Evaluation of Elekta Agility multi-leaf collimator performance using statistical process control tools

Purpose: To evaluate the performance and stability of Elekta Agility multi-leaf collimator (MLC) leaf positioning using a daily, automated quality control (QC) test based on megavoltage (MV) images in combination with statistical process control tools, and identify special causes of variations in performance. Methods: Leaf positions were collected daily for 13 Elekta linear accelerators over 11-37 months using the automated QC test, which analyzes 23 MV images to determine the location of MLC leaves relative to radiation isocenter. Leaf positioning stability was assessed using individual and moving range control charts. Specification levels of +/- 0.5, +/- 1, and +/- 1.5 mm were tested to determine positional accuracy. The durations between out-of-control and out-of-specification events were determined. Peaks in out-of-control leaf positions were identified and correlated to servicing events recorded for the whole duration of data collection. Results: Mean leaf position error was -0.01 mm (range -1.3-1.6). Data stayed within +/- 1 mm specification for 457 days on average (range 3-838) and within +/- 1.5 mm for the entire date range. Measurements stayed within +/- 0.5 mm for 1 day on average (range 0-17); however, our MLC leaves were not calibrated to this level of accuracy. Leaf position varied little over time, as confirmed by tight individual (mean +/- 0.19 mm, range 0.09-0.43) and moving range (mean 0.23 mm, range 0.10-0.53) control limits. Due to sporadic out-of-control events, the mean in-control duration was 2.8 days (range 1-28.5). A number of factors were found to contribute to leaf position errors and out-of-control behavior, including servicing events, beam spot motion, and image artifacts. Conclusions: The Elekta Agility MLC model was found to perform with high stability, as evidenced by the tight control limits. The in-specification durations support the current recommendation of monthly MLC QC tests with a +/- 1 mm tolerance. Future work is on-going to determine if performance can be optimized further using high-frequency QC test results to drive recalibration frequency.