title: Design and implementation of a system for treating paediatric patients with stereotactically-guided conformal radiotherapy.
abstract: OBJECTIVE
  Stereotactically-guided conformal radiotherapy (SCRT) allows the delivery of highly conformal dose distributions to localised brain tumours. This is of particular importance for children, whose often excellent long-term prognosis should be accompanied by low toxicity. The commercial immobilisation system in use at our hospital for adults was felt to be too heavy for children, and precluded the use of anaesthesia, which is sometimes required for paediatric patients. This paper therefore describes the design and implementation of a system for treating children with SCRT. This system needed to be well tolerated by patients, with good access for treating typical childhood malignancies.
  
  
  METHODS
  A lightweight frame was developed for immobilisation, with a shell-based alternative for patients requiring general anaesthetic. Procedures were set up to introduce the patients to the frame system in order to maximise patient co-operation and comfort. Film measurements were made to assess the impact of the frame on transmission and surface dose. The reproducibility of the systems was assessed using electronic portal images.
  
  
  RESULTS
  Both frame and shell systems are in clinical use. The frame weighs 0.6 kg and is well tolerated. It has a transmission of 92-96%, and fields which pass through it deliver surface doses of 58-82% of the dose at d(max), compared to 18% when no frame is present. However, the frame is constructed to maximise the availability of unobstructed beam directions. Reproducibility measurements for the frame showed a mean random error of 1.0+/-0.2mm in two dimensions (2D) and 1.4+/-0.7 mm in 3D. The mean systematic error in 3D was 2.2mm, and 90% of all overall 3D errors were less than 3.4mm. For the shell system, the mean 2D random error was 1.5+/-0.2mm.
  
  
  CONCLUSIONS
  Two well-tolerated immobilisation devices have been developed for fractionated SCRT treatment of paediatric patients. A lightweight frame system gives a wide range of possible unobstructed beam directions, although beams that intersect the frame are not precluded, provided that output corrections are applied. A shell system allows the use of general anaesthesia. Both systems give reproducible immobilisation to complement the high-precision treatment delivery.
authors.affiliation: Joint Department of Physics, The Royal Marsden NHS Trust, Downs Road, Sutton, Surrey SM2 5PT, UK.
authors.forename: E J
authors.initials: EJ
authors.lastname: Adams
authors.forename: B L
authors.initials: BL
authors.lastname: Suter
authors.forename: A P
authors.initials: AP
authors.lastname: Warrington
authors.forename: P
authors.initials: P
authors.lastname: Black
authors.forename: F
authors.initials: F
authors.lastname: Saran
authors.forename: M
authors.initials: M
authors.lastname: Brada
mesh_terms: D001932:Brain Neoplasms / Q000532:radiotherapy*; D002648:Child; D006801:Humans; D007103:Immobilization; D011880:Radiotherapy Planning, Computer-Assisted; D020266:Radiotherapy, Conformal / Q000379:methods*; D015203:Reproducibility of Results; D013238:Stereotaxic Techniques; D014057:Tomography, X-Ray Computed