title: The first clinical treatment with kilovoltage intrafraction monitoring (KIM): a real-time image guidance method.
abstract: OBJECTIVE
  Kilovoltage intrafraction monitoring (KIM) is a real-time image guidance method that uses widely available radiotherapy technology, i.e., a gantry-mounted x-ray imager. The authors report on the geometric and dosimetric results of the first patient treatment using KIM which occurred on September 16, 2014.
  
  
  METHODS
  KIM uses current and prior 2D x-ray images to estimate the 3D target position during cancer radiotherapy treatment delivery. KIM software was written to process kilovoltage (kV) images streamed from a standard C-arm linear accelerator with a gantry-mounted kV x-ray imaging system. A 120° pretreatment kV imaging arc was acquired to build the patient-specific 2D to 3D motion correlation. The kV imager was activated during the megavoltage (MV) treatment, a dual arc VMAT prostate treatment, to estimate the 3D prostate position in real-time. All necessary ethics, legal, and regulatory requirements were met for this clinical study. The quality assurance processes were completed and peer reviewed.
  
  
  RESULTS
  During treatment, a prostate position offset of nearly 3 mm in the posterior direction was observed with KIM. This position offset did not trigger a gating event. After the treatment, the prostate motion was independently measured using kV/MV triangulation, resulting in a mean difference of less than 0.6 mm and standard deviation of less than 0.6 mm in each direction. The accuracy of the marker segmentation was visually assessed during and after treatment and found to be performing well. During treatment, there were no interruptions due to performance of the KIM software.
  
  
  CONCLUSIONS
  For the first time, KIM has been used for real-time image guidance during cancer radiotherapy. The measured accuracy and precision were both submillimeter for the first treatment fraction. This clinical translational research milestone paves the way for the broad implementation of real-time image guidance to facilitate the detection and correction of geometric and dosimetric errors, and resultant improved clinical outcomes, in cancer radiotherapy.
authors.affiliation: Radiation Physics Laboratory, Sydney Medical School, University of Sydney, Camperdown, New South Wales 2006, Australia.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Keall
authors.affiliation: Radiation Physics Laboratory, Sydney Medical School, University of Sydney, Camperdown, New South Wales 2006, Australia and School of Physics, University of Sydney, Camperdown, New South Wales 2006, Australia.
authors.forename: Jin
authors.initials: J
authors.lastname: Aun Ng
authors.affiliation: Radiation Physics Laboratory, Sydney Medical School, University of Sydney, Camperdown, New South Wales 2006, Australia.
authors.forename: Ricky
authors.initials: R
authors.lastname: O'Brien
authors.affiliation: Radiation Physics Laboratory, Sydney Medical School, University of Sydney, Camperdown, New South Wales 2006, Australia and Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Emma
authors.initials: E
authors.lastname: Colvill
authors.affiliation: Radiation Physics Laboratory, Sydney Medical School, University of Sydney, Camperdown, New South Wales 2006, Australia.
authors.forename: Chen-Yu
authors.initials: CY
authors.lastname: Huang
authors.affiliation: Department of Oncology, Aarhus University Hospital, 8000 Aarhus C, Denmark and Institute of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark.
authors.forename: Per
authors.initials: P
authors.lastname: Rugaard Poulsen
authors.affiliation: Department of Oncology, Aarhus University Hospital, 8000 Aarhus C, Denmark and Institute of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark.
authors.forename: Walther
authors.initials: W
authors.lastname: Fledelius
authors.affiliation: School of Physics, University of Sydney, Camperdown, New South Wales 2006, Australia and Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Prabhjot
authors.initials: P
authors.lastname: Juneja
authors.affiliation: Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Emma
authors.initials: E
authors.lastname: Simpson
authors.affiliation: Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Linda
authors.initials: L
authors.lastname: Bell
authors.affiliation: Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Florencia
authors.initials: F
authors.lastname: Alfieri
authors.affiliation: Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Thomas
authors.initials: T
authors.lastname: Eade
authors.affiliation: Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Kneebone
authors.affiliation: School of Physics, University of Sydney, Camperdown, New South Wales 2006, Australia and Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia.
authors.forename: Jeremy T
authors.initials: JT
authors.lastname: Booth
mesh_terms: D000465:Algorithms; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000295:instrumentation / Q000379:methods*; D008297:Male; D009038:Motion; D010315:Particle Accelerators; D011467:Prostate / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000528:radiation effects; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000532:radiotherapy; D011859:Radiography / Q000295:instrumentation / Q000379:methods*; D061089:Radiotherapy, Image-Guided / Q000295:instrumentation / Q000379:methods*; D012984:Software