DOS 542 Week 1 Assignment

Actions for Weeks One and Two Assignment

Construct a table that identifies daily, monthly and annual QA for the linear accelerator, and the AAPM
recommended tolerances for each test.
Chapter 17 in Khan is a good resource. You may also use the tables in the AAPM task reports but you must
cite where you found the information.
Post your table as an attachment in this discussion forum for peer review by Wednesday, Oct 5th.
Comment /offer suggestions for the tables of at least 2 group members by Friday, Oct 7th. Based on group
comments make changes to your table if necessary.

Table 1 Daily

Procedure

Non-IMRT

IMRT Tolerance

Tolerance

SRS/SBRT
Tolerance

X-ray output
constancy
Electron output

3%

constancy
Laser localization

2mm

ODI at isocenter

2mm

1.5mm

1mm

Functional

IMRT Tolerance

SRS/SBRT

Collimator size
indicator
Door Interlock

Functional

(beam off)
Door closing safety
AV system
Stereotactic

interlocks
Radiation Area

Functional

Monitor
Beam on indicator

Table 2 Monthly

Procedure

Non-IMRT

Tolerance
X-ray output

2%

constancy
Ekectron output
constancy
Backup monitor
chamber constancy
Typiacal dose rate

output constancy
Photon beam profile

1%

profile constancy
Electron beam

2%/2mm

energy constancy
Light/radiation field

2mm or 1% on a side

coincidence
Light/radiation field

1mm or 1% on a side

coincidence
1mm

device for lasers

compared with front
pointer
Gantry/collimator

1 degree

angle indicators (@
cardinal angles)
(digital only)
Accessory Tray (i.e.

2mm

port film graticle

tray)
Jaw position
indicators
(symmetric)
Jaw position
indicators
(asymmetric)

2% at SRS dose
rate,MU

constancy
Electron beam

(asymmetric)
Distance check

2% at IMRT dose rate

1mm

Cross-hair centering
(walkout)
Treatment couch

2mm/1 deg

position indicators
Wedge placement

2mm

accuracy
Compensator

1mm

placement accuracy
Latching of wedges,

Functional

blocking tray
Localizing lasers
Laser Guard

+/-2mm
Functional

Interlock Test
Beam Output

2%

2mm/1 deg

1mm/0.5 deg

+/-1mm

<+/-1mm

IMRT Tolerance

SRS/SBRT

constancy
(Respiratory Gating)
In-room respiratory

Functional

monitoring system
Phase, amplitude
beam control
(Respiratory Gating)
Gating Interlock

Table 3 Annual

Procedure

Non-IMRT
Tolerance

X-ray flatness
change from
baseline
X-ray symmetry
change from
baseline
Electron flatness
change from

+/-1%

Tolerance

baseline
SRS arc rotation

Monitor units set vs.

mode

delivered 1.0 MU or
2%
Gantry arc set vs
delivered: 1 deg or
2% whichever is
greater

x-ray/electron

+/-1%

output calibrations
TG-51
Spot check of field

2% for field size,4x4cm2

size dependent
output factors for xray (two or more
FSs)
Output factors for

+/- 2% baseline

electron applicators
x-ray beam quality

+/- 1mm

Physical Wedge

+/-2%

Transmission
x-ray monitor unit

+/-2%

linearity
Electron monitor

+/-5%(2-4MU), +/2%>/= 5%
+/-2%>/=5MU

unit linearity
X ray constancy vs

+/-2% from baseline

Dose rate
X-ray constancy vs

+/- 1% baseline

gantry angle
Electron output
constancy vs gantry
angle
Electron output off
axis factor constancy

+/-5%(2-4 MU)

vs gantry angle
Arc mode
PDD or TMOR and

1% (TBI) or 1mm PDD shift (TSET) from baseline

OAF constancy
TBI/TSET output

2% from baseline

calibration
TBI/TSET output
calibration
Collimator rotation

+/- 1mm from baseline

isocenter
Gantry Rotation
Isocenter
Couch rotation
isocenter
Electron applicator
interlocks
Coincidence of

Functional
+/-2mm baseline

radiation and

+/- 2mm from

+/- 1mm from

baseline

baseline

Functional

mechanical isocenter
Table Top Sag
2mm from baseline
Table angle

1 deg

Table travel max

+/-2mm

range
Stereotactic

accessories,
lockouts, etc
Follow

Functional

manufacturers test
procedures
Beam Energy

2%

Constancy(Gating)
Temporal accuracy

100 ms of expected

of phase/amplitude
gate on
Calibration of

surrogate for
repiratory
phase/amplitude
Interlock testing

Functional

Table 4.: Commercially available CT-based IGRT systems/

Feature

Elekta XVI

Image Configuration

Kv-CBCT

Varian

Siemens

OBI

Artiste

Kv-CBCT Mv-CBCT

TomoTherapy

Siemens
Primato

MVCT

m
kvCT-on

45x45x17

40x40x27.

40

rails
50

Automati

4
Automatic

Automatic in 2

Manual

couch motion

c couch

couch

directions

couch

Rotation
Geometric accuracy

Optional

motion
None

motion
None
Optional
Submillimeter

motion
Optional

Dose (cGy)
Image acquisition and

0.1-3.5
2 mins

0.2-2.0
1.5mins

3-10
1.5mins

0.05-1
3 s per

Field of view
Correctio

50x50x25.6
Translation Automatic

n Method

reconstruction time

0.7-3.0
5 s per slice

slice

Table 5: Summary of QC test recommended for CT-based IGRT systems. Tolerances may change according to
expectations, experience, and performance.

Frequency
Daily

Quality Metric
Safety

Quality Check
Collision and other

Tolerance
Functional

System operation and

interlocks
Warning lights
Laser/image/treatment

accuracy

isocentre coincidence
Phantom localization

+/-2mm

and repositioning with

Monthly or upon

Geometric

upgrade

couch shift
Geometric calibration
maps
kV/MV/laser
alignment
Couch shifts:

Image quality

If used for
calculation
Annual

Replace/refresh

+/-1mm

accuracy of motions
Scale, distance, and
orientation accuracy
Uniformity. Noise
High contrast spatial

Baseline
<=2mm (or 51p/cm)

resolution
Low contrast

Baseline

Image quality

detectability
CT number accuracy

Baseline

Dose
Imaging system

and stability
Imaging dose
x-ray generator

performance
Performance (kv
systems only)
Tube potential, mA,

Baseline

ms accuracy, and
Geometric

linearity
Anteroposterior,
mediolateral, and
craniocaudal

Accurate

orientations are
maintained (upon
upgrade from CT to
System operation

Section
Image Input Tests

Topic
Image Geometry

IGRT system)
Long and short term

Support clinical use

planning of resources

and current imaging

(disk space,

policies and

manpower etc)

procedures

Test
Document and verify

Reasons
Vendor and scanner-specific

parameters used to determine

file formats and conventions

geometric description of each

can cause very specific

image (e.g., number of

geometrical errors when

pixels, pixel size, slice

converted

Geometric location and

thickness.)
Document and verify

for RTP system.

Vendor and scanner-specific

orientation of the scan

parameters used to determine

file formats and conventions

geometric location of each

can cause very specific

image, particularly left-right

geometrical errors when

and head-foot orientations.

converted

Verify that all text information

for RTP system.

Incorrect name or scan

is correctly transferred

sequence identification

Text Information

could cause misuse of the

Verify accuracy of grayscale

scans
Wrong grayscale data may

values, particularly for

cause incorrect

conversion of CT number to

identification of anatomy or

electron density

misinterpretation of the

Image unwarping

Test all features, including the

scans
Methodologies which

(removing distortions)

documentation tools which

modify imaging information

assure that the original and

may leave incorrect data in

modified images are correctly

place

identified within the system

Verify type (e.g. external

Incorrect attributes may

surface, internal structure,

cause incorrect usage of the

inhomogeneity) and

structure

Imaging Data

Anatomical
Structure Tests

Structure attributes

capabilities that are dependent

Relative electron density

on that type
Verify that correct definition

Relative electron densities

definition

for relative electron density

used during dose

(r.e. density) is used: 1.

calculations

Assigned bulk density which

depend on the choice of

sets specified r.e. density

method for definition of r.e.

everywhere inside structure

density and on its correct

Check color, type of rendering,

implementation.
Display errors can cause

and type of contours to be

planning errors due to

drawn when displaying

misinterpretations.

Auto-segmentation

structure.
Check parameters for auto-

Incorrect parameters can

parameters

contouring and other types of

lead to incorrect structure

Auto-structure definition for

definition. Parameters are

each structure.

likely to be defined

Display characteristics

separately
Structure created from

Resolve issues such as:

for each structure.

This is the most common

contours

Can non-axial contours be

way to define 3-D

used?

structures.

Is number of contour points

Errors in functionality, use

limited?

or interpretation could lead

What is the response to sharp

to

corners in contours?

systematic errors in

What happens with missing

treatment planning for a

contours?

large number

Is regular spacing required

of patients.

between contours?
Does algorithm handle
Structure constructed by

bifurcated structures?
Resolve issues such as:

Planning target volumes

expansion or contraction

What are the limits of the

(PTVs) are often defined by

from another structure

expansion algorithm?

expansion from the clinical

2-D or 3-D expansion? If 3-

target volume (

D, verification must be

CTV). Errors

performed in 3-D. If 2-D, 3-D

in the expansion could

implications should be

cause errors in target

understood.

definition

 Verify algorithm with

complex surfaces (e.g., sharp
point, square corners,
convexities, etc.)
Check bookkeeping issues
(e.g., is expansion updated
upon change of source
Structure constructed

structure?.)
Test should include same

Numerous independent

from non-axial contours

tests as for creation of

difficulties can arise

structures from axial contours

dependent on

but should be performed

the underlying 3-

separately for all contour

dimensionality of the data

orientations.

structures and

Verify bookkeeping for

design of the code.

Capping (how end

source of structure definition.

Verify that all methods of

Capping can affect dose

structure is based on

capping are performed

calculation results, target

contours)

correctly and 3-D implications

volume shapes, BEV

are understood.

display and DRR

Document default capping

generation, effects of lung

for different structures.

densities and other

Establish clinical protocols

important parts of the plan.

for each 3-D anatomical

Structure definition

structure.
Verify basic surface

These tests should convince

generation functionality using

the user that the algorithm

simple contours.

generally works correctly.

Run test cases for situations

in which the exact
formulation of the surface
mesh has been calculated by
hand.
Verify surface generation
functionality for extreme
cases (e.g., sharply pointed
contours, unclosed
contours) Tests will depend on

Contour Tests

Manual Contour

algorithm.
Define standard procedures

Incorporate standard checks

Acquisition

for contour acquisition.

into the acquisition of

Check and document

manual

separation and SSDs to AP and

contours to prevent

lateral

systematic and/or patient-

reference points for check of

specific

integrity of digitization.

errors.

Check laser alignment marks.

Digitize standard contours

Geometrical accuracy of the

weekly or use other process-

digitization device can be

related

quite user- dependent. Many

checks to check geometric

digitization systems suffer

accuracy.

from position-dependent

Verify the geometric

distortions. Digitizer

accuracy of the digitizer over

behavior

the entire

can also be time-dependent.

Contouring on 2-D

surface of the digitizer.

Verify:

Contouring on CT images is

images

The accuracy of the contour

the basis of most 3-D

display with respect to the

planning. Errors in contour

image

coordinates or display can

display.

lead

The 3-D location of the

to incorrect anatomy being

contour in the coordinate

used for planning. Contour

systems in

accuracy may be dependent

which the planning system

on image type or

calculates dose.

orientation.

Digitization process

The response of the

contouring algorithm to
extreme situations
(e.g., too many points entered,
looped contour, >1 distinct
closed contours created.)
The identification of each
contour and its associated 3-D
structure.
Contouring on CT images is

the basis of most 3-D

planning. Errors in contour
coordinates or display can lead
to incorrect anatomy being
used for planning. Contour
accuracy may be dependent on
image type or orientation.
Tests may include:
Contouring structures on a
scanned phantom and
comparing
contours to the known
dimensions of the phantoms
structures.
Contouring structures on a
grayscale phantom constructed
in
software. This eliminates any
image acquisition and pixel
averaging errors.
A subset of tests should be
performed for each type of
image,
and for each slice orientation
(sagittal, coronal, axial,
oblique),
since the contouring features
and/or use of the contours may
not
be independent of these
Autotracking contouring

parameters.
Verify proper response of the

The gradient range used to

tracking algorithm for various

identify the threshold to be

situations (e.g., different

autotracked can affect the

grayscale gradients, different

size and location of the

image

contour.

types, markers, contrast, image

Misunderstandings of

artifacts).

partial volume effects may

 Tests may involve scanned

lead to

phantoms or simulated

improper contours.

grayscale
phantoms as described above.
Partial volume effects
probably
are most easily sorted out
using images which model the
effects
of slice thickness changes on
Bifurcated structures

the grayscale values.

Resolve issues such as:

The algorithm for creating

Can the system maintain

bifurcated structures may

more than one contour per

affect the calculation of

slice for a

volumes of these structures

particular structure?
Does it form the 3-D
structure correctly? Check 3-D
surfaces
Contours on projection

visually and check DVHs.

Check that points defined on

Incorrect handling of

images (DRRs, BEVs)

projection images define lines

contours on projection

through the 3-D data.

images can lead to

Check that contours drawn

misinterpretation of plan

on projection images are

displays

projected
correctly when viewed in full
3-D displays.
Check intersection of such
contours with various axial,
sagittal,
Contours on CT

and coronal slices.

Same tests as above

scannograms

CT scannograms have
significant divergence in the
axial direction but typically
negligible divergence in the

Extracting contours from

Determine the general

sagittal direction
Contour extraction onto

surfaces

limitations and functionality of

axial and non-axial images

the

or reconstructions provides

implementation:

one of the best was to

Can contours be cut onto a

quantitatively check the 3-D

slice of arbitrary orientation?

description of anatomical

Are enough points used to

structures

accurately define the contour?

Does an extracted contour
overwrite the original drawn
contour?
What happens for complex
structures which result in
multiple
independent contours on a
Density Description

Relative electron density

single slice?
Verify that the system creates

Incorrect relative electron

Tests

representation

the correct relative electron

density info may result in

density representation.

incorrect dose calculations

Verify that the representation

is maintained correctly when
contours and/or images are
CT number conversion

modified.
Verify that the CT number to

Incorrect conversion can

Hounsfield number to relative

cause incorrect result for

electron density conversion are

density-corrected

performed correctly. The

calculations

conversion may be scanner

Editing

dependent.
Verify the proper operation of

Image grayscale might be

functions used to edit the

altered due to the presence

relative electron density

of contrast or image
artifacts, leading to
incorrect derived relative

Verify display tools used to

electron densities
Incorrect information may

measure relative electron

lead to errors in planning

Electron density within

density
Verify that the density in the

Incorrect density will lead

bolus

bloused region is set to the

to incorrect density-

assigned value. Particularly

corrected calcs.

Measurement tools

Bolus Tests

check use of bolus to edit a CT

Density measurement

image
Verify that tools read the

Error reading density values

tools

correct values within the bolus

makes verification of

Automated bolus design

Verify that:

correct behavior difficult

Incorrect behavior will lead

Bolus is designed correctly.

to wrong design or

Bolus information is

implementation of bolus.

correctly exported for

manufacture
and physical bolus is correctly
made.
Confirm whether bolus is

Could lead to incorrect

associated with a single beam

calculation results.

or with the entire plan

Confirm whether the bolus is

Could lead to incorrect

associated with a single beam

calculation results.

Monitor unit calc

or with the entire plan

Confirm the proper method to

Possible incorrect MU calc

Ouput and graphic

calc MU when bolus is used

Verify that bolus is displayed

or patient set up
Possible incorrect bolus

displays

properly in all displays

setup or use during

and hardcopy output.

treatment.

Beam Assignment

Dose calculation

Verify that bolus is properly

documented within the plan
Image use and

Grayscale windom and

and in the hardcopy output.

Verify functionality of

Window/level settings can

display tests

level settings

window and level setting.

greatly effect the

Determine whether displayed

interpretation

window/level values agree

of imaging data.

Creation and use of

with those on scanner/film.

Verify accuracy of the

Use of sagittal, coronal, and

reformatted images

geometric location of the

oblique reconstructions is

image.

an

Verify accuracy of the

important part of the 3-D

grayscale reconstruction and

visualization features used

of

in

any interpolation performed

treatment planning.

during that reconstruction.

Check consistency between

the new images and the

Removal of imaging table

original images.
Verify the capability to remove

Use of CT information

unwanted imaging info, such

which describes material

as the patient support table

which
will not be present during
dose delivery will cause
dose
distribution to not be
representative of the real
dose

Geometrical accuracy of

Verify accuracy of the

distribution.
Inaccuracies in geometry

slices associated with

geometrical location of the

can lead to errors in the 3D

images

slices with respect to the rest

visualization and in

ROI analysis

of the patient anatomy

Verify mean, minimum, and

planning
CT numbers and electron

maximum CT number inside

densities are important

a region of interest ~in a slice

when

and in a volume! for a range

evaluating the accuracy of

of situations.
Verify point coordinates,

the dose calculation results.

Measurements are often

distances, and angles in each

used for important planning

coordinate system for each

and evaluation such as

display type

placing beams and

Positional measurements

identifying anatomical
Confirm color and other

markers
Incorrect rendering may

rendering functions

misrepresent the

Multiple window display

Verify that each panel of a

geometrical situation
Inconsistencies could lead

use

multiple window display is

to incorrect planning

kept current as the planning

decisions

session proceeds
Verify that the library of

Incorrect beam choice leads

available machines and beams

to wrong dose calculation

is

and

correct. Clinical beams should

monitor units.

3D object rendering

Beam configuration
tests

Machine library

be segregated from
research or other beams.

Machine/beam

Verify that the availability of

Wrong accessories lead to

accessories

machine and beam-specific

plans that are not usable,

accessories, such as electron

incorrect, or misleading.

cones or wedge, is correct.

Verify that limitations are

Incorrect limitations lead to

correct for jaws, multileaf

plans that are not usable.

Parameter limitations

collimator, field sizes for fields

with wedges,
compensators, MLC, electron
applicators. Verify MU
limits, MU/deg. limits, angle
limits ~gantry, table,
Beam names and numbers

Readouts

collimator!, etc.
Verify correct use and display

Incorrect numbering/names

of user-defined names and

can lead to incorrect

numbers.

treatments due to confusing

Verify correct use and

documentation.
Lack of agreement between

display of angle readouts for

readout information in RTP

gantry, collimator, and table.

system and machine leads to

Verify correct use and

systematic machine

display of linear motion

treatment

readouts

errors.

of table, collimator jaws, and

MLC.
Check names and motion
Beam technique tools

Wedges

limitations.
Verify correct functionality of

Incorrect functioning of

tools such as those to move

these features will lead to

isocenters or set SSDs.

internal

Verify that wedge

mistakes in planning.
This can lead to incorrect

characterizations such as

wedge use in plan or during

coding,

treatment.

directions, field size

limitations, and availability are
Compensators

correct.
Verify correct use and display.

Incorrect use during

treatment may cause

important
System readout

General system

Verify that the planning system

dosimetric errors.
Problems can cause

conventions and

conventions

conventions agree with

systematic treatment errors.

motion description

system documentation and are

testing

used consistently
Internal consistency

throughout the system.

Examine the machine settings

Problems here will cause

and 2-D and 3-D displayed

systematic planning system

orientation of the beam for a

errors.

variety of gantry, collimator,

and target angles. Confirm that
the displayed orientations
agree with the parameter
specifications and with
calculated dose distributions.
For example, the user
should confirm that the beam
diverges in the direction
away from the gantry, and that
the hot spot for a wedged
field appears under the toe of
Readouts

the wedge.
Verify that the planning system

Errors may cause very

parameters ~transformed

isolated but systematic

as necessary! agree with the

treatment

actual machine settings

errors.

required to obtain the desired

treatment configuration.
This can be done by
configuring the treatment
machine
according to the planning
system specifications and
comparing to the planning
system displays, especially a
Test frequency

3-D room view display.

Verify the accuracy of this

Systematic errors might be

information at the

missed at new releases

Multi-user environment

Field Shape design

Block type

tests

commissioning of the RTP

unless

system and at each major

checks are made.

software update.
Establish a procedure to ensure

User might interfere with

consistent beam information in

each others plans, or access

multi-user and network

to the machine database, or

environments
Verify that the system

other similar problems

Could lead to incorrect

distinguishes between

identification of blocked or

island

irradiated

blocks, in which the aperture

areas.

delineates the block shape, and

aperture or conformal
blocks, for which the drawn
aperture encloses the open
irradiated area. Divergent and
nondivergent
blocks should also be
Block transmission

MLC leaf fits

considered.
Verify correct specification of

Incorrect transmission entry

transmission or block

or use leads to incorrect

thickness

dose

for full blocks and partial

under blocks.

transmission blocks.
Document and test all methods

Inappropriate aperture shape

used to fit the MLC leaves to

can lead to extra dose to

the desired field shape.

normal
tissue or missing some of

Electron applicators

Verify availability and size of

the target.
Can lead to plans which

Hardcopy output

electron applicators
Check all output showing

cannot be used
Inappropriate

beam apertures and/or used for

documentation may lead to

beam aperture fabrication

incorrect fabrication

~e.g., MLC leaf positions,

of the aperture, or

BEV

inappropriate clinical QA

plots! for accuracy against the

checks.

Manual aperture

Film magnification

displays.
Confirm that film

Incorrect block shape could

entry tests

factors

magnification is correct for

be used in plan.

film
digitization entry.
Check geometrical accuracy of

Could lead to incorrect

aids such as a circular cursor

margins during aperture

Number of point in

with definable radius

Evaluate the effects of any

design
Could lead to incorrect

aperture definition

limitation on number of

aperture shape

Editing apertures

defining points
Evaluate how the algorithm

Could lead to incorrect

Defining apertures on

handles aperture editing

Confirm geometry, particularly

aperture shape.
This could lead to incorrect

BEV/DRR displays

the distance from the

interpretation of planned

source at which the displayed

aperture.

BEV plane is located.

Confirm correct 3-D

Might lead to incorrect

projections of anatomical

aperture design or choice of

information including

beam

contours, structures, and 3-D

direction.

Special drawing aids

3D projections

points
Wedge tests

Orientation and angle

into BEV/DRR displays.

Confirm that wedge

Wedge labeling or

specifications

orientation and angle

orientation conventions

specifications are

which do not agree

consistent throughout the

with the RTP system can

planning system, including the

lead to confusion in plans

hardcopy output. If possible,

and

they should agree with

treatment.

treatment
2D display

machine conventions.
Check display of wedges in

Visual orientation checks

different 2-D planes ~parallel,

are most effective way to

orthogonal, oblique! for

prevent

different beam directions,

wrong wedge orientation in

collimator

plan or treatment.

rotations, and wedge

3D display

Orientation and field size

orientations.
Check display of wedges in

Incorrect wedge orientation

room view 3-D displays for

leads to large dose

situations as described above.

Verify that wedge orientations

differences
May lead to plans which

limitations

and field sizes not allowed by

cannot be delivered.

the treatment machine are not

allowed in the planning
system.
These limits might be defined
separately for each beam
energy, so they should be
tested for each energy/wedge
Autowedges (wedges

combination.
Confirm that the division of a

Could lead to incorrect dose

inside the head of

field into fractional open and

distribution or monitor

machine)

wedged fields agrees in the

units.

RTP system and on the

treatment
Dynamic Wedges

machine.
Verify that the implementation

Incorrect use of dynamic

in the RTP system has the

wedge possible

same capabilities, limitations,

orientations, and naming
conventions as on the
Beam geometry tests

Axial beam divergence

Non-axial divergence

BEV/DRR displays

treatment machine.
Test intersection of divergent

Incorrect divergence leads

beam and aperture edges with

to selection of wrong field

axial slices.

sizes or

Test intersection of divergent

aperture shape.
Incorrect divergence leads

beam and aperture edges with

to selection of wrong field

sagittal, coronal, and oblique

sizes or

slices. For systems that are not

aperture shape, especially if

fully 3-D, there may be 2-D

3-D effects are not

limitations in the projections

completely

which must be taken into

understood.

account.
Verify projection of

Incorrect projections lead to

contours/structures defined on

selection of wrong aperture

axial

shape,

slices into BEV-type displays.

especially if 3-D effects are

Compare with the grayscale

not completely understood.

images for DRR displays. This

is most easily done with a

simple phantom containing
only a few internal structures.
Verify projection of divergent
beam and aperture edges.
Check at several different
3D displays

SSDs and projection distances.

Verify that apertures defined

Incorrect projections lead to

on 2-D planes are correctly

selection of wrong aperture

projected in 3-D.

shape,

Verify that the relationships

especially if 3-D effects are

between structure and beam

not completely understood.

and aperture edges are correct.

2-D limitations of the system
must be considered ~e.g., a
2-D system may not correctly
display divergence in the
Patient and beam labels

third direction!.
Verify patient orientation

Incorrect labeling can

with respect to beam and

mislead treatment therapists

orientation annotations.

or

Verify correctness of

physicians.

orientations and annotations

for
machine position views or
icons associated with 2-D or 3D
Methodology and

displays.
Evaluate and confirm the

Must calculate dose to

correct functioning of methods

regions which are

used to identify the regions to

important.

Calculation grid

be calculated.
Evaluate and verify proper

Incorrect grid use can result

definition

functioning of:

in dose in incorrect places,

grid size definition

miscalculation, incorrect

use of uniform and/or non-

display, misalignment,

uniform grid spacing.

incorrect

interpolation method for

display, misalignment of

determining dose between grid

dose and beam, etc.

Regions to be calculated

Algorithm Use Tests

points
invalidation of calculations if
grid size, spacing, or
extent is changed
proper alignment of
coordinate system in which
dose
computation points are defined
relative to the image
coordinate system and the
machine coordinate system
~i.e., the collimator system!
Status of density

must also be checked

Verify correct bookkeeping for

Misleading dose

corrections

status of corrections.

distributions, incorrect

Determine how status of

monitor units are

corrections is stored and

possible.

documented.
Verify functionality associated

This is just as important as

with reading stored

doing the original dose

anatomical, beam, dose, and

calculation correctly.

Reading saved plan info

source information. Tests

should be designed with
detailed knowledge of the
Calculation validity logic

system.
Evaluate system rules for

Incorrect logic will either 1!

recalculation of dose

waste valuable time and

distribution when changes are

resources; or 2! leave an

made in anatomy, beam

invalid dose calculation for

definitions, beam weights, or

incorrect interpretation.

normalization. Often, only

the affected beam~s! will be

Dose display tests

Dose calculation

recalculated.
Verify that default algorithm

If more than one algorithm

algorithm selection

selections are appropriate,

is available, most likely the

and that the selected algorithm

different algorithms are

is the one actually used.

intended for specific

Verify that:

purposes.
Point displays used for

Dose points

 point is defined at the desired

critical structure doses and

3-D coordinates

for

point is displayed at the

investigating dose

correct 3-D position

distribution behavior.

dose at point is displayed

Interactive point doses

correctly
Verify that:

Problems would affect

point coordinates correctly

results of plan optimization.

correspond to cursor position

on
display
dose at point is displayed
Consistency

correctly
Verify that:

Inconsistency demonstrates

doses in intersecting planes

algorithm limitations or

are consistent

problems,

doses displayed with

makes evaluations

different display techniques

impossible.

are
Dose grids

2D dose displays

Consistent
Verify that dose is correctly

Interpolations done

interpolated between grid

incorrectly give wrong dose

points

results,

for both small and large

particularly in penumbra

spacing ~see for example Ref.

regions.

74!.
Verify that:

This is the main kind of

isodose lines ~IDLs! are

display used to decide if

correctly located

coverage of

the colorwash display lines

PTV is actually adequate.

up correctly with IDLs and

agrees with the point dose
Isodose suraces

displays
Verify that:

Might lead to use of plans

surfaces are displayed

with too much or too little

correctlyparticularly check

target

higher

coverage, or other

dose surfaces, which may

misrepresentations of the

break up into numerous small

dose distribution

volumes unattached to each

with respect to the anatomy.

other.
surfaces are consistent with
Beam display

isodose lines on planes

Verify that:

Must be aligned correctly

positions and field sizes are

with dose distribution or

correct

entire plan

wedges are shown and the

should be doubted.

orientation is correct
beam edges and apertures are
DVH Tests

VROI identification

shown correctly
Test creation of the voxel

Misidentification of VROI

VROI description used to

leads to incorrect DVH.

create
DVHs against structure
Structure identification

description.
Test Boolean combinations of

Incorrect complex VROI

objects ~VROI and DVH of

also leads to incorrect DVH.

Normal Tissue-Target!, and

how voxels which belong to
multiple structures are
Voxel dose interpolation

handled.
Verify accuracy of dose

Interpolation from one 3-D

interpolated into each voxel.

grid to another could lead to

grid-based artifacts or

Structure volume

Histogram bins and limits

DVH calculation

Test accuracy of volume

inaccuracies.
Structure volume is basis of

determination with irregularly

much NTCP modeling.

shaped objects, since regular

Also,

shapes ~particularly

volume may be directly

rectangular objects! can be

used in physician plan

subject to numerous

evaluation

grid-based artifacts.
Verify that appropriate

considerations.
Inappropriate bins and/or

histogram bins and limits are

limits to DVH can lead to

used.
Test DVH calculation

misleading DVH.
Basic calculation must be

algorithm with known dose

sound, else incorrect clinical

distributions.

decisions about plan

evaluation may result.

DVH types

Verify that standard ~direct!,

Each type of DVH display

differential, and cumulative

is useful in particular

histograms67 are all calculated

situations.

and displayed correctly.

Test DVH plotting and output

Hardcopy output must be

using known dose

correct, as this may be used

distributions.

for

Plan and DVH

Verify relationship of plan

physician decision making.

Plan normalization is

normalization

normalization ~dose! values to

critical to the dose axis of

Dose and VROI grid

DVH results.
Review and understand

the DVH.
Grid-based artifacts can

effects

relationship of dose and VROI

cause errors in volume,

grids.

dose,

DVH plotting and output

DVH, and the evaluation of

Use of DVHs from

Test correct use of DVHs from

the plan.
Comparison of DVHs from

different cases

different cases with

different plans depends

different DVH bin sizes, dose

critically on bin sizes, etc.

Non-dosimetric

Source input and

grids, etc.
For source location entry

Dose calculations for

brachytherapy tests

geometrical accuracy

using a digitizer and

brachytherapy are very

orthogonal or

sensitive to exact

stereo-shift films, checks

source positions.

should be made of the data

entry
software, the film acquisition
process, source identification,
and other associated activities.
3-D seed coordinate
representation after entry
should be confirmed.
Automatic seed identification
and locating software must be
verified.
For source location entry
using CT images,76 other tests
should be included.
For applicator trajectory

identification, the appropriate

tests
described above should be
performed. In addition, the
accuracy of dwell points or
source locations along the
trajectory should be
Source displays

confirmed.
Verify accuracy of source

Accurate display of source

position display on:

position is crucial to plan

2-D slices, including CT and

development and

reconstructed images and the

optimization.

arbitrary planes often used in

non-CT brachytherapy.
3-D views
Special views, such as the
Probes Eye View used in
stereotactic brain implant
planning.77
Dummy sources in phantom
can be scanned, DRRs
generated to use as a check for
radiograph-based
Optimization and

identification and positioning.

Test automated

Incorrect functioning of

evaluation

brachytherapy optimization

optimization and evaluation

tools, such as

tools can

automatic determination of

result in sub-optimal or

dwell positions and times to

incorrect treatment.

yield a specified dose

distribution with an afterloader
unit.
Test designs should be very
dependent on algorithm used.
See Appendix 5.
Test other standard tools such
as DVHs.

References
1. Klein E, Hanley J, Bayouth J, et al. AAPM TG-142 Report: QA of Medical Accelerators.
Med Phys. September 2009; 36(9):4197-4212
2. Bissonnette JP, Balter PA, Dong L, et al. Quality assurance for image-guided radiation
therapy utilizing CT-based technologies: A report of the AAPM TG-179. Med Phys. April
2012; 39(4): 1946-1963.
3. Fraass B, Doppke K, Hunt M. American Association of Physicists in Medicine Radiation
Therapy committee Task Group 53: Quality assurance for clinical radiotherapy treatment
planning. Med Phys. October 1998; 25(10): 1773-1829.