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We studied the dosimetry of single-isocenter treatment plans generated to treat a solitary intracranial lesion using linac-based stereotactic radiosurgery (SRS). A common metric for evaluating SRS plan quality is the volume of normal brain tissue irradiated by a dose of at least 12 Gy (V12), which is important because multiple studies have shown a strong correlation between V12 and incidence of radiation necrosis. Unrealistic expectations for values of V12 can lead to wasted planning time. We present a model that estimates V12 without having to construct a full treatment plan. This model was derived by retrospectively analyzing 50 SRS treatment plans, each clinically approved for delivery using circular collimator cone arc therapy (CAT). Each case was re-planned for delivery via dynamic conformal arc therapy (DCAT), and then scaling arguments were used to extend dosimetric data to account for different prescription dose (PD) values (15, 18, 21, or 24 Gy). We determined a phenomenological expression for the total volume receiving at least 12 Gy (TV12) as a function of both planning target volume (PTV) and PD: T V 12 / 1 c c = n ∗ P D / 1 G y + d ∗ P T V / 1 c c a ∗ P D / 1 G y c , where a , c , n , d are fit parameters, and a separate set of values is determined for each plan type. In addition, we generated a sequence of plots to clarify how the relationship between conformity index (CI) and TV12 depends on plan type (CAT vs DCAT), PTV, and PD. These results can be used to suggest realistic plan parameters and planning goals before the start of treatment planning. In the absence of access to more sophisticated pre-planning tools, this model can be locally generated and implemented at relatively low cost with respect to time, money, and expertise.

Purpose This study aims to compare stereotactic radiosurgery (SRS) planning of epilepsy that complies with Radiosurgery or Open Surgery for Epilepsy (ROSE) guidelines in GammaKnife, non‐coplanar conformal (NCC) plan in Eclipse, dynamic conformal arc (DCA) plan in Brainlab, and a volumetric modulated arc therapy (VMAT) plan in Eclipse. Methods Twenty plans targeting Mesial temporal lobe epilepsy (MTLE) was generated using GammaKnife, Eclipse with 20 NCC beams, Brainlab with 5 DCA, and Eclipse VMAT with 4 arcs observing ROSE trial guidelines. Multivariate analysis of variance and Wilcoxon signed‐rank test were used to compare dosimetric data of the plans and perform pairwise comparison, respectively. Results The plans obeyed the recommended prescription isodose volume (PIV) within 5.5–7.5 cc and maximum doses to brainstem, optic apparatus (OA) of 10 and 8 Gy, respectively, for a prescription dose of 24 Gy. The volumes of the target were in the range 4.0–7.4 cc. Mean PIV, maximum dose to brainstem, OA were 6.5 cc, 10 Gy, 7.9 Gy in GammaKnife; 7.2 cc, 6.1 Gy, 4.5 Gy in Eclipse NCC; 7.2 cc, 6.4 Gy, 5.7 Gy in Brainlab DCA; and 5.2 cc, 8.4 Gy, 6.1 Gy in Eclipse VMAT plans, respectively. Multivariate analysis of variance showed significant differences among the 4 SRS planning techniques (P‐values

Purpose This study aimed to evaluate and compare different system calibration methods from a large cohort of systems to establish a commissioning procedure for surface‐guided frameless cranial stereotactic radiosurgery (SRS) with intrafractional motion monitoring and gating. Using optical surface imaging (OSI) to guide non‐coplanar SRS treatments, the determination of OSI couch‐angle dependency, baseline drift, and gated‐delivered‐dose equivalency are essential. Methods Eleven trained physicists evaluated 17 OSI systems at nine clinical centers within our institution. Three calibration methods were examined, including 1‐level (2D), 2‐level plate (3D) calibration for both surface image reconstruction and isocenter determination, and cube phantom calibration to assess OSI‐megavoltage (MV) isocenter concordance. After each calibration, a couch‐angle dependency error was measured as the maximum registration error within the couch rotation range. A head phantom was immobilized on the treatment couch and the isocenter was set in the middle of the brain, marked with the room lasers. An on‐site reference image was acquired at couch zero, the facial region of interest (ROI) was defined, and static verification images were captured every 10° for 0°–90° and 360°–270°. The baseline drift was assessed with real‐time monitoring of the motionless phantom over 20 min. The gated‐delivered‐dose equivalency was assessed using the electron portal imaging device and gamma test (1%/1mm) in reference to non‐gated delivery. Results The maximum couch‐angle dependency error occurs in longitudinal and lateral directions and is reduced significantly (P 98% gamma‐test passing rate. Conclusion A commissioning method is recommended using the 3D plate calibration, which is verified by radiation isocenter and validated with couch‐angle dependency, baseline drift, and gated‐delivered‐dose equivalency tests. This method characterizes OSI uncertainties, ensuring motion‐monitoring accuracy for SRS treatments.

Purpose Surface imaging (SI) offers a nonionizing, near real time alternative to radiographic imaging for intrafraction radiosurgery localization. In this work, we systematically compared a commercial SI system vs a commercial room mounted x‐ray localization system in phantom. Methods An anthropomorphic head phantom with fiducial markers was imaged with linear accelerator on‐board x‐ray imaging, SI, and room mounted x‐ray imaging (RM) at ±45° and ±90° couch angles for three different head tilts and six different isocenters (72 total positions). The shifts generated by the three systems were compared as functions of couch angle, head tilt, and isocenter position with the on‐board imaging shifts used as ground truth. Two sample Kolmogorov–Smirnov tests were used to evaluate equivalence of the groups. Results The magnitude of the displacement vectors for RM minus on‐board imaging and SI minus on‐board imaging over all 72 phantom positions were 0.7 ± 0.3 mm for both cases. The RM and SI showed no significant difference based on couch angle or isocenter position. Both systems showed decreasing accuracy with increasing couch angle, but both systems agreed with ground truth to

The purpose of this work is to assess eight detectors performance for output factor (OF), percent depth dose (PDD), and beam profiles in a 6‐MV Clinac stereotactic radiosurgery mode for cone irradiation using Monte Carlo simulation as reference. Cones with diameters comprised between 30 and 4 mm have been studied. The evaluated detectors were ionization chambers: pinpoint and pinpoint 3D, diodes: SRS, P and E, Edge, MicroDiamond and EBT3 radiochromic films. The results showed that pinpoints underestimate OF up to −2.3% for cone diameters ≥10 mm and down to −12% for smaller cones. Both nonshielded (SRS and E) and shielded diodes (P and Edge) overestimate the OF respectively up to 3.3% and 5.2% for cone diameters ≥10 mm and in both cases more than 7% for smaller cones. MicroDiamond slightly overestimates the OF, 3.7% for all the cones and EBT3 film is the closest to Monte Carlo with maximum difference of ±1% whatever the cone size is. For the profiles and the PDD, particularly for the small cones, the size of the detector predominates. All diodes and EBT3 agree with the simulation within ±0.2 mm for beam profiles determination. For PDD curve all the active detectors response agree with simulation up to 1% for all the cones. EBT3 is the more accurate detector for beam profiles and OF determinations of stereotactic cones but it is restrictive to use. Due to respectively inappropriate size of the sensitive volume and composition, pinpoints and diodes do not seem appropriate without OF corrective factors below 10 mm diameter cone. MicroDiamond appears to be the best detector for OF determination regardless all cones. For off‐axis measurements, the size of the detector predominates and for PDD all detectors give promising results.

Purpose The challenges of accurate dosimetry for stereotactic radiotherapy (SRT) with small unflattened radiation fields have been widely reported in the literature. In this case, suitable dosimeters would have to offer a submillimeter spatial resolution. The CyberKnife® (Accuray Inc., Sunnyvale, CA, USA) is an SRT‐dedicated linear accelerator (linac), which can deliver treatments with submillimeter positional accuracy using circular fields. Beams are delivered with the desired field size using fixed cones, the InCise™ multileaf collimator or a dynamic variable‐aperture Iris™ collimator. The latter, allowing for field sizes to be varied during treatment delivery, has the potential to decrease treatment time, but its reproducibility in terms of output factors (OFs) and dose profiles (DPs) needs to be verified. Methods A 2D monolithic silicon array detector, the “Octa”, was evaluated for dosimetric quality assurance (QA) for a CyberKnife system. OFs, DPs, percentage depth‐dose (PDD) and tissue maximum ratio (TMR) were investigated, and results were benchmarked against the PTW SRS diode. Cross‐plane, in‐plane and 2 diagonal dose profiles were measured simultaneously with high spatial resolution (0.3 mm). Monte Carlo (MC) simulations with a GEANT4 (GEometry ANd Tracking 4) tool‐kit were added to the study to support the experimental characterization of the detector response. Results For fixed cones and the Iris, for all field sizes investigated in the range between 5 and 60 mm diameter, OFs, PDDs, TMRs, and DPs in terms of FWHM measured by the Octa were accurate within 3% when benchmarked against the SRS diode and MC calculations. Conclusions The Octa was shown to be an accurate dosimeter for measurements with a 6 MV FFF beam delivered with a CyberKnife system. The detector enabled real‐time dosimetric verification for the variable aperture Iris collimator, yielding OFs and DPs consistent with those obtained with alternative methods.

This study details a validation process for linear accelerator‐based treatment of trigeminal neuralgia using HD‐MLC field collimation. Nine trigeminal neuralgia treatment plans utilizing HD‐MLC were selected for absolute dose measurement at isocenter using a commercial scintillating detector in an anthropomorphic phantom. Four plans were chosen for film dosimetry measurements in each of the three principal planes to assess spatial dose distribution agreement with the treatment planning system. Additionally, trajectory log analysis for each treatment field in the nine cases was performed to assess mechanical positioning accuracy of the MLC system during delivery. Scintillator and film measurements both revealed mean dose agreement at isocenter of better than 3% while FWHM of the 2D dose distribution in each plane showed agreement between plan and measurement within 0.2 mm. Analysis of log files revealed a maximum MLC leaf positioning error of 0.04 mm across 178 treatment fields. In conjunction with a quality‐controlled treatment delivery methodology, an appropriately commissioned treatment planning system can be used for accurate and clinically appropriate design of trigeminal neuralgia treatment plans utilizing HD‐MLC.

Purpose To investigate the accuracy of the dosimetry of radiation fields produced by small ELEKTA cone collimators used for stereotactic radiosurgery treatments (SRS) using commercially available detectors EBT3 GafchromicTM film, IBA Stereotactic diode (SFD), and the recently developed detector DUO, which is a monolithic silicon orthogonal linear diode array detector. Methods These three detectors were used for the measurement of beam profiles, output factors, and percentage depth dose for SRS cone collimators with cone sizes ranging from 5 to 50 mm diameter. The measurements were performed at 10 cm depth and 90 cm SSD. Results The SRS cone beam profiles measured with DUO, EBT3 film, and IBA SFD agreed well, results being in agreement within ±0.5 mm in the FWHM, and ±0.7 mm in the penumbra region. The output factor measured by DUO with 0.5 mm air gap above agrees within ±1% with EBT3. The OF measured by IBA SFD (corrected for the over‐response) agreed with both EBT3 and DUO within ±2%. All three detectors agree within ±2% for PDD measurements for all SRS cones. Conclusions The characteristics of the ELEKTA SRS cone collimator have been evaluated by using a monolithic silicon high spatial resolution detector DUO, EBT3, and IBA SFD diode. The DUO detector is suitable for fast real‐time quality assurance dosimetry in small radiation fields typical for SRS/SRT. This has been demonstrated by its good agreement of measured doses with EBT 3 films.

The photon optimization (PO) algorithm was recently released by Varian Medical Systems to improve volumetric modulated arc therapy (VMAT) optimization within Eclipse (Version 13.5). The purpose of this study is to compare the PO algorithm with its predecessor, progressive resolution optimizer (PRO) for lung SBRT and brain SRS treatments. A total of 30 patients were selected retrospectively. Previously, all the plans were generated with the PRO algorithm within Eclipse Version 13.6. In the new version of PO algorithm (Version 15), dynamic conformal arcs (DCA) were first conformed to the target, then VMAT inverse planning was performed to achieve the desired dose distributions. PTV coverages were forced to be identical for the same patient for a fair comparison. SBRT plan quality was assessed based on selected dose–volume parameters, including the conformity index, V 20 for lung, V 30 Gy for chest wall, and D 0.035 cc for other critical organs. SRS plan quality was evaluated based on the conformity index and normal tissue volumes encompassed by the 12 and 6 Gy isodose lines (V 12 and V 6). The modulation complexity score (MCS) was used to compare plan complexity of two algorithms. No statistically significant differences between the PRO and PO algorithms were found for any of the dosimetric parameters studied, which indicates both algorithms produce comparable plan quality. Significant improvements in the gamma passing rate (increased from 97.0% to 99.2% for SBRT and 96.1% to 98.4% for SRS), MCS (average increase of 0.15 for SBRT and 0.10 for SRS), and delivery efficiency (MU reduction of 29.8% for SBRT and 28.3% for SRS) were found for the PO algorithm. MCS showed a strong correlation with the gamma passing rate, and an inverse correlation with total MUs used. The PO algorithm offers comparable plan quality to the PRO, while minimizing MLC complexity, thereby improving the delivery efficiency and accuracy.

Purpose Tumor motion amplitude varies during treatment. The purpose of the study was to evaluate the intra‐ and interfraction tumor motion and variability in patients with liver cancer treated with fiducial‐based real‐time tracking stereotactic body radiotherapy (SBRT). Methods Fourteen liver patients were treated with SBRT using a CyberKnife. Two to four fiducial markers implanted near the tumor were used for real‐time monitoring using the Synchrony system. The tumor motion information during treatment was extracted from the log files recorded by the Synchrony system. Logfile‐based amplitudes in the superior–posterior (SI), left–right (LR) and anterior–posterior (AP) directions were compared to the 4DCT‐based amplitudes. The intra‐ and interfraction amplitude variations and the incidence of baseline shifts were analyzed for 66 fractions administered to 14 patients. Results The median (range) logfile‐based liver motion amplitudes for all patients were 11.9 (5.1–17.3) mm, 1.3 (0.4–4) mm and 3.8 (0.9–7.7) mm in the SI, LR and AP directions, respectively. Compared with the logfile‐based amplitude, the 4DCT‐based amplitude was underestimated (P < 0.05). The median (range) intra‐ and interfraction liver motion amplitude variations were 4.3 (1.6–6.0) mm (SI), 0.5 (0.2–2.2) mm(LR) and 1.5 (0.3–3.3) mm (AP) and 1.7 (0.5–4.6) mm (SI), 0.3 (0.1–3.0) mm (LR) and 0.7 (0.3–2.7) mm (AP), respectively. Baseline shifts exceeding 2 mm, 3 mm and 5 mm were observed in 27.3%, 7.6% and 3% of the measurements, respectively, within 10 min, and in 66.7%, 38.1% and 19%, respectively, within 30 min for the square root of the sum of the squares of the distances in the SI, LR and AP directions (3D). The tumor motion amplitude was found to be correlated with the baseline shift. Conclusions Most patients showed significant intra‐ and interfraction liver motion amplitude variations over the entire course of radiation. More caution is needed for patients with large tumor motion amplitudes.

The Convolution algorithm, implemented in Leksell GammaPlan® ver. Here, 10, is the first algorithm for Leksell Gamma Knife that takes heterogeneities into account and models dose build‐up effects close to tissue boundaries. The aim of this study was preliminary comparison of the Convolution and TMR10 algorithms for real clinical cases and dosimetric verification of the algorithms, using measurements in a phantom. A total of 25 patients involved in comparison of the Convolution and TMR10 algorithms were divided into three groups: patients with benign tumors close to heterogeneities, patients with functional disorders, and patients with tumors located far from heterogeneities. Differences were observed especially in the group of patients with tumors close to heterogeneities, where the difference in maximal dose to critical structures for the Convolution algorithm was up to 15% compared to the TMR10 algorithm. Dosimetric verification of the algorithm was performed, using a radiochromic gel dosimeter based on Turnbull blue dye in a special heterogeneous phantom. Relative dose distributions measured with the radiochromic gel dosimeter agreed very well with both the TMR10 and Convolution calculations. We observed small discrepancies in the direction in which the largest inhomogeneity was positioned. Verification results indicated that the Convolution algorithm provides a different dose distribution, especially in regions close to heterogeneities and particularly for lower isodose volumes. However, the results obtained with gamma analyses in the gel dosimetry experiment did not verify the assumption that the Convolution algorithm provides more accurate dose calculation.

Purpose Dosimetry of small fields defined by stereotactic cones remains a challenging task. In this work, we report the results of commissioning measurements for the new Elekta stereotactic conical collimator system attached to the Elekta VersaHD linac and present the comparison between the measured and Monte Carlo (MC) calculated data for the 6 MV FFF beam. In addition, relative output factor (ROF) dependence on the stereotactic cone aperture variation was studied and penumbra comparison for small MLC‐based and cone‐based fields was performed. Methods Cones with nominal diameters of 15 mm, 12.5 mm, 10 mm, 7.5 mm, and 5 mm were employed in our study. Percentage depth dose (PDD), off‐axis ratios (OAR), and ROF were measured using a stereotactic field diode (SFD). BEAMnrc code was used for MC simulations. Results MC calculated and measured PDDs for all cones agreed within 1%/0.5 mm, and OAR profiles agreed within 1%/0.5 mm. ROF obtained from the measurements and MC calculations agreed within 2% for all cone sizes. Small‐field correction factors for the SFD detector Kfield,3 × 3(SFD) were derived using MC calculations as a baseline and were found to be 0.982, 0.992, 0.997, 1.015, and 1.017 for the 5, 7.5, 10, 12.5, and 15‐mm cones respectively. The difference in ROF was about 10%, 6%, 3.5%, 3%, 2.5%, and 2% for ±0.3 mm variations in 5, 7.5, 10, 12.5, and 15‐mm cone aperture respectively. In case of single static field, cone‐based collimation produced a sharper penumbra compared to the MLC‐based. Conclusions Accurate MC simulation can be an effective tool for verification of dosimetric measurements of small fields. Due to the very high sensitivity of output factors on the cone diameter, manufacture‐related variations in cone size may lead to considerable variations in dosimetric characteristics of stereotactic cones.

Purpose To present the k-means clustering algorithm as a tool to address treatment planning considerations characteristic of stereotactic radiosurgery using a single isocenter for multiple targets. Methods For 30 patients treated with stereotactic radiosurgery for multiple brain metastases, the geometric centroids and radii of each met were determined from the treatment planning system. In-house software used this as well as weighted and unweighted versions of the k-means clustering algorithm to group the targets to be treated with a single isocenter, and to position each isocenter. The algorithm results were evaluated using within-cluster sum of squares as well as a minimum target coverage metric that considered the effect of target size. Both versions of the algorithm were applied to an example patient to demonstrate the prospective determination of the appropriate number and location of isocenters. Results Both weighted and unweighted versions of the k-means algorithm were applied successfully to determine the number and position of isocenters. Comparing the two, both the within-cluster sum of squares metric and the minimum target coverage metric resulting from the unweighted version were less than those from the weighted version. The average magnitudes of the differences were small (−0.2 cm2 and 0.1% for the within cluster sum of squares and minimum target coverage, respectively) but statistically significant (Wilcoxon signed-rank test, P < 0.01). Conclusions The differences between the versions of the k-means clustering algorithm represented an advantage of the unweighted version for the within-cluster sum of squares metric, and an advantage of the weighted version for the minimum target coverage metric. While additional treatment planning considerations have a large influence on the final treatment plan quality, both versions of the k-means algorithm provide automatic, consistent, quantitative, and objective solutions to the tasks associated with SRS treatment planning using a single isocenter for multiple targets.

AlignRT is a surface imaging system that has been utilized for localizing and tracking patient position during radiotherapy. AlignRT has two calibration procedures that can set the system's isocenter called “Monthly Calibration” (MC) and “Isocentre Calibration” (IC). The MC utilizes a calibration plate. In addition to the calibration plate, the IC utilizes a cubic phantom that is imaged with the linac treatment beam to aid in aligning the AlignRT and treatment‐beam isocenters. This work evaluated the effects of misaligning the calibration plate during the calibration process. The plate was intentionally shifted away from isocenter ±3.0 mm in the longitudinal and lateral directions and ±1.0 mm in the longitudinal, lateral, and vertical directions. A mock stereotactic radiosurgery (SRS) treatment was used to evaluate the effects of the miscalibrations. An anthropomorphic head phantom was placed in an SRS treatment position and monitored with the AlignRT system. The AlignRT‐indicated offsets were recorded at 270°, 315°, 0°, 45°, and 90° couch angles for each intentional misalignment of the calibration plate during the MC. The IC was also performed after each miscalibration, and the measurements were repeated and compared to the previous results. With intentional longitudinal and lateral shifts of ±3.0 mm and ±1.0 mm of the calibration plate, the average indicated offsets at couch rotations of ±90° were 4.3 mm and 1.6 mm, respectively. This was in agreement with the theoretical offset of √2*(shift‐of‐the‐calibration plate). Since vertical shifts were along the rotation axis of the couch, these shifts had little effect on the offsets with changing couch angle. When the IC was applied, the indicated offsets were all within 0.5 mm for all couch angles for each of the miscalibrations. These offsets were in agreement with the known magnitude of couch walkout. The IC method effectively removes the potential miscalibration artifacts of the MC method due to misalignments of the calibration plate.

Author(s): Chapman, Christopher H; McGuinness, Christopher; Gottschalk, Alexander R; Yom, Sue S; Garsa, Adam A; Anwar, Mekhail; Braunstein, Steve E; Sudhyadhom, Atchar; Keall, Paul; Descovich, Martina | Abstract: Purpose/objectivesFor lung stereotactic body radiation therapy (SBRT), real-time tumor tracking (RTT) allows for less radiation to normal lung compared to the internal target volume (ITV) method of respiratory motion management. To quantify the advantage of RTT, we examined the difference in radiation pneumonitis risk between these two techniques using a normal tissue complication probability (NTCP) model.Materials/method20 lung SBRT treatment plans using RTT were replanned with the ITV method using respiratory motion information from a 4D-CT image acquired at the original simulation. Risk of symptomatic radiation pneumonitis was calculated for both plans using a previously derived NTCP model. Features available before treatment planning that identified significant increase in NTCP with ITV versus RTT plans were identified.ResultsPrescription dose to the planning target volume (PTV) ranged from 22 to 60 Gy in 1-5 fractions. The median tumor diameter was 3.5 cm (range 2.1-5.5 cm) with a median volume of 14.5 mL (range 3.6-59.9 mL). The median increase in PTV volume from RTT to ITV plans was 17.1 mL (range 3.5-72.4 mL), and the median increase in PTV/lung volume ratio was 0.46% (range 0.13-1.98%). Mean lung dose and percentage dose-volumes were significantly higher in ITV plans at all levels tested. The median NTCP was 5.1% for RTT plans and 8.9% for ITV plans, with a median difference of 1.9% (range 0.4-25.5%, pairwise P l 0.001). Increases in NTCP between plans were best predicted by increases in PTV volume and PTV/lung volume ratio.ConclusionsThe use of RTT decreased the risk of radiation pneumonitis in all plans. However, for most patients the risk reduction was minimal. Differences in plan PTV volume and PTV/lung volume ratio may identify patients who would benefit from RTT technique before completing treatment planning.

The purpose of this work was to compare dose distributions between two radiosurgery modalities, single‐isocenter volumetric modulated arc therapy (VMAT), and GammaKnife Perfexion (GK), in the treatment of a large number (≥7) of brain metastases. Twelve patients with 103 brain metastases were analyzed. The median number of targets per patient was 8 (range: 7–14). GK plans were compared to noncoplanar VMAT plans using both 6‐MV flattening filter‐free (FFF) and 10‐MV FFF modes. Parameters analyzed included radiation therapy oncology group conformity index (CI), 12, 6, and 3 Gy isodose volumes (V12 Gy, V6 Gy, V3 Gy), mean and maximum hippocampal dose, and maximum skin dose. There were statistically significant differences in CI (2.5 ± 1.6 vs 1.6 ± 0.8 and 1.7 ± 0.9, P

Purpose The aim of this study is to compare the dosimetric differences between four techniques for spine stereotactic body radiotherapy (SBRT): CyberKnife (CK), volumetric modulated arc therapy (VMAT), and helical tomotherapy (HT) with dynamic jaws (HT‐D) and fixed jaws (HT‐F). Materials/methods Data from 10 patients were utilized. All patients were planned for 24 Gy in two fractions, with the primary objectives being: (a) restricting the maximum dose to the cord to ≤ 17 Gy and/or cauda equina to ≤ 20 Gy, and (b) to maximize the clinical target volume (CTV) to receive the prescribed dose. Treatment plans were generated by separate dosimetrists and then compared using velocity AI. Parameters of comparison include target volume coverage, conformity index (CI), gradient index (GI), homogeneity index (HI), treatment time (TT) per fraction, and monitor units (MU) per fraction. Results PTV D2 and D5 were significantly higher for CK compared to VMAT, HT‐F, and HT‐D (P < 0.001). The average volume of CTV receiving the prescription dose (CTV D95) was significantly less for VMAT compared to CK, HT‐F and HT‐D (P = 0.036). CI improved for CK (0.69), HT‐F (0.66), and HT‐D (0.67) compared to VMAT (0.52) (P = 0.013). CK (41.86) had the largest HI compared to VMAT (26.99), HT‐F (20.69), and HT‐D (21.17) (P < 0.001). GI was significantly less for CK (3.96) compared to VMAT (6.76) (P = 0.001). Likewise, CK (62.4 min, 14059 MU) had the longest treatment time and MU per fraction compared to VMAT (8.5 min, 9764 MU), HT‐F (13 min, 10822 MU), and HT‐D (13.5 min, 11418 MU) (P < 0.001). Conclusion Both CK and HT plans achieved conformal target coverage while respecting cord tolerance. Dose heterogeneity was significantly larger in CK. VMAT required the least treatment time and MU output, but had the least steep GI, CI, and target coverage.

The Canadian Organization of Medical Physicists (COMP), in close partnership with the Canadian Partnership for Quality Radiotherapy (CPQR) has developed a series of Technical Quality Control (TQC) guidelines for radiation treatment equipment. These guidelines outline the performance objectives that equipment should meet in order to ensure an acceptable level of radiation treatment quality. This particular TQC contains detailed performance objectives and safety criteria for CyberKnife® Technology. The quality control recommendations in this document are based upon previously published guidelines and the collective experience of all Canadian sites using this technology. This TQC guideline has been field tested at the newest Canadian CyberKnife installation site and includes recommendations for quality control of the Iris™ and InCise™ MLC collimation systems.

Single‐isocenter, multitarget cranial stereotactic radiosurgery (SRS) is more efficient than using an isocenter for each target, but spatial positioning uncertainties can be magnified at locations away from the isocenter. This study reports on the spatial accuracy of two frameless, linac‐based SRS systems for multitarget, single‐isocenter SRS as a function of distance from the isocenter. One system uses the ExacTrac platform for image guidance and the other localizes with cone beam computed tomography (CBCT). For each platform, a phantom with 12 target BBs distributed up to 13.8 cm from the isocenter was aligned starting from five different initial offsets and then imaged with the treatment beam at seven different gantry and couch angles. The distribution of the resulting positioning errors demonstrated the value of adding a 1‐mm PTV margin for targets up to about 7–8 cm from the isocenter. For distances 10 cm or more, the CBCT‐based alignment remained within 1.1 mm while the ExacTrac‐based alignment differed by up to 2.2 mm.