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PURPOSE Our objective was to demonstrate the efficacy of a telehealth training course on high-dose-rate (HDR) brachytherapy for gynecologic cancer treatment for clinicians in low- and middle-income countries (LMICs) METHODS A 12-week course consisting of 16 live video sessions was offered to 10 cancer centers in the Middle East, Africa, and Nepal. A total of 46 participants joined the course, and 22 participants, on average, attended each session. Radiation oncologists and medical physicists from 11 US and international institutions prepared and provided lectures for each topic covered in the course. Confidence surveys of 15 practical competencies were administered to participants before and after the course. Competencies focused on HDR commissioning, shielding, treatment planning, radiobiology, and applicators. Pre- and post-program surveys of provider confidence, measured by 5-point Likert scale, were administered and compared. RESULTS Forty-six participants, including seven chief medical physicists, 16 senior medical physicists, five radiation oncologists, and three dosimetrists, representing nine countries attended education sessions. Reported confidence scores, both aggregate and paired, demonstrated increases in confidence in all 15 competencies. Post-curriculum score improvement was statistically significant ( P < .05) for paired respondents in 11 of 15 domains. Absolute improvements were largest for confidence in applicator commissioning (2.3 to 3.8, P = .009), treatment planning system commissioning (2.2 to 3.9, P = .0055), and commissioning an HDR machine (2.2 to 4.0, P = .0031). Overall confidence in providing HDR brachytherapy services safely and teaching other providers increased from 3.1 to 3.8 and 3.0 to 3.5, respectively. CONCLUSION A 12-week, low-cost telehealth training program on HDR brachytherapy improved confidence in treatment delivery and teaching for clinicians in 10 participating LMICs.

The past decade has seen the increasing integration of magnetic resonance (MR) imaging into radiation therapy (RT). This growth can be contributed to multiple factors, including hardware and software advances that have allowed the acquisition of high-resolution volumetric data of RT patients in their treatment position (also known as MR simulation) and the development of methods to image and quantify tissue function and response to therapy. More recently, the advent of MR-guided radiation therapy (MRgRT) - achieved through the integration of MR imaging systems and linear accelerators - has further accelerated this trend. As MR imaging in RT techniques and technologies, such as MRgRT, gain regulatory approval worldwide, these systems will begin to propagate beyond tertiary care academic medical centers and into more community-based health systems and hospitals, creating new opportunities to provide advanced treatment options to a broader patient population. Accompanying these opportunities are unique challenges related to their adaptation, adoption, and use including modification of hardware and software to meet the unique and distinct demands of MR imaging in RT, the need for standardization of imaging techniques and protocols, education of the broader RT community (particularly in regards to MR safety) as well as the need to continue and support research, and development in this space. In response to this, an ad hoc committee of the American Association of Physicists in Medicine (AAPM) was formed to identify the unmet needs, roadblocks, and opportunities within this space. The purpose of this document is to report on the major findings and recommendations identified. Importantly, the provided recommendations represent the consensus opinions of the committee's membership, which were submitted in the committee's report to the AAPM Board of Directors. In addition, AAPM ad hoc committee reports differ from AAPM task group reports in that ad hoc committee reports are neither reviewed nor ultimately approved by the committee's parent groups, including at the council and executive committee level. Thus, the recommendations given in this summary should not be construed as being endorsed by or official recommendations from the AAPM.

In this work we present a systematic study on the microstructure of soft materials which combine the anisotropy of lyotropic liquid crystals with the mechanical stability of a physical gel. Systematic small-angle neutron (SANS) and X-ray (SAXS) scattering experiments were successfully used to characterize the lyotropic lamellar phase (Lalpha) of the system D2O - n-decanol - SDS which was gelled by two low molecular weight organogelators, 1,3:2,4-dibenzylidene-d-sorbitol (DBS) and 12-hydroxyoctadecanoic acid (12-HOA). Surprisingly, a pronounced shoulder appeared in the scattering curves of the lamellar phase gelled with 12-HOA, whereas the curves of the DBS-gelled Lalpha phase remained almost unchanged compared to the ones of the gelator-free Lalpha phase. The appearance of this additional shoulder strongly indicates the formation of a synergistic structure, which neither exists in the gelator-free Lalpha phase nor in the isotropic binary gel. By comparing the thicknesses of the 12-HOA (25-30 nm) and DBS (4-8 nm) gel fibers with the lamellar repeat distance (7.5 nm), we suggest that the synergistic structure originates from the minimization of the elastic free energy of the lamellar phase. In the case of 12-HOA, where the fiber diameter is significantly larger than the lamellar repeat distance, energetically unfavored layer ends can be prevented, when the layers cylindrically enclose the gel fibers. Interestingly, such structures mimic similar schemes found in neural cells, where axons are surrounded by lamellar myelin sheets.

Surfactant-based lyotropic liquid crystal gels (LLCGs) are soft materials which combine the anisotropic order of a surfactant-based lyotropic liquid crystal with the mechanical stability of a gel. The most prominent example of a “natural“ LLCG is the biological cell. This review summarizes potential applications of surfactant-based LLCGs and the different strategies via which these materials can be obtained. The main focus, however, is on gelation with low molecular weight gelators (LMWG), which form self-assembled fibrillar networks (SAFiN). We will discuss whether or not the resulting surfactant-based LLCGs are orthogonal self-assembled systems, i.e. systems where the two coexisting structures (lyotropic liquid crystal and SAFiN) form independently.

While most Radiation Oncology clinics have adopted electronic charting in one form or another, no consensus document exists that provides guidelines for safe and effective use of the Radiation Oncology electronic medical records (RO-EMR). Task Group 262 was formed to provide these guidelines as well as to provide recommendations to vendors for improving electronic charting functionality in the future. Guidelines are provided in the following areas: Implementation and training for the RO-EMR, acceptance testing and quality assurance (QA) of the RO-EMR, use of the RO-EMR as an information repository, use of the RO-EMR as a workflow manager, electronic charting for brachytherapy and non-standard treatments, and information technology (IT) considerations associated with the RO-EMR. The report was based on a literature search by the task group, an extensive survey of task group members on their respective RO-EMR practices, an AAPM membership survey on electronic charting, as well as group consensus.

In this chapter, small field dosimetry for two dedicated radiosurgery treatment delivery devices, the CyberKnife and the ZAP-X, are presented. After a short technical overview and introduction to the respective device, small field dosimetry beam data is discussed. For each device, the adaptation of reference dosimetry protocols for the machine-specific reference field is covered. Measurement methods to collect data for output factors, percent depth dose (PDD) or tissue-phantom ratio (TPR), and off-axis factors are presented. Suitable detectors for measuring each beam data type are listed. Sample data to visualize the specific characteristics of each beam dataset are provided. This chapter covers the difference between beam data from the fixed cones, IRIS collimator and multi-leaf collimator (M6) for the CyberKnife, including selected comparison data plots.

Lyotropic liquid crystal (LLC) gels are a new class of liquid crystal (LC) networks that combine the anisotropy of micellar LLCs with the mechanical stability of a gel. However, so far, only micellar LLC gels with lamellar and hexagonal structures have been obtained by the addition of gelators to LLCs. Here, the first examples of lyotropic nematic gels are presented. The key to obtain these nematic gels is the use of gelators that have a non-amphiphilic molecular structure and thus leave the size and shape of the micellar aggregates essentially unchanged. By adding these gelators to lyotropic nematic phases, an easy and reproducible way to obtain large amounts of lyotropic nematic gels is established. These nematic gels preserve the long-range orientational order and optical birefringence of a lyotropic nematic phase but have the mechanical stability of a gel. LLC nematic gels are promising new materials for elastic and anisotropic hydrogels to be applied as water-based stimuli-responsive actuators and sensors.

Stereotactic accuracy and target engagement largely rely on rigid immobilization of the skull. However, advanced imaging, image reconstructions, and adaptive treatment algorithms have made frameless image guidance without rigid immobilization a mainstay of stereotactic radiosurgery and radiotherapy deliveries. While these methods for achieving stereotactic precision require some immobilization, these obviate the need for an invasive head ring fixation. Because these approaches allow the target to still move to some degree and this movement must be compensated for, frameless image guidance requires intra-treatment imaging and target tracking and, critically, requires verification of accuracy. In this chapter, the different approaches are described, including key technological features of various frameless image-guided approaches. The anticipation is that these methods, which are primarily used for stereotactic radiosurgery, will continue to evolve to incorporate other imaging modalities, such as MRI, and eventually be generalized to other stereotactic procedures.

An interstitial brachytherapy approach for gynecologic cancers is typically considered for patients with lesions exceeding 5 mm within tissue or that are not easily accessible for intracavitary applications. Recommendations for treating gynecologic malignancies with this approach are available through the American Brachytherapy Society, but vary based on available resources, staffing, and logistics. The intent of this manuscript is to share the collective experience of 3 academic centers that routinely perform interstitial gynecologic brachytherapy. Discussion points include indications for interstitial implants, procedural preparations, applicator selection, anesthetic options, imaging, treatment planning objectives, clinical workflows, timelines, safety, and potential challenges. Interstitial brachytherapy is a complex, high-skill procedure requiring routine practice to optimize patient safety and treatment efficacy. Clinics planning to implement this approach into their brachytherapy practice may benefit from considering the discussion points shared in this manuscript.

We present a systematical investigation of gelled lyotropic liquid crystals (LLCs). This new class of soft materials combines the anisotropy of LLCs with the mechanical stability of a physical gel. The studied LLC system consists of sodium dodecyl sulfate as a surfactant, n-decanol as a cosurfactant, and water as a solvent. At room temperature, four liquid crystalline phases (lamellar Lα, nematic Nd and Nc, and hexagonal H1) are formed depending on the composition. We were successful in gelling the lyotropic lamellar phase with the low-molecular-weight organogelator 12-hydroxyoctadecanoic acid (12-HOA). The obtained gelled lamellar phase shows optical birefringence, elastic response, and no macroscopic flow. However, we were not able to obtain gels with hexagonal or nematic structure. These findings can be explained twofold. When gelling the hexagonal phase, the long-range hexagonal order was destroyed and an isotropic gel was formed. The reason might be the incompatibility between the gel fiber network and the two-dimensional long-range translational order of the cylindrical micelles in the hexagonal phase. Otherwise, the lyotropic nematic phase was transformed into an anisotropic gel with the lamellar structure during gelation. Evidently, the addition of the gelator 12-HOA to the lyotropic system considerably widens the lamellar regime because the integration of the surface-active 12-HOA gelator molecules into the nematic micelles flattens out the micelle curvature. We further investigated the successfully gelated Lα phase to examine the impacts of the gel network and the remaining monomeric gelator on both the structure and properties of the gelled lamellar phase. Small-angle X-ray scattering results showed an arrested lamellar layer spacing in the gelled state, which indicates a higher translational order for the gelled lamellar phases in comparison with their gelator-free counterparts.

Purpose To improve the quality of our gynecologic brachytherapy practice and reduce reportable events, we performed a process analysis after the failure modes and effects analysis (FMEA). Methods and Materials The FMEA included a multidisciplinary team specifically targeting the tandem and ring brachytherapy procedure. The treatment process was divided into six subprocesses and failure modes (FMs). A scoring guideline was developed based on published FMEA studies and assigned through team consensus. FMs were ranked according to overall and severity scores. FM ranking >5% of the highest risk priority number (RPN) score was selected for in-depth analysis. The efficiency of each existing quality assurance to detect each FM was analyzed. Results We identified 170 FMs, and 99 were scored. RPN scores ranged from 1 to 192. Of the 13 highest-ranking FMs with RPN scores >80, half had severity scores of 8 or 9, with no mode having severity of 10. Of these FM, the originating process steps were simulation (5), treatment planning (5), treatment delivery (2), and insertion (1). Our high-ranking FM focused on communication and the potential for applicator movement. Evaluation of the efficiency and the comprehensiveness of our quality assurance program showed coverage of all but three of the top 49 FMs ranked by RPN. Conclusions This is the first reported FMEA process for a comprehensive gynecologic brachytherapy procedure overview. We were able to identify FMs that could potentially and severely impact the patient's treatment. We continue to adjust our quality assurance program based on the results of our FMEA analysis.

Precise and accurate patient positioning is necessary when doing stereotactic radiosurgery (SRS) to ensure adequate dosing to the tumor and sparing of normal tissues. This prospective cross-sectional study aimed to assess feasibility of a commercially available modified frameless SRS positioning system for use in veterinary radiotherapy patients with brain tumors. Fifty-one dogs and 12 cats were enrolled. Baseline and verification CT images were acquired. The verification CT images from 32 dogs and five cats had sufficient images for fusion to baseline CT images. A rigid box-based fusion was performed to determine interfraction motion. Forty-eight dogs and 11 cats were assessed for intrafraction motion by cine CT. Seventy percent of dogs and 60% of cats had interfraction 3D vector translational shifts >1 mm, with mean values of 1.9 mm in dogs, and 1.8 mm in cats. In dogs muscle wasting was weakly correlated with translational shifts. The maximum angular interfraction motion observed was 6.3° (roll), 3.5° (pitch), and 3.3° (yaw). There was no correlation between angular interfraction motion and weight, brachycephaly, or muscle wasting. Fifty-seven percent of dogs and 50% of cats had respiration-related intrafraction motion. Of these, 4.5% of dogs and 10% of cats had intrafraction motion >1 mm. This study demonstrates the modified Brainlab system is feasible for SRS in dogs and cats. The smaller cranial size and difference in anatomy increases setup uncertainty in some animals beyond limits usually accepted in SRS. Image-guided positioning is recommended to achieve clinically acceptable setup accuracy (

Objective To calculate dose delivered to the lumbosacral plexus (LSP) with cervical brachytherapy using 3-dimensional imaging, and to compare this with the position of the tandem in the pelvis using bony landmarks. We also report long-term LSP toxicity outcomes. Methods and Materials Treatment planning images from 55 patients treated with tandem and ring brachytherapy from October 2009 through November 2012 were reviewed. The LSP was contoured on planning computed tomographic scans to calculate dose received. Lumbosacral plexus dose was studied as a function of tandem distance from the sacrum and pubic symphysis (STratio) measured on digitally reconstructed radiographs. Patient and implant characteristics were included as covariates on LSP dose. Clinical follow up on LSP toxicity was recorded. Results Patients were prescribed 550 to 700 cGy using computed tomography–based imaged-guided brachytherapy for 4 to 5 fractions. The maximum dose to 2 cc (D2cc) of LSP ranged from 44 to 287 cGy per implant. The median D2cc was 118 cGy, corresponding to 18% of prescription dose. Patients with an STratio less than 0.33 (closer to the sacrum) and at least 0.33 had median LSP doses of 138 and 98 cGy, respectively. Lumbosacral plexus dose did not change significantly with body mass index, uterus position, or tumor stage. Two patients reported symptoms of peripheral neuropathy, with a median follow-up of 14.7 months. Conclusions The mean D2cc per fraction to the LSP is roughly 20% of the prescribed high dose-rate and varies with the position of the tandem from the sacrum. The dose threshold for radiation-induced neuropathy of the LSP remains undefined.

Setup variability affects the appropriate delivery of radiation and informs the setup margin required to treat radiation patients. Twenty-four veterinary patients with head and neck cancers were enrolled in this prospective, cross-sectional study to determine the accuracy of an indexed board immobilization device for positioning. Couch position values were defined at the first treatment based on setup films. At subsequent treatments, patients were moved to the previously defined couch location, orthogonal films were acquired, table position was modified, and displacement was recorded. The mean systematic displacement, random displacement, overall displacement, and mean displacement values of the three-dimensional (3D) vector were calculated. Three hundred thirty-two pairs of orthogonal setup films were analyzed for displacement in cranial-caudal, lateral, and dorsal-ventral directions. The mean systematic displacements were 0.5, 0.8, and 0.5 mm, respectively. The mean random displacements were 1.0, 1.1, and 0.7 mm, respectively. The overall displacements were 1.1, 1.4, and 0.9 mm, respectively. The mean 3D vector value was 1.6 mm with a standard deviation of 1.2 mm. Ninety-five percent of the vectors were

Does the presence of a gel network influence the properties of a lyotropic liquid crystal? Does the replacement of oil by a lyotropic liquid crystal influence the properties of an organogel? To answer these questions we study gelled lyotropic liquid crystals (LLC). In the present study we show that it is possible to gel the lamellar phase of the binary system water–didodecyl dimethylammonium bromide (2C12DAB) with the organogelator 12-hydroxyoctadecanoic acid (12-HOA). We compare various properties of the gelled LLC phases with the “parent systems”, i.e., with the binary organogel consisting of n-decane–12-HOA and with the nongelled LC phases, respectively. Optical and electron microscopy, differential scanning calorimetry (DSC), rheometry, as well as small and wide-angle X-ray scattering (SWAXS) proved the coexistence of an Lα phase and a 12-HOA gel network in the gelled Lα phase. However, a small influence of the Lα phase on the gel properties was seen, namely slightly lower sol–gel transition temperatu...

© 2017 American Society for Radiation Oncology Purpose The purpose of this study was to determine if the Sun Nuclear PerFRACTION electronic portal imager device dosimetry software would be able to detect setup errors in a clinical setting and would be able to correctly identify the direction in which the setup error was introduced. Methods and materials A 7-field intensity modulated radiation therapy (IMRT) treatment plan for a centrally located tumor was developed for 1 phantom and 5 canine cadaver heads. Systematic setup errors were introduced by manually moving the treatment couch by 1, 3, and 5 mm in each translational direction to assess stereotactic radiation surgery (SRS), IMRT, and 3-dimensional (3D) treatment tolerances after the initial alignment was performed. An angular setup error of 5° yaw was also assessed. The delivered treatment fluence was automatically imported in the PerFRACTION software and compared with the baseline fluence. Results In the canine phantom, a 5-mm shift was undetected by gamma analysis, and up to a 2-cm shift had to be introduced for the gamma pass rate of 3%/3 mm to fall below a 95% pass rate criterion. The same 5-mm shift using 3% difference caused the pass rates for 2 fields to drop below the 95% tolerance. For each respective translational shift, the affected beam angles were consistent across the cadaver heads and correlated with the direction of translational shift. The best field pass rate, worst field pass rate, and average pass rate across all 7 fields was analyzed to develop clinical guidance on parameter settings for SRS, IMRT, and 3D tolerances. Conclusions PerFRACTION 2-dimensional mode successfully detected setup errors outside the systematic error tolerance for SRS, IMRT, and 3D when an appropriate analysis metric and pass/fail criteria was implemented. Our data confirm that percent difference may be more sensitive in detecting plan failure than gamma analysis.

Purpose: The purpose of this study is to conduct a Failure Modes and Effect Analysis (FMEA) for CyberKnife Stereotactic Radiosurgery to determine the sensitivity of existing QA procedures and determine in which areas new QA procedures needed to be implemented. Methods: Members from each professional team providing service for CyberKnife radiosurgery(Medical Physicists, Nurses, Physicians, Radiation Therapists, and Administrators) were interviewed to gather potential failure modes. A patient flow chart was developed from patient consult to conclusion of last treatment. Failure modes were mapped to nodes in the flow charts to identify potential high‐risk areas. A matrix was created to correlate existing QA procedures with failure modes to identify failure modes that were not covered by any QA as well as identify the sensitivity of QA procedures to prevent failures. Results: 180 failure modes were identified. Current AAPM QA recommendations were found to focus preferentially on technical failure modes (15%), while the majority of failure modes found are process failures and human errors (85%). Creating a Venn diagram of CyberKnife and Gamma Knife failure modes revealed a large overlap area. The most effective QA checks are checklists for physics second chart review and pre‐ treatment time‐out checklists. Existing checklists were modified and new checklists added to address high‐ranked failure modes. New procedure guidelines, e.g. for contouring workflow and add‐on simulations, were developed as QC to address clusters of failure modes. An ARIA‐CyberKnife DICOM interface is being implemented to resolve failure modes centering around multiple fraction, multiple plan treatments and total dose tracking. Conclusions: This work is the first FMEA study for the CyberKnife stereotactic radiosurgery. It will facilitate medical physicists using the CyberKnife to deliver SRS/SBRT treatments to transition from experience‐based technical QA to a comprehensive new quality paradigm including technical, process, and human safety aspects.

Purpose This investigation details the time and teamwork required for CT-guided tandem and ring high-dose-rate brachytherapy. Methods and Materials From 2010 to 2012, 217 consecutive implantations were identified on 52 patients. We gathered key workflow times: preoperative, applicator insertion, CT image, treatment planning, treatment, patient recovery, and total time in clinic. Linear fixed-effects models were used, and key workflow times were the outcome variables and factors including age, body mass index, stage, outside referral, number of implant per patient, number of implants per day, and year of implantation were examined as fixed effects. Results Of the 52 patients, 62% of the patients were Federation Internationale de Gynecologie et d'Obstetrique Stage 2B, 88% were treated with concurrent chemotherapy, and 23% were treated at an outside facility and referred for the procedure. The mean times (minutes) for each step were as follows: preoperative evaluation, 93; insertion, 23; imaging, 45; treatment planning, 137; treatment, removal, and recovery, 115; total clinic time, 401. For the insertion time, the greater implant number per patient was significantly associated with a decreased total insertion time, with and without adjusting for other covariates, p = 0.002 and p = 0.0005, respectively. Treatment planning time was expedited with increasing number of implant per patient and comparing treatment times in 2012 with those in 2010, p = 0.01 and p Conclusions Gynecologic brachytherapy requires a skillfully coordinated and efficient team approach. Identifying critical components and the time required for each step in the process is needed to improve the safety and efficiency of brachytherapy. Continuous efforts should be made to enhance the optimal treatment delivery in high-dose-rate gynecologic brachytherapy.

Im ersten Teil der vorliegenden Masterarbeit wurden vier Flussigkristalle untersucht, die in Tabelle 3.1 aufgefuhrt sind. Die Substanzen TriSi-5PhP-C6, TriSi-5PhP-C5 und DiSi-5PhP-C5 wurden freundlicherweise von Prof. Robert P. Lemieux, Queen´s University, Kingston (Ontario, Kanada) zu Verfugung gestellt. Dabei ist TriSi-5PhP-C6 bereits eingehend mittels Rontgenbeugung analysiert worden [12]. Die neuen Materialien TriSi-5PhP-C5 und DiSi-5PhP-C5 sollen umfassend charakterisiert werden.

Mittels Polarisationsmikroskopie wurde fur die noch nicht charakterisierten Mesogene TriSi-5PhP-C5 und DiSi-5PhP-C5 die Phasensequenz bestimmt. Die Identifikation der flussigkristallinen Phasen erfolgte anhand ihrer charakteristischen Texturen. Die erhaltene Phasenabfolge und Ubergangstemperaturen fur die untersuchten Mesogene sind in Tabelle 4.1 gezeigt.

Der zweite Teil der vorliegenden Masterarbeit befasst sich mit der Untersuchung von drei Flussigkristallen mittels Freeze-Fracture Transmissionselektronenmikroskopie (FFTEM). Die untersuchten Mesogene sind in Tabelle 5.1 aufgelistet. Die Technik der Freeze-Fracture Transmissionselektronenmikroskopie wurde ursprunglich fur biologische Systeme entwickelt [49, 50]. In den 1970er Jahren wurde sie auch in der Flussigkristallforschung etabliert [51, 52, 53].

© 2016 The Authors. Purpose The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. Methods and Materials The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. Results The new curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. Conclusions The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint.

Purpose To investigate the effect of tumor site, measurement precision, tumor–surrogate correlation, training data selection, model design, and interpatient and interfraction variations on the accuracy of external marker-based models of tumor position. Methods and Materials Cyberknife Synchrony system log files comprising synchronously acquired positions of external markers and the tumor from 167 treatment fractions were analyzed. The accuracy of Synchrony, ordinary-least-squares regression, and partial-least-squares regression models for predicting the tumor position from the external markers was evaluated. The quantity and timing of the data used to build the predictive model were varied. The effects of tumor–surrogate correlation and the precision in both the tumor and the external surrogate position measurements were explored by adding noise to the data. Results The tumor position prediction errors increased during the duration of a fraction. Increasing the training data quantities did not always lead to more accurate models. Adding uncorrelated noise to the external marker-based inputs degraded the tumor–surrogate correlation models by 16% for partial-least-squares and 57% for ordinary-least-squares. External marker and tumor position measurement errors led to tumor position prediction changes 0.3–3.6 times the magnitude of the measurement errors, varying widely with model algorithm. The tumor position prediction errors were significantly associated with the patient index but not with the fraction index or tumor site. Partial-least-squares was as accurate as Synchrony and more accurate than ordinary-least-squares. Conclusions The accuracy of surrogate-based inferential models of tumor position was affected by all the investigated factors, except for the tumor site and fraction index.