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Purpose: A fully automated, fast, on-line prostate repositioning scheme using implanted markers, kilovoltage/megavoltage imaging, and remote couch movements has been developed and clinically applied. The initial clinical results of this stereographic targeting (SGT) method, as well as phantom evaluations, are presented. Methods and Materials: Using the SGT method, portal megavoltage images are acquired with the first two to six monitor units of a treatment beam, immediately followed by acquisition of an orthogonal kilovoltage image without gantry motion. The image pair is automatically analyzed to obtain the marker positions and three-dimensional prostate displacement and rotation. Remote control couch shifts are applied to correct for the displacement. The SGT performance was measured using both phantom images and images from 10 prostate cancer patients treated using SGT. Results: With phantom measurements, the accuracy of SGT was 0.5, 0.2, and 0.3 mm (standard deviation [SD]) for the left–right, craniocaudal, and anteroposterior directions, respectively, for translations and 0.5° (SD) for the rotations around all axes. Clinically, the success rate for automatic marker detection was 99.5%, and the accuracy was 0.3, 0.5 and 0.8 mm (SD) in the left–right, craniocaudal, and anteroposterior axes. The SDs of the systematic center-of-mass positioning errors (Σ) were reduced from 4.0 mm to <0.5 mm for all axes. The corresponding SD of the random (σ) errors was reduced from 3.0 to <0.8 mm. These small residual errors were achieved with a treatment time extension of <1 min. Conclusion: Stereographic targeting yields systematic and random prostate positioning errors of <1 mm with <1 min of added treatment time. [Copyright &y& Elsevier]

Purpose: The no action level (NAL) protocol reduces systematic displacements relative to the planning CT scan by using the mean displacement of the first few treatment fractions as a setup correction in all subsequent fractions. This approach may become nonoptimal in case of time trends or transitions in the systematic displacement of a patient. Here, the extended NAL (eNAL) protocol is introduced to cope with this problem. Methods and Materials: The initial setup correction of eNAL is the same as in NAL. However, in eNAL, additional weekly follow-up measurements are performed. The setup correction is updated after each follow-up measurement based on linear regression of the available measured displacements to track and correct systematic time-dependent changes. We investigated the performance of eNAL with Monte Carlo simulations for populations without systematic displacement changes over time, with large gradual changes (time trends), and with large sudden changes (transitions). Weekly follow-up measurements were simulated for 35 treatment fractions. We compared the outcome of eNAL with NAL and optimized shrinking action level (SAL) protocol with weekly measurements. Results: Without time-dependent changes, eNAL, SAL, and NAL performed comparably, but SAL required the largest imaging workload. For time trends and transitions, eNAL performed superiorly to the other protocols and reduced systematic displacements to the same magnitude as in case of no time-dependent changes (SD ∼1 mm). Conclusion: Extended NAL can reduce systematic displacements to a minor level irrespective of the precise nature of the systematic time-dependent changes that may occur in a population. [Copyright &y& Elsevier]

Purpose: Lung tumors located in the lower lobe are the most mobile. Multiple computed tomographic (CT) scans, which had been performed for radiotherapy planning, were analyzed to determine the minimal number of required scans.Methods and Materials: Six spiral CT scans (3 rapid and 3 slow) from 7 such patients were coregistered. Reproducibility of target volumes was defined as the ratio between the overlapping and encompassing volume (COM/SUM) from scans derived using one technique. Volumetric and dosimetric analyses were performed.Results: Slow CT scans generated larger and more reproducible target volumes than rapid planning scans, with a mean COM/SUM ratio of 71.9 +/- 8.7% and 58.0 +/- 12.7%, respectively. When only a single slow CT scan was used for planning, the addition of a symmetrical 3D margin of 5 mm ensured 99% coverage of the "optimal" target volume, which was derived from summation of target volumes from all six scans.Conclusion: Planning target volumes (PTVs) derived from a single slow CT scan plus a 5-mm margin covered the "optimal" PTVs generated from six scans. Although these "slow PTVs" were larger, the increase in V(20) (the volume of lung tissue receiving a dose > or = 20 Gy) was limited. This indicates that only two CT scans, i.e., a full rapid scan of the entire thorax and a limited slow scan, are necessary for treatment planning in peripheral lung cancers. [ABSTRACT FROM AUTHOR]

Purpose: To quantify the residual geometric uncertainties after on-line corrections with intraprostatic fiducial markers, this study analyzed the deformation of the prostate and, in particular, the seminal vesicles relative to such markers. Patients and Methods: A planning computed tomography (CT) scan and three repeat CT scans were obtained for 21 prostate cancer patients who had had three to four cylindrical gold markers placed. The prostate and whole seminal vesicles (clinical target volume [CTV]) were delineated on each scan at a slice thickness of 1.5 mm. Rigid body transformations (translation and rotation) mapping the markers onto the planning scan positions were obtained. The translation only (Tonly) or both translation and rotation were applied to the delineated CTVs. Next, the residue CTV surface displacements were determined using nonrigid registration of the delineated contours. For translation and rotation of the CTV, the residues represented deformation; for Tonly, the residues stemmed from deformation and rotation. Tonly represented the residues for most currently applied on-line protocols. The patient and population statistics of the CTV surface displacements were calculated. The intraobserver delineation variation was similarly quantified using repeat delineations for all patients and corrected for. Results: The largest CTV deformations were observed at the anterior and posterior side of the seminal vesicles (population average standard deviation ≤3 mm). Prostate deformation was small (standard deviation ≤1 mm). The increase in these deviations when neglecting rotation (Tonly) was small. Conclusion: Although prostate deformation with respect to implanted fiducial markers was small, the corresponding deformation of the seminal vesicles was considerable. Adding marker-based rotational corrections to on-line translation corrections provided a limited reduction in the estimated planning margins. [Copyright &y& Elsevier]

Purpose: To investigate in a three-dimensional framework the effectiveness and reproducibility of reducing the respiratory motion of liver tumors using abdominal compression in a stereotactic body frame. Methods and Materials: A total of 12 patients with liver tumors, who were treated with stereotactic body radiotherapy, were included in this study. These patients had three gold fiducial markers implanted in the healthy liver tissue surrounding the tumor. Fluoroscopic videos were acquired on the planning day and before each treatment fraction to visualize the motion of the fiducial markers during free breathing and varying levels of abdominal compression. Software was developed to track the fiducial markers and measure their excursions. Results: Abdominal compression reduced the patient group median excursion by 62% in the craniocaudal and 38% in the anteroposterior direction with respect to the median free-breathing excursions. In the left–right direction, the median excursion increased 15% (maximal increase 1.6 mm). The median residual excursion was 4.1 mm in the craniocaudal, 2.4 mm in the anteroposterior, and 1.8 mm in the left–right direction. The mean excursions were reduced by compression to <5 mm in all patients and all directions, with two exceptions (craniocaudal excursion reduction of 20.5 mm to 7.4 mm and of 21.1 mm to 5.9 mm). The residual excursions reproduced well during the treatment course, and the craniocaudal excursions measured on the treatment days were never significantly (α = 0.05) greater than on the planning days. Fine tuning the compression did not considerably change the excursion on the treatment days. Conclusions: Abdominal compression effectively reduced liver tumor motion, yielding small and reproducible excursions in three dimensions. The compression level established at planning could have been safely used on the treatment days. [Copyright &y& Elsevier]

Purpose: To determine the effect of image-guided procedures (with computed tomography [CT] and electronic portal images before each treatment fraction) on target coverage in stereotactic body radiotherapy for liver patients using a stereotactic body frame (SBF) and abdominal compression. CT guidance was used to correct for day-to-day variations in the tumor's mean position in the SBF. Methods and Materials: By retrospectively evaluating 57 treatment sessions, tumor coverage, as obtained with the clinically applied CT-guided protocol, was compared with that of alternative procedures. The internal target volume-plus (ITV(+)) was introduced to explicitly include uncertainties in tumor delineations resulting from CT-imaging artifacts caused by residual respiratory motion. Tumor coverage was defined as the volume overlap of the ITV(+), derived from a tumor delineated in a treatment CT scan, and the planning target volume. Patient stability in the SBF, after acquisition of the treatment CT scan, was evaluated by measuring the displacement of the bony anatomy in the electronic portal images relative to CT. Results: Application of our clinical protocol (with setup corrections following from manual measurements of the distances between the contours of the planning target volume and the daily clinical target volume in three orthogonal planes, multiple two-dimensional) increased the frequency of nearly full (> or = 99%) ITV(+) coverage to 77% compared with 63% without setup correction. An automated three-dimensional method further improved the frequency to 96%. Patient displacements in the SBF were generally small (< or = 2 mm, 1 standard deviation), but large craniocaudal displacements (maximal 7.2 mm) were occasionally observed. Conclusion: Daily, CT-assisted patient setup may substantially improve tumor coverage, especially with the automated three-dimensional procedure. In the present treatment design, patient stability in the SBF should be verified with portal imaging. [ABSTRACT FROM AUTHOR]