2010 ACMP Annual Meeting

San Antonio, Texas

Task Group 142 report: Quality

assurance of medical accelerators
2009

Chris Serago, Ph.D.

TG 142 member

Many slides are borrowed from Eric Klein

Task Group 142 report:
Quality assurance of medical accelerators

Eric E. Klein, Chair

Washington University
Joseph Hanley John Bayouth
Hackensack University Medical Center University of Iowa
Fang-Fang Yin William Simon
Duke University Sun Nuclear Corp.
Sean Dresser Christopher Serago
Northside Hospital Mayo Clinic
Francisco Aguirre Lijun Ma
M. D. Anderson Cancer Center University of California, San Francisco
Bijan Arjomandy Chihray Liu
M. D. Anderson Cancer Center University of Florida
Consultants:
Carlos Sandin Todd Holmes
Elekta Oncology Varian Medical Systems
Task Group Charge

Charge: 1. To update, as needed, recommendations of Table 11 of the

AAPM TG-40 (1994) Report on Quality Assurance. 2. To add
recommendations for asymmetric jaws, multileaf collimation, and
dynamic/virtual wedges.

New Technology since TG 40

MLC, Asymmetric Jaws, Dynamic & virtual wedges
EPIDs
Imaging: kV and cone beam
Respiratory gating

Clinical procedures not emphasized in TG 40

SRS, SBRT, TBI, IMRT

Refinements to linear accelerators since TG 40

Since TG 40 (1994)
TG 50: AAPM REPORT NO. 72, Basic applications
of multileaf collimators (2001)

TG 58: AAPM REPORT No. 75, Clinical use of electronic

portal imaging: (2001)

TG 76: AAPM REPORT No. 91, The management of

respiratory motion in radiation oncology (2006)

TG 106: Accelerator beam data commissioning equipment

and procedures: A suggested protocol (2008)

TG 104: AAPM REPORT No. 104, The role of in-room kV x-

ray imaging for patient setup and target localization
(2009)

TG 100: Method for evaluating QA needs in radiation

therapy (Future date??)
Background to TG 142

The underlying principle behind TG-40 was the International

Commission on Radiation Units and Measurements
(ICRU) recommendation that the dose delivered to the patient
be within +5% of the prescribed dose.

Taking into consideration the many steps involved in delivering dose to

a target volume in a patient, each step must be performed with
accuracy better than 5% to achieve this recommendation.

The goal of a QA program for linear accelerators is to assure that the

machine characteristics do not deviate significantly from their
baseline values acquired at the time of acceptance and
commissioning.
Linac QA TG-40 (1994)
Daily
TG 40 Monthly
TG 40 Annually
MLC QA per TG-50 (2001)
TG-58 (EPIDs) (2001)
The Resource Problem
Lack of adequate guidance for resource
allocation
Lack of qualified personnel
Rapid implementation of new technology
– More sophisticated equipment
– More resources
– Clinics are under pressure to
implement new technology
Lack of timely guidelines
Task Group No. 100: Method for Evaluating QA Needs in
Radiation Therapy

Initially “Replacement for TG-40”

New approach compared to previous AAPM
recommendations and philosophy
Based on “Failure Modes and Effects
Analysis”
Individual departments responsible for
development of unique QA programs
Based on procedures and resources
performed at individual institutions
Failure Modes and Effects Analysis
Three part system
– Frequency of error
– Severity of error
– Probability that an error would be detected

Probability of Severity Probability of RPN

error detection

A B C A*B*C
Risk Priority Number (RPN) = Frequency*Severity*Probability
Proposed Quality Assurance
Process

Custom designed QA programs

AAPM Report will provide templates
Scoring performed by individual departments
Tolerances set by individual departments
Annual evaluation and modifications based
on score changes
Task Group No. 142:
QA of Medical Accelerators
I. INTRODUCTION
A. Purpose
B. Background

II. QUALITY ASSURANCE OF MEDICAL ACCELERATORS

A. General
B. Test Frequencies
C. Guidelines for Tolerance Values
D. Ancillary Devices Not in TG-40
Asymmetric Jaws
Dynamic/Virtual/Universal Wedges
MLC
TBI/TSET
Radiographic Imaging
Megavoltage Planar Imaging (Portal Imagers)
Planar kV Imaging
Serial and Cone-
Cone-Beam CT
Respiratory Gating

III. SUMMARY OF RECOMMENDATIONS/IMPLEMENTATION SCHEME

BACKGROUND
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
Machine parameters can deviate from their baseline values as a result
of many reasons
– Machine malfunction
– Mechanical breakdown
– Physical accidents
– Component failure
– Major component replacement
– Gradual changes as a result of aging
These patterns of failure must be considered when establishing a
periodic QA program
QA of MEDICAL ACCELERATORS
What This Report Doesn’t Do
– Describe the techniques for performing QA tests (TG 198)
– Accelerator beam data commissioning equipment and procedures –
TG-106
– QA for TomoTherapy –TG-148
– QA for Robotic Radiosurgery – TG-135
– QA for Non-Radiographic Radiotherapy Localization & Positioning
Systems – TG-147
Does add Specific Recommendations / Supplements the
Work of
– Basic Applications of Multileaf Collimators – TG-50
– Clinical use of electronic portal imaging - TG-58
– Management of Respiratory Motion– TG-76
– Kilovoltage localization in therapy – TG-104
TG198 - An implementation guide for TG-
142: QA of medical linear accelerators

1) Provide specific procedural guidelines for

performing the tests recommended in TG-142.
2) Provide estimate of the range of times,
appropriate personnel and qualifications
necessary to complete the tests in TG-142. 3)
Provide Sample Daily/Weekly/Monthly/Annual
QA forms.
Task Group No. 142:
QA of Medical Accelerators

“The recommendations of this task group are not

intended to be used as regulations. These
recommendations are guidelines for qualified medical
physicists (QMP) to use and appropriately interpret for
their individual institution and clinical setting. Each
institution may have site-specific or state mandated
needs and requirements which may modify their usage
of these recommendations.”
Task Group No. 142:
Guidelines for Tolerance Values
The recommendations of TG-142 should be
flexible enough to take into account quality,
costs, equipment condition, available test
equipment, and institutional needs.
We do recommend using the tests and
frequencies outlined in the tables that follow,
until methods such as TG-100 supersede this
report.
Task Group No. 142: General

A Consistent beam profile is an important

quantity for accurate and reproducible dose
delivery in radiotherapy.
In our tables, the monthly tolerance values are
specific to a consistent beam shape, whereby
baseline off axis factors were measured with a
QA device immediately following
commissioning or annual data.
Ongoing QA measurements are compared to the
baseline off axis factors.
Task Group No. 142: General
Chosen O.A. point locations will generally fall within core of the field

1 N TPL − BPL
⋅ ⋅100% ≤ Tolerance %
N L =1 BPL

where: TPL and BPL are off-axis ratios at Test and Baseline Points,
respectively, at off axis Point L
N is the number of off-axis points
TPL = (MPL/MPC) where M represents the measurement value and C
is the central axis measurement.
Similarly, the baseline points are represented by BPL =
(MBPL/MBPC)
Task Group No. 142:
QA of Medical Accelerators

The types of treatments delivered with the machine

should also have a role in determining the QA
program that is appropriate for that treatment
machine.

For example, machines that are used for SRS/SBRT

treatments, TBI or IMRT require different tests and/or
tolerances.
Task Group No. 142:
Test Frequencies

In this report there are additional factors that affect the

frequency of the tests, specifically: the type of
treatments delivered on the machine; and the
manufacturer of the machine.

For example, electron output is to be tested more

frequently on a Siemens machine which possesses an
electron beam specific, unsealed monitor chamber
system, compared to the Varian machine with a multi-
modality sealed monitor chamber.
Task Group No. 142:
Guidelines for Tolerance Values
Acceptance Testing Procedure (ATP) Standards
– Acceptance testing sets the baseline for future dosimetric
measurements for beam performance constancy, verifies
that the equipment is mechanically functional and operates
within certain tolerances from absolute specified values.
Tolerances and Action Levels
– Level 1 – Inspection Action
– Level 2 – Scheduled Action
– Level 3 – Immediate Action or Stop Treatment Action or
Corrective Action
With these 3 action levels, there is an institutional need to specify
the thresholds associated with Levels 2 and 3. Level 1 threshold
isn’t a critical requirement but can lead to improvements in the
QA program.
TG-142: Daily
Tolerance
Tolerance (non- Tolerance (IMRT (Stereotactic
Procedure IMRT machines) machines) machines)
Dosimetry
X-ray output constancy (all energies)
Electron output constancy (Weekly, except 3%
for machines with unique e- monitoring
requiring daily)

Mechanical
Laser localization 2 mm 1.5 mm 1 mm
Distance indicator (ODI)@ iso 2 mm 2 mm 2 mm
Collimator size indicator 2 mm 2 mm 1 mm
Safety
Door interlock (beam off) Functional
Door closing safety Functional
Audiovisual monitor(s) Functional
Stereotactic interlocks (lockout) NA NA Functional
Radiation area monitor (if used) Functional
Beam on indicator Functional
Daily
Tolerance
Tolerance (non- Tolerance (IMRT (Stereotactic
Procedure IMRT machines) machines) machines)
Dosimetry
X-ray output constancy (all energies)
Electron output constancy (Weekly, except 3%
for machines with unique e- monitoring
requiring daily)

Mechanical
Laser localization 2 mm 1.5 mm 1 mm
Distance indicator (ODI)@ iso 2 mm 2 mm 2 mm
Collimator size indicator 2 mm 2 mm 1 mm
Safety
Door interlock (beam off) Functional
Door closing safety Functional
Audiovisual monitor(s) Functional
Stereotactic interlocks (lockout) NA NA Functional
Radiation area monitor (if used) Functional
Beam on indicator Functional
TG-142: Monthly

Tolerance (non- Tolerance (IMRT Tolerance

Procedure
IMRT machines) machines) Stereotactic machines

Dosimetry
X-ray output constancy
Electron output constancy 2%
Backup monitor chamber constancy
2% (@ IMRT dose 2% (@ stereo dose
Typical dose rate2 output constancy NA
rate) rate, MU)
Photon beam profile constancy
1%
Electron beam profile constancy
Electron beam energy constancy 2%/2mm
Monthly
Tolerance (non-
(non- Tolerance
Tolerance (IMRT
Procedure IMRT Stereotactic
machines)
machines) machines

Mechanical
Light/radiation field coincidence* 2 mm or 1% on a side
Light/radiation field coincidence*
(Asymmetric) 1 mm or 1% on a side
Distance check device used for lasers/ODI (vs.
front pointer) 1mm
Gantry/collimator angle indicators (@ cardinal
angles) (Digital only) 1.0 deg
Accessory trays (i.e. Port film graticle tray) 2 mm
Jaw position indicators (Symmetric)3 2 mm
Jaw position indicators (Asymmetric)1 1 mm
Cross-hair centering (walk-out) 1 mm
Treatment couch position indicators4 2 mm/1 deg 2 mm/ 1 deg 1 mm/ 0.5 deg
Wedge placement accuracy 2mm
Latching of wedges, blocking tray5 Functional5
Localizing lasers ±2 mm ±1 mm <±1 mm
Monthly
Tolerance (non-
(non- Tolerance
Tolerance (IMRT
Procedure IMRT Stereotactic
machines)
machines) machines
Monthly
Tolerance (non-
(non- Tolerance
Tolerance (IMRT
Procedure IMRT Stereotactic
machines)
machines) machines

Respiratory gating
Beam output constancy 2%
Phase, Amplitude beam control Functional
In room respiratory monitoring system Functional
Gating interlock Functional
TG-142: Annual
Tolerance
Tolerance (non- Tolerance (IMRT
Procedure Stereotactic
IMRT machines) machines)
machines
Dosimetry
X-ray flatness change from baseline 1%
X-ray symmetry change from baseline ±1%
Electron flatness change from baseline 1%
Electron symmetry change from baseline ±1%
Monitor units set vs.
delivered:1.0 MU or
2% (whichever is
SRS Arc rotation mode (range: 0.5 to 10 greater)
NA NA
MU/deg )
Gantry arc set vs.
delivered: 1.0 deg or
2% (whichever is
greater)
X-ray/electron output calibration (TG-51) ±1%(absolute)
Spot check of field size dependent output 2% for field size < 4x4 cm2, 1% 4x4 cm2
factors for X-ray (2 or more FS)
Output factors for electron applicators
±2% from baseline
(spot check of 1 applicator/energy)
X-ray beam quality (PDD10, TMR1020) ±1% from baseline
Electron beam quality (R50) ±1mm
Transmission factor constancy for all ±1% from baseline
treatment accessories
Physical wedge transmission factor ±2%
constancy
Annual
Tolerance (non-
(non- Tolerance
Tolerance (IMRT
Procedure IMRT Stereotactic
machines)
machines) machines

X-ray monitor unit linearity [output . ±5% (2-4 MU), ±2% ±5% (2-4), ±2%
±2% 5MU
constancy ] 5MU 5MU
Electron monitor unit linearity [output . ±2% 5MU
constancy ]
X-ray output constancy vs dose rate ±2% from baseline
X-ray output constancy vs gantry angle ±1% from baseline
Electron output constancy vs gantry ±1% from baseline
angle
Electron and X-ray Off-axis factor ±1% from baseline
constancy vs gantry angle
Arc mode (expected MU, degrees) ±1% from baseline
TBI/TSET Mode Functional
PDD or TMR and OAF constancy 1% (TBI) or 1mm PDD shift (TSET) from baseline
TBI/TSET Output calibration 2% from baseline
TBI/TSET accessories 2% from baseline
Annual
Tolerance (non-
(non- Tolerance
Tolerance (IMRT
Procedure IMRT Stereotactic
machines)
machines) machines
Mechanical
Collimator rotation isocenter ±1 mm from baseline
Gantry rotation isocenter ±1 mm from baseline
Couch rotation isocenter ±1 mm from baseline
Electron applicator interlocks Functional
Coincidence of radiation and mechanical ±2mm from
±2mm from baseline ±1mm from baseline
isocenter baseline
Table top sag 2mm from baseline

Table Angle 1 degree

Table travel maximum range movement

±2mm
in all directions
Stereotactic accessories, lockouts, etc NA Functional
Safety
Follow manufacturers test procedures Functional
Respiratory gating
Beam energy constancy 2%
Temporal accuracy of Phase/Amplitude
100 ms of expected
Gate-on
Calibration of surrogate for respiratory
100 ms of expected
phase/amplitude

Interlock testing Functional

Dynamic/Universal/Virtual Wedges
Dynamic-incl. EDW (Varian), Virtual (Siemens), Universal (Elekta) Wedge quality assurance
Frequency Procedure Tolerance
Dynamic Universal Virtual
Morning Check-out
Daily Functional
run for 1 angle
C.A.
C.A. Axis
Axis 45º 5% from
45º or 60°
Wedge factor for or 60° unity,
Monthly WF
all energies WF otherwise
(within
(within 2%
2%)*
2%)*
Check of wedge
angle for 60°, full Check of Off-center ratios @ 80%
Annual field & spot check field width @ 10cm to be within
for intermediate 2%
angle, field size
* Recommendation to check 45º if angles other than 60º are used.
Multileaf Collimation
Multi-leaf collimation quality assurance (with differentiation of IMRT vs. non-IMRT machines)
Frequency Procedure Tolerance

Visual inspection for discernable

Qualitative test (i.e. matched
Weekly (IMRT machines) deviations such as an increase in
segments, aka, “picket fence”)
interleaf trransmission

Setting vs. radiation field for

2mm
two patterns (non-IMRT)

Backup diaphragm settings

2mm
(Elekta only)

Travel speed (IMRT) Loss of leaf speed > 0.5 cm/sec

Monthly

1mm for leaf positions of an

IMRT field for 4 cardinal gantry
Leaf position accuracy (IMRT) angles. (Picket fence test may be
used, test depends on clinical
planning – segment size)
Multileaf Collimation: Annual Tests
MLC Transmission (Average of leaf and
±0.5% from baseline
interleaf transmission), All Energies

Leaf position repeatability ±1.0 mm

MLC spoke shot 1.0 mm radius

Coincidence of Light Field and X-ray Field

±2.0 mm
(All energies)
<0.35 cm Max Error RMS, 95% of error
Arc dynamic leaf-speed test
counts <0.35 cm (Varian)

Arc dynamic interlock trip test Leaf position interlock occurs (Varian)

<0.35 cm Max Error RMS, 95% of error

Arc dynamic typical plan test
counts <0.35 cm (Varian)
<0.35 cm Max Error RMS, 95% of error
Segmental IMRT (Step and Shoot) Test
counts <0.35 cm (Varian)
Moving window imrt (4 cardinal gantry <0.35 cm Max Error RMS, 95% of error
angles) counts <0.35 cm (Varian)
Imaging Tests: Daily
Non-SRS/SBRT Applications SRS/SBRT Applications
Procedure
Tolerances Tolerances
Daily
MV imaging (EPID)
Collision interlocks Functional Functional
Spatial linearity1 (x and y) (single gantry
< 2 mm 1 mm
angle)
Imaging & Treatment coordinate
< 2 mm 1 mm
coincidence (single gantry angle)

Positioning/repositioning < 2 mm 1 mm

KV imaging2
Collision interlocks Functional Functional
Imaging & treatment coordinate
< 2 mm 1 mm
coincidence

Positioning/repositioning < 2 mm 1 mm

Cone-beam CT (kV & MV)

Collision interlocks Functional Functional
Positioning/repositioning < 2 mm 1 mm
Imaging Tests: Monthly
Non-SRS/SBRT SRS/SBRT Applications
Procedure
Applications Tolerances Tolerances
MV imaging (EPID)
Imaging & treatment coordinate
< 2 mm 1 mm
coincidence (4 Cardinal angles)
Scaling3 < 2 mm < 2 mm
Spatial resolution Baseline4 Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline
kV imaging
Imaging & treatment coordinate
< 2 mm 1 mm
coincidence (4 Cardinal angles)
Scaling < 2 mm 1 mm
Spatial linearity (x and y) (single gantry
< 2 mm 1 mm
angle)
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline
Cone-beam CT (kV & MV)
Imaging & treatment coordinate
< 1.5 mm 1 mm
coincidence
Geometric distortion < 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
HU constancy Baseline Baseline
Uniformity and noise Baseline Baseline
Spatial linearity (x and y) (single gantry
< 1 mm 1 mm
angle)
Imaging Tests: Annual
Non-SRS/SBRT SRS/SBRT Applications
Procedure
Applications Tolerances Tolerances

MV imaging (EPID)
Full range of travel SDD ±5 mm ±5 mm
Imaging dose5 Baseline Baseline
Beam quality / energy Baseline Baseline
kV imaging
Beam quality / energy Baseline Baseline
Imaging dose Baseline Baseline
Cone-beam CT (kV & MV)
Imaging dose Baseline Baseline
SUMMARY OF RECOMMENDATIONS/
IMPLEMENTATION SCHEME

The tabulated items of this report have been considerably

expanded as compared with the original TG 40 report and
the recommended tolerances accommodate differences
in the intended use of the machine functionality (non-
IMRT, IMRT, and Stereotactic Delivery).
SUMMARY OF RECOMMENDATIONS/
IMPLEMENTATION SCHEME

1) A QA team support all QA activities and draft policies

and procedures. The policy should establish roles and
responsibilities. For QA measurements, detailed
instructions on equipment use, cross-calibration,
measurement frequency, and documentation of the
results should be provided.

2) The 1st step is to establish institution-specific baseline

and absolute reference values. The QA team needs to
meet and monitor the results against the established
values.
SUMMARY OF RECOMMENDATIONS/
IMPLEMENTATION SCHEME

3) A QMP should lead the QA team. The QMP provides

action level and methods of notification when tolerances
are exceeded.

4) Daily QA tasks may be carried out by a RTT using a

cross-calibrated dosimetry system that is robust and
easy-to-setup. Correction factors should be documented
in a permanent electronic or hardcopy format for
inspection purposes. The QMP should review and sign off
on the reports at least once per month.
SUMMARY OF RECOMMENDATIONS/
IMPLEMENTATION SCHEME

5) Monthly tasks should be performed by (or directly

supervised by) a QMP. It is recognized there is overlap of
tests for daily, monthly, and annual. This overlap should
have independence achieved with independent
measurement devices. This will identify trends that may go
undetected.

6) It is recommended annual measurements be performed by

a QMP. QA devices should be checked prior to
measurements. The measurements should be carried out
using commissioning quality equipment as recommended
the TG-106 report.
SUMMARY OF RECOMMENDATIONS/
IMPLEMENTATION SCHEME
7) End-to-end system checks ensure fidelity of overall
system. This can be done by creating plans typical of the
facility’s clinic, transferring the plan data across the data
network, and delivering them.

8) During the annual QA, absolute outputs should be

calibrated as per TG51. Subsequently, all secondary QA
dosimeters should be cross-checked against such
calibrations.
SUMMARY OF RECOMMENDATIONS/
IMPLEMENTATION SCHEME

Upon completion of the measurements, an annual QA

report be generated. The report should state
significant findings based on tolerance values. The
report can be divided into sections; (1) Dosimetry,
(2) Mechanical, (3) Safety, (4) Imaging, and (5)
Special Devices/Procedures. The QA report should
be signed and reviewed by the QMP and filed for
future machine maintenance and inspection needs.