The use of small fields in radiotherapy techniques has increased substantially, in particular in stereotactic treatments and large uniform or nonuniform fields that are composed of small fields such as for intensity modulated radiation therapy (IMRT). This has been facilitated by the increased availability of standard and add-on multileaf collimators and a variety of new treatment units. For these fields, dosimetric errors have become considerably larger than in conventional beams mostly due to two reasons; (i) the reference conditions recommended by conventional Codes of Practice (CoPs) cannot be established in some machines and (ii) the measurement of absorbed dose to water in composite fields is not standardized. In order to develop standardized recommendations for dosimetry procedures and detectors, an international working group on reference dosimetry of small and nonstandard fields has been established by the International Atomic Energy Agency (IAEA) in cooperation with the American Association of Physicists in Medicine (AAPM) Therapy Physics Committee. This paper outlines a new formalism for the dosimetry of small and composite fields with the intention to extend recommendations given in conventional CoPs for clinical reference dosimetry based on absorbed dose to water. This formalism introduces the concept of two new intermediate calibration fields: (i) a static machine-specific reference field for those modalities that cannot establish conventional reference conditions and (ii) a plan-class specific reference field closer to the patient-specific clinical fields thereby facilitating standardization of composite field dosimetry. Prior to progressing with developing a CoP or other form of recommendation, the members of this IAEA working group welcome comments from the international medical physics community on the formalism presented here.

This review provides a complete technical description of the CyberKnife ® VSI™ System, the latest addition to the CyberKnife product family, which was released in September 2009. This review updates the previous technical reviews of the original system version published in the late 1990s. Technical developments over the last decade have impacted virtually every aspect of the CyberKnife System. These developments have increased the geometric accuracy of the system and have enhanced the dosimetric accuracy and quality of treatment, with advanced inverse treatment planning algorithms, rapid Monte Carlo dose calculation, and post-processing tools that allow trade-offs between treatment efficiency and dosimetric quality to be explored. This review provides a system overview with detailed descriptions of key subsystems. A detailed review of studies of geometric accuracy is also included, reporting a wide range of experiments involving phantom tests and patient data. Finally, the relationship between technical developments and the greatly increased range of clinical applications they have allowed is reviewed briefly.

Monte Carlo (MC) simulation of dose to water and dose to detector has been used to calculate the correction factors needed for dose calibration and output factor measurements on the CyberKnife system. Reference field ionization chambers simulated were the PTW 30006, Exradin A12, and NE 2571 Farmer chambers, and small volume chambers PTW 31014 and 31010. Correction factors for Farmer chambers were found to be 0.7%-0.9% larger than those determined from TRS-398 due mainly to the dose gradient across the chamber cavity. For one microchamber where comparison was possible, the factor was 0.5% lower than TRS-398 which is consistent with previous MC simulations of flattening filter free Linacs. Output factor detectors simulated were diode models PTW 60008, 60012, 60017, 60018, Sun Nuclear edge detector, air-filled microchambers Exradin A16 and PTW 31014, and liquid-filled microchamber PTW 31018 microLion. Factors were generated for both fixed and iris collimators. The resulting correction factors differ from unity by up to +11% for air-filled microchambers and -6% for diodes at the smallest field size (5 mm), and tend towards unity with increasing field size (correction factor magnitude <1% for all detectors at field sizes >15 mm). Output factor measurements performed using these detectors with fixed and iris collimators on two different CyberKnife systems showed initial differences between detectors of >15% at 5 mm field size. After correction the measurements on each unit agreed within ∼1.5% at the smallest field size. This paper provides a complete set of correction factors needed to apply a new small field dosimetry formalism to both collimator types on the CyberKnife system using a range of commonly used detectors.

Monte Carlo simulation was used to calculate correction factors for output factor (OF), percentage depth-dose (PDD), and off-axis ratio (OAR) measurements with the CyberKnife M6 System. These include the first such data for the InCise MLC. Simulated detectors include diodes, air-filled microchambers, a synthetic microdiamond detector, and point scintillator. Individual perturbation factors were also evaluated. OF corrections show similar trends to previous studies. With a 5 mm fixed collimator the diode correction to convert a measured OF to the corresponding point dose ratio varies between  -6.1% and  -3.5% for the diode models evaluated, while in a 7.6 mm  ×  7.7 mm MLC field these are  -4.5% to  -1.8%. The corresponding microchamber corrections are  +9.9% to  +10.7% and  +3.5% to  +4.0%. The microdiamond corrections have a maximum of  -1.4% for the 7.5 mm and 10 mm collimators. The scintillator corrections are <1% in all beams. Measured OF showed uncorrected inter-detector differences >15%, reducing to <3% after correction. PDD corrections at d > d were<2% for all detectors except IBA Razor where a maximum 4% correction was observed at 300 mm depth. OAR corrections were smaller inside the field than outside. At the beam edge microchamber OAR corrections were up to 15%, mainly caused by density perturbations, which blurs the measured penumbra. With larger beams and depths, PTW and IBA diode corrections outside the beam were up to 20% while the Edge detector needed smaller corrections although these did vary with orientation. These effects are most noticeable for large field size and depth, where they are dominated by fluence and stopping power perturbations. The microdiamond OAR corrections were <3% outside the beam. This paper provides OF corrections that can be used for commissioning new CyberKnife M6 Systems and retrospectively checking estimated corrections used previously. We recommend the PDD and OAR corrections are used to guide detector selection and inform the evaluation of results rather than to explicitly correct measurements.

Robotic radiosurgery using more than one circular collimator can improve treatment plan quality and reduce total monitor units (MU). The rationale for an iris collimator that allows the field size to be varied during treatment delivery is to enable the benefits of multiple-field-size treatments to be realized with no increase in treatment time due to collimator exchange or multiple traversals of the robotic manipulator by allowing each beam to be delivered with any desired field size during a single traversal. This paper describes the Iris variable aperture collimator (Accuray Incorporated, Sunnyvale, CA, USA), which incorporates 12 tungsten-copper alloy segments in two banks of six. The banks are rotated by 30 degrees with respect to each other, which limits the radiation leakage between the collimator segments and produces a 12-sided polygonal treatment beam. The beam is approximately circular, with a root-mean-square (rms) deviation in the 50% dose radius of <0.8% (corresponding to <0.25 mm at the 60 mm field size) and an rms variation in the 20-80% penumbra width of about 0.1 mm at the 5 mm field size increasing to about 0.5 mm at 60 mm. The maximum measured collimator leakage dose rate was 0.07%. A commissioning method is described by which the average dose profile can be obtained from four profile measurements at each depth based on the periodicity of the isodose line variations with azimuthal angle. The penumbra of averaged profiles increased with field size and was typically 0.2-0.6 mm larger than that of an equivalent fixed circular collimator. The aperture reproducibility is < or =0.1 mm at the lower bank, diverging to < or =0.2 mm at a nominal treatment distance of 800 mm from the beam focus. Output factors (OFs) and tissue-phantom-ratio data are identical to those used for fixed collimators, except the OFs for the two smallest field sizes (5 and 7.5 mm) are considerably lower for the Iris Collimator. If average collimator profiles are used, the assumption of circular symmetry results in dose calculation errors that are <1 mm or <1% for single beams across the full range of field sizes; errors for multiple non-coplanar beam treatment plans are expected to be smaller. Treatment plans were generated for 19 cases using the Iris Collimator (12 field sizes) and also using one and three fixed collimators. The results of the treatment planning study demonstrate that the use of multiple field sizes achieves multiple plan quality improvements, including reduction of total MU, increase of target volume coverage and improvements in conformality and homogeneity compared with using a single field size for a large proportion of the cases studied. The Iris Collimator offers the potential to greatly increase the clinical application of multiple field sizes for robotic radiosurgery.

A previous study of the corrections needed for output factor measurements with the CyberKnife system has been extended to include new diode detectors (IBA SFD and Exradin D1V), an air filled microchamber (Exradin CC01) and a scintillation detector (Exradin W1). The dependence of the corrections on detector orientation (detector long axis parallel versus perpendicular to the beam axis) and source to detector distance (SDD) was evaluated for these new detectors and for those in our previous study. The new diodes are found to over-respond at the smallest (5 mm) field size by 2.5% (D1V) and 3.3% (SFD) at 800 mm SDD, while the CC01 under-responds by 7.4% at the same distance when oriented parallel to the beam. Corrections for all detectors tend to unity as field size increases. The W1 corrections are <0.5% at all field sizes. Microchamber correction factors increase substantially if the detector is oriented perpendicular to the beam (by up to 23% for the PTW 31014). Corrections also vary with SDD, with the largest variations seen for microchambers in the perpendicular orientation (up to 13% change at 650 mm SDD versus 800 mm) and smallest for diodes (~1% change at 650 mm versus 800 mm). The smallest and most stable corrections are found for diodes, liquid filled microchambers and scintillation detectors, therefore these should be preferred for small field output factor measurements. If air filled microchambers are used, then the parallel orientation should be preferred to the perpendicular, and care should be taken to use corrections appropriate to the measurement SDD.

Methods are described which relate the uncertainty in relative electron density derived from CT numbers to the uncertainty in treatment plan calculation for both photon and electron beams. These relationships are used to generate tolerance levels for electron density quality assurance measurements. These tolerance levels are dependent on treatment beam energy and tissue thickness, and are generally broader than current recommendations. The predicted treatment plan errors associated with these tolerance levels are shown to be consistent with calculations made using two commercial treatment planning systems. The tolerance levels are also shown to be practical by comparison against quality assurance measurements made on a conventional CT scanner and a treatment simulator CT system over a 12-month period. The results demonstrate that broader tolerances than are currently recommended can be justified in all situations except for electron beam treatments in which the therapeutic range falls within lung tissue.

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