title: Impact of immobilization on intrafraction motion for spine stereotactic body radiotherapy using cone beam computed tomography.
abstract: OBJECTIVE
  Spine stereotactic body radiotherapy (SBRT) involves tight planning margins and steep dose gradients to the surrounding organs at risk (OAR). This study aimed to assess intrafraction motion using cone beam computed tomography (CBCT) for spine SBRT patients treated using three immobilization devices.
  
  
  METHODS
  Setup accuracy using CBCT was retrospectively analyzed for 102 treated spinal metastases in 84 patients. Thoracic and lumbar spine patients were immobilized with either an evacuated cushion (EC, n = 24) or a semirigid vacuum body fixation (BF, n = 60). For cases treated at cervical/upper thoracic (thoracic [T]1-T3) vertebrae, a thermoplastic S-frame (SF) mask (n = 18) was used. Patient setup was corrected by using bony anatomy image registration and couch translations only (no rotation corrections) with shifts confirmed on verification CBCTs. Repeat imaging was performed mid- and post-treatment. Patient translational and rotational positioning data were recorded to calculate means, standard deviations (SD), and corresponding margins ± 2 SD for residual setup errors and intrafraction motion.
  
  
  RESULTS
  A total of 355 localizations, 333 verifications, and 248 mid- and 280 post-treatment CBCTs were analyzed. Residual translations and rotations after couch corrections (verification scans) were similar for all immobilization systems, with SDs of 0.6 to 0.9 mm in any direction and 0.9° to 1.6°, respectively. Margins to encompass residual setup errors after couch corrections were within 2 mm. Including intrafraction motion, as measured on post-treatment CBCTs, SDs for total setup error in the left-right, cranial-caudal, and anterior-posterior directions were 1.3, 1.2, and 1.0 mm for EC; 0.9, 0.7, and 0.9 mm for BF; and 1.3, 0.9, and 1.1 mm for SF, respectively. The calculated margins required to encompass total setup error increased to 3 mm for EC and SF and remained within 2 mm for BF.
  
  
  CONCLUSIONS
  Following image guidance, residual setup errors for spine SBRT were similar across three immobilization systems. The BF device resulted in the least amount of intrafraction motion, and based on this device, we justify a 2-mm margin for the planning OAR and target volume.
authors.affiliation: Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario, Canada.
authors.forename: Winnie
authors.initials: W
authors.lastname: Li
authors.forename: Arjun
authors.initials: A
authors.lastname: Sahgal
authors.forename: Matthew
authors.initials: M
authors.lastname: Foote
authors.forename: Barbara-Ann
authors.initials: BA
authors.lastname: Millar
authors.forename: David A
authors.initials: DA
authors.lastname: Jaffray
authors.forename: Daniel
authors.initials: D
authors.lastname: Letourneau
mesh_terms: D059925:Anatomic Landmarks / Q000000981:diagnostic imaging; D002574:Cervical Vertebrae; D054893:Cone-Beam Computed Tomography; D019583:Dose Fractionation, Radiation; D006801:Humans; D007103:Immobilization / Q000295:instrumentation / Q000379:methods*; D008159:Lumbar Vertebrae; D008279:Magnetic Resonance Imaging / Q000379:methods; D009068:Movement; D058958:Organs at Risk / Q000000981:diagnostic imaging; D056888:Patient Positioning / Q000379:methods; D016634:Radiosurgery / Q000379:methods*; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D061106:Radiotherapy Setup Errors / Q000517:prevention & control; D061089:Radiotherapy, Image-Guided / Q000379:methods; D012189:Retrospective Studies; D013125:Spinal Neoplasms / Q000556:secondary / Q000601:surgery*; D013904:Thoracic Vertebrae