title: Linearity of patient positioning detection : a phantom study of skin markers, cone beam computed tomography, and 3D ultrasound.
abstract: BACKGROUND
  Three-dimensional ultrasound (3D-US) is a modality complementary to kilovoltage cone beam computed tomography (kV-CBCT) and skin markers for patient positioning detection. This study compares the linearity of evaluations based on measurements using a modern 3D-US system (Elekta Clarity®; Elekta, Stockholm, Sweden), a kV-CBCT system (Elekta iView®), and skin markers.
  
  
  METHODS
  An investigator deliberately displaced a multimodal phantom by up to ± 30 mm along different axes. The following data points were acquired: 27 along the lateral axis, 29 along the longitudinal axis, 27 along the vertical axis, and 27 along the space diagonal. At each of these 110 positions, the displacements according to skin' markers were recorded and scans were performed using both 3D-US and kV-CBCT. Shifts were detected by matching bony anatomy or soft tissue density to a reference planning CT in the case of kV-CBCT and for 3D-US, by matching ultrasound volume data to a reference planning volume. A consensus value was calculated from the average of the four modalities. With respect to this consensus value, the linearity (offset and regression coefficient, i.e., slope), average offset, systematic error, and random error of all four modalities were calculated for each axis.
  
  
  RESULTS
  Linearity was similar for all four modalities, with regression coefficients between 0.994 and 1.012, and all offsets below 1 mm. The systematic errors of skin markers and 3D-US were higher than for kV-CBCT, but random errors were similar. In particular, 3D-US demonstrated an average offset of 0.36 mm to the right, 0.08 mm inferiorly, and 0.15 mm anteriorly; the systematic error was 0.36 mm laterally, 0.35 mm longitudinally, and 0.22 mm vertically; the random error was 0.15 mm laterally, 0.30 mm longitudinally, and 0.12 mm vertically. A total of 109 out of 110 (99 %) 3D-US measurements were within 1 mm of the consensus value on either axis.
  
  
  CONCLUSIONS
  The linearity of 3D-US was no worse than that of skin markers or kV-CBCT. Average offsets, systematic errors, and random errors were all below 1 mm. Optimal margins in the order of 1 mm could be achieved in the controlled laboratory setting of this phantom study.
authors: Department of Radiation Oncology, University Hospital of LMU, Munich, Germany, hendrik.ballhausen@med.lmu.de.
authors: Hendrik
authors: H
authors: Ballhausen
authors: Sheila
authors: S
authors: Hieber
authors: Minglun
authors: M
authors: Li
authors: Katia
authors: K
authors: Parodi
authors: Claus
authors: C
authors: Belka
authors: Michael
authors: M
authors: Reiner
mesh_terms: D054893:Cone-Beam Computed Tomography / Q000379:methods*; D057918:Fiducial Markers; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D056888:Patient Positioning / Q000379:methods*; D019047:Phantoms, Imaging; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D061106:Radiotherapy Setup Errors; D012016:Reference Values; D012680:Sensitivity and Specificity; D014463:Ultrasonography / Q000379:methods*
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