be used for wedge factor determination.

Wedge factor Wedge angle

15° 30° 45° 60°

Measured
Specified, by the manufacturer

Note: Wedge factors shall also be measured for “LEFT” and “RIGHT” orientations for 270° and
at 0° and 90° for “IN” orientation to observe any change with collimator orientation (chambers
shall be accurately centred for these measurements). Wedge factor also depends on the depth
of measurement and depth dependence must be correctly determined for planning calculations.

4.10 Blocking Tray Transmission

The transmission of the blocking tray is measured using an ion chamber in a phantom
under the condition listed below with and without the tray in place. Compare with baseline value.

Field size: 10 x 10 cm and 20 x 20 cm

SCD: 100 cm
Depth: 5 cm
Tray thickness: 9 mm PMMA Tolerance: 2% (1%)

14
5. Electron Beam Characteristics

Linac capable of producing electrons of different beam energies, it is necessary to carry

out the following checks for each nominal beam energy.

5.1 Congruence between optical and radiation fields

The congruence between optical and radiation field should be assessed at the depth of
the reference plane with a distance between source and the entry surface on the phantom
corresponding to the normal treatment distance. These checks should at least be carried out for
square fields: 5 cm x 5 cm, 10 cm x 10 cm and 30 cm x 30 cm (or for a field of maximum
dimensions) defined at the level of the reference plane in normal conditions of use; for gantry
positions of 0°, 90°, 180° and 270° and for each nominal electron energy. In all cases, the
separation between optical field edge and the 50% isodose line must be ≤ 2 mm for all
field dimensions.

5.2 Flatness and Symmetry

Flatness and symmetry should be checked at the depth of the reference plane for
normal conditions of use. The distance between source and the entry surface on the phantom
should correspond to the normal treatment distance. All measurements should be performed for
large fields (≥ 15 cm x 15 cm) and at least one measurement with the field of maximum
dimensions at the level of reference plane. Measurements should be repeated for gantry
positions of 0°, 90°, 180° and 270°, for each nominal beam-energy.

5.2.1 Flatness

Along X - axis :
Along Y - axis : Tolerance: R ≥ 0.85
Along diagonal axis :

Where, R = L90% / L50%,and

L90% and L50% are widths of 90% & 50% isodoses.

5.2.2 Maximum dose

Maximum value of dose :

in the radiation field
Tolerance: ≤ 103%
5.2.3 Symmetry

Ratio of the doses at :

symmetrical points within the
area defined by the 90% isodose
Tolerance: ± 2%

Note: Check films and transverse beam profiles for all the fields and beam energies, available
on the unit, should accompany this data sheet for our records. Some alternative methods for
checking field flatness and symmetry of electron beam profiles are given in Appendix 3 for
reference.

15
5.2.4 Stability of Flatness

The stability of flatness during rotation of gantry has to be verified (1) at gantry positions
of 0°, 90°, 180° and 270°, (2) at the reference depth in a phantom, and (3) for maximum field
size available. The points of measurements are chosen simultaneously on the radiation beam
axis and laterally on the major axes of the field at 2/3 of the distance between the centre and
edge of the light field.

Ratio of dose at lateral points and :

dose on the radiation beam axis
Tolerance: shall remain within 0.97 & 1.03

5.3 Radiation field penumbra

It is lateral distance between 80% and 20% isodose lines. All measurements are done at
the reference depth, which is usually at dmax .Penumbra width should be measured for all beam
energies.

Penumbra width :

5.4 Energy verification

The nominal energies of electron beams are tested using "range-energy" relationship.
The energy distribution at the surface of the medium is characterised by model energy, Ep,0
(MeV) which is related to the extrapolated practical range, Rp,(cm) in water by the formula:

Ep,0 = C1 + C2 * Rp + C3 * Rp 2
Where,
C1 = 0.22 MeV, C2 = 1.98 MeV . cm-1 & C3 = 0.0025 MeV . cm-2

The mean energy, E0 , is related to 50% range, R50, (cm) by the formula:
_
E0 = 2.33 * R50

Note: Rp and R50 should be determined under reference conditions, using sufficiently large
field size to ensure electron diffusion conditions.

5.5 Energy stability verification

Ratio of ionisation (J2) measured :

at a depth of near 50% value of dose Tolerance: ± 4%
maximum to ionisation (J1) measured
at the depth of dose maximum

16
5.6 Variation of surface dose and depth of dose maximum with field sizes

Field size, cm x cm
Test 5x5 10x10 15x15 20x20 30x30
Percent surface dose(Ds)
(with respect to the dose maximum)
Depth of dose maximum(dm), cm

5.7 Electron beam air-gap corrections

Air-gap correction factors are measured for all electron energies using an ion chamber in
a polystyrene phantom placed at the isocentre for a 10 x 10 cm field at dmax. Measure air-gap
corrections for the clinical range of applicators and compare with the baseline data obtained at
commissioning.
Tolerance: 2%

5.8 Arc Mode

Check a range of MUs and arc lengths, and compare stop angles and MUs delivered.
Also measure the doses delivered for the arc and compare to the doses delivered to that for the
static reference field.

Position a cylindrical chamber in air at isocentre. For each gantry angle, measure the
open field and the scanned field exposure. At gantry angles of 90° and 270°, also measure
exposure for collimator angles of 90°. Calculate the ratio of the scanned field to the reference
field outputs. (Note: check gantry clearance before commencement of arc mode tests).

Tolerance: 3% or 1 MU, whichever is greater, for arc angles between 45° and 89°
2% or 1 MU, whichever is greater, for arc angles 90° or greater

(Note: Measured dose for an arc should be within 2% of the static dose measured at 0°).

6. Dose Monitoring System

It should be ensured that for a given nominal beam energy, the monitor response is
independent of dose rate, the direction of the radiation beam, temperature and pressure. The
variation of monitor response with dose rate is related to the ion recombination in monitor
chamber due to inadequate voltage supply to the chamber. Hence, monitor should be calibrated
for each dose rate in clinical use.

6.1 Reproducibility

Reproducibility is defined in terms of Coefficient of variation, C and calculated from:

C = 100 * Rσ / Rav
Where, Rσ is standard deviation and Rav is the mean of observations R. If Ri is the ratio between
the ith "monitor units" and "the units indicated by the dosimeter" and n is the number of
measurements (at least 10 measurements should be made for one nominal energy in photon

17
mode and one nominal energy in electron mode within the range of dose rates commonly used
in actual clinical situations), then

n
Rσ = √ {Σ (Ri - Rav)2 / n}
i
n
Rav = Σ (Ri / n)
i

Coefficient of variation (measured : Tolerance: ±0.5%

for 20 cm x 20 cm field size at
normal treatment distance)

Note : These measurements should be made with both gantry and collimator at 0°.

6.2 Linearity

The linearity of a monitor is defined as follows: if L is the reading on a calibrated

dosimeter placed at calibration depth for calibration field size and U is the corresponding
Monitor chamber reading then the quotient, S, of L & U determines the monitor linearity
response. This measurement is done with both gantry and collimator at 0°, increasing number of
monitor units, one nominal energy in electron mode, one nominal energy in photon mode and
accelerator operating within the range of dose rates most commonly used. Hence,

S=L/U

S factor :
(at least 10 measurements should be
taken to verify monitor linearity response) Tolerance: ±1%

6.3 Dependence of monitor response on gantry rotation

With gantry at 0°, 90°, 180° and 270° a series of measurements are made with a dose
rate within the range commonly used in clinical practice. Calculate the mean of the
measurements corresponding to each gantry position and the mean of the sum, Rm. If Rmax
and Rmin are the maximum and minimum values of the mean respectively, then the ratio H is
defined by:

Rmax - Rmin
H = ---------------------- * 100
Rav

6.3.1 Stationary Beam Radiotherapy :

6.3.2 Moving Beam Radiotherapy :

(measurements are made during
a scan of 45° in different ranges
and two different directions) Tolerance: H ≤ 3%

18
6.4 Dependence of the monitor response on field shape

The jaws of the collimator can influence the monitor response. In order to quantify this
effect, measurements are made with two fields of dimension: 5 cm x 30 cm and 30 cm x 5 cm,
normal to each other. The detector is maintained in the same position relative to the short side
of the field. Give a dose, say, of 100 MU and take at least five readings for each field shape.

Detector Response
Field size, cm x cm 1 2 3 4 5 Ave.
5 x 30
30 x 5

6.5 Stability of the monitor response with Time

Test Readings
1 2 3 4 5 6
Monitor response, at different times of
the day

Monitor response, at different days of

the week
Tolerance: ≤ 2%

Note: This test shall be carried out for each nominal beam energy, in use.

7. Treatment Table

The treatment table should be carefully evaluated for it’s various motions and
movements so that it could be used for patient treatment with confidence. Besides performing
the tests described herein under, all linear and angular scale markings should also be checked.

7.1 Vertical movement

Amplitude of horizontal movement of :

the projection of the cross-wire when the
the table is moved vertically by ± 20 cm
on either side of the normal treatment distance
Tolerance: ± 2 mm
7.2 Isocentric rotation

Fix a sheet of paper on the top of the table, which is at the height of isocentre and with
table half extended longitudinally, rotate throughout its circular course. Observe the shift in
cross-wire position during the rotation. Repeat this procedure at least 3 times and record the
observations.

1 2 3
Diameter of the circle described :
by the projection of the cross-wires
Tolerance: ≤ 2 mm

19
7.3 Longitudinal movement

Changes in the height of table top :

when the table, at the level of isocentre,
is moved longitudinally through it’s full length
Tolerance: ≤ 5 mm

7.4 Transversal movement

Changes in the height of table top :

when the table, at the level of
isocentre, is moved transversally
through it’s full length
Tolerance: ≤ 2 mm

7.5 Verification of graduations

Linear scales : Tolerance: ≤ 2.5 mm

Rotational scales : Tolerance: 1°

8. Measurements of Radiation Transmission through Beam Limiting Jaws

Measurements of radiation transmission through beam limiting jaws shall be made with
any residual aperture shielded by at least two TVL of x-ray shielding material. For non-
overlapping jaws, measurements shall be made at minimum radiation field size.

8(a) Each beam limiting jaw (excluding MLC jaws) shall attenuate x-radiation such that kerma
rate due to transmitted radiation does not exceed 2% of the maximum kerma rate
measured along the central axis of the beam at NTD in a 10 x 10 cm radiation beam.

8(b) For radiation fields of any size, the average kerma rate due to transmission through the
beam limiting jaws, including MLC jaws, shall not exceed 0.75% of the maximum kerma
rate on the central axis at NTD in a 10 x 10 cm radiation field.

If this limit is exceeded when areas of greater than 300 cm2 at NTD are protected by
MLC jaws, the conditions under which the limit is exceeded and the extent to which the limit is
exceeded shall be stated by the vendor of the equipment.

8(c) When a MLC is provided that by itself does not comply with the requirements of (a) & (b)
above, and consequently requires adjustable of interchangeable jaws in order to comply, these
shall be adjusted automatically to provide the minimum size radiation field surrounding the
radiation fields defined by MLC jaws.

The kerma rate due to transmitted radiation through the parts of a MLC jaws that project
into the rectangular field formed by the automatically adjustable jaws, referred to above,
shall not exceed 5% of the maximum kerma rate measured along the central axis at
NTD in a 10 x 10 cm radiation field.

20
9. Leakage Radiation Measurements

Measurements Tolerance

9.1 Kerma rate due to leakage radiations :

(excluding neutrons) at any point outside the : ≤ 0.2% of the air kerma rate on
useful beam but inside a plane circular area : the axis at same distance
of radius 2 m centred around and perpendicular :
to the central axis of the beam at normal :
treatment distance

9.2 Kerma rate due to leakage radiations : ≤ 0.5% of the air kerma rate on
(excluding neutrons) at 1 m from the path : the central axis of the beam
of electrons between their origin and the :
target or electron window :

9.3 Kerma rate of leakage radiation through : Imparts less energy to patient
adjustable beam limiting devices : than a treatment field of 10 cm2

9.4 Contribution of the neutrons dose to overall patient dose

9.4.1 Inside the treatment area : < 0.1% of the photon dose rate

9.4.2 Outside the treatment area : Negligible

Note: State clearly the experimental set-up and detectors used for photon and neutron
leakage radiation levels measurement.

9.4.3 Experimental set up :

9.4.4 Detectors used :

** Appendix 4 describes procedure for leakage radiation measurement.

10. Survey of the Linac Installation

Draw a neat diagram (on a separate sheet of paper) of radiation installation indicating
clearly areas occupied by the radiation and non - radiation workers, including members of the
public. Earmark these locations as A, B, C,......, etc. Measure air kerma rate (of photons and
neutrons separately) at these locations under maximum scattering conditions for four cardinal
gantry positions of 0°, 90°, 180° and 270°. These measurements are essential for evaluation of
the safety integrity of radiation installation. Appropriate build-up caps should be used wherever
necessary. Tabulate the kerma rate values for analysis and evaluation.

21
10.1 Measured kerma rate levels for-------------------------------------- MV accelerator

Gantry Position Photon air- kerma rate at the location

A B C D E F G H I
0°
90°
180°
270°

10.2 Comments, if any:

11. Miscellaneous

List of Instruments and Accessories Used

Sr. No. Equipment used Date of calibration Pressure & Polarity effect
Temperature correction correction, if any
1.

2.

3.

4.

5.

6.

7.

Measurements carried out by Measurement results verified out by

Signature: Signature:
Name : Name:
Designation: Designation:
Date : Date:

22
 APPENDIX 1

Reference Conditions

For the different measurements, it is preferable to use as the depth of the reference
plane, the recommended values established as function of the type and energy of the radiation
beam (NACP, 1980, AAPM, 1983; CFMRI No.2. 1986).

For measurements within photon beams, the reference plane should pass through the
isocentre of the electron accelerator. If not, the entry surface on the phantom is placed at the
normal treatment distance.

For measurements within electron beams, the entry surface on the phantom is placed at
the normal treatment distance. The phantom should be large enough to allow conditions of
maximal electron diffusion.

Measurements are made either on the radiation beam axis or in a plane perpendicular to
the radiation beam axis, at a depth within a "water- equivalent" phantom chosen from the table
below.
Photon Beam
Nominal energy, MV Depth of reference plane, in water phantom Field size, at NTD
E < 10 5 cm 10 cm x 10 cm

E ≥ 10 10 cm 10 cm x 10 cm

However, it is prudent to use a single depth of 10 cm for reference plane for all beam energies.

Electron Beam
Energy, Ep, MeV Depth of reference plane, in water Field size, at NTD
1≤E<5 Maximum absorbed dose on central axis 10 cm x 10 cm
5 ≤ E < 10 Dose maximum or 1 cm 10 cm x 10 cm
10 ≤ E < 20 Dose maximum or 2 cm 10 cm x 10 cm
20 ≤ E < 30 Dose maximum or 3 cm 10 cm x 10 cm
30 ≤ E < 50 Dose maximum or 3 cm 15 cm x 15 cm

23
 APPENDIX 2
Essential Equipment Required for Dosimetric Measurements

1. Essential dosimetric equipment

1.1 Two ionisation chambers: One cylindrical and one flat (preferably with no polarity effect);
1.2 Associated electrometer - with preferably two opposite polarities and dual voltages;
1.3 Solid phantom - an assembly of tissue equivalent plates of different thickness;
1.4 Water phantom;
1.5 Radiographic films;
1.6 Photo-densitometer with manual or automatic scanning system;
1.7 Barometer;
1.8 Thermometer;
1.9 Chronometer

Other accessories are also required to carry out mechanical checks (e.g., precision spirit
level, plumb line, etc).

2. Dosimetric measurements

Several types of detectors can be used for dosimetry. The most commonly employed
detectors are:

♦ Ionisation chamber (cylindrical or flat),

♦ Radiographic films,
♦ Semiconductor diodes,
♦ Thermoluminescent dosimeters

The performance requirements of measuring instruments depend on the condition of

their use. In order to obtain good reproducibility of the measurements, it is recommended that
the irradiation and environmental conditions should correspond to those prevailing during the
reference measurement and to verify the stability of the monitor response with time or to make
the necessary corrections in case of eventual differences.

2.1 Ionisation chambers

Air cavity ionisation chambers are the detectors of choice for most measurements. They
shall meet requirement that: (a) their response is relatively independent of the influence of the
beam characteristics (beam quality, dose and dose rate) and (b) they possess good
reproducibility and repeatability. Cylindrical chambers which can be used for photon beams or
for electron beams with an energy of 10 MeV or more should preferably be small (internal
diameter < 6mm, length < 25 mm). The leakage and parasite currents produced in the chamber
and associated electrometer assembly shall be negligible fraction of the current measured
during irradiation of the chamber - particularly for measurements of low doses made at large
depths in the medium as well as at the edges and outside of the beam. For electron energies of
less than 10 MeV, flat chambers are recommended. When a polarity effect (particularly strong in

24
some flat chambers) is present, it is necessary to use the average of the measurements
obtained with negative polarity and positive polarity for all conditions of measurement.

2.2 Film dosimetry

Films give practical and rapid indications of the dose distribution in a given plane. The
advantage of films lies in their high spatial resolution, which is particularly useful in regions of
high dose gradients. The sensitometric curve depends on type of the film used and can even
vary between different batches of the same emulsion. It is therefore necessary to verify the
sensitometric curve for each batch. If the curve is not linear, the necessary corrections for non-
linearity need to be applied for correct dose evaluation. The film development process also
plays a vital role in dosimetry and needs to standardised with care.

2.3 Solid state detectors

Semiconductor diodes should only be used for relative measurements. Because of their
small size, they are particularly suitable for measuring dose distributions in regions of high dose
gradients. The use of these dosimeters requires some particular precautions since their
response exhibit dependence on energy, beam direction and temperature. In addition, large
variations in sensitivity can occur as they age.

Thermoluminescent dosimeters (most commonly used for in-vivo dosimetry) give

measurements of dose distribution with high precision as long as some particular precautions
are taken during their calibration:

• materials which present small variations with beam quality should only be used,
• calibration should be carried out with a suitable reference dosimeter in conditions close to
the actual use conditions,
• validity of the calibration limits should preferably be determined by testing (with a reference
dosimeter) the behaviour of the thermoluminiscent dosimeters when for example, the
energy, the depth and the dimensions of the field are varied.

In addition, it is necessary to determine the dosimetric properties of thermoluminiscent

dosimeters for each reader system, since the results obtained can vary greatly from one
installation to another.

3. Phantoms

All measurements should preferably be carried out in a water phantom but practical
considerations may necessitate the use of solid tissue-equivalent phantoms. However, it should
be mandatory to study the characteristics of the solid phantom before its use in practical
dosimetry studies. This will facilitate inter-comparison of the measured values in different
phantoms and thereby lead to proper interpretation of the experimental data.

25
 APPENDIX 3

Some Alternative Definitions of Field Flatness and Symmetry

Some manufacturers prefer to define electron beam field flatness(Fs) as follows:

Fs = 100 * (Imax - Imin)/(Imax + Imin)

Where, Imax and Imin are maximum and minimum intensities within the region 1.5 cm inside
field borders (50% intensity level). Tolerance limits are 5% for low energy electron beams upto 9
MeV and 3% beyond 9 MeV.

Field Symmetry: Field symmetry (Ss) is defined by these manufacturers by the following
equation:

Ss = 100 * |AL - AR| / |AL + AR|

Where, AL and AR are areas under the left and right halves of the profile. Tolerance limit is 2%.

AAPM definition of Field Flatness & Symmetry

AAPM has adopted the following definition for field flatness:

Fa = 100 * (Imax - Ica) / Ica , and

Fa = 100 * (Ica - Imin) / Ica

whichever is greater. The maximum and minimum signals are determined over the range of 2
cm inside the field borders. Ica is the signal on the central axis. Tolerance limit is 3% while 5%
is considered acceptable.

Field Symmetry is defined by AAPM as follows:

Sa = 100 * |Il / Ir - 1|

Where, Il and Ir are signals at two most asymmetric points within the region 2 cm inside the
geometric field borders. The tolerance limit is 2%.

Any of these definitions could be used for testing flatness and symmetry of a clinical
electron beam because definitions given in the main text and above give clinically acceptable
results.

26
 APPENDIX 4
Leakage Radiation Measurement on a Medical Linear Accelerator

Leakage radiation is the radiation that emerges from the source housing through its
protective barriers. Besides, in an electron accelerator, some of the electrons being accelerated
may hit wave-guide tube and thus produce off-target radiations. Accelerators operating at
potentials 10 MV or above produce unwanted neutrons with a range of energies. Contributions
of each component must be evaluated separately. It is mandatory to keep leakage radiation
levels within the limit prescribed by the national competent authority.

The equipment shall be provided with radiation shielding which shall be so designed that
the kerma rate due to leakage radiation (excluding neutrons) at any point outside the maximum
useful beam, but inside a plane circular area of radius 2 m centred around, and perpendicular
to, the central axis of the beam at the normal treatment distance, shall not exceed 0.2% of air-
kerma rate on the axis at the same distance. The air-kerma rate should be measured with the
useful beam blocked with thick absorbing plug. Except in area defined above, the kerma rate of
leakage radiation (excluding neutrons) at 1 m from the path of electrons between their origin
and the target or electron window shall not exceed 0.5% of air-kerma rate on the central axis of
the beam at the normal treatment distance.

The contribution of neutrons to the dose inside and outside the treated area should be
kept as low as practicable. Inside the field the neutron tissue-kerma rate should be kept below
1% of the x-ray kerma rate. Measurements made in primary beam from electron accelerator
have indicated that dose equivalent rate of neutrons does not exceed 1% of the dose equivalent
rate of photons (NBS Special Publication 554). This implies that the neutron absorbed dose rate
is never greater than 0.1% of photon dose rate and makes only a small addition to the
therapeutic dose. Neutrons outside the primary x-ray beam make only marginal contribution to
the integral dose received by the patient. Outside the treated area the neutron kerma rate shall
be reduced as far as practicable.

The adjustable beam limiting diaphragms shall be so constructed that leakage radiation
imparts less energy to the patient than is imparted by a treatment field of 10 cm2. This implies
that for a field of 10 cm x 10 cm the leakage radiation shall contribute less than 10% of the
energy imparted by the useful beam. Similarly, if the maximum field size is 35 cm x 40 cm, the
transmission of radiation through the diaphragms shall not exceed 0.8 %.

X-ray and electron accelerators working above 10 MeV may produce a significant
amount of photo-disintegration of the nucleus. For most elements, the threshold for photo-
disintegration occurs between 10-20 MeV. A variety of methods - like activation foils, P2O5,
track registration in organic foils, BF3 and other counters in moderating hydrogenous spheres, -
could be used to measure the neutron contribution to the patient dose. More than one
measurement technique should be used to get reliable results.

27
 Measurements outside the treatment room have in some instances shown a significant
dose equivalent rate of neutrons outside the door to the labyrinth. Care should therefore be
taken both at design stage and during protection surveys to ensure that there is no significant
hazard from neutrons outside the treatment room.

The presence of neutrons in the primary beam may also result in measurable
radioactivity in components of diaphragm, target, etc. The amount of radioactivity shall be
evaluated and adequate precautions should be taken to avoid unnecessary exposures during
patient set-up.

Geometry of leakage measurement

The leakage radiation through the source housing in beam "ON" position should be
measured as follows:

Choose 16 measurement points located on the surface of a sphere of radius 1 m from

the source. Take 2 points on the poles of the sphere, 4 equally spaced points on its equator and
distribute the remaining points uniformly on the surface of the sphere. Close the diaphragms
completely with at least 3 TVL of lead or any other suitable shielding material. Measure air-
kerma rates at these 16 points individually. Ensure that the kerma rates due to leakage radiation
are within the prescribed limits given above.

28