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Aim  The correlation between the MLC QA (IBA Dosimetry, Germany) results of the picket fence test created with intentional errors and the patient's quality assurance (QA) evaluation was investigated to assess the impact of multileaf collimator (MLC) positioning error on patient QA.  Materials and methods  The picket fence, including error-free and intentional MLC errors, defined in Bank In, Bank Out, and Bank Both were analyzed using MLC QA. The QA of 15 plans consisting of stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), and conventionally fractionated volumetric-modulated arc therapy (VMAT) acquired with electronic portal imaging devices (EPID) was evaluated in the presence of error-free and MLC errors. The QA of plans were analyzed with 2%/2 mm and 3%/3 mm criteria.  Results  The passing rates of the picket fence test were 97%, 92%, 91%, and 87% for error-free and intentional errors. The criterion of 3%/3 mm wasn’t able to detect an MLC error for either SRS/SBRT or conventionally fractionated VMAT. The criterion of 2%/2mm was more sensitive to detect MLC error for the conventionally fractionated VMAT than SRS/SBRT. While only two of SBRT plans had <90%, four of conventionally fractionated VMAT plans had a <90% passing rate.  Conclusion  We found that the systematic MLC positioning errors defined with picket fence have a smaller but measurable impact on SRS/SBRT than the VMAT plan for a conventionally fractionated and relatively complex plan such as head and neck and endometrium cases.

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Effect of Multileaf Collimator Leaf Position Error Determined by Picket Fence Test on Gamma Index Value in Patient-Specific Quality Assurance of Volumetric-Modulated Arc Therapy Plans