SIMULATION CHECK LIST

IMAGING PROTOCOL

TPS - QA Topic Test CT input Create an anatomical description based on a standard set of CT scans provided by the vendor, in the format to be employed by the user. Anatomical description Create a patient model based on the standard CT data discussed above. Contour the external surface, internal anatomy, etc. Create 3-D objects and display. Beam description Verify that all beam technique functions work, using a standard beam description provided by the vendor. Photon beam dose calculations Perform dose calculations for a standard photon beam data set. Tests should include various open fields, different SSDs, blocked fields, MLC shaped fields, inhomogeneity test cases, multibeam plans, asymmetric jaw fields, wedged fields and others. Electron beam dose calculations Perform a set of dose calculations for a standard electron beam data set. Include open fields, different SSDs, shaped fields, inhomogeneity test cases, surface irregularity test cases and others.

TPS - QA Topic Test Brachytherapy dose calculations Perform dose calculations for single sources of each type, as well as several multisource implant calculations, including standard implant techniques such as a gynaecological insertion with tandem and ovoids, two plane breast implant, etc. Dose display, DVHs Display dose calculation results. Use a standard dose distribution provided by the vendor to verify that the DVH code works as described. User created dose distributions may also be used for additional tests. Hard copy output Print out all hard copy documentation for a given series of plans, and confirm that all textual and graphical information is output correctly.

Telecobalt– Daily QA Procedure Tolerance Safety Mechanical  Door interlock Functional  Radiation room monitor  Audiovisual monitor Mechanical Lasers 2 mm    Distance indicator (ODI) Source position to be checked weekly

Telecobalt – Monthly QA Procedure Tolerance Dosimetry    Output constancy 2% Mechanical checks Light/radiation field coincidence 3 mm    Field size indicator (collimator setting) 2 mm    Gantry and collimator angle indicator 1°    Cross-hair centering 1 mm Latching of wedges, trays Functional Safety interlocks    Emergency off Wedge interlocks

Telecobalt – Annual QA Procedure Tolerance Dosimetry Safety interlocks  Output constancy 2%  Field size dependence of output constancy Central axis dosimetry parameter constancy (PDD/TAR) Transmission factor constancy for all standard accessories Wedge transmission factor constancy Timer linearity and error 1% Output constancy vs. gantry angle Beam uniformity vs. gantry angle 3% Safety interlocks Follow test procedures of manufacturers Functional

Telecobalt – Annual QA Procedure Tolerance Mechanical checks    Collimator rotation isocenter 2 mm diameter    Gantry rotation isocenter    Couch rotation isocenter    Coincidence of collimator, gantry, couch axis with isocenter    Coincidence of radiation and mechanical isocenter    Tabletop sag 2 mm    Vertical travel of table    Field-light intensity Functional

Linac – Daily QA Procedure Tolerance Dosimetry Mechanical Safety    X-ray output constancy 3%    Electron output constancyb Mechanical    Localizing lasers 2 mm    Distance indicator (ODI) Safety    Door interlock Functional    Audiovisual monitor

Linac – Monthly QA Procedure Tolerance Dosimetry Safety interlocks X-ray output constancy 2% Electron output constancy Backup monitor constancy X-ray central axis dosimetry parameter (PDD, TAR) constancy Electron central axis dosimetry parameter constancy (PDD) 2 mm at therapeutic depth X-ray beam flatness constancy Electron beam flatness constancy 3% X-ray and electron symmetry Safety interlocks Emergency off switches Functional Wedge, electron cone interlocks

Linac – Monthly QA Procedure Tolerance Mechanical checks    Light/radiation field coincidence 2 mm or 1% on a sided    Gantry/collimator angle indicators 1°    Wedge position 2 mm (or 2% change in transmission factor)    Tray position 2 mm    Applicator position    Field size indicators    Cross-hair centering 2 mm diameter    Treatment couch position indicators 2 mm/1°    Latching of wedges, blocking tray Functional    Jaw symmetrye    Field light intensity

Linac – Annual QA Procedure Tolerance Dosimetry    X-ray/electron output calibration constancy 2%    Field size dependence of x-ray output constancy    Output factor constancy for electron applicators    Central axis parameter constancy (PDD, TAR)    Off-axis factor constancy    Transmission factor constancy for all treatment accessories    Wedge transmission factor constancyf    Monitor chamber linearity 1%    X-ray output constancy vs. gantry angle    Electron output constancy vs. gantry angle    Off-axis factor constancy vs. gantry angle    Arc mode Manufacturers' specifications

Linac – Annual QA Procedure Tolerance Safety interlocks    Follow manufacturers test procedures Functional Mechanical checks    Collimator rotation isocenter 2 mm diameter    Gantry rotation isocenter    Couch rotation isocenter    Coincidence of collimator, gantry, couch axes with isocenter    Coincidence of radiation and mechanical isocenter    Tabletop sag 2 mm    Vertical travel of table

HDR Brachytherapy – QA - Door interlock Run a test treatment No Warning lights Audio/Visual communication Check the audio and video systems Emergency and interrupt buttons Radiation monitor and/or personal alarm dosimeter Check their presence and that the correct threshold alarm is inserted Emergency equipment Check their presence through a list and their ease to be used (e.g. the lid of the shielded storage container could be opened)

HDR Brachytherapy – QA - Date and time Check that it corresponds to the actual date and time no Integrity of transfer tubes and applicators Tube used for treatment; done by dummy run No Visual inspection of all transfer tubes and Source and dummy position Using a transparent test phantom, a check ruler, or a film, run a treatment test at different positions 2 mm Timer absolute accuracy Run a test treatment 2 %

HDR Brachytherapy – QA - Calibration of the source Air kerma strength measured with local standard compared with vendor-supplied value 3 % This test is optional. Air kerma strength measured with local standard compared with the value obtained with the redundancy standard Source strength Check that the source strength is correctly specified N/A Treatment plan, first application Independent calculation Treatment plan, follow-up application Check that dwell times are correctly adjusted for decay no

HDR Brachytherapy – QA - Control Type of action Tolerance Verification of local standard Verification by an authorized laboratory N/A Stability of the local standard Measurement with long-life source 0.5 % Calibration of the redundancy standard Calibration of thimble chamber in Co-60 or the lowest high-energy accelerator X-ray Stability of the redundancy standard

HDR Brachytherapy – QA - Leakage radiation Use a dose-rate meter to measure room ambiance dose rate 10 μSv/h Applicator too long or too short Run a test treatment 2 mm Missing applicator Do not connect the catheter to the trolley and run a test treatment N/A Device disabled Check that the source retracts if console is turned off Run a test treatment and check if the battery works when the main switch is turned off Simulation markers Verify construction/spacing of all simulation markers 1 mm

HDR Brachytherapy – QA - Emergency procedure Review and update if necessary N/A Practice emergency procedure Dry run Quality assurance manual

External beam therapy units - Emergency procedures External beam therapy units Emergency procedures should be posted at the treatment unit for this event. In general, the first step is to use the source driving mechanism to return the source to the shielded position. If this is not immediately successful and there is a patient on the treatment couch, the patient should be removed from the area and the area must be secured from further entry. Emphasis should be placed on avoiding exposure of the staff to the primary beam. The RSO is then notified and takes over the control of the situation.

Remote after loading Brachytherapy units - Emergency procedures 1) Observation at console of error message and emergency indicators (audible and visible alarms) 2) Recovery from the console (e.g., pressing an “emergency OFF” button) 3) Entry into the room with a portable radiation survey meter (opening the door activates the interlock that retracts the source) 4) Monitoring radiation levels in the room 5) Recovery from the afterloading unit (by pressing an “emergency OFF” button on the remote afterloading unit (RAU) 6) Manual retraction of the source (using a hand crank) 7) Patient survey and RAU survey (confirming source is in the safe) 8) Applicator removal and placement in the emergency container 9) Patient survey and emergency container survey (to confirm source is not in the patient and is in the emergency container) 10) Removal of the patient from the vault (with subsequent survey monitoring).