A high-precision system for conformal intracranial radiotherapy

PURPOSE: Currently, optimally precise delivery of intracranial radiotherapy is possible with stereotactic radiosurgery and fractionated stereotactic radiotherapy. We report on an optimally precise optically guided system for three-dimensional (3D) conformal radiotherapy using multiple noncoplanar fixed fields. METHODS AND MATERIALS: The optically guided system detects infrared light emitting diodes (IRLEDs) attached to a custom bite plate linked to the patient's maxillary dentition. The IRLEDs are monitored by a commercially available stereo camera system, which is interfaced to a personal computer. An IRLED reference is established with the patient at the selected stereotactic isocenter, and the computer reports the patient's current position based on the location of the IRLEDs relative to this reference position. Using this readout from the computer, the patient may be dialed directly to the desired position in stereotactic space. The patient is localized on the first day and a reference file is established for 5 different couch positions. The patient's image data are then imported into a commercial convolution-based 3D radiotherapy planning system. The previously established isocenter and couch positions are then used as a template upon which to design a conformal 3D plan with maximum beam separation. RESULTS: The use of the optically guided system in conjunction with noncoplanar radiotherapy treatment planning using fixed fields allows the generation of highly conformal treatment plans that exhibit a high degree of dose homogeneity and a steep dose gradient. To date, this approach has been used to treat 28 patients. CONCLUSION: Because IRLED technology improves the accuracy of patient localization relative to the linac isocenter and allows real-time monitoring of patient position, one can choose treatment-field margins that only account for beam penumbra and image resolution without adding margin to account for larger and poorly defined setup uncertainty. This approach enhances the normal tissue sparing, high degree of conformality, and homogeneity characteristics possible with 3D conformal radiotherapy.     

Image localization for frameless stereotactic radiotherapy

Purpose: Infrared light-emitting diodes (IRLEDs) have been used for optic-guided stereotactic radiotherapy localization at the University of Florida since 1995. The current paradigm requires stereotactic head ring placement for the patient’s first fraction. The stereotactic coordinates and treatment plan are determined relative to this head ring. The IRLEDs are attached to the patient via a maxillary bite plate, and the position of the IRLEDs relative to linac isocenter is saved to file. These positions are then recalled for each subsequent treatment to position the patient for fractionated therapy. The purpose of this article was to report a method of predicting the desired IRLED locations without need for the invasive head ring.

Methods and Materials: To achieve the goal of frameless optic-guided radiotherapy, a method is required for direct localization of the IRLED positions from a CT scan. Because it is difficult to localize the exact point of light emission from a CT scan of an IRLED, a new bite plate was designed that contains eight aluminum fiducial markers along with the six IRLEDs. After a calibration procedure to establish the spatial relationship of the IRLEDs to the aluminum fiducial markers, the stereotactic coordinates of the IRLED light emission points are determined by localizing the aluminum fiducial markers in a stereotactic CT scan.

Results: To test the accuracy of direct CT determination of the IRLED positions, phantom tests were performed. The average accuracy of isocenter localization using the IRLED bite plate was 0.65 ± 0.17 mm for these phantom tests. In addition, the optic-guided system has a unique compatibility with the stereotactic head ring. Therefore, the isocentric localization capability was clinically tested using the stereotactic head ring as the absolute standard. The ongoing clinical trial has shown the frameless system to provide a patient localization accuracy of 1.11 ± 0.3 mm compared with the head ring.

Conclusion: Optic-guided radiotherapy using IRLEDs provides a mechanism through which setup accuracy may be improved over conventional techniques. To date, this optic-guided therapy has been used only as a hybrid system that requires use of the stereotactic head ring for the first fraction. This has limited its use in the routine clinical setting. Computation of the desired IRLED positions eliminates the need for the invasive head ring for the first fraction. This allows application of optic-guided therapy to a larger cohort of patients, and also facilitates the initiation of extracranial optic-guided radiotherapy.     

射波刀VSI系统的主要性能测试

目的 测试射波刀VSI系统实施立体定向放疗的准确性和可靠性。方法 对射波刀VSI系统的机器人系统、患者定位系统、目标定位系统、加速器系统、可变准直器系统5个子系统的性能分别进行测试,记录机器人系统机械臂到位精度、患者定位系统的床到位精度、目标定位系统的追踪精度、加速器系统相关剂量学参数和可变准直器系统重复性。对射波刀VSI系统综合投照精度进行端到端(E2E)的系统测试。结果 机器人系统所有节点机械臂运动的平均到位偏差≤0.1 mm,单个节点最大到位偏差≤0.29 mm。可变准直器系统所有尺寸孔径重复性误差≤0.28 mm。床到位精度与追踪精度均<0.2 mm和0.5°。固定和可变2种类型准直器系统激光束与辐射射束中心偏差≤0.4 mm。6 mV射线的射线质与离轴比曲线等参数均在正常范围内。射波刀剂量输出稳定性、线性与随射束角度变化的差异均<1.0%。固定和可变2种类型准直器的透射因子均<0.4%。射波刀VSI系统综合投照精度的E2E测试最大偏差为0.87 mm。结论 射波刀VSI系统能够准确、精确地实施立体定向放疗。     

Commissioning an image-guided localization system for radiotherapy

PURPOSE: To describe the design and commissioning of a system for the treatment of classes of tumors that require highly accurate target localization during a course of fractionated external-beam therapy. This system uses image-guided localization techniques in the linac vault to position patients being treated for cranial tumors using stereotactic radiotherapy, conformal radiotherapy, and intensity-modulated radiation therapy techniques. Design constraints included flexibility in the use of treatment-planning software, accuracy and precision of repeat localization, limits on the time and human resources needed to use the system, and ease of use. METHODS AND MATERIALS: A commercially marketed, stereotactic radiotherapy system, based on a system designed at the University of Florida, Gainesville, was adapted for use at the University of Washington Medical Center. A stereo pair of cameras in the linac vault were used to detect the position and orientation of an array of fiducial markers that are attached to a patient's biteblock. The system was modified to allow the use of either a treatment-planning system designed for stereotactic treatments, or a general, three-dimensional radiation therapy planning program. Measurements of the precision and accuracy of the target localization, dose delivery, and patient positioning were made using a number of different jigs and devices. Procedures were developed for the safe and accurate clinical use of the system. RESULTS: The accuracy of the target localization is comparable to that of other treatment-planning systems. Gantry sag, which cannot be improved, was measured to be 1.7 mm, which had the effect of broadening the dose distribution, as confirmed by a comparison of measurement and calculation. The accuracy of positioning a target point in the radiation field was 1.0 +/- 0.2 mm. The calibration procedure using the room-based lasers had an accuracy of 0.76 mm, and using a floor-based radiosurgery system it was 0.73 mm. Target localization error in a phantom was 0.64 +/- 0.77 mm. Errors in positioning due to couch rotation error were reduced using the system. CONCLUSION: The system described has proven to have acceptable accuracy and precision for the clinical goals for which it was designed. It is robust in detecting errors, and it requires only a nominal increase in setup time and effort. Future work will focus on evaluating its suitability for use in the treatment of head-and-neck cancers not contained within the cranial vault.     

A new irradiation unit constructed of self-moving gantry-CT and linac

PURPOSE: To improve reproducibility in stereotactic irradiation (STI) without using noninvasive immobilization devices or body frames, we have developed an integrated computed tomography (CT)-linac irradiation system connecting CT scanner and linac via a common treatment couch. METHODS AND MATERIALS: This system consists of a linac, a CT scanner, and a common treatment couch. The linac and the CT gantry are positioned on opposite ends of the couch so that, by rotating the treatment couch, linac radiotherapy or CT scanning can be performed. The rotational axis of the linac gantry is coaxial with that of the CT gantry, and the position of the linac isocenter on the couch matches the origin of the coordinate system for CT scanning when the couch is rotated 180 degrees toward the CT side. Instead of the couch moving into the gantry, as in conventional CT, in this case the table is fixed and scanning is accomplished by moving the gantry. We evaluated the rotational accuracy of the common couch and the scan-position accuracy of the self-moving gantry CT. RESULTS: The positional accuracy of the common couch was 0.20, 0.18, and 0.39 mm in the lateral, longitudinal, and vertical directions, respectively. The scan-position accuracy of the CT gantry was less than 0.4 mm in the lateral, longitudinal, and vertical directions. CONCLUSION: This irradiation system has a high accuracy and is useful for noninvasive STI and for verification of the position of a target in three-dimensional conformal radiotherapy.     

Ultrasound-guided extracranial radiosurgery: technique and application

PURPOSE: Stereotactic radiosurgery is an effective treatment modality for many intracranial lesions, but target mobility limits its utility for extracranial applications. We have developed a new technique for extracranial radiosurgery based on optically guided three-dimensional ultrasound (3DUS). The 3DUS system provides the ability to image the target volume and critical structures in real time and determine any misregistration of the target volume with the linear accelerator. In this paper, we describe the system and its initial clinical application in the treatment of localized metastatic disease. METHODS AND MATERIALS: The extracranial stereotactic system consists of an ultrasound unit that is optically tracked and registered with the linear accelerator coordinate system. After an initial patient positioning based on computed tomographic (CT) simulation, stereotactic ultrasound images are acquired and correlated with the CT-based treatment plan to determine any soft-tissue shifts between the time of the planning CT and the actual treatment. Optical tracking is used to correct any patient offsets that are revealed by the real-time imaging. RESULTS: Preclinical testing revealed that the ultrasound-based stereotactic navigation system is accurate to within 1.5 mm in comparison with an absolute coordinate phantom. Between March 2001 and March 2002, the system was used to deliver extracranial radiosurgery to 17 metastatic lesions in 16 patients. Treatments were delivered in 1 or 2 fractions, with an average fractional dose of 16 Gy (range 12.5-24 Gy) delivered to the 80% isodose surface. Before each fraction, the target misalignment from isocenter was determined using the 3DUS system and the misalignments averaged over all patients were anteroposterior = 4.8 mm, lateral = 3.6 mm, axial = 2.1 mm, and average total 3D displacement = 7.4 mm (range = 0-21.0 mm). After correcting patient misalignment, each plan was delivered as planned using 6-11 noncoplanar fields. No acute complications were reported. CONCLUSIONS: A system for high-precision radiosurgical treatment of metastatic tumors has been developed, tested, and applied clinically. Optical tracking of the ultrasound probe provides real-time tracking of the patient anatomy and allows computation of the target displacement before treatment delivery. The patient treatments reported here suggest the feasibility and safety of the technique.     

Clinical use of dual image-guided localization system for spine radiosurgery

The recently released Novalis TX linac platform provides various image guided localization methods including a stereoscopic X-ray imaging technique (ExacTrac) and a volumetric cone beam computed tomography (CBCT) imaging technique. The ExacTrac combined with the robotic six dimensional (6D) couch provides fast and accurate patient setup based on bony structures and offers "snap shot" imaging at any point during the treatment to detect patient motion. The CBCT offers a three dimensional (3D), volumetric image of the patient's setup with visualization of anatomic structures. However, each imaging system has a separate isocenter, which may not coincide with each other or with the linac isocenter. The aim of this paper was to compare the localization accuracy between Exactrac and CBCT for single fraction spine radiosurgery treatments. The study was performed for both phantom and patients (96 clinical treatments of 57 patients). The discrepancies between the isocenter between the ExacTrac and CBCT in four dimensions (three translations and one rotation) were recorded and statistically analyzed using two-tailed t-test.     

Independent 6D quality assurance of stereotactic radiotherapy repositioning on linacs

PurposeA high level of accuracy while positioning the patient is mandatory for frameless stereotactic radiotherapy (SRT), as large doses in multiple fractions can be delivered near organs at risk. The objective of this study is to propose an end-to-end quality assurance method to verify that submillimetre alignment can be achieved with stereotactic conventional linacs.MethodsWe used a TrueBeam® linear accelerator equipped with a 6DOF robotic couch. The “ISO Cube” phantom was used with a homemade stand designed to generate known translational and rotational offsets. A reference CT scan was performed with straight alignment of the phantom. The procedure introduced 1.6° angular offset for the couch pitch and roll, at various gantry angles. The couch base was also moved between 0° and 270°. We compared the results with the daily machine performance check tests (MPC, Varian).ResultsThe mean isocentre size, MV and kV imager offsets were found to agree to within 0.1 mm, 0.1 mm and 0.3 mm respectively, and were in close agreement between the methods. For a total four months data collection period, the mean deviation between requested and measured 6DOF couch shifts was 0.6 mm and 0.2°. Errors on field size were smaller than 1 mm for 97.7% of the 324 data points.ConclusionResults demonstrate that the linac equipped with a 6DOF robotic positioner and CBCT imaging satisfies requirements for SRT. Our methodology, based on a modified Winston-Lutz quality control, allowed us to quantitatively assess end-to-end accuracy of a linac in order to safely deliver SRT.     

Initial clinical experience with frameless stereotactic radiosurgery: analysis of accuracy and feasibility.

PURPOSE: To report on preliminary clinical experience with a novel image-guided frameless stereotactic radiosurgery system. METHODS AND MATERIALS: Fifteen patients ranging in age from 14 to 81 received radiosurgery using a commercially available frameless stereotactic radiosurgery system. Pathologic diagnoses included metastases (12), recurrent primary intracranial sarcoma (1), recurrent central nervous system (CNS) lymphoma (1), and medulloblastoma with supratentorial seeding (1). Treatment accuracy was assessed from image localization of the stereotactic reference array and reproducibility of biteplate reseating. We chose 0.3 mm vector translation error and 0.3 degree rotation about each axis as the maximum tolerated misalignment before treating each arc. RESULTS: The biteplates were found on average to reseat with a reproducibility of 0.24 mm. The mean registration error from CT localization was found to be 0.5 mm, which predicts that the average error at isocenter was 0.82 mm. No patient treatment was delivered beyond the maximum tolerated misalignment. The radiosurgery treatment was delivered in approximately 25 min per patient. CONCLUSION: Our initial clinical experience with stereotactic radiotherapy using the infrared camera guidance system was promising, demonstrating clinical feasibility and accuracy comparable to many frame-based systems.     

Technical considerations for fractionated stereotactic radiotherapy of hepatocellular carcinoma

Technical aspects of fractionated stereotactic radiotherapy for solitary hepatocellular carcinoma have been investigated. Precise positioning of the patient and substantial reduction of the liver movement due to respiration were achieved by placing the patient ventrally on the treatment couch without a body cast. Repeated CT examinations were required for verification of tumor targeting. Though there were geometrical limitations on gantry rotation when the linac couch was rotated from its standard position, dose distributions obtained were found to be excellent. A patient with a small solitary lesion in the posterior segment of the liver received 52 Gy in 13 fractions over 29 days. He tolerated the treatment well without experiencing any morbidities or deterioration of liver functions. Three months later his alpha-fetoprotein value returned to normal and CT examinations revealed tumor shrinkage as well as a reduction in the viability of the tumor cells. The results suggest that it is possible to overcome technical difficulties associated with fractionated stereotactic radiotherapy of intraabdominal tumors.      

The accuracy of frameless stereotactic intracranial radiosurgery

Purpose

To determine the accuracy of frameless stereotactic radiosurgery using the BrainLAB ExacTrac system and robotic couch by measuring the individual contributions such as the accuracy of the imaging and couch correction system, the linkage between this system and the linac isocenter and the possible intrafraction motion of the patient in the frameless mask.

Materials and methods

An Alderson head phantom with hidden marker was randomly positioned 31 times. Automated 6D couch shifts were performed according to ExacTrac and the deviation with respect to the linac isocenter was measured using the hidden marker. ExacTrac-based set-up was performed for 46 patients undergoing hypofractionated stereotactic radiotherapy for 135 fractions, followed by verification X-rays. Forty-three of these patients received post-treatment X-ray verification for 79 fractions to determine the intrafraction motion.

Results

The hidden target test revealed a systematic error of 1.5 mm in one direction, which was corrected after replacement of the system calibration phantom. The accuracy of the ExacTrac positioning is approximately 0.3 mm in each direction, 1 standard deviation. The intrafraction motion was 0.35 ± 0.21 mm, maximum 1.15 mm.

Conclusion

Intrafraction motion in the BrainLAB frameless mask is very small. Users are strongly advised to perform an independent verification of the ExacTrac isocenter in order to avoid systematic deviations.     

Intracranial application of IMRT based radiosurgery to treat multiple or large irregular lesions and verification of infra-red frameless localization system

We have employed a frameless localization system for intracranial radiosurgery, utilizing a custom biteblock with fiducial markers and an infra-red camera for set-up and monitoring patient position. For multiple brain metastases or large irregular lesions, we use a single-isocenter intensity-modulated approach. We report our quality assurance measurements and our experience using Intensity Modulated Radiosurgery (IMRS) to treat such intracranial lesions. A phantom with integrated targets and fiducial markers was utilized to test the positional accuracy of the system. The frameless localization system was used for patient setup and target localization as well as for motion monitoring during treatment. Inverse optimization planning gave satisfactory dose coverage and critical organ sparing. Patient setup was guided by the infrared camera through fine adjustment in three translational and three rotational degrees for isocenter localization and verified by orthogonal kilovoltage (kV) images, taken before treatment to ensure the accuracy of treatment. The relative localization of the camera based system was verified to be highly accurate along three translational directions of couch motion and couch rotation. After verification, we began treating patients with this technique. About 8–12 properly selected fixed beams with a single isocenter were sufficient to achieve good dose coverage and organ sparing. Portal dosimetry with an Electronic Portal Imaging Device (EPID) and kV images provided excellent quality assurance for the IMRS plan and patient setup. The treatment time was less than 60 min to deliver doses of 16–20 Gy in a single fraction. The camera-based system was verified for positional accuracy and was deemed sufficiently accurate for stereotactic treatments. Single isocenter IMRS treatment of multiple brain metastases or large irregular lesions can be done within an acceptable treatment time and gives the benefits of dose-conformity and organ-sparing, easy plan QA, and patient setup verification.     

Variation in the isocentre of a Philips Linear Accelerator (SL–20) used for stereotactic radiosurgery/stereotactic radiotherapy

Stereotactic irradiation, either in the form of stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) of brain lesions requires high precision and submillimetre accuracy in the isocentre, the main determinants being gantry and couch rotations. It is thus necessary to evaluate the isocentre variation due to gantry and couch rotations in the particular setup for SRS/SRT. This paper describes variation in the isocentre of a Philips (now Elekta) SL-20 linear accelerator modified for adapting a couch-mounted radiosurgery system. By considering the isocentre as defined by a mechanical index as the standard, the variations in the isocentre of the linear accelerator were independently measured for the gantry and for couch rotations. The variation in the isocentre for gantry rotation was found to be between 0.1 mm and 0.9 mm, conforming to the submillimetre accuracy required for SRS/SRT. However, the isocentre variation due to couch rotation varied considerably, possibly because the couch is of the RAM type. The isocentre variation due to couch rotation is rectified by microadjusting the couch mount at the time of treatment using a laser target localizing frame. It is our conclusion that a modified linear accelerator can be used for performing SRS/SRT after careful and separate evaluation of the isocentre stability due to gantry and couch rotations.     

CyberKnife放射治疗肿瘤的临床研究

CyberKnife是一种影像引导下的无框架立体定向放射治疗肿瘤的国际前沿性新技术。它可使其放射线到达传统立体定向放射外科治疗技术无法接近的病变部位;在放射治疗前和放疗的过程中,其先进的影像导航系统可对病灶进行准确的实时监控和跟踪;目标如有移动,会补偿性的自动修正治疗床的位置或射束的方向;非等中心照射特征可使放射线的剂量分布在病变部位达到最大程度的均匀性和适形度,消除以往传统立体定向放射外科治疗技术在靶区剂量分布方面存在的冷点和热点问题;既可以实施单次治疗,也可以进行分次照射,是真正意义上的全新概念的肿瘤立体定向放射外科治疗系统。     

Heavy charged-particle stereotactic radiosurgery: cerebral angiography and CT in the treatment of intracranial vascular malformations

A method is described for stereotactic localization of intracranial arteriovenous malformations (AVM) and for calculating treatment plans for heavy charged-particle Bragg peak radiosurgery. A stereotactic frame and head immobilization system is used to correlate the images of multivessel cerebral angiography and computed tomography. The AVM is imaged by angiography, and the frame provides the stereotactic coordinates for transfer of this target to CT images for the calculation of treatment plans. The CT data are used to calculate the residual ranges and compensation for the charged-particle beam required for each treatment port. Three-dimensional coordinates for the patient positioner are calculated, and stereotactic radiosurgery is performed. Verification of the accuracy of the stereotactic positioning is obtained with computer-generated overlays of the vascular malformation, stereotactic fiducial markers, and bony landmarks on orthogonal radiographs immediately prior to treatment. Using these procedures, the accuracy of the repositioning of the patient at each of a series of imaging and treatment procedures is typically within 1 mm in each of three orthogonal planes.     

Stereotactic body radiation therapy: evaluation of setup accuracy and targeting methods for a new couch integrated immobilization system

A new stereotactic frame system was designed at Indiana University to utilize the precision motion control of newer accelerator couches and treat obese patients previously untreatable in other frame systems during stereotactic body radiation therapy (SBRT). The repositioning accuracy and target reproducibility of this frame was evaluated in the treatment of both lung and liver tumors. The external coordinate system on the new frame was validated using a phantom system. Translational motions were carried out using couch motors. Five patients were treated with SBRT and twenty-three verification CT scans were acquired. The displacement of the gross tumor volume (GTV) and adjacent vertebral body between the original CT scan and the verification CT scans was determined. The mean setup accuracy for the patient study was less than 5 mm. Mean displacement of the GTV was 3.0 mm (0.0-6.0 mm) in the lateral (x) direction, 4.1 mm (0.0-8.9 mm) in the superior-inferior (y) direction, and 2.6 mm (0.0-10.0 mm) in the cranio-caudal (z) direction. Comparison of vertebral body position showed mean displacement of 2.4 mm (0.0 to 8.0 mm), 1.9 mm (0.0 mm to 2.0 mm), and 0.9 mm (0.0 to 5.0 mm) for the same shift directions. Repositioning could be accurately carried out from an initial reference position using the treatment couch controllers. Adequate set-up accuracy using a frame system capable of accommodating wide girth patients was achieved and was comparable to other published studies for narrower frames. With these results, a 5 mm expansion for PTV margins remains the standard for our institution.     

Elekta Precise Table characteristics of IGRT remote table positioning

INTRODUCTION: Cone beam CT is a powerful tool to ensure an optimum patient positioning in radiotherapy. When cone beam CT scan of a patient is acquired, scan data of the patient are compared and evaluated against a reference image set and patient position offset is calculated. Via the linac control system, the patient is moved to correct for position offset and treatment starts. This procedure requires a reliable system for movement of patient. In this work we present a new method to characterize the reproducibility, linearity and accuracy in table positioning. The method applies to all treatment tables used in radiotherapy. MATERIAL AND METHODS: The table characteristics are investigated on our two recent Elekta Synergy Platforms equipped with Precise Table installed in a shallow pit concrete cavity. Remote positioning of the table uses the auto set-up (ASU) feature in the linac control system software Desktop Pro R6.1. The ASU is used clinically to correct for patient positioning offset calculated via cone beam CT (XVI)-software. High precision steel rulers and a USB-microscope has been used to detect the relative table position in vertical, lateral and longitudinal direction. The effect of patient is simulated by applying external load on the iBEAM table top. For each table position an image is exposed of the ruler and display values of actual table position in the linac control system is read out. The table is moved in full range in lateral direction (50 cm) and longitudinal direction (100 cm) while in vertical direction a limited range is used (40 cm). RESULTS AND DISCUSSION: Our results show a linear relation between linac control system read out and measured position. Effects of imperfect calibration are seen. A reproducibility within a standard deviation of 0.22 mm in lateral and longitudinal directions while within 0.43 mm in vertical direction has been observed. The usage of XVI requires knowledge of the characteristics of remote table positioning. It is our opinion that the method presented meets the requirements in high precision IGRT.     

Intrafraction variations in linac-based image-guided radiosurgery of intracranial lesions

PurposeThis study investigated image-guided patient positioning during frameless, mask-based, single-fraction stereotactic radiosurgery of intracranial lesions and intrafractional translational and rotational variations in patient positions.Patients and methodsA non-invasive head and neck thermoplastic mask was used for immobilization. The Exactrac/Novalis Body system (BrainLAB AG, Germany) was used for kV X-ray imaging guided positioning. Intrafraction displacement data, obtained by imaging after each new table position, were evaluated.ResultsThere were 269 radiosurgery treatments performed on 190 patients and a total of 967 setups within different angles. The first measured error after each table rotation (mean 2.6) was evaluated (698 measurements). Intrafraction translational errors were (1 standard deviation [SD]) on average 0.8, 0.8, and 0.7 mm for the left–right, superior–inferior, and anterior–posterior directions, respectively, with a mean 3D-vector of 1.0 mm (SD 0.9 mm) and a range from –5 mm to +5 mm. On average, 12%, 3%, and 1% of the translational deviations exceeded 1, 2, and 3 mm, respectively, in the three directions.ConclusionThe range of intrafraction patient motion in frameless image-guided stereotactic radiosurgery is often not fully mapped by pre- and post-treatment imaging. In the current study, intrafraction motion was assessed by performing measurements at several time points during the course of stereotactic radiosurgery. It was determined that 12% of the intrafraction values in the three dimensions are above 1 mm, the usual safety margin applied in stereotactic radiosurgery.     

Preliminary experience with frameless stereotactic radiotherapy

Purpose: To report initial clinical experience with a novel high-precision stereotactic radiotherapy system.Methods and Materials: Sixty patients ranging in age from 2 to 82 years received a total of 1426 treatments with the University of Florida frameless stereotactic radiotherapy system. Of the total, 39 (65%) were treated with stereotactic radiotherapy (SRT) alone, and 21 (35%) received SRT as a component of radiotherapy. Pathologic diagnoses included meningiomas (15 patients), low-grade astrocytomas (11 patients), germinomas (9 patients), and craniopharyngiomas (5 patients). The technique was used as means of dose escalation in 11 patients (18%) with aggressive tumors. Treatment reproducibility was measured by comparing bite plate positioning registered by infrared light-emitting diodes (IRLEDs) with the stereotactic radiosurgery reference system, and with measurements from each treatment arc for the 1426 daily treatments (5808 positions). We chose 0.3 mm vector translation error and 0.3° rotation about each axis as the maximum tolerated misalignment before treating each arc.Results: With a mean follow-up of 11 months, 3 patients had recurrence of malignant disease. Acute side effects were minimal. Of 11 patients with low grade astrocytomas, 4 (36%) had cerebral edema and increased enhancement on MR scans in the first year, and 2 required steroids. All had resolution and marked tumor involution on follow-up imaging. Bite plate reproducibility was as follows. Translational errors: anterior-posterior, 0.01 ± 0.10; lateral, 0.02 ± 0.07; axial, 0.01 ± 0.10. Rotational errors (degrees): anterior-posterior, 0.00 ± 0.03; lateral, 0.00 ± 0.06; axial, 0.01 ± 0.04. No patient treatment was delivered beyond the maximum tolerated misalignment. Daily treatment was delivered in approximately 15 min per patient.Conclusion: Our initial experience with stereotactic radiotherapy using the infrared camera guidance system was good. Patient selection and treatment strategies are evolving rapidly. Treatment accuracy was the best reported, and the treatment approach was practical.