Evaluation of patient setup uncertainty of optical guided frameless system for intracranial stereotactic radiosurgery.

The optically-guided frameless system (OFLS) has been used in our clinic for intracranial stereotactic radiosurgery (SRS) since 2006, as it is especially effective in IMRT-based radiosurgery (IMRS), which allows treating multiple brain lesions simultaneously using single isocenter approach. This study reports our retrospective analysis of patient setup accuracy using this system. The OFLS consists of a bite block with fiducial markers and an infra-red camera system. To test reproducibility, patients are taken for reseat verification after bite block construction. Upon the completion of radiosurgery planning, the isocenter position(s) and images are sent to the optical guidance computer where fiducials are manually registered from the CT scan. During treatment, patient setup is monitored and guided by the camera readings on the fiducials. In addition, two orthogonal kV images are acquired and used as an isocenter verification tool. In addition, we have analyzed the reseat and fiducial digitization data of 56 patients. Retrospective comparison of kV images with reference images has been carried out for all the patients to evaluate actual patient setup accuracy at the time of treatment. The histogram of the findings shows that 82.2% of patients had 3D isodisplacement (E < or = 1 mm; 5.2% had 1< E < or = 2 mm). Hence, for 87.5 % of the patients in the study, treatments were finished under the optical guidance with a maximum setup error of 2 mm and the median setup error of 0 mm. For the remaining 12.5% of patients in the study, the isodisplacements were greater than 2 mm and the treatment records showed that those patients were repositioned, guided by the orthogonal kV-images. It is found that the OFLS in the SRS treatment has acceptable accuracy when used in conjunction with orthogonal kV images, and the use of orthogonal kV images as a verification tool ensures the efficacy of frameless localization in the radiosurgery treatment.