AAPM Medical Physics Practice Guideline 8.b: Linear accelerator performance tests.

The purpose of this guideline is to provide a list of critical performance tests to assist the Qualified Medical Physicist (QMP) in establishing and maintaining a safe and effective quality assurance (QA) program. The performance tests on a linear accelerator (linac) should be selected to fit the clinical patterns of use of the accelerator and care should be given to perform tests which are relevant to detecting errors related to the specific use of the accelerator. Current recommendations for linac QA were reviewed to determine any changes required to those tests highlighted by the original report as well as considering new components of the treatment process that have become common since its publication. Recommendations are made on the acquisition of reference data, routine establishment of machine isocenter, basing performance tests on clinical use of the linac, working with vendors to establish QA tests and performing tests after maintenance and upgrades. The recommended tests proposed in this guideline were chosen based on consensus of the guideline's committee after assessing necessary changes from the previous report. The tests are grouped together by class of test (e.g., dosimetry, mechanical, etc.) and clinical parameter tested. Implementation notes are included for each test so that the QMP can understand the overall goal of each test. This guideline will assist the QMP in developing a comprehensive QA program for linacs in the external beam radiation therapy setting. The committee sought to prioritize tests by their implication on quality and patient safety. The QMP is ultimately responsible for implementing appropriate tests. In the spirit of the report from American Association of Physicists in Medicine Task Group 100, individual institutions are encouraged to analyze the risks involved in their own clinical practice and determine which performance tests are relevant in their own radiotherapy clinics.

Percent depth-dose distribution discrepancies from very small volume ion chambers.

As very small ion chambers become commercially available, medical physicists may be inclined to use them during the linear accelerator commissioning process to better characterize the beam in steep dose gradient areas. For this work, a total of eight different ion chambers (volumes from 0.007 cc to 0.6 cc) and four different scanning systems were used to scan PDDs at both +300V and -300V biases. We observed a reproducible, significant difference (overresponse with depth) in PDDs acquired when using very small ion chambers, with specific bias/water tank combinations - up to 5% at a depth of 25 cm in water. This difference was not observed when the PDDs were sampled using the ion chamber in static positions in conjunction with an external electrometer. This suggests noise/signal interference produced by the controller box and cable system assemblies, which can become relatively significant for the very small current signals collected by very small ion chambers, especially at depth as the signal level is even further reduced. Based on the results observed here, the use of very small active volume chambers under specific scanning conditions may lead to collection of erroneous data, introducing systematic errors into the treatment planning system. In case the use of such a chamber is required, we recommend determining whether such erroneous effect exists by comparing the scans with those obtained with a larger chamber.

Site-specific tolerance tables and indexing device to improve patient setup reproducibility.

While the implementation of tools such as image-guidance and immobilization devices have helped to prevent geometric misses in radiation therapy, many treatments remain prone to error if these items are not available, not utilized for every fraction, or are misused. The purpose of this project is to design a set of site-specific treatment tolerance tables to be applied to the treatment couch for use in a record and verify (R&V) system that will insure accurate patient setup with minimal workflow interruption. This project also called for the construction of a simple indexing device to help insure reproducible patient setup for patients that could not be indexed with existing equipment. The tolerance tables were created by retrospective analysis on a total of 66 patients and 1,308 treatments, separating them into five categories based on disease site: lung, head and neck (H&N), breast, pelvis, and abdomen. Couch parameter tolerance tables were designed to encompass 95% of treatments, and were generated by calculating the standard deviation of couch vertical, longitudinal, and lateral values using the first day of treatment as a baseline. We also investigated an alternative method for generating the couch tolerances by updating the baseline values when patient position was verified with image guidance. This was done in order to adapt the tolerances to any gradual changes in patient setup that would not correspond with a mistreatment. The tolerance tables and customizable indexing device were then implemented for a trial period in order to determine the feasibility of the system. During this trial period we collected data from 1,054 fractions from 65 patients. We then analyzed the number of treatments that would have been out of tolerance, as well as whether or not the tolerances or setup techniques should be adjusted. When the couch baseline values were updated with every imaging fraction, the average rate of tolerance violations was 10% for the lung, H&N, abdomen, and pelvis treatments. Using the indexing device, tolerances for patients with pelvic disease decreased (e.g., from 5.3 cm to 4.3 cm longitudinally). Unfortunately, the results from breast patients were highly variable due to the complexity of the setup technique, making the couch an inadequate surrogate for measuring setup accuracy. In summary, we have developed a method to turn the treatment couch parameters within the R&V system into a useful alert tool, which can be implemented at other institutions, in order to identify potential errors in patient setup.