1

of 21
Linac QA

Daily
Machine-type tolerance
Procedure Non- IMRT SRS/SBRT
IMRT
Dosimetry
X-ray output constancy (all energies)
Electron output constancy (weekly, 3%
except 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
 2 of 21
Linac QA

Monthly
Machine-type tolerance
Procedure Non- IMRT SRS/SBRT
IMRT
Dosimetry
X-ray output constancy
Electron output constancy 2%
Backup monitor chamber constancy
Typical dose rate output constancy NA 2% (@ IMRT dose 2% (@ stereo dose rate, MU)
rate)
Photon beam profile constancy 1%
Electron beam profile constancy 1%
Electron beam energy constancy 2%/2 mm

Mechanical
Light/radiation field coincidence 2 mm or 1% on a
side
Light/radiation field coincidence 1 mm or 1% on a
(asymmetric) side
Distance check device for lasers 1 mm
compared with front pointer
Gantry/collimator angle indicators (@ 1.0
cardinal angles) (digital only)
Accessory trays (i.e., port film graticle 2 mm
tray)
Jaw position indicators (symmetric) 2 mm
Jaw position indicators (asymmetric) 1 mm
Cross-hair centering (walkout) 1 mm
Treatment couch position indicators 2 mm/1 2 mm/1 1 mm/0.5
Wedge placement accuracy 2 mm
Compensator placement accuracy 1 mm
Latching of wedges, blocking tray Functional
Localizing lasers 2 mm 1 mm <1 mm

Safety
Laser guard-interlock test Functional

Respiratory gating
Beam output constancy 2%
Phase, amplitude beam control Functional
In-room respiratory monitoring system Functional
Gating interlock Functional
 3 of 21
Linac QA

Annual
Machine-type tolerance
Procedure Non- IMRT SRS/SBRT
IMRT
Dosimetry
X-ray flatness change from baseline 1%
X-ray symmetry change from baseline 1%
Electron flatness change from baseline 1%
Electron symmetry change from baseline 1%
SRS arc rotation mode (range: 0.510 NA NA Monitor units set vs
MU/deg) delivered: 1.0 MU or 2%
(whichever is greater) Gantry
are set vs delivered: 1.0 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
factors for x ray (two or more FSs) <4x4 cm2 , 1%
4x4 cm2
Output factors for electron applicators 2% from
(spot check of one applicator/energy) baseline
X-ray beam quality (PDD10 or TMR2010) 1% from
baseline
Electron beam quality (R50) 1 mm
Physical wedge transmission factor 2%
constancy
X-ray monitor unit linearity (output 2% 5 5% (2-4 MU), 5% (2-4 MU), 2% 5 MU
constancy) MU 2% 5 MU
Electron monitor unit linearity (output 2% 5 MU
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 angle 1% from
baseline
Electron and x-ray off-axis factor 1% from
constancy vs gantry angle baseline
Arc mode (expected MU, degrees) 1% from
baseline
TBI/TSET mode Functional
 4 of 21
Linac QA

Annually
Machine-type tolerance
Procedure Non- IMRT SRS/SBRT
IMRT
Dosimetry (continued)
PDD or TMR and OAF constancy 1% (TBI) or 1 mm
PDD shift (TSET)
from baseline
TBI/TSET output calibration 2% from baseline
TBI/TSET accessories 2% from baseline

Mechanical
Collimator rotation isocenter 1 mm from
baseline
Gantry rotation isocenter 1 mm from
baseline
Couch rotation isocenter 1 mm from
baseline
Electron applicator interlocks Functional
Coincidence of radiation and mechanical 2 mm 2 mm from 1 mm from baseline
isocenter from baseline
baseline
Table top sag 2 mm from
baseline
Table angle 1
Table travel maximum range movement 2 mm
in all directions
Stereotactic accessories, lockouts, etc. NA NA Functional

Safety
Follow manufacturers test procedures Functional

Respiratory gating
Beam energy constancy 2%
Temporal accuracy of phase/amplitude 100 ms of
gate on expected
Calibration of surrogate for respiratory 100 ms of
phase/amplitude expected
Interlock testing Functional

American Association of Physicsts in Medicine. Task Group 142 Report: Quality Assurance of Medical accelerators.
Med Phys . 2009;36:4197-4212.
 5 of 21
IGRT QA

Daily
Machine-type tolerance
Procedure Non-SRS/SBRT SRS/SBRT
Planar kV and MV (EPID) imaging
Collision interlocks Functional Functional
Positioning/repositioning 2 mm 1 mm
Imaging and treatment coordinate 2 mm 1 mm
coincidence (single gantry angle)

Cone-beam CT (kV and MV)

Collision interlocks Functional Functional
Imaging and treatment coordinate 2 mm 1 mm
coincidence
Positioning/repositioning 1 mm 1 mm
 6 of 21
IGRT QA

Monthly
Machine-type tolerance
Procedure Non-SRS/SBRT SRS/SBRT
Planar MV imaging (EPID)
Imaging and treatment coordinate 2 mm 1 mm
coincidence (four cardinal angles)
Scaling 2 mm 2 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline

Planar kV imaging
Imaging and treatment coordinate 2 mm 1 mm
coincidence (four cardinal angles)
Scaling 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
Uniformity and noise Baseline Baseline

Cone-beam CT (kV and MV)

Geometric distortion 2 mm 1 mm
Spatial resolution Baseline Baseline
Contrast Baseline Baseline
HU constancy Baseline Baseline
Uniformity and noise Baseline Baseline
 7 of 21
IGRT QA

Annually
Machine-type tolerance
Procedure Non-SRS/SBRT SRS/SBRT
Planar MV imaging (EPID)
Full range of travel SDD 5 mm 5 mm
Imaging dose Baseline Baseline

Planar kV imaging
Beam quality/energy Baseline Baseline
Imaging dose Baseline Baseline

Cone-beam CT (kV and MV)

Imaging dose Baseline Baseline

Klein E, Hanley J, Bayouth J, et al. Task Group 142 report: Quality assurance of medical
accelerators. Med. Phys. 2009; 36(9): 4197-4212. http://dx.doi.org/10.1118/1.3190392.
 8 of 21
CT Sim QA

Daily
Performance parameter Description Tolerance
Electromechanical
Alignment of gantry lasers with the center To verify proper identification 2 mm
of imaging plane of scan plane with gantry
lasers

Image performance
CT number accuracy CT number for water 0 5 HU
Image noise Manufacturer
specifications
In plane spatial integrity in X or Y direction 1 mm
 9 of 21
CT Sim QA

Monthly
Performance parameter Description Tolerance
Electromechanical
Orientation of gantry lasers with respect To verify that the gantry lasers 2 mm over the length
to the imaging plane are parallel and orthogonal of laser projection
with the imaging plane over
the full length of laser
projection
Spacing of lateral wall lasers with respect To verify that lateral wall 2 mm
to lateral gantry lasers and scan plane lasers are accurately spaced
from the scan plane. This
distance is used for patient
localization marking
Orientation of wall lasers with respect to To verify that the wall lasers 2 mm over the length
the imaging plane are parallel and orthogonal of laser projection
with the imaging plane over
the full length of laser
projection
Orientation of the ceiling laser with To verify that the ceiling laser 2 mm over the length
respect to the imaging plane is orthogonal with the of laser projection
imaging plane
Orientation of the CT-scanner tabletop To verify that the CT-scanner 2 mm over the length
with respect to the imaging plane tabletop is level and and width of the
orthogonal with the imaging tabletop
plane
Table vertical and longitudinal motion To verify that the table 1 mm over the range
longitudinal motion of table motion
according to digital indicators
is accurate and reproducible

Image performance
CT number accuracy 4 to 5 different materials
In plane spatial integrity In both directions 1 mm
Field uniformity Most commonly used kVp within 5 HU
settings
 10 of 21
CT Sim QA

Annually
Performance parameter Description Tolerance
Electromechanical
Table indexing and position To verify table indexing and 1 mm over the scan
position accuracy under range
scanner control
Gantry tilt accuracy To verify accuracy of gantry 1 over the gantry tilt
tilt indicators range
Gantry tilt position accuracy To verify that the gantry 1 or 1 mm from
accurately returns to nominal nominal position
position after tilting
Scan localization To verify accuracy of scan 1 mm over the scan
localization from pilot images range
Radiation profile width To verify that the radiation Manufacturer
profile width meets specifications
manufacturer specification

Image performance
CT number accuracy Electron density phantom
Field uniformity Other used kVp settings within 5 HU
Electron density to CT number conversion Consistent with
commissioning results
and test phantom
manufacturer
specifications
Spatial resolution Manufacturer
specifications
Contrast resolution Manufacturer
specifications
 11 of 21
CT Sim QA

Semi-Annually
Performance parameter Description Tolerance
Electromechanical
Sensitivity profile width To verify that the sensitivity 1 mm from nominal
profile width meets value
manufacturer specifications
Other
Performance parameter Description Tolerance
Electromechanical
Generator tests ( After replacement of To verify proper operation of Manufacturer
major generator component) the x-ray generator specifications or Report
No. 39
recommendations

Mutic S, Palta J, Butker E, et al. Quality assurance for computed-tomography simulators and the
computed tomography-simulation process: Report of the AAPM Radiation Therapy Committee
Task Group No.66. Med. Phys. 2003; 30(10): 2762-2792. http://dx.doi.org/10.1118/1.1609271
 12 of 21
Conventional Sim QA

Daily
Procedure Tolerance
Localizing Lasers 2 mm
Distance Indicator (ODI) 2 mm
Monthly
Procedure Tolerance
Field size indicator 2 mm
Gantry/collimator angle indicator 1
Cross-hair centering 2 mm diameter
Focal spot-axis indicator 2 mm
Fluoroscopic image quality Baseline
Emergency/collision avoidance Functional
Light/radiation field coincidence 2 mm or 1%
Film processor sensitometry Baseline
 13 of 21
Conventional Sim QA

Annually
Procedure Tolerance
Mechanical Checks
Collimator rotation isocenter 2 mm diameter
Gantry rotation isocenter 2 mm diameter
Couch rotation isocenter 2 mm diameter
Coincidence of collimator, gantry, couch axes, and isocenter 2 mm diameter
Tabletop sag 2mm
Vertical travel of couch 2mm

Radiographic Checks
Exposure rate Baseline
Tabletop exposure with fluoroscopy Baseline
kVp and mAs calibration Baseline
High- and low-contrast resolution Baseline

Kutcher G, Cola L, Gollin M, et al. Comprehensive QA for radiation oncology: report of the AAPM
Radiation Therapy Committee Task Group 40. Med Phys . 1994;21:581-618.
http://dx.doi.org/10.1118/1.597316
 14 of 21
TPS QA

Daily
Item Details
Review report log listing system failures, error
messages, hardware malfunctions, and other
problems. Triage list and remedy any serious
Error log problems that occur during the day.
Change log Keep log of hardware/software changes.
Weekly
Item Details
Digitizer Review digitizer accuracy.
Review all hardcopy output, including scaling
Hardcopy output for plotter and other graphics-type output.
Verify integrity of all RTP system data files and
executables using checksums or other simple
software checks. Checking software should be
Computer files provided by the vendor.
Review clinical treatment planning activity.
Discuss errors, problems, complications,
Review clinical planning difficulties. Resolve problems.
Monthly
Item Details
Review the CT data within the planning system
for geometrical accuracy, CT number
CT data input into RTP consistency (also dependent on the QA and use
system of the scanner), and derived electron density.
Review all RTP problems (both for RTP system
and clinical treatment planning) and prioritize
Problem review problems to be resolved.
Review current configuration and status of all
Review of RTP system RTP system software, hardware, and data files.
 15 of 21
TPS QA

Annually
Item Details
Annual checks. Review acceptability of
agreement between measured and calculated
Dose calculations doses for each beam/source.
Review functioning and accuracy of digitizer
tablet, video/laser digitizer, CT input, MR input,
printers, plotters, and other imaging output
Data and I/O devices devices.
Review BEV/DRR generation and plot accuracy,
CT geometry, density conversions, DVH
calculations, other critical tools, machine-
specific conversions, data files, and other critical
Critical software tools data.
Variable
Item Details
Checks and/or recommissioning may be
Beam parameterization required due to machine changes or problems.
Checks and/or recommissioning may be
Software changes, required due to changes in the RTP software,
including operating any support/additional software such as image
systems transfer software, or the operating system.

Fraass B, Doppke K, Hunt M, et al. American Association of Physicists in

Medicine Radiation Therapy Committee Task Group 53: Quality assurance for
clinical radiotherapy treatment planning.Med. Phys.1998;25(10): 1773-1829.
http://dx.doi.org/10.1118/1.598373
 16 of 21
SRS QA

Daily
Item Tolerance
Safety interlocks (Door, console
EMO, Key) Functional
CCTV cameras and monitors Functional
Audio monitor Functional
Collimator assembly collision
detector Functional
Accelerator warm-up 6000 MU; for
open chambers 3000 MU; for sealed
chambers N/A
<2%: no change needed; >2%:
Accelerator output adjust calibration
Detection of incorrect and missing
secondary collimator Functional
Visual check of beam laser and a
standard floor mark < 1 mm
AQA test < 1 mm from baseline
 17 of 21
SRS QA

Monthly
Item Tolerance
Safety interlocks Functional
Energy constancy 2%
Beam symmetry >3%
Beam shape >2% Compared to beam data
Output >2%
Imager alignment 1 mm or center pixel 2 pixels
Contrast, noise and spatial
resolution of amorphous silicon To be decided by user based on
detector. Homogeneity/bad pixels available literature
Custom CT model: CT QA (spatial
accuracy, electron density) See TG 66
Verify relative location of beam
laser vs. radiation CAX has not
changed 0.5 mm
Visually check isocentric plan to
verify beam laser illuminates
isocrystal; rotate through path sets
each month Laser on isocrystal for each node
Intracranial and extracranial E2E; set
schedule to cycle through each
clinically used tracking method and <0.95 mm or < 1.5 mm for motion
path tracking
Nonisocentric patient QA or DQA; DTA 2 mm/2% Synchrony DTA
ideally performed quarterly 3%/3mm
Observe Synchrony treatment or
simulation; listen for unusual noise
and visually check for vibrations No significant change
 18 of 21
SRS QA

Annually
Item Tolerance
EPO button Functional
TG 51 or IAEA TRS-398, including Adjust calibration if > 1% difference
secondary independent check. is found
Beam data checks on at least three
collimators, including largest and
smallest collimator (TPR or PDD,
OCR, output factors) To be decided by user
Dose output linearity to lowest
MU/beam used. 1%
Imager kVp accuracy, mA station
exposure linearity, exposure
reproducibility, focal spot size See table in report for references
Signal to noise ratio, contrast to
noise ratio, relative modulation
transfer function, imager sensitivity
stability, bad pixel count and
pattern, uniformity corrected
images, detector centering and
imager gain statistics Compare to baseline
TG 53 as applicable TG 53
CT QA (in addition to monthly) See TG 66
Data security and verification Functional
2nd Order Path Calibration;
currently only possible with the
help of a service engineer Each node < 0.5 mm RMS < 0.3 mm
Check noise level of optical markers < 0.2 mm
Run Synchrony E2E test with at least
20 deg phase shift; analyze
penumbra spread To be decided by user
In addition to tolerances listed
above, update all parameters and
Monthly QA checklists
Daily QA Update parameters
 19 of 21
SRS QA

Special
Item Tolerance
Software upgrade
Patient exclusion zone boundaries Functional
Beam data security Functional
Up-to-date with regulatory and
HIPAA compliance procedures institutional policies

Imager exchange
Up-to-date with regulatory and
institutional policies

Dietrich S, Cavedon C, Chuang C, et al. Report of AAPM TG 135: Quality assurance

 20 of 21
Brachytherapy QA

Applicators
Inspect applicators for fit and function
Obtain a radiograph of the applicator with radiopaque dummy marker in place for visual
inspection
Instruction for all nursing personnel on examination of the applicator at time of cleaning
and sterilization for flaws and missing parts and proper reporting
Remote After loading Systems
Radiographic imaging should be obtained to verify positional accuracy and geometry of
applicator
Radioactive Sources
Location of sources to be tracked at all times
Periodic Inventory and inspection of radioactive sources as indicated by radioactive
materials license
Systematic record of all sources
Inspect Cs sources for curvature
Leak testing of sources before initial use and regular review thereafter (semi-annual to 3
years depending on source)
 21 of 21
Brachytherapy QA

Remote After loading Equipment

Equipment functioning as intended
Safety procedures are created
Training provided to all personnel involved in treatments including emergency
procedures
Physicians and Physicists have required presence for all HDR procedures
In room radiation monitors present
Radiation Monitors available outside of room for survey prior to entry and post
procedure
Daily QA
testing of all safety equipment including, survey meters, radiation monitors, door
interlocks, & radiation on lights
Testing of operation of after loading equipment
Presence of Emergency procedure equipment including, forceps, large lead pig, &stop
watch
All monitors and interlocks to be checked for functionality
Door interlocks checked for functionality
Emergency off buttons checked for functionality
Treatment interrupt buttons checked for functionality
Verify treatment unit displays time date and current source strength
Verify source-position accuracy
Verify dwell-time accuracy & treatment termination
Test integrity of applicator connections
Monthly QA
Verification of source activity
Verification of decay chart
Measurement of source transit time & timer linearity
Verify Source-position accuracy
Verify integrity of applicators
Verify timer accuracy and linearity
Power failure system test
Source Exchange QA
As completed at Monthly QA
Radiation Survey

Thomason C, Vann AM, Lenards N. QA Brachytherapy. [SoftChalk]. La Crosse, WI: UW-L

Medical Dosimetry Program; 2017.