title: Treatment accuracy of fractionated stereotactic radiotherapy.
abstract: OBJECTIVE
  To assess the geometric accuracy of the delivery of fractionated stereotactic radiotherapy (FSRT) for brain tumours using the Gill-Thomas-Cosman (GTC) relocatable frame. Accuracy of treatment delivery was measured via portal images acquired with an amorphous silicon based electronic portal imager (EPI). Results were used to assess the existing verification process and to review the current margins used for the expansion of clinical target volume (CTV) to planning target volume (PTV).
  
  
  METHODS
  Patients were immobilized in a GTC frame. Target volume definition was performed on localization CT and MRI scans and a CTV to PTV margin of 5mm (based on initial experience) was introduced in 3D. A Brown-Roberts-Wells (BRW) fiducial system was used for stereotactic coordinate definition. The existing verification process consisted of an intercomparison of the coordinates of the isocentres and anatomy between the localization and verification CT scans. Treatment was delivered with 6 MV photons using four fixed non-coplanar conformal fields using a multi-leaf collimator. Portal imaging verification consisted of the acquisition of orthogonal images centred through the treatment isocentre. Digitally reconstructed radiographs (DRRs) created from the CT localization scans were used as reference images. Semi-automated matching software was used to quantify set up deviations (displacements and rotations) between reference and portal images.
  
  
  RESULTS
  One hundred and twenty six anterior and 123 lateral portal images were available for analysis for set up deviations. For displacements, the total errors in the cranial/caudal direction were shown to have the largest SD's of 1.2 mm, while systematic and random errors reached SD's of 1.0 and 0.7 mm, respectively, in the cranial/caudal direction. The corresponding data for rotational errors (the largest deviation was found in the sagittal plane) was 0.7 degrees SD (total error), 0.5 degrees (systematic) and 0.5 degrees (random). The total 3D displacement was 1.8 mm (mean), 0.8 mm (SD) with a range of 0.3-3.9 mm.
  
  
  CONCLUSIONS
  Portal imaging has shown that the existing verification and treatment delivery techniques currently in use result in highly reproducible setups. Random and systematic errors in the treatment planning and delivery chain will always occur, but monitoring and minimising them is an essential component of quality control. Portal imaging provides fast and accurate facility for monitoring patients on treatment and the results of this study have shown that a reduction in CTV to PTV margin from 5 to 4 mm (resulting in a considerable increase in the volume of normal tissue sparing) could be made.
authors.affiliation: Radiotherapy Physics, The Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ2, UK.
authors.forename: Shaleen
authors.initials: S
authors.lastname: Kumar
authors.forename: Kevin
authors.initials: K
authors.lastname: Burke
authors.forename: Colin
authors.initials: C
authors.lastname: Nalder
authors.forename: Paula
authors.initials: P
authors.lastname: Jarrett
authors.forename: Cephas
authors.initials: C
authors.lastname: Mubata
authors.forename: Roger
authors.initials: R
authors.lastname: A'hern
authors.forename: Mandy
authors.initials: M
authors.lastname: Humphreys
authors.forename: Margaret
authors.initials: M
authors.lastname: Bidmead
authors.forename: Michael
authors.initials: M
authors.lastname: Brada
mesh_terms: D000236:Adenoma / Q000532:radiotherapy*; D003397:Craniopharyngioma / Q000532:radiotherapy*; D019583:Dose Fractionation, Radiation; D006801:Humans; D007103:Immobilization; D008279:Magnetic Resonance Imaging; D008577:Meningeal Neoplasms / Q000532:radiotherapy*; D008579:Meningioma / Q000532:radiotherapy*; D009464:Neuroma, Acoustic / Q000532:radiotherapy*; D017785:Photons / Q000627:therapeutic use; D010911:Pituitary Neoplasms / Q000532:radiotherapy*; D011878:Radiotherapy / Q000379:methods*; D012680:Sensitivity and Specificity; D012825:Silicon; D013238:Stereotaxic Techniques; D014057:Tomography, X-Ray Computed
chemical_list: D012825:Silicon