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Background: The IAEA/WHO postal dose audit programme has been operating since 1969 with the aim of improving the accuracy and consistency of dosimetry in radiotherapy in low-income and middle-income countries world-wide. This study summarises the 50 years’ experience of audits and explores the quality of reference dosimetry in participating radiotherapy centres throughout the years. Material and methods: During the IAEA/WHO postal audits the dose determined from the mailed dosimeter is compared with that stated by the participant. Agreement to within ±5% is regarded acceptable whilst deviations outside ±5% limits trigger follow-up actions. Of particular interest in this study was the dependence of clinical dosimetry quality on factors related to the centre infrastructure and expertise in dosimetry of its staff. Results: The IAEA/WHO dose audit programme noted great increase in the overall percentage of acceptable results from about 50% in its early years to 99% at present, although there is some variability of results amongst participating countries. Whereas results for younger radiotherapy machines show the agreement rate between the measured and the stated doses well above 90%, for those over 20 years old the rate dropped to

Introduction: Within an International Atomic Energy Agency (IAEA) co-ordinated research project (CRP), a remote end-to-end dosimetric quality audit for intensity modulated radiation therapy (IMRT)/ volumetric arc therapy (VMAT) was developed to verify the radiotherapy chain including imaging, treatment planning and dose delivery. The methodology as well as the results obtained in a multicentre pilot study and national trial runs conducted in close cooperation with dosimetry audit networks (DANs) of IAEA Member States are presented. Material and methods: A solid polystyrene phantom containing a dosimetry insert with an irregular solid water planning target volume (PTV) and organ at risk (OAR) was designed for this audit. The insert can be preloaded with radiochromic film and four thermoluminescent dosimeters (TLDs). For the audit, radiotherapy centres were asked to scan the phantom, contour the structures, create an IMRT/VMAT treatment plan and irradiate the phantom. The dose prescription was to deliver 4 Gy to the PTV in two fractions and to limit the OAR dose to a maximum of 2.8 Gy. The TLD measured doses and film measured dose distributions were compared with the TPS calculations. Results: Sixteen hospitals from 13 countries and 64 hospitals from 6 countries participated in the multicenter pilot study and in the national runs, respectively. The TLD results for the PTV were all within +/- 5% acceptance limit for the multicentre pilot study, whereas for national runs, 17 participants failed to meet this criterion. All measured doses in the OAR were below the treatment planning constraint. The film analysis identified seven plans in national runs below the 90% passing rate gamma criteria. Conclusion: The results proved that the methodology of the IMRT/VMAT dosimetric end-to-end audit was feasible for its intended purpose, i.e., the phantom design and materials were suitable; the phantom was easy to use and it was robust enough for shipment. Most importantly the audit methodology was capable of identifying suboptimal IMRT/VMAT delivery.

Background and purpose: An audit methodology for verifying the implementation of output factors (OFs) of small fields in treatment planning systems (TPSs) used in radiotherapy was developed and tested through a multinational research group and performed on a national level in five different countries. Materials and methods: Centres participating in this study were asked to provide OFs calculated by their TPSs for 10 × 10 cm2, 6 × 6 cm2, 4 × 4 cm2, 3 × 3 cm2 and 2 × 2 cm2 field sizes using an SSD of 100 cm. The ratio of these calculated OFs to reference OFs was analysed. The action limit was ±3% for the 2 × 2 cm2 field and ±2% for all other fields. Results: OFs for more than 200 different beams were collected in total. On average, the OFs for small fields calculated by TPSs were generally larger than measured reference data. These deviations increased with decreasing field size. On a national level, 30% and 31% of the calculated OFs of the 2 × 2 cm2 field exceeded the action limit of 3% for nominal beam energies of 6 MV and for nominal beam energies higher than 6 MV, respectively. Conclusion: Modern TPS beam models generally overestimate the OFs for small fields. The verification of calculated small field OFs is a vital step and should be included when commissioning a TPS. The methodology outlined in this study can be used to identify potential discrepancies in clinical beam models. Keywords: Dosimetry audit, Small field output factors, Treatment planning system

Background: Dosimetric effects of inaccuracies of output factors (OFs) implemented in treatment planning systems (TPSs) were investigated. Materials and methods: Modified beam models (MBM) for which the OFs of small fields (down to 1 × 1 cm2) were increased by up to 12% compared to the original beam models (OBM) were created for two TPSs. These beam models were used to recalculate treatment plans of different complexity. Treatment plans using stereotactic 3D-conformal (s3D-CRT) for brain metastasis as well as VMAT plans for head and neck and prostate cancer patients were generated. Dose distributions calculated with the MBM and the OBM were compared to measured dose distributions acquired using film dosimetry and a 2D-detector-array. For the s3D-CRT plans the calculated and measured dose at the isocenter was evaluated. For VMAT, gamma pass rates (GPRs) were calculated using global gamma index with 3%/3 mm, 2%/3 mm, 1%/3 mm and 2%/2 mm with a 20% threshold. Contribution of small fields to the total fluence was expressed as the ratio (F) of fluence trough leaf openings smaller than 2 cm to the total fluence. Results: Using film dosimetry for the s3D-CRT plans, the average of the ratio of calculated dose to measured dose at the isocenter was 1.01 and 1.06 for the OBM and MBM model, respectively. A significantly lower GPR of the MBM compared to the OBM was only found for the localized prostate cases (F = 12.4%) measured with the 2D-detector-array and an acceptance criterion of 1%/3 mm. Conclusion: The effects of uncertainties in small field OFs implemented in TPSs are most pronounced for s3D-CRT cases and can be clearly identified using patient specific quality assurance. For VMAT these effects mainly remain undetected using standard patient specific quality assurance. Using tighter acceptance criteria combined with an analysis of the fluence generated by small fields can help identifying inaccuracies of OFs implemented in TPSs.

Background: The IAEA has developed and tested an on-site, end-to-end IMRT/VMAT dosimetry audit methodology for head and neck cases using an anthropomorphic phantom. The audit methodology is described, and the results of the international pilot testing are presented. Material and methods: The audit utilizes a specially designed, commercially available anthropomorphic phantom capable of accommodating a small volume ion chamber (IC) in four locations (three in planning target volumes (PTVs) and one in an organ at risk (OAR)) and a Gafchromic film in a coronal plane for the absorbed dose to water and two-dimensional dose distribution measurements, respectively. The audit consists of a pre-visit and on-site phases. The pre-visit phase is carried out remotely and includes a treatment planning task and a set of computational exercises. The on-site phase aims at comparing the treatment planning system (TPS) calculations with measurements in the anthropomorphic phantom following an end-to-end approach. Two main aspects were tested in the pilot study: feasibility of the planning constraints and the accuracy of IC and film results in comparison with TPS calculations. Treatment plan quality was scored from 0 to 100. Results: Forty-two treatment plans were submitted by 14 institutions from 10 countries, with 79% of them having a plan quality score over 90. Seventeen sets of IC measurement results were collected, and the average measured to calculated dose ratio was 0.988 +/- 0.016 for PTVs and 1.020 +/- 0.029 for OAR. For 13 film measurement results, the average gamma passing rate was 94.1% using criteria of 3%/3 mm, 20% threshold and global gamma. Conclusions: The audit methodology was proved to be feasible and ready to be adopted by national dosimetry audit networks for local implementation.

The aim of this study was to test two different solid state dosimetry systems for the purpose of end-to-end audits of radiotherapy volumetric modulated arc therapy (VMAT) technique; a lithium formate electron paramagnetic resonance system and a lithium fluoride thermoluminescent dosimetry system. As a complement to the solid state systems, ion chamber measurements were performed. A polystyrene phantom with a planning target volume (PTV) and an organ at risk (OAR) structure was scanned using CT. A VMAT dose plan was optimized to deliver 2 Gy to the target volume and to minimize the dose to the OAR. The different detectors were inserted into the phantom and the planned dose distribution was delivered. The measured doses were compared to the treatment planning system (TPS) calculated doses. Good agreement was found between the TPS calculated and the measured doses, well accepted for the dose determinations in remote dosimetry audits of VMAT treatment technique. Funding Agencies|Swedish Cancer foundation [110322, E2.40.18]

The International Atomic Energy Agency (IAEA) has a long tradition of supporting development of methodologies for national networks providing quality audits in radiotherapy. A series of co-ordinated research projects (CRPs) has been conducted by the IAEA since 1995 assisting national external audit groups developing national audit programs. The CRP ‘Development of Quality Audits for Radiotherapy Dosimetry for Complex Treatment Techniques’ was conducted in 2009–2012 as an extension of previously developed audit programs. Material and methods. The CRP work described in this paper focused on developing and testing two steps of dosimetry audit: verification of heterogeneity corrections, and treatment planning system (TPS) modeling of small MLC fields, which are important for the initial stages of complex radiation treatments, such as IMRT. The project involved development of a new solid slab phantom with heterogeneities containing special measurement inserts for thermoluminescent dosimeters (TLD) and radiochromic films. The phantom and the audit methodology has been developed at the IAEA and tested in multi-center studies involving the CRP participants. Results. The results of multi-center testing of methodology for two steps of dosimetry audit show that the design of audit procedures is adequate and the methodology is feasible for meeting the audit objectives. A total of 97% TLD results in heterogeneity situations obtained in the study were within 3% and all results within 5% agreement with the TPS predicted doses. In contrast, only 64% small beam profiles were within 3 mm agreement between the TPS calculated and film measured doses. Film dosimetry results have highlighted some limitations in TPS modeling of small beam profiles in the direction of MLC leave movements. Discussion. Through multi-center testing, any challenges or difficulties in the proposed audit methodology were identified, and the methodology improved. Using the experience of these studies, the participants could incorporate the auditing procedures in their national programs.

Background and purpose: Remote beam output audits, which independently measure an institution’s machine calibration, are a common component of independent radiotherapy peer review. This work reviews the results and trends of these audit results across several organisations and geographical regions. Materials and methods: Beam output audit results from the Australian Clinical Dosimetry Services, International Atomic Energy Agency, Imaging and Radiation Oncology Core, and Radiation Dosimetry Services were evaluated from 2010 to the present. The rate of audit results outside a ±5% tolerance was evaluated for photon and electron beams as a function of the year of irradiation and nominal beam energy. Additionally, examples of confirmed calibration errors were examined to provide guidance to clinical physicists and auditing bodies. Results: Of the 210,167 audit results, 1323 (0.63%) were outside of tolerance. There was a clear trend of improved audit performance for more recent dates, and while all photon energies generally showed uniform rates of results out of tolerance, low (6 MeV) and high (≥18 MeV) energy electron beams showed significantly elevated rates. Twenty nine confirmed calibration errors were explored and attributed to a range of issues, such as equipment failures, errors in setup, and errors in performing the clinical reference calibration. Forty-two percent of these confirmed errors were detected during ongoing periodic monitoring, and not at the time of the first audit of the machine. Conclusions: Remote beam output audits have identified, and continue to identify, numerous and often substantial beam calibration errors. Keywords: Global harmonization group, Remote beam output audit, Dosimetry audit, Calibration, QA

The IAEA has introduced an Optically Stimulated Luminescence Dosimetry (OSLD) system to conduct postal audits to Secondary Standard Dosimetry Laboratories (SSDLs) for radiation protection level. The audit independently checks 137 Cs radiation protection air kerma calibrations provided by the SSLDs. The OSLD system has replaced the previously used TLD based audit for radiation protection. The OSLD system used in the audit consists of nanoDot dosimeters and MicroSTARii reader (Landauer, IL, USA). Prior to introducing the audit service, an extensive commissioning process quantified the dosimeter reading reproducibility, signal depletion and fading, linearity of response to air kerma, individual sensitivities of OSLDs and optical annealing procedure for the dosimeters. In an audit run, the participating SSLDs are supplied with two dosimeter sets consisting of two lightweight holders each preloaded with two OSLDs. The participants are asked to irradiate them with 5 mGy air kerma free in air, following their standard laboratory procedures. The OSLDs returned to the IAEA are evaluated by the IAEA Dosimetry Laboratory. The OSLDs demonstrated acceptable reading reproducibility of 1.75% and a signal depletion of 0.25% per readout. The OSLDs signal fading resulted in a signal decrease of 2.1% in the period from eight days to over 160 days post irradiation. A relative expanded (k = 2) uncertainty of the OSLD determined air kerma was estimated to 3.08%. In two audit runs in 2015–2016, 29 SSDLs participated. The average ratio of the air kerma measured by the IAEA to the air kerma stated by the SSDL was 0.998 and the standard deviation of the distribution of results was 1.8%. All participants except one had results within the acceptance limits of ±7%. One laboratory with the result outside the acceptance limit was invited to a follow-up procedure with the aim to resolve the discrepancy.

The IAEA Dosimetry Laboratory (DOL) aims to improve the accuracy of clinical dosimetry in hospitals world-wide by providing independent remote audits for high energy photon beams. A thermoluminescent dosimetry (TLD) system has been used by the DOL to provide audit services for over 47 years. Two additional systems: an optically stimulated luminescent dosimetry (OSLD) system and a radiophoto luminescent dosimetry (RPLD) system underwent a commissioning process. The systems’ parameters, reading methodology and the dosimetric characteristics were investigated and compared. The read-out procedure for each system was established and optimized. Dosimetric characteristics such as reproducibility, signal fading with time after irradiation, signal per dose dependence and energy response were investigated. Additional tests to check signal depletion per readout and individual sensitivities of dosimeters were performed for RPLDs and OSLDs and also reading position dependence for the RPLD system was checked. The reproducibility of 4 readings of one dosimeter is 0.48% for TLDs, 0.16% for OSLDs and 0.15% for RPLDs. The fading effect after 100 days was 4% for TLD, 2% for OSLD and 0.4% for RPLD. Energy response of TLDs and RPLDs is comparable, higher corrections were found for OSLDs. The RPLD dose-response is sub-linear whereas TLD and OSLD response is supra-linear at the dose range under study (1–4 Gy). The TLD reading procedure is destructive but OSLDs and RPLDs can be read repeatedly and the signal depletion per reading is 0.036% for OSLDs and 0.017% for RPLDs. The sensitivity correction factors for RPLDs and OSLDs were determined with the standard deviation in response of 1000 dosimeters of 2.2% for OSLD and 0.9% for RPLD. The combined standard uncertainties (k = 1) are 1.60% for TLDs, 1.46% for OSLDs and 1.51% for RPLDs. All three systems can be successfully used for auditing purposes if corrections for all described effects are applied.

Introduction and purpose An IAEA co-ordinated research project (CRP) is under implementation that develops methodology for remote dosimetry audits of IMRT techniques to be offered to radiotherapy centres by national audit networks in low and middle income countries. Materials and methods The CRP involves four audit steps: (i) remote verification of TPS calculation of small beam output factors relevant to IMRT (ii) dosimetry audit of MLC positional performance for IMRT using radiochromic film, (iii) film audit of single clinical IMRT field dose delivery and (iv) ‘end-to-end’ dosimetry audit for multiple field IMRT techniques using TLDs and radiochromic films. New procedures, phantoms, instructions and data sheets for audited centres were developed at the IAEA and tested through multinational pilot studies. Research groups from 14 countries participate in the CRP. Results The results of the first CRP step show agreement within 1% of participants’ TPS output factors and the reference data for field sizes ⩾4 × 4 cm2 but dose overestimation by TPSs by 2–3% for field sizes ⩽3 × 3 cm2. The second step confirmed that most audited MLCs perform as expected. The results of the third CRP step show that TPS plans prepared by participants and delivered to films agree well; however, comparison of gamma analysis techniques highlighted differences among centres. The fourth step ‘end-to-end’ IMRT audit is on-going. Conclusion A four step methodology for remote dose audits of IMRT and related beam characteristics has been developed at the IAEA and is being tested before dissemination to national audit networks operating across the world. Disclosure No conflicts of interest.