This report provides guidance for users of linear accelerator (linac) manufacturer integrated quality control (MIQC) tools. MIQC tools have been developed and introduced by radiotherapy linac vendors, and have the potential to improve both the quality and efficiency of linac quality control (QC). They usually utilise the Electronic Portal Imaging Device (EPID), but may acquire data from other sources, and automatically perform and analyse tests of various treatment machine QC parameters. The currently available systems meeting this definition are Varian machine performance check, CyberKnife automated quality assurance /end-to-end, TomoTherapy Quality Assurance, and Elekta machine QA (also known as AQUA). This guidance report covers the commissioning and implementation of MIQC. The guidance has been developed by a radiotherapy special interest group working party on behalf of the Institute of Physics and Engineering in Medicine. Recommendations within the report are derived from the experience of the working party members, existing guidance, literature, and a United Kingdom survey conducted in 2022 (Pearsonet al2023Phys. Med. Biol.68245018). Topics covered include developing an understanding of the QC system, independence review of MIQC, commissioning, implementation, ongoing QC and calibration, software upgrades and periodic review. The commissioning section covers detector commissioning, repeatability and reproducibility, baseline and tolerance setting, concordance with existing QC, sensitivity testing, cost-benefits analysis, and risk assessment methods. In order to offer practical guidance, case studies covering each aspect of commissioning are included. They are real-world examples or experiences from early adopters, each applied to a different example MIQC system. The examples will be directly applicable to users of that specific MIQC system, but also provide practical guidance on clinical implementation to users of the other systems.

PURPOSE:The aim was to develop and evaluate an EPID-based MLC positional test that addresses known weaknesses of the picket fence test and has sufficient accuracy so that the AAPM MPPG 8.b. MLC position action limit of ± 0.5 mm can be implemented. METHODS:Weaknesses and inaccuracies in the picket fence test were identified and a new test plan and analysis algorithm named stakitt was developed. Stakitt was evaluated for repeatability and for sensitivity on the Varian TrueBeam linac with both Millennium MLC and HDMLC and on a Varian Clinac with Millennium MLC. Sensitivity was tested via deliberate introduction of errors into the test plan of magnitude: ± 0.1, ± 0.5, ± 1.0 and ± 1.5 mm. Measured sensitivity was compared to published sensitivity of the picket fence test. Additionally, a use case was presented based on results from a TrueBeam linac to highlight the effect of MLC backlash on MLC positions at non-zero gantry angles. RESULTS:Repeatability was observed to within 0.04 mm (3 SD) with the TrueBeams being more repeatable than the Clinac. The deliberately introduced errors were accurately measured to within 0.28 mm and were comparable to the traditional picket fence. Reduced accuracy was recorded for the HDMLC small leaves, which was attributed to an apparent variation in measured leaf width across the range of travel, which impacted the measurement of the leaf tip position. The clinical use case demonstrated variability in MLC leaf positions between gantry 90° and gantry 270° that were of the magnitude of the MLC backlash. CONCLUSION:The stakitt test addresses the weaknesses of the picket fence test and has accuracy appropriate for implementation of a ± 0.5 mm action limit. However, such an action limit may not be currently practical at non-zero gantry angles due to the impact of MLC leaf backlash.

Abstract Purpose Multi‐leaf‐collimator (MLC) leaf position accuracy is important for accurate dynamic radiotherapy treatment plan delivery. Machine log files have become widely utilized for quality assurance (QA) of such dynamic treatments. The primary aim is to test the sensitivity of machine log files in comparison to electronic portal imaging device (EPID)‐based measurements to MLC position errors caused by leaf backlash. The secondary aim is to investigate the effect of MLC leaf backlash on MLC leaf motion during clinical dynamic plan delivery. Methods The sensitivity of machine log files and two EPID‐based measurements were assessed via a controlled experiment, whereby the length of the “T” section of a series of 12 MLC leaf T‐nuts in a Varian Millennium MLC for a Trilogy C‐series type linac was reduced by sandpapering the top of the “T” to introduce backlash. The built‐in machine MLC leaf backlash test as well as measurements for two EPID‐based dynamic MLC positional tests along with log files were recorded pre‐ and post‐T‐nut modification. All methods were investigated for sensitivity to the T‐nut change by assessing the effect on measured MLC leaf positions. A reduced version of the experiment was repeated on a TrueBeam type linac with Millennium MLC. Results No significant differences before and after T‐nut modification were detected in any of the log file data. Both EPID methods demonstrated sensitivity to the introduced change at approximately the expected magnitude with a strong dependence observed with gantry angle. EPID‐based data showed MLC positional error in agreement with the micrometer measured T‐nut length change to 0.07 ± 0.05 mm (1 SD) using the departmental routine QA test. Backlash results were consistent between linac types. Conclusion Machine log files appear insensitive to MLC position errors caused by MLC leaf backlash introduced via the T‐nut. The effect of backlash on clinical MLC motions is heavily gantry angle dependent.

AbstractPurposeCalibration of a radiotherapy electronic portal imaging device (EPID) using the pixel‐sensitivity‐map (PSM) in place of the flood field correction improves the utility of the EPID for quality assurance applications. Multiple methods are available for determining the PSM and this study provides an evaluation to inform on which is superior.MethodsThree different empirical methods (“Calvary Mater Newcastle” [CMN], “Varian,” and “WashU”) and a Monte Carlo‐based method of PSM determination were investigated on a single Varian TrueBeam STx linear accelerator (linac) with an aS1200 EPID panel. PSM measurements were performed for each empirical method three successive times using the 6 MV beam. The resulting PSM from each method was compared to the Monte Carlo method as a reference using 2D percentage deviation maps and histograms plus crossplane profiles. The repeatability of generated PSMs was also assessed via 2D standard deviation (SD) maps and histograms. Additionally, the Beam‐Response generated by removal of the PSM from a raw EPID image for each method was visually contrasted. Finally, the practicality of each method was assessed qualitatively and via the measured time required to acquire and export the required images.ResultsThe median pixel‐by‐pixel percentage deviation between each of the empirical PSM methods and the Monte Carlo PSM was ‐0.36%, 0.24%, and 0.74% for the CMN, Varian, and WashU methods, respectively. Ninety‐five percent of pixels were found to be repeatable to within ‐0.21%, 0.08%, 0.19%, and 0.35% (1 SD) for the CMN, Monte Carlo, Varian, and WashU methods, respectively. The WashU method was found to be quickest for data acquisition and export and the CMN the slowest.ConclusionFor the first time four methods of generating the EPID PSM have been compared in detail and strengths and weaknesses of each method have been identified. All methods are considered likely to be clinically acceptable and with similar practical requirements.

Abstract Purpose The EPID PSM is a useful EPID calibration method for QA applications. The dependence of the EPID PSM on the photon beam used to acquire it has been investigated in this study for the four available PSM methods. The aim is to inform upon the viability of applying a single PSM for all available photon beams to simplify PSM implementation and maintenance. Methods Four methods of PSM determination were each measured once in a single session on a single TrueBeam ® STx linac using 6 MV, 10 MV, 6 MV Flattening‐Filter‐Free (FFF), and 10 MV FFF photon beams. The resultant PSM was assessed for both intra‐ and inter‐method beam dependence via comparison between PSM of the same method compared to the 6 MV PSM and via comparison between PSM of the same beam with the corresponding Monte Carlo PSM. Comparisons were performed via 2D percentage deviation plots with associated histograms, 1D crossplane profiles, and via mean, median, and standard deviation percentage deviation statistics. Generated beam‐response was compared qualitatively via 1D crossplane profile comparison and quantitatively via symmetry assessment with comparison to the IC profiler device. Results The Varian method provided the most consistent PSM with varying photon beam, with median percent deviation from the 6 MV PSM within 0.14% for all other beams. Qualitatively, each method provided similar beam‐response profiles. The measured beam‐response symmetry agreed to within 0.2% between the Calvary Mater Newcastle (CMN) method and IC profiler, but agreement reduced to within 0.9% and 2.2% for the Varian and WashU methods. PSM percent deviation with Monte Carlo PSM was within 0.75% for all methods and beams. Conclusion Results suggest that the PSM may be independent of photon beam to clinically relevant levels. The Varian method of PSM determination introduces the least beam dependence into the measured PSM.

Purpose A predictive linac quality assurance system based on the output of the Machine Performance Check (MPC) application was developed using statistical process control and autoregressive integrated moving average forecast modeling. The aim of this study is to demonstrate the feasibility of predictive quality assurance based on MPC tests that allow proactive preventative maintenance procedures to be carried out to better ensure optimal linac performance and minimize downtime. Method and Materials Daily MPC data were acquired for a total of 490 measurements. The initial 85% of data were used in prediction model learning with the autoregressive integrated moving average technique and in calculating upper and lower control limits for statistical process control analysis. The remaining 15% of data were used in testing the accuracy of the predictions of the proposed system. Two types of prediction were studied, namely, one-step-ahead values for predicting the next day's quality assurance results and six-step-ahead values for predicting up to a week ahead. Results that fall within the upper and lower control limits indicate a normal stage of machine performance, while the tolerance, determined from AAPM TG-142, is the clinically required performance. The gap between the control limits and the clinical tolerances (as the warning stage) provides a window of opportunity for rectifying linac performance issues before they become clinically significant. The accuracy of the predictive model was tested using the root-mean-square error, absolute error, and average accuracy rate for all MPC test parameters. Results The accuracy of the predictive model is considered high (average root-mean-square error and absolute error for all parameters of less than 0.05). The average accuracy rate for indicating the normal/warning stages was higher than 85.00%. Conclusion Predictive quality assurance with the MPC will allow preventative maintenance, which could lead to improved linac performance and a reduction in unscheduled linac downtime.

AbstractAccurate quantification of absorbed radiation dose is important for safe and effective delivery of radiation therapy. An important aspect to this is reference dosimetry, which is performed under reference conditions specified by international codes of practice. Such measurements are usually performed in a water phantom. In the Sun Nuclear Corporation (SNC) three‐dimensional (3D) scanner water tank system the detector holder is fixed to a horizontal metallic drive rail (MDR) which is in close proximity to the active volume of the detector. In this project, the dosimetric effects of the MDR on reference dosimetry were investigated for MV photons, MeV electrons, and kV photons by comparing reference dosimetry measurements in the SNC 3D scanner against similar measurements in a Standard Imaging (SI) one‐dimensional (1D) tank and against measurements in the SNC 3D scanner with an additional, custom‐made spacer placed beneath the chamber holder to increase the chamber ‐ MDR separation. A second experiment investigated the difference in chamber reading dependent on chamber to MDR separation by fixing the chamber in the tank independently of the MDR and successively moving the MDR vertically to alter the separation. The results showed that measurements in the SNC 3D scanner agree with both SI 1D tank and SNC 3D scanner with spacer to within ±0.3% for MV photons, ±0.1% for electrons and ±1.2% for kV photons within the calculated setup uncertainty. The second experiment showed that the contribution of backscatter from the MDR was significant if the distance between MDR and chamber was reduced below the chamber's designed position in the SNC 3D scanner. The exception was for kV photons where the contribution of backscatter from the MDR was measured to be 0.5% at the designed distance. Further investigation would be useful for kV photons, where the experiment showed relatively large measurement uncertainties.

The characteristics of the focal spot of the linear accelerator (linac) play a role in determining the resulting dose distribution within the patient, and hence probability of treatment success. A direct measurement of focal spot position is not recommended by AAPM Task Group 142, but factors influenced by focal spot position, such as beam symmetry and isocentre position, are. Traditional methods of measuring focal spot position are time consuming and can only be performed at gantry 0°. The presented method has been proposed using a phantom of novel design to accurately measure the position of the focal spot relative to the collimator’s axis of rotation (CAX) at any gantry angle, and to measure the intra-fraction movement of the focal spot relative to the mean position during treatment. The method was reproducible to within 0.012 mm/0.029 mm (mean/max) for the three Varian linacs tested. The focal spot position was shown to deviate from the CAX by up to 0.386 mm during gantry rotation. The focal spot position was more unstable at the start of treatment, with the worst performing linac having an initial displacement of up to 0.15 mm from its mean position before stabilizing to within 0.01 mm after 3 s. The method proposed is a beneficial addition to the quality assurance (QA) schedule of any clinic, allowing quick determination of source position and movement at any gantry angle. Measurement of focal spot allows the possibility of fine-tuning the electron beam steering system to improve the standard of the photon beam and of stereotactic treatments.

Beam steering is the process of calibrating the angle and translational position with which a linear accelerator's (linac's) electron beam strikes the x-ray target with respect to the collimator rotation axis. The shape of the dose profile is highly dependent on accurate beam steering and is essential for ensuring correct delivery of the radiotherapy treatment plan. Traditional methods of beam steering utilize a scanning water tank phantom that makes the process user-dependent This study is the first to provide a methodology for both beam angle steering and beam translational position steering based on EPID imaging of the beam and does not require a phantom. Both the EPID-based beam angle steering and beam translational steering methods described have been validated against IC Profiler measurement. Wide field symmetry agreement was found between the EPID and IC Profiler to within 0.06 +/- 0.14% (1 SD) and 0.32 +/- 0.11% (1 SD) for flattened and flatteningfilter-free (FFF) beams, respectively. For a 1.1% change in symmetry measured by IC Profiler the EPID method agreed to within 0.23%. For beam translational position steering, the EPID method agreed with IC Profiler method to within 0.03 +/- 0.05 mm (1 SD) at isocenter. The EPID-based methods presented are quick to perform, simple, accurate and could easily be integrated with the linac, potentially via the MPC application. The methods have the potential to remove user variability and to standardize the process of beam steering throughout the radiotherapy community.

Multileaf-collimator (MLC) defined small fields in radiotherapy are used in high dose, ultra-conformal techniques such as stereotactic radiotherapy and stereotactic radiosurgery. Proximity to critical structures and irreversible damage arising from inaccurate delivery mean that correct positioning of the MLC system is of the utmost importance. Some of the existing techniques for MLC positioning quality assurance make use of electronic portal imaging device (EPID) images. However, conventional collimation verification algorithms based on the full width at half maximum (FWHM) fail when applied to small field images acquired by an EPID due to overlapping aperture penumbrae, lateral electron disequilibrium and radiation source occlusion. The objective of this study was to investigate sub-pixel edge detection and other techniques with the aim of developing an automatic and autonomous EPID-based method suitable for MLC positional verification of small static fields with arbitrary shapes. Methods investigated included derivative interpolation, Laplacian of Gaussian (LoG) and an algorithm based on the partial area effect hypothesis. None of these methods were found to be suitable for MLC positioning verification in small field conditions. A method is proposed which uses a manufacturer-specific empirically modified FWHM algorithm which shows improvement over the conventional techniques in the small field size range. With a measured mean absolute difference from planned position for Varian linacs of 0.01 ± 0.26 mm, compared with the erroneous FWHM value of 0.70 ± 0.51 mm. For Elekta linacs the proposed algorithm returned 0.26 ± 0.25 mm, in contrast to the FWHM result of 1.79 ± 1.07 mm.

Alignment of the On-Board Imager (OBI) X-ray tube is important for ensuring imaging to treatment isocenter coincidence, which in turn is important for accurate Image Guided Radiotherapy (IGRT). Varian introduced a new X-ray tube alignment procedure for the TrueBeam linac in software version 2.5 MR2 as part of the machine performance check (MPC) application. This study evaluated the new procedure against conventional methods and examined the clinical significance of X-ray tube misalignment. Long term stability and short term repeatability of MPC tube alignment was assessed as well as sensitivity of the method to setup error. Standard quality assurance tests expected to be sensitive to tube misalignment were performed before and after tube alignment. These tests included: IsoCal verification; MPC kV imager offset; Winston-Lutz: kV imaging to treatment/radiation isocenter coincidence; CBCT image QA using the Catphan phantom; and OBI image geometric accuracy and center pixel alignment. Tube alignment measurements were performed with MPC, the two-plate method, and wire-on-faceplate method. The X-ray tube was then realigned by approximately 1.01 mm in the tangential plane based upon MPC and the tube alignment and standard quality assurance measurements were repeated. The time taken for each tube alignment method was estimated. The MPC method of tube alignment was found to be repeatable, insignificantly sensitive to phantom setup error and quick and simple to perform. The standard QA tests were generally insensitive to the tube alignment change, possibly because of the IsoCal correction. However, reduction in the magnitude of IsoCal correction and MPC kV imager offset was recorded after tube alignment. There was also apparent improvement in CBCT image uniformity. The MPC procedure is recommended for X-ray tube alignment.

PurposeAn ideal commissioning and quality assurance (QA) program for Volumetric Modulated Arc Therapy (VMAT) delivery systems should assess the performance of each individual dynamic component as a function of gantry angle. Procedures within such a program should also be time‐efficient, independent of the delivery system and be sensitive to all types of errors. The purpose of this work is to develop a system for automated time‐resolved commissioning and QA of VMAT control systems which meets these criteria.MethodsThe procedures developed within this work rely solely on images obtained, using an electronic portal imaging device (EPID) without the presence of a phantom. During the delivery of specially designed VMAT test plans, EPID frames were acquired at 9.5 Hz, using a frame grabber. The set of test plans was developed to individually assess the performance of the dose delivery and multileaf collimator (MLC) control systems under varying levels of delivery complexities. An in‐house software tool was developed to automatically extract features from the EPID images and evaluate the following characteristics as a function of gantry angle: dose delivery accuracy, dose rate constancy, beam profile constancy, gantry speed constancy, dynamic MLC positioning accuracy, MLC speed and acceleration constancy, and synchronization between gantry angle, MLC positioning and dose rate. Machine log files were also acquired during each delivery and subsequently compared to information extracted from EPID image frames.ResultsThe largest difference between measured and planned dose at any gantry angle was 0.8% which correlated with rapid changes in dose rate and gantry speed. For all other test plans, the dose delivered was within 0.25% of the planned dose for all gantry angles. Profile constancy was not found to vary with gantry angle for tests where gantry speed and dose rate were constant, however, for tests with varying dose rate and gantry speed, segments with lower dose rate and higher gantry speed exhibited less profile stability. MLC positional accuracy was not observed to be dependent on the degree of interdigitation. MLC speed was measured for each individual leaf and slower leaf speeds were shown to be compensated for by lower dose rates. The test procedures were found to be sensitive to 1 mm systematic MLC errors, 1 mm random MLC errors, 0.4 mm MLC gap errors and synchronization errors between the MLC, dose rate and gantry angle controls systems of 1°. In general, parameters measured by both EPID and log files agreed with the plan, however, a greater average departure from the plan was evidenced by the EPID measurements.ConclusionQA test plans and analysis methods have been developed to assess the performance of each dynamic component of VMAT deliveries individually and as a function of gantry angle. This methodology relies solely on time‐resolved EPID imaging without the presence of a phantom and has been shown to be sensitive to a range of delivery errors. The procedures developed in this work are both comprehensive and time‐efficient and can be used for streamlined commissioning and QA of VMAT delivery systems.

Machine Performance Check (MPC) is an automated and integrated image-based tool for verification of beam and geometric performance of the TrueBeam linac. The aims of the study were to evaluate the performance of the MPC geometric tests relevant to OBI/CBCT IGRT geometric accuracy. This included evaluation of the MPC isocenter and couch tests. Evaluation was performed by comparing MPC to QA tests performed routinely in the department over a 4-month period. The MPC isocenter tests were compared against an in-house developed Winston-Lutz test and the couch compared against routine mechanical QA type procedures. In all cases the results from the routine QA procedure was presented in a form directly comparable to MPC to allow a like-to-like comparison. The sensitivity of MPC was also tested by deliberately miscalibrating the appropriate linac parameter. The MPC isocenter size and MPC kV imager offset were found to agree with Winston-Lutz to within 0.2 mm and 0.22 mm, respectively. The MPC couch tests agreed with routine QA to within 0.12 mm and 0.15 degrees. The MPC isocenter size and kV imager offset parameters were found to be affected by a change in beam focal spot position with the kV imager offset more sensitive. The MPC couch tests were all unaffected by an offset in the couch calibration but the three axes that utilized two point calibrations were sensitive to a miscalibration of the size in the span of the calibration. All MPC tests were unaffected by a deliberate misalignment of the MPC phantom and roll of the order of one degree.

Volumetric-modulated arc therapy (VMAT) treatment delivery requires three key dynamic components; gantry rotation, dose rate modulation, and multi-leaf collimator motion, which are all simultaneously varied during the delivery. Misalignment of the gantry angle can potentially affect clinical outcome due to the steep dose gradients and complex MLC shapes involved. It is essential to develop independent gantry angle quality assurance (QA) appropriate to VMAT that can be performed simultaneously with other key VMAT QA testing. In this work, a simple and inexpensive fully independent gantry angle measurement methodology was developed that allows quantitation of the gantry angle accuracy as a function of time. This method is based on the analysis of video footage of a "Double dot" pattern attached to the front cover of the linear accelerator that consists of red and green circles printed on A4 paper sheet. A standard mobile phone is placed on the couch to record the video footage during gantry rotation. The video file is subsequently analyzed and used to determine the gantry angle from each video frame using the relative position of the two dots. There were two types of validation tests performed including the static mode with manual gantry angle rotation and dynamic mode with three complex test plans. The accuracy was 0.26° ± 0.04° and 0.46° ± 0.31° (mean ± 1 SD) for the static and dynamic modes, respectively. This method is user friendly, cost effective, easy to setup, has high temporal resolution, and can be combined with existing time-resolved method for QA of MLC and dose rate to form a comprehensive set of procedures for time-resolved QA of VMAT delivery system.

Machine performance check (MPC) is an automated and integrated image-based tool for verification of beam and geometric performance of the TrueBeam linac. The aims of the study were to evaluate the performance of the MPC geometric tests relevant to beam collimation (MLC and jaws) and mechanical systems (gantry and collimator). Evaluation was performed by comparing MPC to QA tests performed routinely in the department over a 4-month period. The MPC MLC tests were compared to an in-house analysis of the Picket Fence test. The jaw positions were compared against an in-house EPID-based method, against the traditional light field and graph paper technique and against the Daily QA3 device. The MPC collimator and gantry were compared against spirit level and the collimator further compared to Picket Fence analysis. In all cases, the results from the routine QA procedure were presented in a form directly comparable to MPC to allow a like-to-like comparison. The sensitivity of MPC was also tested by deliberately miscalibrating the appropriate linac parameter. The MPC MLC was found to agree with Picket Fence to within 0.3 mm and the MPC jaw check agreed with in-house EPID measurements within 0.2 mm. All MPC parameters were found to be accurately sensitive to deliberately introduced calibration errors. For the tests evaluated, MPC appears to be suitable as a daily QA check device.

AbstractModern day Stereotactic treatments require high geometric accuracy of the delivered treatment. To achieve the required accuracy the IGRT imaging isocenter needs to closely coincide with the treatment beam isocenter. An influence on this isocenter coincidence and on the spatial positioning of the beam itself is the alignment of the treatment beam focal spot with collimator rotation axis. The positioning of the focal spot is dependent on the linac beam steering and on the stability of the monitor chamber and beam steering servo system. As such, there is the potential for focal spot misalignment and this should be checked on a regular basis. Traditional methods for measuring focal spot position are either indirect, inaccurate, or time consuming and hence impractical for routine use. In this study a novel, phantomless method has been developed using the EPID (Electronic Portal Imaging Device) that utilizes the different heights of the MLC and jaws. The method has been performed on four linear accelerators and benchmarked against an alternate ion chamber‐based method. The method has been found to be reproducible to within ±0.012 mm (1 SD) and in agreement with the ion chamber‐based method to within 0.001 ± 0.015 mm (1 SD). The method could easily be incorporated into a departmental routine linac QA (Quality Assurance) program.