title: Procedures for high precision setup verification and correction of lung cancer patients using CT-simulation and digitally reconstructed radiographs (DRR).
abstract: OBJECTIVE
  In a recent study, large systematic setup errors were detected in patients with lung cancer when a conventional simulation procedure was used to define and mark the treatment isocenter. In the present study, we describe a procedure to omit the session at a conventional simulator to remove simulation errors entirely. Isocenter definition and verification was performed at a computed tomography (CT) simulator, and digitally reconstructed radiographs (DRRs) were used for setup verification and correction at the treatment unit.
  
  
  METHODS
  A CT simulation protocol was developed, in which radiopaque markers were used to verify the coincidence of the isocenter marked on the patients' skin with the isocenter defined in the planning CT scan. This protocol was evaluated for 20 patients. Subsequently, electronic portal images were acquired at the treatment unit. The three-dimensional setup error was established from a template match of the appropriate anatomy visible in two orthogonal beams with the corresponding anatomy in DRRs. An offline setup correction protocol was applied to reduce systematic setup errors.
  
  
  RESULTS
  For all patients, the skin marks defined the planning CT scan isocenter to within +/- 1.5 mm in each of the three main directions. Random setup errors at the treatment unit were 1.8, 2.0, and 1.9 mm (1 SD) for the lateral (x), the superior-inferior (y), and the anterior-posterior (z) directions, respectively. With the use of the correction protocol, the systematic errors for x, y, and z were 1.5, 1.5, and 1.3 mm (1 SD).
  
  
  CONCLUSIONS
  Because the distributions of treatment setup errors measured against DRRs obtained in our CT simulation were equal to previously obtained distributions measured against simulator films, conventional simulation can be omitted and DRRs are well-suited for setup verification. By adopting our CT simulation procedure, the large systematic simulation setup errors, which remain hidden if a conventional simulation is performed, can be avoided.
authors.affiliation: Department of Radiation Oncology, Daniel den Hoed Cancer Center/University Hospital, Rotterdam, The Netherlands.
authors.forename: John R
authors.initials: JR
authors.lastname: Van Sörnsen de Koste
authors.forename: Hans C J
authors.initials: HC
authors.lastname: de Boer
authors.forename: Regine H
authors.initials: RH
authors.lastname: Schuchhard-Schipper
authors.forename: Suresh
authors.initials: S
authors.lastname: Senan
authors.forename: Ben J M
authors.initials: BJ
authors.lastname: Heijmen
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000532:radiotherapy; D018288:Carcinoma, Small Cell / Q000000981:diagnostic imaging / Q000532:radiotherapy; D004938:Esophageal Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D011859:Radiography; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D015203:Reproducibility of Results