Image guiding devices used in radiation therapy help align patients for treatment.

The
imaging devices must meet recommended guidelines to assure that treatment delivery following
image guided alignment is accurate. A quality assurance (QA) program is necessary to make sure
that the imaging devices are within the recommended tolerance guidelines. QA programs should
be tailored for each facility and should be flexible enough to account for quality, costs,
equipment condition, available test equipment, and institutional needs.1 The QA program at Self
Regional Healthcare Cancer Center was established using the following references:

Varian OBI Customer Acceptance Procedure and Results, 2011

AAPM Task Group Report 142: Quality Assurance of Medical Accelerators, 2009

South Carolina X-ray Regulations Title B Revision Dated June 26, 2009 Section 61-64
RHB 4.9

AAPM Task Group Report 179: Quality Assurance for Image-Guided Therapy Utilizing
CT-based technologies, 2012

Phantom Laboratory CatPhan Model 504 CBCT phantom Manual, 2012

Please see the tables below for the on board imaging (OBI) and electronic portal imaging

device (EPID) QA procedures and frequencies followed by Self Regional Healthcare Cancer
Center.

ROUTINE OBI TEST

DAILY

MONTHLY

ANNUAL

Collision Interlocks
Spatial Resolution
Hounsfield Units Constancy
Spatial Linearity
Geometric Distortion
Hounsfield Unit Linearity
Contrast Resolution
CT Scan Slice Geometry
Blade Calibration Check
KV Source Position Accuracy
KV imager Position Accuracy
Imaging and Treatment

X
X
X
X
X
X
X**

X
X
X

X
X
X
X
X
X
X
X
X
X
X
X

X
X

X
X
X
X
X
X
X
X
X
X
X

Coincidence
Positioning/re-positioning
accuracy
Door Interlock
X-ray on Lamp
Half Value Layer
Timer Accuracy
KVp Accuracy
mA/mAs Linearity
Collimation Accuracy
Output Linearity
Output Reproducibility
Required Postings
Required Documentation

Review

**even months only in pelvis mode (per Varian recommendations)

ROUTINE EPID TEST

DAILY

MONTHLY

ANNUAL

Collision Interlocks
Positioning/Repositioning
Imaging and Treatment

X
X
X

Coordinate Coincidence
Scaling
Spatial Resolution
Contrast
Uniformity and Noise
Full Range of Travel SDD
Imaging Dose

X
X
X

X
X
X

X
X
X
X**

X
X
X
X
X
X

Collision Interlocks: Verify that machine motion is disabled and an audio alarm can be
heard when the collision detectors on the kV source, kV detector, and portal imager are
depressed.
Spatial Resolution: This test verifies the spatial resolution of the scanned image using
the High Resolution module of the CatPhan. Test structures within the phantom are used to
evaluate the visible spatial resolution against the baseline.
Hounsfield Units Constancy: Following a scan of the CatPhan with both Standard Head
and Pelvis mode, the OBI software histogram tools are used to determine the HU for air, acrylic,
and LDPE. The results should be within +/- 40 HU of baseline values. The listed expected HU is
from the phantom manual with an uncertainty listed as +/- 5%. This test is performed monthly by
a physicist with the Pelvis CBCT performed on even months and the Standard Head on the odd
months.
Spatial Linearity and Geometric Distortion: The CatPhan cone beam CT (CBCT)
phantom is imaged. The known 5.0 cm separation between the four inside dots in the vertical and
horizontal directions are electronically measured to ensure accuracy within 1 mm for both the
Standard Head and Pelvis techniques.
Contrast Resolution: Low contrast detectibility is measured using the Low Contrast
Sensitivity module of the CatPhan. The measured values are compared against the baseline
values. This test is only specified for pelvis mode.

CT Scan Slice Geometry: The CatPhan CBCT phantom is imaged using the standard 2.5
mm slice thickness with Pelvis technique. Using the embedded CT slice tool, the actual slice
thickness is measured to ensure it is within the manufacturers specification of 5%.
Blade Calibration Check: With the blade calibration plate on the treatment couch and
the imager vertical, a blade setting of X = 10 and Y = 10 is kV imaged and measured to ensure it
is within the manufacturers specification of 2.5 mm.
KV Source Position Accuracy: This test checks that the source to isocenter distance is
reproducible and accurate to within 2 mm using a tape measure. This is measured from the
surface of the face plate with the filter removed. Using the known distance from the source to the
face plate, the isocenter is verified.
KV imager Position Accuracy: This test checks that the imager to isocenter distance is
reproducible and accurate to within 2 mm using a tape measure. With the imager at the routine
P2 position, the distance from the front face of the imager panel to the isocenter should measure
50 cm 1.8 cm offset = 48.2 cm.
Imaging and Treatment Coincidence: This test is performed by CBCT scanning the
isoblock which has a 2mm diameter BB embedded in the center. Using the QA patient file, the
image is evaluated when compared to the reference CT. The tolerance is less than 1.5 mm
deviation. This test is performed monthly by physics and daily by therapists using the QA
indexed bar phantom. The gantry isocenter is checked monthly using the MV imager and the
Winston Lutz block phantom.
Positioning/re-positioning accuracy: Utilizing the Winston Lutz block phantom pre and
post CBCT shifts are compared to the known distances. The results in all three coordinate
directions Vertical, lateral, and longitudinal should be within 2 mm. This test is performed
monthly by physics and daily by therapists using the indexed bar phantom.
Imaging Dose: Measurements are taken with an ion chamber placed in an acrylic CT
phantom and compared against baseline values.
Full Range of Travel: Images are taken with the portal imager placed at 120cm, 150cm,
and 170cm. These images are compared against those acquired during acceptance testing and
verified to be within + 5mm.
Collimation Accuracy: Set the field size to 20x20 and measure the field size to verify
the accuracy.

Door Interlock: Make sure that the x-rays cut off when the treatment room door is
opened.
X-ray on Lamp: Make sure that the X-ray On lamp is on when x-rays are in use.
Half Value Layer: Verify the HVL.
KVp Accuracy: Set the kV and measure the actual output then determine the %
variation.
mA/mAs Linearity: The difference in mR/mAs between 2 stations should be less than
10% of the sum of the mR/mAs of the 2 stations.
Noise: The EPID is set to Vert. = -50 cm (Auto Go) the clinac jaws are set to the edges of
the PI imager detector ( FS = 20.0x27.0). In AM maintenance High Quality Image is selected and
then the "Noise" button is selected. A noise image is acquired. When the image comes up,
"View" - "Measure" - "Area Histogram" are selected. The ROI is set to be "Full Image" and the
values found under "Pixel Statistics" are recorded.
Uniformity: The EPID is set to Vert. = -50 cm (Auto Go) and the clinac jaws are set to
FS = 15x15cm. 16.0 cm of solid water is placed on the couch surface, SSD = 92cm. In AM
maintenance High Quality Image is selected and "Image" is selected. In service mode: 6x, 3MU,
DR 100MU/min is input. An image is acquired. When the image comes up, "View" - "Measure" "Histogram" are selected. The ROI is set to "10x10" and the values found under "Pixel Statistics"
are recorded. Check noise at center and four positions: 12 o'clock, 3 o'clock, 6 o'clock and 9
o'clock.
References
1. Klein EE, Hanley J, Bayouth J, et al. Task Group 142 report: quality assurance of
medical accelerators. Med Phys. 2009;36(9):4197-4212. http://dx.doi.org/10.1118/1.3190392
2. Discussion and review of the OBI Annual Performance Review Evaluation with
Angelika Impeduglia-Gielow, Medical Physicist at Self Regional Healthcare Cancer Center,
October 6, 2015.