title: Evaluation of the geometric accuracy of surrogate-based gated VMAT using intrafraction kilovoltage x-ray images.
abstract: OBJECTIVE
  To evaluate the geometric accuracy of beam targeting in external surrogate-based gated volumetric modulated arc therapy (VMAT) using kilovoltage (kV) x-ray images acquired during dose delivery.
  
  
  METHODS
  Gated VMAT treatments were delivered using a Varian TrueBeam STx Linac for both physical phantoms and patients. Multiple gold fiducial markers were implanted near the target. The reference position was created for each implanted marker, representing its correct position at the gating threshold. The gating signal was generated from the RPM system. During the treatment, kV images were acquired immediately before MV beam-on at every breathing cycle, using the on-board imaging system. All implanted markers were detected and their 3D positions were estimated using in-house developed software. The positioning error of a marker is defined as the distance of the marker from its reference position for each frame of the images. The overall error of the system is defined as the average over all markers. For the phantom study, both sinusoidal motion (1D and 3D) and real human respiratory motion was simulated for the target and surrogate. In the baseline case, the two motions were synchronized for the first treatment fraction. To assess the effects of surrogate-target correlation on the geometric accuracy, a phase shift of 5% and 10% between the two motions was introduced. For the patient study, intrafraction kV images of five stereotactic body radiotherapy (SBRT) patients were acquired for one or two fractions.
  
  
  RESULTS
  For the phantom study, a high geometric accuracy was achieved in the baseline case (average error: 0.8 mm in the superior-inferior or SI direction). However, the treatment delivery is prone to geometric errors if changes in the target-surrogate relation occur during the treatment: the average error was increased to 2.3 and 4.7 mm for the phase shift of 5% and 10%, respectively. Results obtained with real human respiratory curves show a similar trend. For a target with 3D motion, the technique is able to detect geometric errors in the left-right (LR) and anterior-posterior (AP) directions. For the patient study, the average intrafraction positioning errors are 0.8, 0.9, and 1.4 mm and 95th percentile errors are 1.7, 2.1, and 2.7 mm in the LR, AP, and SI directions, respectively.
  
  
  CONCLUSIONS
  The correlation between external surrogate and internal target motion is crucial to ensure the geometric accuracy of surrogate-based gating. Real-time guidance based on kV x-ray images overcomes the potential issues in surrogate-based gating and can achieve accurate beam targeting in gated VMAT.
authors.affiliation: Department of Radiation Oncology, Stanford University, Stanford, CA 94305-5847, USA. rli2@stanford.edu
authors.forename: Ruijiang
authors.initials: R
authors.lastname: Li
authors.forename: Edward
authors.initials: E
authors.lastname: Mok
authors.forename: Bin
authors.initials: B
authors.lastname: Han
authors.forename: Albert
authors.initials: A
authors.lastname: Koong
authors.forename: Lei
authors.initials: L
authors.lastname: Xing
mesh_terms: D019583:Dose Fractionation, Radiation; D057918:Fiducial Markers; D006801:Humans; D009068:Movement; D009369:Neoplasms / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000532:radiotherapy; D019047:Phantoms, Imaging; D011880:Radiotherapy Planning, Computer-Assisted / Q000295:instrumentation* / Q000592:standards; D014057:Tomography, X-Ray Computed / Q000295:instrumentation* / Q000592:standards