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To evaluate the accuracy of a commercial optical surface tracking (OST) system and to demonstrate how it can be implemented to monitor patient positioning during non-coplanar single isocenter stereotactic treatments of brain metastases. A 3-camera OST system was used (Catalyst HD (TM), C-RAD) on a TruebeamSTx with a 6DoF couch. The setup accuracy and agreement between the OST system, and CBCT and kV-MV imaging at couch angles 0 degrees and 270 degrees, respectively, were examined. Film measurements at 3 depths in the Rando-Alderson phantom were performed using a single isocenter non-coplanar VMAT plan containing 4 brain lesions. Setup of the phantom was performed with CBCT at couch 0 degrees and subsequently monitored by OST at other couch angles. Setup data for 7 volunteers were collected to evaluate the accuracy and reproducibility of the OST system at couch angles 0 degrees, 45 degrees, 90 degrees, 315 degrees, and 270 degrees. These results were also correlated to the couch rotation offsets obtained by a Winston-Lutz (WL) test. The Rando-Alderson phantom, as well as volunteers, were fixated using open face masks (Orfit). For repeated tests with the Rando-Alderson phantom, deviations between rotational and translational isocenter corrections for CBCT and OST systems are always within 0.2 degrees (pitch, roll, yaw), and 0.1mm and 0.5mm (longitudinal, lateral, vertical) for couch positions 0 degrees and 270 degrees, respectively. Dose deviations between the film and TPS doses in the center of the 4 lesions were -1.2%, -0.1%, -0.0%, and -1.9%. Local gamma evaluation criteria of 2%/2 mm and 3%/1 mm yielded pass rates of 99.2%, 99.2%, 98.6%, 89.9% and 98.8%, 97.5%, 81.7%, 78.1% for the 4 lesions. Regarding the volunteers, the mean translational and rotational isocenter shift values were (0.24 +/- 0.09) mm and (0.15 +/- 0.07) degrees. Largest isocenter shifts were found for couch angles 45 & x2da; and 90 & x2da;, confirmed by WL couch rotation offsets. Patient monitoring during non-coplanar VMAT treatments of brain metastases is feasible with submillimeter accuracy.

Background Immobilization devices are crucial to minimize patient positioning uncertainties in radiotherapy (RT) treatments. Accurate inter and intra-fraction motions is particularly important for intracranial and stereotactic radiation treatment which require high precision in dose delivery. Recently, a new immobilization device has been developed specifically for the radiation treatment of intracranial malignancies. To date, no data are available on the use of this device in daily clinical practice. The aim of this study is to investigate the intra and inter-fraction variations, patient comfort and radiographer confidence of the immobilization system from two distinct institutions: HagaZiekenhuis, Den Haag, Netherlands and IRCCS Ospedale Sacro Cuore Don Calabria, Negrar, Italy. Material and method Sixteen patients (10 diagnosed with brain metastases and 6 with primary central nervous systemic tumor) from IRCCS Ospedale Sacro Cuore Don Calabria and 17 patients (all diagnosed with brain metastases tumor) from HagaZiekenhuis were included in this study. The median target volume was 436 cc (range 3.2–1628 cc) and 4.58 cc (range 0.4–27.19 cc) for IRCCS and Haga, respectively. For patients treated in IRCCS Sacro Cuore Don Calabria, the median dose prescription was 30 Gy (range 27–60 Gy) and median number of fractions 10 (range 3–30). In Haga the median dose prescription was 21 Gy (range 8–21 Gy) and the median number of fraction was 1 (range 1–3). The immobilization device was assembled during CT simulation. A short interview to the patient regarding the device’s comfort level was conducted at the end of the simulation procedure. Additionally, simulation setup time and radiographer (RTT) procedures (i.e. mask preparation) were evaluated. Prior to radiation treatment delivery, an automatic rigid match on the cranial bones between cone beam computed tomography (CBCT) and planning-CT was performed. A couch shift was performed subsequently. An extra post-treatment CBCT was acquire after the treatment delivery. This post-treatment CBCT was matched with pre-treatment CBCT to identify any possible intra-fraction motion. All online matches were validated by experienced radiation oncologist or RTT. A total of 126 CBCT’s were analyzed offline by radiation oncologist/medical physicist. The data of the pre-treatment CBCT match was used to quantify inter-fraction motion. The post-treatment CBCT was matched with pre-treatment CBCT to identify any possible intra-fraction motion. Results During the molding of the mask, all patients responded positive to the comfort. Median time required by the RTTs to assemble the immobilization system was 9 min (range 6–12 min). In terms of comfort, all patients reported a good-to high level of satisfaction. The RTTs also respond positively towards the use of the locking mechanism and clips. Results of positioning uncertainties were comparable between the two institutes. The mean inter-fraction motion for all translational and rotational directions were Conclusions This study demonstrates the efficacy and feasibility of the immobilization device in the intracranial radiation treatment. Both patient comfort and preparation time by RTTs are considered adequate. In combination with online daily imaging procedure, this device can achieve submillimeter accuracy required for intracranial and stereotactic treatments.

To investigate the impact of the calculation resolution of the anisotropic analytical algorithms (AAA) for a variety of small fields in homogeneous and heterogeneous media and for RapidArc plans.Dose distributions calculated using AAA version 8.6.15 (AAA8) and 10.0.25 (AAA10) were compared to measurements performed with GafChromic EBT film, using phantoms made of polystyrene or a combination of polystyrene and cork. The accuracy of the algorithms calculated using grid resolutions of 2.5 and 1.0 mm was investigated for different field sizes, and for a limited selection of RapidArc plans (head and neck, small meningioma, and lung). Additional plans were optimized to create excessive multileaf collimator modulation and measured on a homogenous phantom. Gamma evaluation criterion of 3% dose difference and 2- or 1-mm distance to agreement (DTA) were applied to evaluate the accuracy of the algorithms.For fieldsor = 3 x 3 cm2, both versions of AAA predicted lower peak doses and broader penumbra widths than the measurements. However, AAA10 and a finer calculation grid improved the agreement. For RapidArc plans with many small multileaf collimator (MLC) segments and relatively high number of monitor units (MU), AAA8 failed to identify small dose peaks within the target. Both versions performed better in polystyrene than in cork. In homogeneous cork layers, AAA8 underestimated the average target dose for a clinical lung plan. This was improved with AAA10 calculated using a 1 mm grid.AAA10 improves the accuracy of dose calculations, and calculation grid of 1.0 mm is superior to using 2.5 mm, although calculation times increased by factor of 5. A suitable upper MU constraint should be assigned during optimization to avoid plans with high modulation. For plans with a relative high number of monitor units, calculations using 1 mm grid resolution are recommended. For planning target volume (PTV) which contains relatively large area of low density tissue, users should be aware of possible dose underestimation in the low density region and recalculation with AAA10 grid 1.0 mm is recommended.