HDR Brachytherapy

Session 5; Topic 3
Afterloader System Commissioning & QA
date

Educator
Institution
 Learning Objectives

o Perform acceptance, commissioning, and QA tests including:

• Mechanical
• Safety
• Software/IT
• Interlocks
o Understand QA tests required after faults and repairs
o Understand past incidents
o Describe the differences between the procedure for a regular
source exchange and those for initial commissioning

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Document Checklist

Before you get the afterloader

❑ Vendor website:
❑ User Manual (How-to for the equipment)
❑ Technical Manual (For engineering/Physics)
❑ Acceptance Testing Document
❑ Etc.

❑ Resource Documents
❑ IAEA
❑ ESTRO
❑ Local regulations 3
Delivery and Install (D&I)
 D&I: Checking Transport Damage

• Outside of package ok?

• Afterloader:
• Visible scratches, dents?
• Frayed cables?

• Shipping Manifesto:
• Agrees with purchase order?
• All items delivered and
accounted for?

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Acceptance Testing
 When does acceptance testing happen?

Acceptance
Delivery and Commissioning:
Testing: Vendor
Install: Vendor Site Physicist
& Site Physicist
• Delivery and Install:
• Machine is property of vendor (or installer).
• Anything that breaks will be fixed by vendor at no cost to customer

• Acceptance testing:
• Performed by vendor and site physicist together (can also mean vendor
logged in remotely)

• Commissioning: Site physicist gets machine ready for the clinic

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 What is Acceptance Testing?

• Vendor and Customer have agreed on afterloader performance

standard in the purchase contract

• Vendor must demonstrate to customer that afterloader performs

to this standard at the time of install

• Standards are tested and documented according to procedures

defined in acceptance testing document

• Once vendor and customer BOTH sign the acceptance testing

document, afterloader changes ownership from vendor to
customer
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 Acceptance testing “how-to”
• Request acceptance testing document from vendor in advance of
delivery & install
• Compare acceptance test specifications to anything outlined in
purchase contract

• Bring any discrepancy to vendor attention as soon as possible

• Ask questions if any of the tests seem to be unclear

• Determine time needed for acceptance testing (~1/2 day for

afterloaders if everything goes perfectly, 1 day more typical)

• Keep copy of signed document for records

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Acceptance Test Document Example

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 Example acceptance tests

• Confirm treatment console functions

• Key switches, mains power, battery power, door interlocks
and other indicators
• Console display
• Data retainment post-treatment (or interruption)

• Confirm source retraction

• Post treatment
• Treatment interruption
• Loss of electrical/pneumatic power
• Improper connection
• Constriction/blockages in applicator &/or transfer tube
• Emergency button
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Commissioning
 Four Stages of Commissioning

1. Regulatory: Radiation Protection Survey (recall Session 2)

2. IT & System Administration

3. Treatment Unit Functionality

4. Setting Up QA:
• Daily
• Quarterly
• Annual
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Commissioning HDR Afterloader Stage 2:

IT Connectivity, System Administration

 IT Connectivity: Why now?
• Any connectivity/data transfer issues take time to resolve
• All of the following tests can be done in parallel to IT sorting out
issues

• Connectivity tests:
• MRI/CT/Simulator to planning system
• Planning system to afterloader
• Planning system to electronic medical record system (if applicable)
• Planning system and afterloader to printer
• USB transfer of data in case network is down
(also called “sneaker net”)
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System Administrators
• Administer software (time & date)

• User Administration
• Assigning roles and rights to individuals

• Verify and maintain backup

• 2-3 people (reason: people are out sick, change

jobs, are unavailable on short notice)
• 1 person from IT department (if applicable)
• Lead brachytherapy physicist
• One other appropriate person 16
 Role for Physicist
• Patient administration (add/delete patients)
• Creation of standard plans
• Dummy run settings (options vary with vendor)
• For example:
• Check all channels with dummy @start of treatment, then treat
all channels
• Check all channels with dummy @ start of treatment, then run
dummy for each channel before source is run
• Measure and enter source strength
• Determine source decay settings (eg. once daily, exact time,
etc)
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 Backup

• Backup to external drive each night

• Backup to off-site location

• Reason: broken waterpipes above backup disk, natural
catastrophes (floods, earthquakes, hurricanes)
• Could be done weekly or monthly

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Commissioning HDR Afterloader Stage 3:

Treatment Unit Functionality

Components of system tests

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 Checking Safety Interlocks

• Radiation safety to be covered in detail in a later session

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Components of system tests

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 Source Position Accuracy I
• Several commercial tools available
• Embedded distance markers for
reference (highly accurate
machining of ± 0.1 mm)
• Autoradiograph of source on film
• From most distal source to range
used for treatment
• Tolerance ± 1 mm
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 Source Position Accuracy II
• Verifies source positioning accuracy
• Run for every channel and transfer
tube at commissioning
• Multi-channel tools also available
• With camera mounted above,
position of dummy source relative to
live source can be confirmed
• By disconnecting transfer tube,
channel obstruction can be checked
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Components of system tests

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 Timer Function

1. Program a test run with a defined time (typical 2 min)

2. Deliver treatment
3. Measure treatment time independently
• Calibrated stopwatch
• Phone timer function

4. Tolerance ± 0.5 s

5. Human reaction time ~ 0.25 s

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Timer Accuracy (Transit Dose/Source Velocity)
o Recall this from session 4

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 Poll Question #1

The film from your source position measurement shows a

discrepancy of > 2mm. What can be done?

a) A trained physicist should be able to adjust the source position

so it’s in the correct place. A re-validation film will be necessary.
b) A trained physicist should be able to adjust the source position
so it’s in the correct place. A re-validation film is not necessary.
c) You will need to have a service engineer adjust the source
position. A re-validation film will not be necessary.
d) You can’t fix it. You just need to live with it

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 Poll Question #1

The film from your source position measurement shows a

discrepancy of > 2mm. What can be done?

a) A trained physicist should be able to adjust the source position

so it’s in the correct place. A re-validation film will be necessary.
b) A trained physicist should be able to adjust the source position
so it’s in the correct place. A re-validation film is not necessary.
c) You will need to have a service engineer adjust the source
position. A re-validation film will not be necessary.
d) You can’t fix it. You just need to live with it
BEFORE you adjust the source position, also take ANOTHER film to
confirm the source position is actually out of tolerance. 29
Transfer tube and applicator commissioning

• Transfer tubes and applicators are an integral part of

the treatment unit
• Each individual part must be commissioned
• To be covered in the next session…

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Components of system tests

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 Testing Treatment Workflow (End-to-End Test)
• Create a treatment workflow
• Perform end-to-end test using a phantom
• Every step of the workflow should be
performed by the staff doing it in clinic
• Check that the afterloader functions as
intended
• Check that staff is clear about how to use
equipment
• Start with easy patients

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Example of How-to-Do End to End test

• Commission Transfer tube and Applicator (next session)

• Have technologist image the applicator

• Physicist creates treatment plan for source positions for

autoradiograph

• Technician delivers treatment plan on the afterloader unit

• If available to site: check dose using TLD/film

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Other Commissioning Tasks:

Transfer Tubes
Applicators
Treatment Planning System
 Ongoing equipment QA

• Some of the tests conducted during commissioning will need to be

repeated on a regular basis as part of ongoing QA:

• Daily (on the day of treatment BEFORE any treatment)

• After a source exchange (Ir-192), or quarterly (Co-60)
• Annually

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 Daily QA
• Checks to be done on the day of a patient treatment (before treatment):
• Date/time in system
• Source strength/decay
• Source position (film or filmless)
• Timer accuracy
• Safety interlocks
– Door
– Transfer tube
– Applicator
• Intercom/CCTV functional
• Radiation warning/lights functional
• Interrupt and emergency stop functional
• Emergency equipment present
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 Source exchange or quarterly QA
• Checks to be done after a source exchange, or quarterly:
• Well chamber constancy check
• Source strength measurement**
• Source positional check (film)**
• Timer linearity & error check
• Transfer tube check (length)
• Daily QA tests**
• Add new source information in treatment unit and planning system
• Generation of new decay tables for the treatment console and
planning area
**THESE CHECKS SHOULD ALSO BE DONE AFTER ANY REPAIRS THAT
REQUIRE REMOVAL OF THE SOURCE FROM THE AFTERLOADER
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 Annual QA
• Checks to be done annually:
• Applicator checks/recommissioning
• Check well chamber calibration date (may need recalibration)
• Check electrometer calibration date (may need recalibration)
• Review of all documentation, checklists and forms
• Emergency procedures refresher and dry-run

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 Poll Question #2

The daily QA tests differ from source exchange/annual QA tests in

what way?

a) They are mostly functional tests and only needed to be done on

treatment days
b) They are mostly functional tests and are needed to be done on
treatment days as well as during source exchange/annual QA
c) They require the use of the well-chamber
d) They need to be done multiple times per day

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 Poll Question #2

The daily QA tests differ from source exchange/annual QA tests in

what way?

a) They are mostly functional tests and only needed to be done on

treatment days
b) They are mostly functional tests and are needed to be done on
treatment days as well as during source exchange/annual QA
c) They require the use of the well-chamber
d) They need to be done multiple times per day

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 Why do all of these tests?
• Mistakes happen. Things break. We are human.

• Refer to ICRU Publication 97 (Prevention of HDR brachytherapy

accidents) https://journals.sagepub.com/doi/pdf/10.1177/ANIB_35_2

Examples:
• HDR units damaged in transit
• Source cable separated from the drive unit (remained out of the afterloader)
• New source strength not added to afterloader at source exchange
• Source detached from cable (remained in catheter and inside patient for 4
days – patient died 1 day later)
• Inadequate bunker shielding
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 Resources

• AAPM TG 56: Code of Practice for Brachytherapy Physics

• Mayadev, Jyoti, et al. "A failure modes and effects analysis

study for gynecologic high-dose-rate
brachytherapy." Brachytherapy 14.6 (2015): 866-875

• Bellezzo, Murillo, et al. "Mechanical evaluation of the Bravos

afterloader system for HDR
brachytherapy." Brachytherapy(2019)

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