title: Near simultaneous computed tomography image-guided stereotactic spinal radiotherapy: an emerging paradigm for achieving true stereotaxy.
abstract: OBJECTIVE
  To report treatment setup data from an emerging technique using near-simultaneous computed tomography (CT) image-guided stereotactic radiotherapy for the treatment of spinal and paraspinal tumors.
  
  
  METHODS
  A targeting system that integrates a CT-on-rails scanner with a linear accelerator (LINAC) was evaluated in the lead-in portion of a Phase I/II protocol for treating patients with paraspinal metastases. Patients were immobilized in supine position by a moldable body cushion vacuum wrapped with a plastic fixation sheet. Planning CT and immediately repeated CT were performed on the LINAC/CT-on-rails unit to assess respiratory-related vertebral body motion. Coplanar intensity-modulated radiotherapy (IMRT) using 7-9 beams was used to deliver 30 Gy in five fractions to the target volume, while limiting the spinal cord dose to <10 Gy. Pretreatment CT scans were fused with the planning CT scans to determine the correct target isocenter by accounting for any translational and roll (axial) rotational discrepancies from the planning CT. (Corrections caused by yaw and pitch rotations have not yet been implemented.) The reproducibility of the treatment isocenter as compared with the planned isocenter was measured with digitally reconstructed radiographs (DRRs), portal film imaging, and immediate post-treatment verification CT scans. Phantom measurements were taken for dose verification for each IMRT plan.
  
  
  RESULTS
  Based on a total of 36 CT scans (3 for planning, 3 for respiration study, 15 pretreatment, and 15 post-treatment) from 3 patients, no respiration-associated vertebral body motion was seen. A comparison of the corrected daily anterior-posterior (AP) and lateral (LAT) digital portal images with the planning AP and LAT DRRs confirmed that the isocenter setup accuracy for the 15 treatments was within 1 mm of the planning isocenter. The results from the immediate post-treatment CT scans reconfirmed the findings from the portal images and verified the absence of spinal movement during the treatment. The ion-chamber measurement for the high-dose region was within 2% of the planning dose for three patient treatment plans. Film dose measurement in an IMRT quality assurance phantom demonstrated good agreement from 90% to 30% isodose lines between the planned and measured results.
  
  
  CONCLUSIONS
  Preliminary experience suggests that the near-simultaneous CT image-guided verification technique can be used as a new platform technology for extracranial applications of stereotactic radiotherapy and radiosurgery to spinal and paraspinal tumors.
authors.affiliation: Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA. Ashiu@mdanderson.org
authors.forename: Almon S
authors.initials: AS
authors.lastname: Shiu
authors.forename: Eric L
authors.initials: EL
authors.lastname: Chang
authors.forename: Jin-Song
authors.initials: JS
authors.lastname: Ye
authors.forename: MingFwu
authors.initials: M
authors.lastname: Lii
authors.forename: Laurence D
authors.initials: LD
authors.lastname: Rhines
authors.forename: Ehud
authors.initials: E
authors.lastname: Mendel
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Weinberg
authors.forename: Sanjay
authors.initials: S
authors.lastname: Singh
authors.forename: Moshe H
authors.initials: MH
authors.lastname: Maor
authors.forename: Radhe
authors.initials: R
authors.lastname: Mohan
authors.forename: James D
authors.initials: JD
authors.lastname: Cox
mesh_terms: D004867:Equipment Design; D006801:Humans; D021621:Imaging, Three-Dimensional; D007103:Immobilization; D009068:Movement; D010315:Particle Accelerators; D019047:Phantoms, Imaging; D016634:Radiosurgery / Q000295:instrumentation / Q000379:methods*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D020266:Radiotherapy, Conformal / Q000379:methods*; D012119:Respiration; D013125:Spinal Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D013238:Stereotaxic Techniques; D014057:Tomography, X-Ray Computed