A Practical Guide To TG142

A Practical Guide to TG-142
A Practical Guide
to TG-142
Quality Assurance of Medical Accelerators
Jimmy Jones, MS
The Methodist Hospital
Houston, TX
In collaboration with
Table of Contents
Table of Contents
Introduction ............................................................................................................................... 6
D-1: Daily Dosimetry, Mechanical, and Safety QA .................................................................. 7
D-1A: Dosimetry Procedures ............................................................................................................... 7
D-1B: Mechanical Procedures ............................................................................................................. 7
D-1C: Safety Procedures .................................................................................................................... 8
D-2: Daily Wedge QA ................................................................................................................ 9
D-2A: Morning Check-Out Run for One Angle .................................................................................... 9
D-3: Daily Imaging QA ............................................................................................................ 10
D-3A: Collision Interlocks .................................................................................................................. 10
D-3B: Positioning/Repositioning & Imaging and Treatment Coordinate Coincidence ........................ 10
W-1: Weekly MLC QA .............................................................................................................. 13
W-1A: MLC Qualitative Test, Travel Speed, and Leaf Position Accuracy ......................................... 13
M-1: Monthly Dosimetry QA ................................................................................................... 16
M-1A: X-Ray and Electron Output, Backup Monitor Chamber, Typical Dose-Rate Output and
Electron Beam Energy Constancy Tests ........................................................................................... 16
M-1B: Photon and Electron Beam Profile Constancy Tests .............................................................. 17
M-2: Monthly Mechanical QA ................................................................................................. 18
M-2A: Light/Radiation Field Coincidence, Jaw Position Indicators, MLC Settings vs. Radiation Field
for Two Patterns (non-IMRT), and Photon Beam Profile Constancy ................................................. 18
M-2B: Distance Check Device for Lasers Compared with Front Pointers and Localizing Lasers ...... 21
M-2C: Gantry/Collimator Angle Indicators ......................................................................................... 23
M-2D: Accessory Trays QA ............................................................................................................... 23
M-2E: Cross-hair Centering and Jaw Positing Indicators .................................................................. 24
M-2F: Treatment Couch Position Indicators QA ................................................................................ 24
M-2G: Wedge Placement Accuracy QA ............................................................................................ 26
M-2H: Latching of Wedges, Blocking Tray QA .................................................................................. 26
M-3: Monthly Imaging QA ....................................................................................................... 27
M-3A: Planar MV Imaging (EPID) AND kV Imaging QA .................................................................... 27
M-3B: Cone-Beam CT (kV and MV) QA ............................................................................................ 29
M-4: Monthly Wedge QA ......................................................................................................... 32
M-4A: Wedge Factor for all Energies ................................................................................................ 32
A-1: Annual Dosimetry QA ..................................................................................................... 33
A-1A: SRS Arc Rotation Mode and Arc Mode QA ............................................................................. 33
A-1B: X-Ray / Electron Output Calibration (TG-51) ........................................................................... 34
A-1C: Spot Check of Field-Size Dependent Output Factors for X-Ray, Output Factors for Electron
Applicators, and Physical Wedge Transmission Factor Constancy ................................................... 34
A-1D: X-Ray Beam Quality and Electron Beam Quality .................................................................... 35
A-1E: X-Ray Monitor Unit Linearity, Electron Monitor Unit Linearity, and X-Ray Output Constancy vs.
Dose-Rate ......................................................................................................................................... 35
A-1F: X-Ray Output Constancy vs. Gantry Angle, Electron Output Constancy vs. Gantry Angle, and
Electron and X-Ray Off-Axis Factor Constancy vs. Gantry Angle ..................................................... 36
A-2: Annual Mechanical QA ................................................................................................... 37
A-2A: Collimator Rotation Isocenter, Gantry Rotation Isocenter, Couch Rotation Isocenter QA ....... 37
Jimmy Jones, MS / Mobius Medical Systems, LP 4
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Table of Contents
A-2B: Electron Applicator Interlocks QA ............................................................................................ 39

A-2C: Coincidence of Radiation and Mechanical Isocenter QA ........................................................ 39
A-2D: Table Top Sag QA .................................................................................................................. 41
A-2E: Table Angle QA ....................................................................................................................... 41
A-3: Annual MLC QA ............................................................................................................... 42
A-3A: MLC Transmission QA ............................................................................................................ 42
A-3B: Leaf Position Repeatability ...................................................................................................... 43
A-3C: MLC Spoke Shot ..................................................................................................................... 43
A-4: Annual Imaging QA ......................................................................................................... 45
A-4A: Full Range of Travel SDD ....................................................................................................... 45
A-5: Annual Wedge QA ........................................................................................................... 46
A-5A: Check of Wedge Angle for 60° ................................................................................................ 46
Appendix A: VMAT Testing .................................................................................................... 47
Varian Recommended VMAT Testing ............................................................................................... 47

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Introduction
Introduction
This manual was designed to assist the clinical physicist with implementation of the American
Association of Physicists in Medicine’s (AAPM) Task Group 142 (TG-142) recommendations
for linear accelerator and associated components quality assurance (QA). It provides examples of
tests that can be performed to fulfill TG-142’s recommendations.
The manual focuses on tests that can be measured with Electronic Portal Imaging Devices EPID
or film measurements. Ion chamber and other device-oriented procedures are described in less
detail. The recommended tests are in no way the only method of fulfilling TG-142’s
recommendations and will most likely require customization for the individual facility. In some
cases alternate workflows are provided and are distinguishable by their light green font. Text in a
light blue font refers to specific test or quantity indicated in a TG-142 table.
The manual has been developed by Jimmy Jones in collaboration with Mobius Medical Systems,
LP. Mobius Medical Systems is the manufacturer of DoseLab TG-142 and DoseLab Pro,
commercial software designed to perform TG-142 analysis. Screenshots in the document were
captured using DoseLab Pro version 6.40.
In using this manual, you may wish to reference the three tables in the Microsoft Excel file
included with download of the document. The tables are combinations of the six tables in the
original AAPM TG-142 report, organized into Daily, Monthly, and Annual recommended tests.
The tables also indicate whether a given test can be performed using DoseLab Pro, and indicate
the section of this document where the test procedure is described.

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D-1: Daily Dosimetry, Mechanical, and Safety QA
D-1: Daily Dosimetry, Mechanical, and Safety

QA
D-1A: Dosimetry Procedures

Recommended Items
A commercially offered, user-friendly device, such as Sun Nuclear’s Daily QA 3 device that
automates data acquisition and analysis and satisfies TG-142’s Daily Dosimetry QA
procedures
Workflow
Follow the manufacturer’s recommendations for specialized devices.
D-1B: Mechanical Procedures

Recommended Items
CNMC Tel-align phantom (laser localization, distance indicator, and collimator size
indicator) or graph paper (collimator size indicator)
Workflow
1. Place the Tel-align phantom at 100 cm SSD,
and align the phantom surface etchings with
the crosshairs.
2. Evaluate the distance indicator reading (ODI)

by verifying that the couch vertical position
is within tolerance.
Note: Baseline couch value and tolerance

should be set monthly with a front pointer.
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D-1: Daily Dosimetry, Mechanical, and Safety QA
3. Verify that the laser localization falls within the recommended tolerance distances for
your machine from the etchings on the phantom (side marks for axial and coronal lasers
shown at left; cross-hairs for ceiling and sagittal lasers shown at right).
4. Tape marks on the wall can also serve as quick visual checks for the axial and coronal
lasers.
5. Set the field size to 10 cm x 10 cm and verify

that the light field falls within the Collimator
Size Indicator tolerance of the phantom.
Alternately, place graph paper at isocenter and
verify collimator settings using the light field.
D-1C: Safety Procedures

Recommended Items
Radiation area monitor and beam-on indicator light
Workflow
1. While the machine is warming up, open the vault door to ensure the beam turns off (door
interlock)
2. Verify that the machine cannot beam back on until the door is shut (door closing safety)
3. Once the machine is warmed up, verify that the radiation monitor (radiation area monitor)
and beam-on indicator lights are working (beam-on indicator).
4. Verify that you can see the treatment table on the closed circuit monitors and that you can
hear sound from inside the vault using the A/V system (audiovisual monitor)

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D-2: Daily Wedge QA
D-2: Daily Wedge QA
D-2A: Morning Check-Out Run for One Angle

Recommended Items
None
Workflow
Run a dynamic wedge (45 ° recommended) while the machine is warming up to verify no
interlocks.

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D-3: Daily Imaging QA
D-3A: Collision Interlocks

Recommended Items
None
Workflow
Manually (and gently) depress each cover on the imaging detector, source housing, and EPID
to verify the machine interlocks.
D-3B: Positioning/Repositioning & Imaging and Treatment

Coordinate Coincidence
Recommended Items
Sun Nuclear WL-QA Cube
Workflow
1. Acquire a computed tomography (CT) scan of the phantom with a slice thickness less
than the specified TG-142 positioning/repositioning tolerance for your system. The
central tungsten sphere should be delineated in the treatment planning software (TPS).
The generated digital reconstructed radiographs (DRRs), reference cone beam CT
(CBCT), and structures will facilitate alignment on the imaging system and result in a
more efficient workflow.
2. Place the WL-QA cube on the treatment couch so that the small
crosshairs on the phantom are aligned with the room lasers.
3. Alternatively use the machine cross-hairs to align the cube instead of

the room lasers: rotate the gantry to align the side cross-hairs and the
cross-hairs on top of the cube. The advantage to this method is that alignment does not
depend on a surrogate for the mechanical isocenter.

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4. Acquire a CBCT image, and position the tungsten sphere at isocenter using the vendor’s
CBCT software for your linear accelerator (linac).
Note: Use a consistent technique for the CBCT image on a daily basis and a common
clinical technique for QA purposes. Consistency helps to identify degradation of the
system due to the imaging components, the mechanical isocenter (or surrogate used to set
up the cube), or the software. Minimize offset errors due to partial volume averaging by
using a minimum slice width of the CBCT scans less than the specified TG-142 tolerance
for your system.
5. Record the couch shift required and compare to the known offsets (provided by the
phantom manufacturer). This will verify that your lasers are within tolerance if they were
used to set up the phantom and that the scaling on the IGRT software is correct.
Note: The difference in the measured offset and known offset should be within the
imaging and treatment coordinate coincidence tolerance for TG-142.
6. Allow the CBCT software to reposition the treatment couch at the determined offset.
7. Enter the room and visually ensure that the lasers match the large crosshairs within the
TG-142 CBCT positioning/repositioning tolerance. Do not move the WL-QA cube.
8. Acquire an EPID image (any gantry angle).
9. Turn on the digital graticule in the treatment software, and verify that the center of the
tungsten sphere is less than the planar kV (shown below right) and MV (shown below
left) imaging and treatment coordinate coincidence TG-142 tolerance away from the
digital graticule.
Note: The imaging isocenter (red) is displayed with a grid overlay (green) to assist in
drawing vectors in the X and Y directions from the imaging isocenter to the center of the
cube.
10. Acquire a kV image and repeat Step 8.

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Alternatively, the repositioning of the WL-QA cube can be accomplished using orthogonal
kV images rather than a CBCT. Technically, the positioning/repositioning procedure is listed
for both CBCT and planar kV and MV imaging. To fulfill both, it would be necessary to
perform the alternative repositioning of the WL-QA cube in addition to Steps 1-8 so that
positioning/reposition of the IGRT system is accomplished with both a CBCT alignment and
a planar image alignment. If this is the intent of TG-142, then at Step 4 the WL-QA cube
would have to be realigned at the intentional offset first.

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W-1: Weekly MLC QA
W-1: Weekly MLC QA
W-1A: MLC Qualitative Test, Travel Speed, and Leaf Position

Accuracy
Recommended Items
 DoseLab Pro software
 Picket fence image (EPID or film-based). DoseLab will only analyze the picket fence
version with separate narrow irradiated strips, not the version with abutting irradiated
strips.
Workflow for Picket Fence Test

1. Deliver a picket fence MLC pattern to an EPID image or similar film
Note: If film is used, scan the film and save it as a .tif image.
2. Load the picket fence image in DoseLab’s Single Image Analysis.
3. Select Machine QA | MLC Strip test from the menu (or select the icon), and the
automated routine will run. Results appear in a new window.

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W-1: Weekly MLC QA
4. Review the summary of the analysis highlighted in green and confirm that all tests pass.
(For a full description of the analysis and user-defined variables and tolerances, please
see the “DoseLab Pro User’s Manual.”)
5. Export the results to PDF, XLS, or to the DoseLab Pro database as desired.
Workflow for Varian Machines

Note: DoseLab Pro’s FractionCHECK module analyzes treatment machines’ DynaLogs and
assesses leaf position accuracy and travel speed, satisfying the MLC weekly and monthly
tests for those two procedures. A picket fence test alone does not satisfy the monthly travel
speed procedure; therefore, this workflow is not considered an alternative.
1. Review the “DoseLab Pro User’s Manual” for information on logging the DynaLogs and
obtaining access to them, if necessary.
2. Select FractionCHECK from DoseLab Pro’s main interface.
3. Browse to the folder where the DynaLogs are stored, and click OK. FractionCHECK
automatically analyzes all DynaLogs in the folder. (Refer to the “DoseLab Pro User’s
Manual” for a complete description of the features, settings, and analysis for
FractionCHECK.”)

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W-1: Weekly MLC QA
4. Review the summary of the analysis highlighted in green and confirm that all tests pass.
5. Export the results to PDF, XLS, or to the DoseLab Pro database as desired.

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M-1: Monthly Dosimetry QA
M-1A: X-Ray and Electron Output, Backup Monitor Chamber,

Typical Dose-Rate Output and Electron Beam Energy
Constancy Tests
Recommended Items
 Ion chamber
 Electrometer
 Solid water or water tank
Workflow
1. Measure X-ray and electron output under reference conditions established at the time of
commissioning for all energies, and verify that the backup monitor chamber is within
tolerance of the primary monitor chamber.
2. Repeat the X-ray and electron output measurements at different dose rates to verify dose-
rate output constancy. (This is necessary because the RF driver and gun current are tuned
independently for each energy.)
3. Measure electron beam energy constancy by comparing full profiles (water tank) or
output ratios at different depths (solid water). Verify that the acquired values are within a
one percent tolerance from baseline values.

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M-1B: Photon and Electron Beam Profile Constancy Tests

Recommended Items
 A commercially offered user-friendly device, such as Sun Nuclear’s Daily QA 3 or
Profiler 2, that automates data acquisition and analysis and satisfies TG-142’s Beam
Profile Constancy QA procedures
 A water tank (requires more time for data acquisition, although the recommended tool for
annual profile constancy tests)
 Sun Nuclear FS-QA phantom, EPID image of the phantom, and DoseLab Pro software
General Workflow
Follow the manufacturer’s recommendations for data acquisition and verify that the obtained
values are within one percent of the baseline photon and electron beam profiles for each
energy.
Water Tank Option Workflow

Acquire a beam profile at selected depths and compare to baseline profiles. Verify that
acquired profiles are within stated tolerances.
Workflow for DoseLab Pro’s Flatness and Symmetry Module

Follow the workflow for the monthly mechanical QA on the next page.

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M-2: Monthly Mechanical QA

M-2A: Light/Radiation Field Coincidence, Jaw Position
Indicators, MLC Settings vs. Radiation Field for Two
Patterns (non-IMRT), and Photon Beam Profile Constancy
Recommended Items
 Sun Nuclear FS-QA Phantom
 EPID image of the phantom or film images at symmetric and asymmetric field sizes
Note: If you use film for analysis, a separate test is required to satisfy the Jaw Position
Indicators procedure.
Workflow (EPID Image Acquisition)

1. Place the FS-QA on the treatment couch at isocenter, align the light field to the cross-
hairs, and set the SSD to 100 cm.
Note: If using film, place the film between the treatment couch and the bottom of the
phantom
2. Set the jaws to 15 cm x 15 cm.
3. Verify that the jaw positions indicators are within tolerance by matching the resultant
light field with the phantom etchings.

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4. Acquire an EPID image (as shown below in the DoseLab Pro Single Image Analysis
module).
5. Repeat Steps 3 and 4 for an asymmetric jaw setting.
6. Repeat steps 3 and 4 for a 10 cm x 10 cm MLC defined field.
7. Repeat steps 3 and 4 for a 15 cm x 15 cm MLC defined field.
Workflow (Film Acquisition)

1. Place the film on the treatment couch at 100 cm SSD.
2. Set the jaws to 15 cm x 15 cm.

Tip: Puncture the edges of the film to delineate the light field edge on all four sides.
3. Place sufficient buildup over the film to produce darkening of the film at depth once
irradiated.
4. Irradiate the film with sufficient dose to produce film darkening.
5. Using a new sheet of film (or an unexposed region), repeat Steps 2-4 for an asymmetric
jaw setting.
6. Using a new sheet of film (or an unexposed region), repeat steps 2-4 for a 10 cm x 10 cm
MLC-defined field.
7. Using a new sheet of film (or an unexposed region), repeat steps 2-4 for a 15 cm x 15 cm
MLC-defined field.

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Workflow (Image Analysis)

1. Load the acquired EPID image or scanned film image into DoseLab Pro’s Single Image
Analysis module.
2. Select Machine QA | Flatness and symmetry from the main menu or by selecting the
icon.
3. Enter the appropriate image information in the Analysis settings area. (Please refer to the
“Dose Lab Pro User’s Manual” for a full description of all user-defined inputs.) At a
minimum, enter the field size of the acquired image.
4. Select Process to begin the automated analysis.

a. During the analysis of the image, a threshold function is used to define the field edge.
If you wish to digitize the embedded bb positions of the phantom or the punctured
marks of the film, select Image has light field marks and then Process once again.
b. If the image is being used to satisfy the photon beam profile constancy, identify the
baseline profile for comparison against in the Analysis settings. First acquire water
scans to ensure that the beam profile is within tolerance. Then acquire an image of the
phantom using the procedure above and use it as your baseline for subsequent
analysis.
Note: The baseline EPID profile will probably not match your water scan profile.
5. Verify that the Light / Radiation field coincidence is within tolerance.
6. Export the results to PDF, XLS, or a database as desired.
7. Repeat Steps 1-6 for all acquired images.

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M-2B: Distance Check Device for Lasers Compared with

Front Pointers and Localizing Lasers
This test verifies that whatever device is used on a daily basis to ensure that ODI and lasers
are within tolerance, is itself within tolerance when compared against front pointers. It
involves positioning a front pointer so that its tip is at 100 cm SSD. The axial lasers (left) and
the sagittal and coronal lasers (right) are verified against the front pointer.
Recommended Items
 Front pointers
 Tel-align phantom
 Solid water (or blocks)
Workflow
1. Verify the front pointers’ calibration distance by standing each up next to each other
verify that the distances match those that share the same values.
2. Verify that the front pointers are not bent.
3. Place a front pointer in the accessory tray so that the tip of the front pointer is at a
distance of 100 cm SSD.
4. Place the Tel-align phantom on the table and raise it until it touches the front pointer.
5. Verify that the table vertical readout position is within the distance check device for
lasers compared with front pointer tolerance relative to the value used on a daily basis for
test D-1B.

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6. Remove the front pointer and its accessory tray and align the phantom with the cross-
hairs and the light field.
7. Verify that the lasers fall within the localizing laser’s tolerance relative to the phantom
etchings and described in test D-1B.
Alternative Workflow (Localizing Lasers)

1. Place the front pointer back at 100 cm SSD and remove the Tel-align phantom.
2. Verify that the coronal lasers are within the localizing lasers tolerance distance from the
tip of the front pointer.
3. Verify that the axial and sagittal lasers split the rod down the middle or are within the
localizing lasers tolerance from the middle of the pointer.
Optional Workflow (Testing the ODI and Table Vertical Travel at Additional Depths)
While not specifically stated in TG-142, you should test the ODI and table vertical travel at
depths other than 100 cm SSD.
1. Place a front pointer in the accessory tray so that the tip of the front pointer is at a
distance of 100 cm SSD.
2. Raise the table until it touches the front pointer.
3. Remove the front pointer and accessory tray, and verify that the ODI reading is within the
distance check device for lasers tolerance.
4. Repeat Steps 1-3 for distances of 80 cm SSD and 120 cm SSD (or clinically relevant
extremes).
Tip: Solid water stacked on the table is needed to obtain shallower depths.

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M-2C: Gantry/Collimator Angle Indicators

This procedure is for cardinal angles and digital indicators only.
Recommended Item
Bubble or digital level
Workflow
1. Verify that the gantry position is within the Gantry / collimator angle indicators tolerance
at all four cardinal angles using the level:
a. Place the level on a flat surface of the gantry head adjacent to the range finder hole
and compare the level readout with the digital gantry readout.
b. Verify that the lasers and cross-hairs intersect while the gantry is in the 90° and 270°
gantry positions.
2. With the gantry at 90° or 270° (Varian IEC scale), rotate the collimator and verify that
the position is within the Gantry / collimator angle indicators tolerance at all four cardinal
angles using the level by placing the level on the Teflon edge where the blocks slide in
and compare the level readout to the digital readout.
M-2D: Accessory Trays QA

Recommended Item
Graticule tray
Workflow:
1. Insert the graticule tray into the accessory mount.
2. Turn on the field light and verify that the cross-hairs and the graticule tray markings are
within the accessory trays tolerance of one another. (This verifies alignment between
treatment isocenter and the physical graticule.)
3. Acquire an MV image with the graticule in place.
4. Turn on the electronic graticule on the linac’s IGRT software.
5. Verify that the electronic graticule and the graticule tray markings are within the
accessory trays tolerance of one another. (This verifies alignment between the physical
graticule tray and the imaging isocenter.)

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M-2E: Cross-hair Centering and Jaw Positing Indicators

Recommended Item
Calibrated graph paper (with millimeter ruling)
Workflow
1. Place the graph paper directly on the couch.
2. Set the gantry, collimator, and couch to 0° and the SSD to 100 cm.
3. Align the cross-hairs and the graph paper.
4. Vary the symmetric jaw settings through clinically relevant field sizes (smallest size used
to the maximum size graph paper can accommodate) and verify that the light field and
the graph paper are within the jaw position indicators tolerance.
Tip: Laminate the graph paper used and mark the standard field sizes on the graph paper
to quickly assess congruency.
5. Repeat Step 4 with the asymmetric jaws at predetermined settings, including settings of 0
cm and 10 cm at minimum.
6. Rotate the collimator through full range of motion and verify that during the rotation the
cross-hairs of the graph paper and the collimator do not deviate beyond the cross-hair
centering tolerance for your machine.
M-2F: Treatment Couch Position Indicators QA

Recommended Items
• Calibrated indexing bar (shown below) or
• Graph paper and indexing bar
Workflow for QA with a Calibrated Indexing Bar

Tip: At the time of commissioning, ask your vendor to provide a calibrated indexing bar with
set demarcations along the lateral direction.
1. Place the treatment couch at isocenter with the indexing bar latched at the 0 position on
the couch.
2. Align the center of the indexing bar with the cross-hairs.

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3. Verify that the couch digital readout is 0 cm (lat), 0 cm (vert), and 140 cm (long) or
within the treatment couch position indicators tolerance of these baseline values.
4. Move the couch laterally to the preset demarcation and verify that the couch readout is
within the treatment couch position indicators tolerance relative to the baseline value.
Tip: Test four lateral offsets total: two in each direction from isocenter at maximal offset
(23 cm for Varian IGRT couches) and an intermediate position.
5. Move the indexing bar to a new position on the couch.
6. Move the couch longitudinally until the indexing bar and the cross-hairs align.
7. Verify that the longitudinal offset is within the treatment couch position indicators
tolerance (The Varian IGRT couch top has 14 cm longitudinal offsets between each
indexing position.)
Workflow for QA with Graph Paper and Indexing Bar

Note: This is a relative positioning verification and not an absolute one since a calibrated
device is not available to verify the benchmark position of 0 cm (lat), 0 cm (vert), and 140 cm
(long).
1. Place the graph paper on the table and align it with the cross-hairs at an SSD of 100 cm.
2. Move the couch laterally to various offsets and verify that the digital couch offset reading
is within the treatment couch position indicators tolerance relative to the graph paper.
3. Place the non-calibrated indexing bar (one used for patient treatment) at one of the
indexing positions on the couch.
4. Move the couch so you can see the cross-hairs from the collimator on the indexing bar.
5. Draw the cross-hairs on the bar.
6. Move the indexing bar to a new indexing position.
7. Move the treatment couch so that the collimator cross-hairs and the cross-hairs drawn on
the indexing bar are aligned.
8. Verify that the couch readout is within the treatment couch position indicators tolerance
from the baseline offset value (14 cm for Varian IGRT couches).

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M-2G: Wedge Placement Accuracy QA

Recommended Item
Ruler
Workflow
1. Set the gantry and collimator to 0°.
2. Insert each wedge into the accessory slot and turn on the field light.
3. Measure the distance from isocenter to the edge of the shadow and verify that the
distance is within the wedge placement accuracy tolerances relative to the baseline
values.
M-2H: Latching of Wedges, Blocking Tray QA

Recommended Items
Wedges and blocking trays that have been commissioned and used clinically
Workflow
1. Visually inspect each wedge and tray for loose screws.
2. Insert each into the accessory tray and verify that each insert and wedge latch correctly.

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M-3: Monthly Imaging QA

The workflow for the monthly QA procedures for Planar MV Imaging (EPID) and Planar kv
Imaging’s Imaging and Treatment Coordinate Coincidence is the same as the daily procedure for
Imaging and Treatment Coordinate Coincidence QA, but at all four cardinal gantry angles.
Please refer to the workflow for “Positioning/Repositioning & Imaging and Treatment
Coordinate Coincidence.”
M-3A: Planar MV Imaging (EPID) AND kV Imaging QA

This procedure is for scaling, special resolution, contrast, and uniformity and noise QA.
Recommended Items
• DoseLab Pro software
• Sun Nuclear MV-QA imaging phantom
• Sun Nuclear kV-QA imaging phantom
• Images of the phantoms for analysis

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Workflow:
1. Set the MV-QA phantom up at isocenter using the phantom stand. Place the phantom in
the stand so that the two sagittal alignment markers are visible.
2. Align the phantom so that the light field cross-hairs (or room lasers) match the cross-hairs
on the face of the phantom and the sagittal alignment markers on the top of the phantom.
3. Acquire an MV image of the phantom with the EPID.

Tip: Position the MV detector as close to the phantom as possible to minimize image
magnification.
4. Repeat Steps 1-3 with the kV-QA phantom and the OBI system.
5. Import the images into DoseLab Pro’s Single Image Analysis module.
6. Select Machine QA | MV and kV Imaging QA.
7. Select the appropriate phantom from the drop-down menu and verify the imported
DICOM information.

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8. Select the Process button for automated analysis of the image. (Refer to the “DoseLab
Pro User’s Manual” for detailed information on the image analysis and preferences.)
Note: The example shown is an automated analysis of the Sun Nuclear kV-QA phantom
image.
9. Record the results, and export them to PDF, or store them in the DoseLab Pro database as
desired.
M-3B: Cone-Beam CT (kV and MV) QA

Recommended Items
• DoseLab Pro software
• Phantom Laboratories Catphan phantom
• Acquired CBCT dataset of the phantom for analysis

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Workflow
1. Set up the Catphan phantom per the manufacturer’s recommendations.
2. Acquire a CBCT of the phantom with a technique that is clinically relevant.
3. In DoseLab Pro, select CT / CBCT from the main interface.
4. Navigate to the stored location of the acquired CBCT and click OK.

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5. Select the correct phantom and verify the imported DICOM information in the Image
information section of the CT Imaging QA window. (Please refer to the “DoseLab Pro
User’s Manual” for a complete description of the analysis performed and the
customizable user settings and tolerances).
6. Record the results, and export them to PDF, or store them in the DoseLab Pro database as
desired.

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M-4: Monthly Wedge QA
M-4: Monthly Wedge QA
M-4A: Wedge Factor for all Energies

Recommended Items
Solid water, ion chamber, electrometer
Workflow
1. Set up the ion chamber and solid water at reference conditions (field size, depth, and
SSD) for which the wedge factor is defined.
Note: Some systems (e.g., Pinnacle) use a reference field of 10 cm x 10 cm at a depth of
10 cm for all measurements, while some use a reference field size the same as that used
during the wedge measurement (i.e., a 15 cm x 15 cm wedge measurement is normalized
to a 15 cm x 15 cm open field and not a 10 cm x 10 cm open field measurement).
2. Acquire an open field measurement.
3. Acquire a measurement with a 45° wedge.

Tip: A 45° wedge is recommended if wedge angles other than 60° are used clinically.
Acquire measurements with the wedge moving in both possible directions and averaging
the results.
4. Divide the wedge reading by the reference reading and verify that the measured output
factor is within the Wedge Factor for all Energies tolerance relative to the baseline value
used for dose calculation.
5. Repeat Steps 2-4 for each energy.

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A-1: Annual Dosimetry QA
A-1A: SRS Arc Rotation Mode and Arc Mode QA

Note: It is not apparent in the TG-142 description of these procedures how they differ. It is
assumed here that the goal is to verify that arc delivery treatments deliver the intended MU
settings at the intended gantry angles.
Recommended Items
None
Workflow
Run a sample arc treatment and verify that the Clinac DynaLogs are within the SRS Arc
Rotation Mode and Arc Mode tolerances for your machine.

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A-1B: X-Ray / Electron Output Calibration (TG-51)

Recommended Items
Water tank, ion chambers, electrometer, TG-51 worksheet
Workflow:
Please refer to AAPM’s TG-51 report for a complete description of how to perform output
calibration.
A-1C: Spot Check of Field-Size Dependent Output Factors for

X-Ray, Output Factors for Electron Applicators, and Physical
Wedge Transmission Factor Constancy
Items Recommended:
Water tank (or solid water), ion chamber, and electrometer
Workflow:
1. Set up the water tank and ion chamber at reference conditions (field size, depth, SSD).
Note: Most treatment planning systems normalize output measurements to an open 10 cm
x 10 cm field size at a depth of 10 cm, but some facilities may choose a depth of dmax
instead. You must verify the reference depth.
2. Acquire a set of reading at the reference conditions and average the results.
3. Acquire a set of readings at various field sizes (or applicator sizes in the case of
electrons). Readings should include at least two field sizes, preferably small (< 4x4 cm2)
and large (>4x4 cm2).
4. Divide the acquired reading by the reference readings and verify that the measured field
size-dependent output factors are within the Spot Check of Field Size Dependent Output
Factors for X-ray tolerance relative to the baseline values used for dose calculations.
5. Repeat Steps 2-4 for all X-ray energies.
6. Repeat Steps 2-4 for each electron energy, testing at least one applicator for each energy.
Note: Reference conditions for electron measurements are typically different than for
electron measurements (e.g., Pinnacle recommends dmax rather than a depth of 10 cm).
You must verify the reference conditions when measuring cone factors.
7. Acquire a set of readings at the reference conditions used to measure the wedge
transmission factors that were input into the treatment planning system. A single field
size is sufficient. For example, Pinnacle normalizes all wedge measurements to an open
10 cm2 field size at a depth of 10 cm, so a series of measurements under these conditions
would suffice for reference measurements.
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8. Acquire a set of readings for each physical wedge with the physical wedge in both
possible orientations and average the results.
9. Divide the acquired wedge reading by the open reference reading and verify that the
measured output factor is within the Physical Wedge Transmission Factor Constancy
tolerance relative the value used for dose calculations.
A-1D: X-Ray Beam Quality and Electron Beam Quality

Recommended Items
Water tank, ion chambers, electrometer, and scanning software
Workflow
Most water tank manufacturers have profile acquisition software that allows you to set up
acquisition queues, shift acquired data where needed, and convert from ionization to dose
where needed. Use these tools and follow the manufacturer’s directions on how do so. Be
sure to complete full scans rather than spot checks of PDD10 and R50, since the scans can be
analyzed for profile constancy at the same time and fulfill other annual dosimetry
requirements set forth by TG-142.
A-1E: X-Ray Monitor Unit Linearity, Electron Monitor Unit

Linearity, and X-Ray Output Constancy vs. Dose-Rate
Recommended Items
Solid water (or water tank), ion chamber, and electrometer
Workflow
1. Set up the solid water (or water tank) and ion chamber at reference conditions, usually
100 cm SSD, 10 x 10 cm2 field size, and a depth of 10 cm.
2. Deliver 400 MU with a clinically relevant dose rate and record the measurement.
3. Using the same setup conditions, deliver 100 MU with the same dose rate and record the
measurement.
4. Verify that the 100 MU reading is1/4th of the 400 MU to within the X-Ray Monitor Unit
Linearity tolerance.
5. Deliver 2 MU with the same dose rate and verify that the reading is 1/50th of the 100 MU
reading to within the X-Ray Monitor Unit Linearity tolerance.
6. Deliver 100 MU with other clinically relevant dose rates, and verify that each100 MU
delivered readings are equal to one another within the X-Ray Output Constancy vs. Dose
Rate tolerance.

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7. Repeat Steps 2-6 for all X-Ray energies.
8. Shift the depth of the ion chamber to a reasonable depth for electrons (near dmax).
9. Deliver 400 MU with a clinically relevant dose rate and record the measurement.
10. Deliver 100 MU with the same dose rate and the same setup.
11. Verify that the 100 MU reading is 1/4th of the 400 MU reading to within the Electron
Monitor Unit Linearity tolerance.
12. Repeat Steps 9-11 for all electron energies.
A-1F: X-Ray Output Constancy vs. Gantry Angle, Electron

Output Constancy vs. Gantry Angle, and Electron and X-Ray
Off-Axis Factor Constancy vs. Gantry Angle
Recommended Items
 Sun Nuclear Daily QA3 device (or Profiler 2 or MapCHECK 2 device)
 Sun Nuclear Isocentric Mounting Fixture (IMF) device
Workflow
1. Insert the IMF device into the gantry accessory mount per vendor recommendations.
2. Insert the Daily QA3 device into the IMF device per vendor recommendations.
3. Deliver 100 MU with low energy photons to the device at a gantry angle of 0 (gantry
facing down) and the maximum field size permitted by the device.
4. Record the output readings at central axis and at specified points off-axis.
5. Repeat Steps 3-4 for all four cardinal gantry angles.
6. Verify the output at each point is equal for each gantry angle to within the X-Ray Output
Constancy vs. Gantry Angle (central axis) and Electron and X-Ray Off-Axis Factor
Constancy vs. Gantry Angle (off-axis diodes) tolerance.
7. Repeat Steps 3-6 for all X-ray energies.
8. Repeat Steps 3-6 for all electron energies.

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A-2: Annual Mechanical QA
A-2A: Collimator Rotation Isocenter, Gantry Rotation

Isocenter, Couch Rotation Isocenter QA
Recommended Items
Solid water and film (radiochromic or gafchromic)
Workflow (Image Acquisition)

1. Place a single piece of film between two layers of solid water (sufficient thickness to
allow dose deposition for the chosen energy) at isocenter. Center the film relative to the
central axis.
2. Set the jaws of the collimator so that a thin field is produced (i.e., 0.4 cm x 20 cm –
symmetric about the central cross-hair).
3. Irradiate the film at various collimator angles. (An equidistant 30° spacing would result
in six spokes.)
Example: This collimator starshot film was produced with gafchromic film. The film
was placed at isocenter and buildup placed on top of the film to permit dose deposition
and film darkening. The film was irradiated with six collimator angles.

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4. Repeat Steps 1-3 with a new piece of film and by varying the couch angle.
5. Repeat Steps 1-3 with a new piece of film and by varying the gantry angle.
Tip: For the gantry isocenter test, stand up the solid water vertically so that it is
perpendicular to the axis of rotation of the gantry. Position the film so that the center of
the film is still at 100 cm SSD and centered relative to the central axis laterally.
Note: Winston-Lutz style testing, described in greater detail in the section “Coincidence
of Radiation and Mechanical Isocenter,” is an alternate to verify rotation isocenter.
Workflow (Image Analysis)

1. Scan the film.
2. Import the scan into DoseLab Pro using the Single Image Analysis module.
3. Select Machine QA | Starshot from the main interface.
4. Adjust the analysis settings as needed. (For a detailed description of the user-defined
settings, preferences, and analysis, please refer to the “DoseLab Pro User’s Manual.”)
5. Select Process.
6. Click near isocenter and press Enter.
7. Select a circle diameter that passes through all the spokes of the image and click.
8. Verify that the diameter of the circle touching all spokes is within the Collimator, Gantry,
and Couch Rotation Isocenter tolerances.
9. Record the results, print them to PDF, or store them in the DoseLab Pro database.

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A-2B: Electron Applicator Interlocks QA

Recommended Items
Electron applicators
Workflow
1. Verify that the machine interlocks when you touch the applicator’s touch pad.
2. Verify that the machine interlocks when the applicator is not fully inserted into the
accessory slot.
A-2C: Coincidence of Radiation and Mechanical Isocenter QA

Recommended Items
 Sun Nuclear WL-QA imaging phantom
 EPID or film images of the WL-QA phantom
Workflow
1. Set up the WL-QA phantom on the treatment couch at isocenter so that the cross-hairs
from the light field align with the central cross-hairs etched into the phantom. Repeat this
with the lateral faces of the phantom by rotating the gantry 90° in both directions.

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2. Acquire an EPID image of the cube at all four cardinal gantry angles.
Tip: It is recommended that the field size for the EPID image be defined by the MLCs
and with a field size smaller than that of the cube itself, but large enough to contain the
tungsten sphere at the center of the cube. This aids in threshold analysis of the image.
3. Select the Multi-Image Winston-Lutz button on DoseLab Pro’s main interface.
4. Navigate to the storage location of the acquired images and select all four images. (You
can select up to eight images if you tested different combinations of
gantry/couch/collimator angles.)
5. Verify the DPI and SID image information were imported from the DICOM file.
6. Adjust the threshold settings as needed to delineate the edge of the field and the sphere,
using the “DoseLab Pro User’s Manual” if necessary.
7. Verify that the total displacement for each image is within the Coincidence of Radiation
and Mechanical Isocenter tolerances.
8. Record, export to PDF, or save within the DoseLab Pro database as desired.

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Alternate Workflow
You can modify this test so that various collimator angles and couch angles are used during
the EPID image acquisition to satisfy the Collimator Rotation Isocenter and Couch Rotation
isocenter respectively. The workflow would be the same as for the gantry, but for each
respective test, the other two variables remain at 0° (i.e., gantry and collimator at 0° and
rotate couch through cardinal angles to acquire EPID images).
A-2D: Table Top Sag QA

Recommended Items
Solid water or heavy weighted objects
Workflow
1. Extend the treatment couch to its maximum longitudinal position towards the gantry with
the surface of the couch at isocenter.
2. Place the solid water at the extended end of the couch.

Note: Solid water is the best option because of its availability in the clinic. However, if
sufficient solid water is not available to mimic the typical weight of the patient load seen
clinically, then augment the weight. Do not exceed the manufacturer’s stated tolerance
for the maximum weight concentrated at the end of the table.
3. Verify that the displacement of the table is less than the Table Top Sag tolerance.
A-2E: Table Angle QA

Recommended Items
None or Graph paper
Workflow
Rotate the couch through its full range and compare the digital readouts to the mechanical
readouts at various angles. Verify that their agreement is within the Table Angle tolerance.
Alternate Workflow
To verify couch centering, place a piece of graph paper on the couch and align it with the
light field cross-hairs. Rotate the couch through its full range and verify that the center of the
light field and graph paper cross-hairs stay within agreement through the full range of
rotation.

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A-3: Annual MLC QA
A-3: Annual MLC QA
Note: Many of the weekly and monthly workflows satisfy the annual MLC procedures. The
reference to those tests is provided in the test description column of the TG-142 spreadsheet.
A-3A: MLC Transmission QA

Recommended Items
 Solid water (or water tank), ion chamber, electrometer
 Gafchromic or radiochromic film or EPID image
Workflow
1. Set up the ion chamber in solid water or a water tank so that the sensitive volume
intersects the cross-hairs of the light field.
2. Acquire a reading with the jaws open: 200 MU with a 10 x 10 cm2 jaw defined field at
100 cm SSD and gantry at 0° (Varian IEC, gantry pointed down) is recommended if there
are no previous measurements. If previous baselines were established, mimic the same
reference field setup from those measurements.
3. Deliver the same number of MUs as in Step 2 and record the output.
4. Divide the offset closed field output by the open field output and verify that the interleaf
leakage is within the MLC Transmission tolerance relative to the baseline.
5. Repeat Steps 2-4 for all energies.
6. Acquire a film of the closed MLCs to visually verify there are no failing regions, since
the above workflow tests only the leakage in one region.

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A-3: Annual MLC QA
A-3B: Leaf Position Repeatability
Recommended Item
Graph paper
Workflow
1. Set the graph paper on the treatment couch at isocenter with the gantry, table rotation,
and collimator set to 0°.
2. Align the graph paper with the light field cross-hairs.
3. Generate an MLC-defined field and note the shadow of the leaves position on the graph
paper.
Tip: Use a sheet of graph paper exclusively for this test so that the MLC pattern can be
drawn onto the graph paper for easier analysis.
4. Retract the MLCs and then reproduce the field.
5. Verify that the leaves return to their previous positions to within the Leaf Position
Repeatability tolerance.
Alternate Workflow
Leaf position repeatability is also satisfied with DoseLab Pro’s FractionCHECK module,
which is described earlier in this document.
A-3C: MLC Spoke Shot

Recommended Items
 Solid water and film (radiochromic or gafchromic)
 EPID image of individual spokes (can be recombined in DoseLab Pro)
Workflow:
1. Set the film at isocenter with the gantry, table rotation, and collimator all set to 0°.
2. Place enough buildup on the film to permit dose deposition and film darkening.
3. Generate a thin MLC-defined field symmetric about the central axis (similar to in section
“Collimator Rotation Isocenter, Gantry Rotation Isocenter, Couch Rotation Isocenter
QA,” but with the MLC field rather than the jaws).
4. Irradiate the film at 45° collimator intervals with the same MLC-generated field. Include
an additional irradiated field to produce a minimum of 5 “spokes” on the image.
5. Scan the film.

6. Import the scan into DoseLab Pro using the Single Image Analysis module.
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A-3: Annual MLC QA
7. Select Machine QA | Starshot from the DoseLab Pro’s main interface.
8. Adjust the analysis settings as needed, referring to the “DoseLab Pro User’s Manual” as
necessary.
9. Select Process.
10. Click near isocenter and press Enter.
11. Select a circle diameter that passes through all the “spokes” of the image and click.
12. Verify that the diameter of the circle touching all “spokes” is within the MLC Spoke Shot
tolerance.
13. Record, export to PDF, or save within the DoseLab Pro database as desired.

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A-4: Annual Imaging QA
A-4: Annual Imaging QA
A-4A: Full Range of Travel SDD

TG-142 requires that this procedure be performed only for MV detectors. However, it is
recommended that you perform this procedure on the kV source and detector also.
Recommended Item
Tape measure
Workflow:
1. With gantry head up, position the MV detector at a preset distance.
Note: Varian customer acceptance uses a value of 0 / 0 / 0 so that the detector itself is at
100 cm away from the source. The imaging layer (without the covers on) is 1.2 cm below
the surface for E-Arm models. It is recommended at the time of commissioning to
determine the distance of the imaging layer with the covers on. This can be done by first
verifying the position with the covers off, then placing the covers on without moving the
detector, and reading out the new distance with the ODI.
2. Measure the distance using either the front pointer or ODI and verify that the distance is
within the Full Range of Travel SDD tolerance.
3. Position the arm at its most distal position and drive the longitudinal and lateral axes to
both limits.
4. Record the total range of travel for each axis and verify that the range is within the Full
Range of Travel SDD tolerance relative to the baseline values determined at customer
acceptance.
Tip: Place a piece of tape on the imager panel and the cross-hairs drawn on it to aid in
displacement measurements.
6. Repeat Steps 1-2 for the kV imager and detector (optional)

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A-5: Annual Wedge QA
A-5: Annual Wedge QA
A-5A: Check of Wedge Angle for 60°

Recommended Items
 Sun Nuclear Profiler 2 device
 Solid water
Workflow
1. Set up the Profiler 2 device per the manufacturer’s recommendations.
2. Add solid water on top of the device so that the diode plane is at a depth of 10 cm.
3. Acquire a 60° dynamic wedge profile.
4. Verify that the off-axis ratios at 80% field size are within 2% of the baseline values.

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Appendix A: VMAT Testing
Appendix A: VMAT Testing
Varian Recommended VMAT Testing

Recommended Items
• EPID or Film for image acquisition
• DoseLab Pro for analysis
Workflow
DoseLab Pro’s VMAT analysis is based on the tests performed in Ling et al. (2008) and
therefore it is necessary to be able to duplicate these tests. You can manually set these tests or
obtain the plans on Varian’s website. Plans include a Picket Fence test performed during an
arc, as well as arcs in which the dose rate, MLC leaf speed, and gantry speed are modulated.
1. Deliver each plan and for each acquire either an EPID image or film image.
2. For the two MLC tests in which the gantry speed, MLC speed, and/or dose rate are
modulated, select the VMAT/Dynamic MLC button in DoseLab Pro.
3. Load the open field image and the MLC field image. DoseLab Pro performs an
automated analysis of the images and provides a detailed summary.
4. Load the picket fence images into DoseLab Pro’s Single Image Analysis module and
perform the Picket Fence analysis as described in section “MLCA Qualitative Test.”

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A Practical Guide To TG142

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A-2B: Electron Applicator Interlocks QA ............................................................................................ 39

Jimmy Jones, MS / Mobius Medical Systems, LP 5

Jimmy Jones, MS / Mobius Medical Systems, LP 6

D-1: Daily Dosimetry, Mechanical, and Safety

D-1A: Dosimetry Procedures

D-1B: Mechanical Procedures

2. Evaluate the distance indicator reading (ODI)

Note: Baseline couch value and tolerance

5. Set the field size to 10 cm x 10 cm and verify

D-1C: Safety Procedures

Jimmy Jones, MS / Mobius Medical Systems, LP 8

D-2: Daily Wedge QA

D-2A: Morning Check-Out Run for One Angle

Jimmy Jones, MS / Mobius Medical Systems, LP 9

D-3: Daily Imaging QA

D-3A: Collision Interlocks

D-3B: Positioning/Repositioning & Imaging and Treatment

3. Alternatively use the machine cross-hairs to align the cube instead of

Jimmy Jones, MS / Mobius Medical Systems, LP 10

8. Acquire an EPID image (any gantry angle).

10. Acquire a kV image and repeat Step 8.

Jimmy Jones, MS / Mobius Medical Systems, LP 12

W-1: Weekly MLC QA

W-1A: MLC Qualitative Test, Travel Speed, and Leaf Position

Workflow for Picket Fence Test

2. Load the picket fence image in DoseLab’s Single Image Analysis.

Jimmy Jones, MS / Mobius Medical Systems, LP 13

Workflow for Varian Machines

2. Select FractionCHECK from DoseLab Pro’s main interface.

Jimmy Jones, MS / Mobius Medical Systems, LP 14

Jimmy Jones, MS / Mobius Medical Systems, LP 15

M-1: Monthly Dosimetry QA

M-1A: X-Ray and Electron Output, Backup Monitor Chamber,

 Solid water or water tank

Jimmy Jones, MS / Mobius Medical Systems, LP 16

M-1B: Photon and Electron Beam Profile Constancy Tests

Water Tank Option Workflow

Workflow for DoseLab Pro’s Flatness and Symmetry Module

Jimmy Jones, MS / Mobius Medical Systems, LP 17

M-2: Monthly Mechanical QA

 DoseLab Pro software

Workflow (EPID Image Acquisition)

2. Set the jaws to 15 cm x 15 cm.

Jimmy Jones, MS / Mobius Medical Systems, LP 18

5. Repeat Steps 3 and 4 for an asymmetric jaw setting.

6. Repeat steps 3 and 4 for a 10 cm x 10 cm MLC defined field.

7. Repeat steps 3 and 4 for a 15 cm x 15 cm MLC defined field.

Workflow (Film Acquisition)

2. Set the jaws to 15 cm x 15 cm.

4. Irradiate the film with sufficient dose to produce film darkening.

Jimmy Jones, MS / Mobius Medical Systems, LP 19

Workflow (Image Analysis)

4. Select Process to begin the automated analysis.

5. Verify that the Light / Radiation field coincidence is within tolerance.

6. Export the results to PDF, XLS, or a database as desired.

7. Repeat Steps 1-6 for all acquired images.

Jimmy Jones, MS / Mobius Medical Systems, LP 20

M-2B: Distance Check Device for Lasers Compared with

 Solid water (or blocks)

2. Verify that the front pointers are not bent.

Jimmy Jones, MS / Mobius Medical Systems, LP 21

Alternative Workflow (Localizing Lasers)