Daily Image Guidance With Cone-Beam Computed Tomography for Head-and-Neck Cancer Intensity-Modulated Radiotherapy: A Prospective Study

The aim of this study was assess the patient setup errors for various tumor sites based on clinical data from a sufficient number of treatments with volumetric‐modulated arc therapy (VMAT) using daily pretreatment CBCT imaging guidance. In addition, we calculated and compared the planning target volume (PTV) margins for all disease sites based on an analysis of specific systematic and random errors in our institution. All patients underwent pretreatment kV‐CBCT imaging. The various tumor sites were divided into four categories; 21 brain (438 fractions), 35 head‐and‐neck tumors (H&N, 933 fractions), 19 thorax and abdomen tumors (T&A, 313 fractions), and 17 prostate cancer tumors (546 fractions). Overall distributions of setup corrections in all directions, frequencies of 3D vector lengths, institution‐specific setup error, and PTV margins were analyzed. The longitudinal distribution for the T&A site represented an asymmetric offset in the negative direction. Rotational distributions were comparable for all treatment sites, and the prostate site had the narrowest distribution of ≤±2∘. The cumulative frequencies of 3D vector length of ≥ 7 mm were rare for brain lesions and H&N, but more common for T&A and prostate lesions at 25.6% and 12.1%, respectively. The overall mean error for all treatment sites were within ±1 mm and ±0.1∘, with the exception of the T&A site, which had overall mean error of 2 mm in the negative longitudinal direction. The largest magnitude of systematic error and random error for the brain lesions and H&N was 1.4 mm in the translational directions, and 3.3 mm for T&A and prostate lesions. The PTV margins required in this analysis are ≤ 4 mm for the brain lesions and H&N in all translational directions, but ranged from 4 to 10 mm for T&A and prostate lesions. Analysis of each institution's specific setup errors using daily CBCT is essential for determining PTV margins and reducing setup uncertainties, because setup errors vary according to each immobilization system and patient.PACS number: 87.55.km

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Assessment of setup uncertainties for various tumor sites when using daily CBCT for more than 2200 VMAT treatments

Baek

Kim

et al. 2014

“…Cone‐beam CT (CBCT) is standard for image‐guided radiation therapy (IGRT) in photon clinics (1) . Its potential in proton therapy treatment has also been investigated, (2) although the proposed usage is limited only to geometric targeting (i.e., beam‐target alignment).…”

Section: Introductionmentioning

confidence: 99%

Using CBCT for pretreatment range check in proton therapy: a phantom study for prostate treatment by anterior–posterior beam

Bentefour

Both

Tang

et al. 2015

This study explores the potential of cone‐beam computed tomography (CBCT) for monitoring relative beam range variations due to daily changes in patient anatomy for prostate treatment by anterior proton beams. CBCT was used to image an anthropomorphic pelvic phantom, in eight sessions on eight different days. In each session, the phantom was scanned twice, first at a standard position as determined by the room lasers, and then after it was shifted by 10 mm translation randomly along one of the X, Y, or Z directions. The filling of the phantom bladder with water was not refreshed from day to day, inducing gradual change of the water‐equivalent path length (WEPL) across the bladder. MIMvista (MIM) software was used to perform image registration and re‐alignment of all the scans with the scan from the first session. The XiO treatment planning system was used to perform data analysis. It was found that, although the Hounsfield unit numbers in CBCT have substantially larger fluctuations than those in diagnostic CT, CBCT datasets taken for daily patient positioning could potentially be used to monitor changes in patient anatomy. The reproducibility of the WEPL, computed using CBCT along anterior–posterior (AP) paths across and around the phantom prostate, over a volume of 360 cc, is sufficient for detecting daily WEPL variations that are equal to or larger than 3 mm. This result also applies to CBCT scans of the phantom after it is randomly shifted from the treatment position by 10 mm. limiting the interest to WEPL variation over a specific path within the same CBCT slice, one can detect WEPL variation smaller than 1 mm. That is the case when using CBCT for tracking daily change of the WEPL across the phantom bladder that was induced by spontaneous change in the bladder filling due to evaporation. In summary, the phantom study suggests that CBCT can be used for monitoring day to day WEPL variations in a patient. The method can detect WEPL variation equal to or greater than 3 mm. The study calls for further investigation using the CBCT data from real patients. If confirmed with real patients' data, CBCT could become, in addition to patient setup, a standard tool for proton therapy pretreatment beam range check.PACS number: 87.55.Tm

Minimal mask immobilization with optical surface guidance for head and neck radiotherapy

Zhao

Maquilan

Jiang

et al. 2017

PurposeFull face and neck thermoplastic masks provide standard‐of‐care immobilization for patients receiving H&N IMRT. However, these masks are uncomfortable and increase skin dose. The purpose of this pilot trial was to investigate the feasibility and setup accuracy of minimal face and neck mask immobilization with optical surface guidance.MethodsTwenty patients enrolled onto this IRB‐approved protocol. Patients were immobilized with masks securing only forehead and chin. Shoulder movement was restricted by either moldable cushion or hand held strap retractors. Positional information, including isocenter location and CT skin contours, were imported to a commercial surface image guidance system. Patients typically received standard‐of‐care IMRT to 60–70 Gy in 30–33 fractions. Patients were first set up to surface markings with optical image guidance referenced to regions of interest (ROIs) on simulation CT images. Positioning was confirmed by in‐room CBCT. Following six‐dimensional robotic couch correction, a new optical real‐time surface image was acquired to track intrafraction motion and to serve as a reference surface for setup at the next treatment fraction. Therapists manually recorded total treatment time as well as couch shifts based on kV imaging. Intrafractional ROI motion tracking was automatically recorded by the optical image guidance system. Patient comfort was assessed by self‐administered surveys.ResultsSetup error was measured as six‐dimensional shifts (vertical/longitudinal/lateral/rotation/pitch/roll). Mean error values were −0.51 ± 2.42 mm, −0.49 ± 3.30 mm, 0.23 ± 2.58 mm, −0.15 ± 1.01o, −0.02 ± 1.19o, and 0.06 ± 1.08o, respectively. Average treatment time was 21.6 ± 8.4 mins). Subjective comfort during surface‐guided treatment was confirmed on patient surveys.ConclusionThese pilot results confirm feasibility of minimal mask immobilization combined with commercially available optical image guidance. Patient acceptance of minimal mask immobilization has been encouraging. Follow‐up validation, with direct comparison to standard mask immobilization, appears warranted.