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Jenny Kouri
DOS 542 QA
10/7/15
Image Guidance Radiation Therapy (IGRT) Quality Assurance (QA)
Since there is no current consensus guideline for a detailed QA of CT-based IGRT
systems, the VA Medical Center in Minneapolis designed a consistent procedure based off of the
AAPM TG-142 and TG-179 report to identify any variation or degradation of imaging data
based of the initial commissioning of the imaging components and software. The VA follows the
recommended guidelines provided by the TG reports but does no more actions than
recommended and no less action than recommended. Daily IGRT QA involves collision
interlocks, OBI-MV isocenter accuracy/coordinate coincidence, and couch shift accuracy for kV,
MV, and CBCT imaging devices.
Collision interlocks simply involve the therapist or physicist to gently tap/touch the arm
petal and cover of the OBI devices. Upon touch, the devices should beep in alarm. If no alarm is
activated during touch, biomedical engineering should be notified. The tolerance for collision
locks must be within function.
(The following paragraph is very similar to last weeks discussion, expect I tried to add
different pictures and other detail. Sorry!!) Daily imaging QA consists of an inquired CT scan
derived from the commissioning process of the QA marker phantom, a cubic device with internal
fiducials and cross hairs for laser alignment. The slice thickness of the CT has a thickness of 2
mm, specified to be less than the recommended slice thickness of the TG-142
positioning/repositioning tolerance. A generated DRR, reference CBCT, and structures designed
during commissioning are uploaded daily to facilitate in the alignment of the imaging system.
The workload for repositioning/positioning and coordinate coincidence involves indexing the
phantom marker at the level of 0 on the couch. This is shown in Figure 1. For consistency, the
lasers are always first matched to the cross hairs on the right side of the marker phantom (your
right, not the patients right). MV and KV right lateral imaging is preformed with the gantry set
at 0. The image taken is then matched to the expected image. Shifts are determined on the
verification mode of the graticule software. The brightest pixel of the daily image is maximized
and identified. The red crossed-lines are checked to see if aligned on the brightest pixel. In
Figure 2 and 3, the superior-inferior is aligned but the right-left is not. The offset is measured.

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The expected shift (A) is 2 cm vertical, longitudinal, and lateral. The daily shift (B) is subtracted
from the expected shift (A). |A-B| < 1mm. Shifts are applied and recorded as the new couch
position (C). This distance must be less than 1mm. The same technique is continued with MV
images. The gantry is then rotated to 90 degrees and kV and MV images are taken again. Shifts
are recorded, compared, and applied for all imaging. After shifts are applied, the room lasers are
visually checked by entering the treatment room between each set of imaging to assure the lasers
are aligned to the cross hairs. For CBCT imaging, the phantom marker is moved down a step on
the leveling device, which misaligns the lasers and cross hairs 2cm in every direction. This is
shown in Figure 4. A kV image is taken first, and then CBCT. CBCT shifts (D) are subtracted
from the new couch position (C). |C-D| < 1mm. Shifts are applied and recorded as the final
couch position. Monthly imaging QA involves the same coordinate coincidence checks, laser
alignment, and couch shifts. Included in monthly QA is scaling orientation and uniformity check
which both have a baseline tolerance.

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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

Figures

Figure 1: The marker phantom is indexed at 0 on the treatment couch. Lasers

are aligned to the right side on the phantoms cross hairs.

Figure 2: The brightest pixel is maximized to best align the daily image with the initial image.
The superior-inferior red line is matched to the brightest pixel. The right-left line red line is not.

Figure 3: There is a 0.01 cm shift right-left. This is within the 1mm tolerance.

Figure 4: The phantom marker has been moved from the top step 2cm in every direction by
lowering to the next step below.