title: Effect of set-up error on the dose across the junction of matching cranial-spinal fields in the treatment of medulloblastoma.
abstract: OBJECTIVE
  The effect of systematic and stochastic setup error on the dose delivered to the gap region for the three field radiation treatment of medulloblastoma is studied. The consequences of such setup error is discussed.
  
  
  METHODS
  The treatment of medulloblastoma is typically a 3 field technique, in which two lateral cranial fields are matched with a spine field. The x-ray dose delivered to the region between the matched fields depends upon the gap size. The choice of the gap width between the cranial and spinal fields is controversial. It is currently a compromise between minimizing the risk of dose hot spots to the spine, and the associated clinical complications, as well as the magnitude of cold spots (underdosing) across the gap, with the associated risk of disease recurrence. In this paper, we examine the effect of gap width with a moving junction, referred to as "field feathering", on the dose across the field junction for a 6MV photon beam. In addition, we have studied 129 portal films and 40 simulation films to assess the accuracy and precision of patient setup during treatment with a plan involving feathered fields. Selected landmarks observable on both portal and simulation films were identified and the variation in the distances to the field edges measured. The distribution of patient setup error was convoluted with the beam profiles for a 6MV linac. These convoluted field edges were used obtain dose profiles across the gap region as a function of gap separation. The consequences for therapy are discussed. In addition, analysis of patient setup error on an alternative treatment involving beam modifiers to broaden the beam penumbra is discussed.
  
  
  RESULTS
  The magnitude of the spatial stochastic and systematic setup error was determined to be approximately three and two millimeters respectively. The dosimetric consequences of patient setup error lead to over and under dosing in the spinal gap region for the three field technique. The degree of under or over dose depends on the nature and magnitude of the patient setup error.
  
  
  CONCLUSIONS
  The effect of patient setup error can lead to significant dosimetric errors in the dose to the gap region depending on the magnitude of the setup errors. The effective over and under dose can be compensated by the use beams modifiers such as a beam spoiler or vibrating jaws.
authors.affiliation: Department of Radiation Oncology, Harvard Medical School, Boston, MA 02115.
authors.forename: E J
authors.initials: EJ
authors.lastname: Holupka
authors.forename: J L
authors.initials: JL
authors.lastname: Humm
authors.forename: N J
authors.initials: NJ
authors.lastname: Tarbell
authors.forename: G K
authors.initials: GK
authors.lastname: Svensson
mesh_terms: D002138:Calibration; D002528:Cerebellar Neoplasms / Q000532:radiotherapy*; D006801:Humans; D008527:Medulloblastoma / Q000532:radiotherapy*; D008954:Models, Biological; D011879:Radiotherapy Dosage / Q000592:standards*; D013125:Spinal Neoplasms / Q000532:radiotherapy*