Canadian Partnership for Quality Radiotherapy

Technical Quality Control Guidelines

for Medical Linear Accelerators and Multileaf Collimators

A guidance document on behalf of:

Canadian Association of Radiation Oncology

Canadian Organization of Medical Physicists

Canadian Association of Medical Radiation Technologists

Canadian Partnership Against Cancer

July 20, 2016

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www.cpqr.ca
Disclaimer
All information contained in this document is intended to be used at the discretion of each individual
centre to help guide quality and safety program improvement. There are no legal standards supporting
this document; specific federal or provincial regulations and license conditions take precedence over the
content of this document. As a living document, the information contained within this document is subject
to change at any time without notice. In no event shall the Canadian Partnership for Quality Radiotherapy
(CPQR) or its partner associations, the Canadian Association of Radiation Oncology (CARO), the Canadian
Organization of Medical Physicists (COMP), and the Canadian Association of Medical Radiation
Technologists (CAMRT), be liable for any damages, losses, expenses, or costs whatsoever arising in
connection with the use of this document.
Technical Quality Control Guidelines for Medical Linear Accelerators and Multileaf Collimators
Part of the Technical Quality Control Guidelines for Canadian Radiation Treatment Centres Suite

Expert Reviewers

Charles Kirkby
Jack Ady Cancer Centre, Lethbridge, Alberta

Esmaeel Ghasroddashti
Jack Ady Cancer Centre, Lethbridge, Alberta

Crystal Angers
Ottawa Hospital, Ottawa, Ontario

Grace Zeng
Peel Regional Cancer Centre, Trillium Health Partners/Credit Valley Hospital, Mississauga, Ontario

Erin Barnett
Stronach Regional Cancer Centre, Newmarket, Ontario

External Validation Centres

BC Cancer Agency – Fraser Valley Centre, Surrey, British Columbia

BC Cancer Agency – Vancouver Island Centre, Victoria, British Columbia
BC Cancer Agency – Vancouver Centre, Vancouver, British Columbia
Centre de santé et de services sociaux de Trois-Rivières, Trois-Rivières, Quebec
Odette Cancer Centre, Toronto, Ontario

Introduction
The Canadian Partnership for Quality Radiotherapy (CPQR) is an alliance amongst the three key national
professional organizations involved in the delivery of radiation treatment in Canada: the Canadian
Association of Radiation Oncology (CARO), the Canadian Organization of Medical Physicists (COMP), and
the Canadian Association of Medical Radiation Technologists (CAMRT). Financial and strategic backing is
provided by the federal government through the Canadian Partnership Against Cancer (CPAC), a national
resource for advancing cancer prevention and treatment. The mandate of the CPQR is to support the
universal availability of high quality and safe radiotherapy for all Canadians through system performance
improvement and the development of consensus-based guidelines and indicators to aid in radiation
treatment program development and evaluation.

This document contains detailed performance objectives and safety criteria for Medical Linear
Accelerators and Multileaf Collimators. Please refer to the overarching document Technical Quality
Control Guidelines for Canadian Radiation Treatment Centres(1) for a programmatic overview of technical

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quality control, and a description of how the performance objectives and criteria listed in this document
should be interpreted.

System Description
Medical linear accelerators (linacs) are cyclic accelerators which accelerate electrons to kinetic energies
from 4 MeV to 25 MeV using non-conservative microwave radio frequency (RF) fields in the frequency
range from 103 MHz (L band) to ~104 MHz (X band), with the vast majority running at 2856 MHz
(S band).(2–5) In a linear accelerator the electrons are accelerated following straight trajectories in special
evacuated structures called accelerating waveguides. Electrons follow a linear path through the same,
relatively low potential difference several times; hence, linacs also fall into the class of cyclic accelerators
just like the other cyclic machines that provide curved paths for the accelerated particles (e.g., betatron).
The high power RF fields used for electron acceleration in the accelerating waveguides, are produced
through the process of decelerating electrons in retarding potentials in special evacuated devices called
magnetrons or klystrons.

Various types of linacs are available for clinical use. Some provide x rays only in the low megavoltage range
(4 MV or 6 MV) while others provide both x rays and electrons at various megavoltage energies. A typical
modern high-energy linac will provide two or three photon energies (usually a combination of a low
[4 to 10 MV] and a high [12 to 25 MV] photon beam) and several electron energies (ranging from
4 to 22 MeV).

Included in the scope of this document are multileaf collimators (MLCs); computer-controlled devices
capable of providing photon beam shielding for linear accelerators using high density leaves (typically
tungsten alloy) which are projected into the radiation field.(6–8) In addition to static beam shaping, beam
intensity modulation can also be achieved by adjusting the position of the MLC in the radiation field
between treatment fields (step and shoot, or static intensity-modulated radiation therapy [IMRT]), by
moving the leaves across the field with varying velocities during the beam-on time (dynamic IMRT), or by
varying the dose rate, gantry speed, and MLC leaf positions during arc delivery (volumetric modulated arc
therapy [VMAT]). By doing this, a desired fluence pattern can be approximated within certain physical
limits.

Current MLC systems vary with respect to design, location, and use. They may be installed as a tertiary
device below the secondary collimators, or they may comprise a total or partial replacement of the
secondary collimators. The leaves must provide an acceptable degree of beam attenuation, provide a
large enough field coverage, and must be well integrated with the rest of the collimator shaping system.
In order to minimize penumbra, various design considerations have been devised by manufacturers to
provide focused field shaping.

Computer control is a key component of the MLC, particularly during the delivery of dynamic treatments.
There must be feedback on the leaf position and beam interlock capabilities when leaf misplacement is

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detected. In addition, there must be interlock capabilities to detect leaf carriage positions that could lead
to unintentional irradiation outside the shielded area. Other safety interlocks must recognize the
unintentional use of the MLC in electron mode and incorporate the use of the MLC in port-film mode.

Related Technical Quality Control Guidelines

In order to comprehensively assess medical linear accelerator performance, additional guideline tests, as
outlined in related CPQR Technical Quality Control (TQC) guidelines must also be completed and
documented, as applicable. Related TQC guidelines, available at cpqr.ca, include:

• Safety Systems
• Major Dosimetry Equipment
• Accelerator-Integrated Cone-Beam Systems for Verification Imaging
• Patient-Specific Dosimetric Measurements for Modulated Therapies

Test Tables
Table 1: Daily Quality Control Tests
Designator Test Performance
Tolerance Action
Daily
DL1 Motion interlock Functional
DL2 Couch brakes Functional
DL3 Beam interrupt/counters Functional
DL4 Lasers/crosshairs 1 mm 2 mm
DL5 Optical distance indicator 1 mm 2 mm
DL6 Optical back pointer 2 mm 3 mm
DL7 Field definition: Jaws/MLC leaves 1 mm 2 mm
DL8 Output constancy – photons 2% 3%
DL9 Output constancy – electrons 2% 3%
Dynamic (Varian), Virtual (Siemens) or Universal
DL10 2% 3%
(Elekta) wedge factors

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Notes on Daily Tests

DL1 This test establishes that motion-enabling features on the linac (e.g., those that allow
the gantry to rotate only under desired conditions) are operational. These include
functionality tests of couch and hand-pendent controls and the proper engagement of
collision interlocks when touch guards are engaged.

DL2 A functional test is performed to establish that brakes on the treatment couch engage
when desired and prevent the couch from floating freely or moving when a small force
is applied.

DL3 This test demonstrates (when applicable): the key interlock prevents the linac from
irradiating; the non-emergency beam interruption system stops the beam; and the
beam terminates after a predefined number of monitor units as verified by a backup
monitor unit counter and/or timer if applicable.

DL4 This test establishes the alignments of crosshairs with appropriate lasers are within the
specified limits.

DL5 At gantry angle 0°, the test demonstrates that the optical distance indicator identifies
the isocentre plane within the specified limits.

DL6 This test verifies the performance accuracy of the optical back pointer for applicable
units.

DL7 Gantry angle 0°, 100 cm source-axis distance (SAD). This test demonstrates the field
edges are accurately defined by jaws and/or MLC leaves. It is sufficient to confirm a
predefined field shape using the projected light field at isocentre. Tolerance and action
levels apply to each edge of a rectangular field at isocentre as defined by the jaws/MLC
leaves. Note that systems with a tertiary collimation MLC system will require both jaw
and MLC leaf positions to be verified.

DL8 Output constancy must be verified for all photon energies in use on the particular
treatment day. Measurement is to be conducted using standard local geometry using a
dosimetry system calibrated against the local secondary standard system.

DL9 Output constancy must be verified for all electron energies in use on the particular
treatment day. Measurement is to be conducted using standard local geometry using a
dosimetry system calibrated against the local secondary standard system.

DL10 Wedge factors for a representative set of dynamic or virtual soft wedges in use on a
particular treatment day must be verified. Machine design characteristics must be

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considered when determining the representative set. Alternatively, a test cycle

designed to test the full range of wedges over multiple days may be considered. Daily
wedge factors for universal wedges are required to ensure functionality and position
reproducibility.

Table 2: Monthly Quality Control Tests

Designator Test Performance
Tolerance Action
Monthly

ML1 Wedge, tray, cone, interlocks Functional

ML2 Accessories integrity and centring Functional
ML3 Gantry angle readouts 0.5° 1.0°
ML4 Collimator angle readouts 0.5° 1.0°
Cross-hairs centring/collimator rotation isocentre
ML5 1 mm 2 mm
(mechanical)
ML6 Couch position readouts 1 mm 2 mm
ML7 Couch rotation isocentre (mechanical) 1 mm 2 mm
ML8 Couch isocentric angle 0.5° 1.0°
ML9 Optical distance indicator 1 mm 2 mm
ML10 Relative dosimetry 2% 3%
ML11 Central axis depth dose reproducibility 1%/2 mm 2%/3 mm
ML12 Beam profile constancy 2% 3%
ML13 Light/radiation coincidence 1 mm 2 mm
ML14 Jaw position accuracy 1 mm 2 mm
ML15 Backup jaw position accuracy (Elekta) 1 mm 2 mm
ML16 MLC leaf position accuracy 1 mm 2 mm
ML17 Dynamic leaf position accuracy (picket fence) 0.5 mm 1 mm
95% 95%
ML18 Dynamic MLC fluence delivery
≤ 3%/3 mm ≤ 5%/3 mm
Variation of dose rate, gantry speed, MLC leaf See note: See note:
ML19
speed and position during arc delivery ML19 ML19
ML20 Records Complete

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Notes on Monthly Tests

ML1 Verify the functionality of latching interlocks (includes verification that electron beams
cannot be turned on unless the MLC leaves are retracted).

ML2 Verify the physical integrity and centring of accessories, including wedges, trays, and
cones, as appropriate.

ML3 The accuracy of the digital and mechanical (if used clinically) gantry angle readouts must
be verified for at least 0°, 90°, 180°, and 270°. The coordinate system convention should
also be verified.

ML4 The accuracy of the digital and mechanical (if used clinically) collimator angle readouts
must be verified for at least 0°, 90°, 180°, and 270°. The coordinate system convention
should also be verified.

ML5 This test establishes the correct centring of the crosshairs as well as the mechanical axis
of rotation of the collimator. Tolerance and action levels refer to the maximum diameter
of the mechanical isocentre and the maximum displacement of the crosshairs projection
from the centre of the mechanical isocentre circle.

ML6 Mechanical and digital couch position readouts must be verified over an appropriate
clinical range in the directions of the three cardinal axes. Also verify coordinate system
convention.

ML7 Isocentric rotation of the couch about the collimator rotation axis must be verified.
Similar to ML5, the tolerance and action levels refer to the maximum displacement of
crosshairs projection from the initial position in the isocentre plane.

ML8 Mechanical and digital couch isocentric rotation angle readouts must be verified over
the applicable clinical range. Also verify coordinate system convention.

ML9 A mechanical device, calibrated against the true radiation isocentre, is used to provide
the base reading for the check of the optical distance indicator. The standards stated in
the Table apply at the isocentre. The optical distance indicator should be checked over
a clinically relevant range of source-to-skin distances (SSDs) and gantry angles. The
tolerance and action levels may be twice as large (i.e., 2 mm and 4 mm) at the clinical
limits of the optical distance indicator’s range.

ML10 Using a dosimetry system calibrated against the local secondary standard, the output of
all clinical beams is checked against yearly reference dosimetry.

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ML11 Measurements are made to confirm that the depth dose has not changed since
commissioning the unit. Tolerance and action levels are specified in percentages for
photon beams and in millimetres for electron beams. A single ratio of doses taken at
clinically relevant depths is sufficient for these measurements. Alternatively, a
tissue-phantom ratio (TPR) measurement or a check of profile constancy at a shallow
depth could be used, and the tolerance and action levels adjusted appropriately.

ML12 This test replaces testing of flatness and symmetry and is intended to be consistent with
the testing suggested in American Association of Physicists in Medicine (AAPM) protocol
TG-142.(9) The goal is to ensure that profiles are delivered in a manner consistent with
that modelled in the associated treatment planning system. Tolerance and action levels
refer to differences from commissioning (or baseline) profiles as defined in the AAPM
protocol TG-142.(9) Separate tests are required for all clinically applicable beams.

ML13 Geometric alignment of the radiation and optical field edges must be established over
a range of field sizes. Tolerance and action levels apply to each edge of a rectangular
field.

ML14 Accuracy of the radiation position of the jaw must be established over a range of jaw
positions. The number of positions tested shall be determined from the jaw calibration
method. In conjunction with this test it is important to establish acceptable dose profiles
for abutting fields at the 0 position. Here the 2 mm action level for each jaw is generally
not sufficient since in principle, abutting fields could have a difference of up to 4 mm
between field edges, which can lead to unacceptable peaks or valleys in dose
distributions. A tolerance of 5% and an action level of 10% in dose profile deviations for
abutting fields are suggested.

ML15 Accuracy of the radiation position of the backup jaw must be established over a range
of positions. The number of positions tested shall be determined from the jaw
calibration method.

ML16 Accuracy of the radiation position of the MLC leaf edges must be established over a
range of MLC positions. The number of MLC positions tested shall be determined from
the MLC calibration method. For some MLC designs this test may be accomplished by
evaluating the radiation position of each leaf relative to a reference leaf.

ML17 For dynamic MLC IMRT, leaf gap accuracy for all leaf pairs is verified via inspection of a
two-dimensional dose map of a picket fence pattern delivered at gantry angle of 0°.

ML18 Specific to IMRT, this test demonstrates that the interplay of leaf velocity, gap width,
gap position, and beam holds combine to deliver a planar dose map consistent with the

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prediction of the treatment planning system. A test plan should consider extreme
conditions (e.g., the highest levels of modulation used clinically for each leaf pair). An
acceptable alternative to this test is the regular (more than once per month)
measurement of patient-specific, dynamic MLC IMRT fields. Tolerance and action levels
are defined via the gamma metric comparing dose map differences (plan versus
measurement). Dose maps are defined with region of interest threshold of 10% of the
maximum dose. Dose differences are global (i.e., with respect to maximum dose).(10)
Detector resolution must be sufficient to identify performance of individual leaves. As
with all tests, tolerance and action levels may be tightened at the user’s discretion.

ML19 The synchronicity of all dynamic parameters during arc delivery. Parameters may be
evaluated independently, using a subset of the tests described by Ling et al. (11) or
Bedford and Warrington,(12) or by the repeat delivery of a standard VMAT plan of
suitable complexity, similar to test ML18. Tolerance and action levels are in reference
to the consistency of dose delivered at different dose rate, gantry or MLC speeds.
Tolerance levels should be based on the performance of the linear accelerator, whereas
action levels should be set to achieve an overall precision consistent with other monthly
tests (approximately 3%/2 mm from baseline).

ML20 Documentation relating to the daily quality control checks, preventive maintenance,
service calls, and subsequent checks must be complete, legible, and the operator
identified.

Table 3: Annual Quality Control Tests

Designator Test Performance
Tolerance Action
Annual

AL1 Profile reproducibility 2% 3%

AL2 Depth dose reproducibility 1% 2%
AL3 Reference dosimetry 1% 2%
AL4 Relative output factor reproducibility 1% 2%
AL5 Wedge transmission factor reproducibility 1% 2%
AL6 Accessory transmission factor reproducibility 1% 2%
AL7 Wedge profile reproducibility 1% 2%
Profile and output reproducibility versus gantry
AL8 1% 2%
angle

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AL9 Monitor chamber linearity 1%/1 MU 2%/2 MU

AL10 End monitor effect 0.5 MU 1 MU
AL11 Collimator rotation isocentre (radiation) 1 mm 2 mm
Gantry rotation isocentre (mechanical and
AL12 1 mm 2 mm
radiation)
AL13 Couch rotation isocentre (radiation) 1 mm 2 mm
Coincidence of radiation and mechanical
AL14 1 mm 2 mm
isocentres
AL15 Coincidence of axes of rotation 1 mm 2 mm
AL16 Couch deflection 3 mm 5 mm
AL17 Leaf transmission (all energies) 1% 2%
AL18 Leakage between leaves (all energies) 2% 3%
AL19 Transmission through abutting leaves 2% 3%
A20 MLC leaf alignment with jaws 0.5° 1°
A21 Dosimetric leaf gap 0.2 mm 0.3 mm
AL22 Independent quality control review Complete

Notes on Annual Tests

AL1 This test establishes that an appropriate subset of the crossplane and inplane profiles at
gantry angle 0° are consistent with water-tank measurements made at the time of
commissioning. Tolerance and action levels refer to differences from commissioning or
baseline. Measurements should be made for all clinically operable beams.

AL2 Depth dose scans necessary for calibration protocols (alternatively TPR measurements)
are also made and used to verify consistency with commissioning/baseline water-tank
measurements. Tolerance and action levels refer to differences from commissioning or
baseline. Measurements should be made for all clinically operable beams.

AL3 A full absolute dosimetry output calibration based on an internationally accepted

protocol (e.g., AAPM TG-51)(13) must be performed annually on each energy used
clinically for both photons and electrons. Independence of output with respect to dose
rate (pulse repetition frequency) must also be established across clinically applicable
dose rates.

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AL4 An appropriate subset of relative output factors are confirmed to be consistent with
commissioning measurements.

AL5 The wedge transmission factors (if applicable) are confirmed to be consistent with
commissioning measurements.

AL6 Transmission factors are confirmed to be consistent with commissioning

measurements. Discretion may be used. Devices where the physical
composition/dimension can be confirmed not to have changed since a previous
measurement need not be measured again.

AL7 This test applies to moving jaw (dynamic and virtual) and universal (Elekta) wedges. This
test confirms that wedged fields produce profiles that are consistent with baseline data
through the central 80% of the field for all clinically used wedge angles.

AL8 This test establishes the independence of output with gantry angle. It requires that
output be measured under identical conditions (e.g., dosimeter under the same amount
of buildup material in each position) and that the difference from the gantry at 0°
position be within the specified limits. In addition to central axis output, beam profiles
shall be measured at three cardinal gantry angles: 0°, 90°, and 270°. Measurements
should be made for all clinically operable beams.

AL9, 10 From a series of radiation measurements with different monitor units the linearity and
the end monitor effect are determined. The larger of the percentage or absolute value
is taken as what is applicable. Measurements should be made for all clinically operable
beams.

AL11 Commonly measured using a star shot technique this test determines the diameter of
the circle that encompasses the radiation isocentre of the collimator as it is rotated
through an appropriate sample of angles within its full range of motion. The diameter
must be within specifications.

AL12 This test determines the diameter of both the mechanical and the radiation isocentre
defined by gantry rotation through its full clinical range of motion. Each diameter must
be within specifications.

AL13 This test determines the diameter of the radiation isocentre defined by couch rotation
through its full clinical range of motion. The diameter must be within specifications.

AL14 The coincidence of radiation and mechanical isocentres is established for the collimator,
gantry and couch; and must meet the specified limits.

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AL15 The three axes of rotation (the collimator/MLC, the couch, and the gantry) must meet
within a sphere of the specified diameter.

AL16 Couch deflection is measured as a difference in surface position (load versus no load) of
the couch extended longitudinally at least 30 cm through isocentre. Under “load” is
considered as a typical patient mass (approximately 70 kg) distributed over the couch
or placed at the centre. Tolerance and action levels are defined relative to the deflection
measured at the time of commissioning.

AL17 The average and maximum MLC leaf transmission is verified in this test for all photon
energies and compared with the values established at the time of commissioning or the
values adopted in the treatment planning system. Tolerance and action levels refer to
changes from the commissioning measurements.

AL18 The average and maximum leakage between adjacent, closed MLC leaves is verified in
this test for all photon energies and compared with the values established at the time
of commissioning or the values adopted in the treatment planning system. Tolerance
and action levels refer to changes from the commissioning measurements.

AL19 The average and maximum leakage between abutting closed MLC leaves is verified in
this test for all photon energies and compared with the values established at the time
of commissioning or the values adopted in the treatment planning system. Tolerance
and action levels refer to changes from the commissioning measurements.

AL20 Use a leaf pattern where one leaf from each leaf bank protrudes well into the field.
Confirm the leaf edge parallelism with the collimator or solid jaw edge.

AL21 A dynamic leaf gap test (sometimes referred to as a dosimetric leaf gap test) is
performed to confirm consistency with baseline measurements. The minimum standard
is to establish this using a single detector (e.g., an ion chamber) method, although
methods that calculate separate factors for each leaf pair may be employed. The value
should be consistent within tolerance for all four cardinal gantry angles.

AL22 To ensure redundancy and adequate monitoring, a second qualified medical physicist
must independently verify the implementation, analysis, and interpretation of the
quality control tests at least annually.

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Acknowledgements

CPQR would like to thank the many people who participated in the production of this guideline. These
include: Kevin Diamond, Laurent Tantôt, and Kyle Malkoske (associate editors); the Quality Assurance and
Radiation Safety Advisory Committee; the COMP Board of Directors, Erika Brown and the CPQR Steering
Committee, and all individuals that submitted comments during the community review of this guideline.

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