SRS Brain Setup Correction Strategies
SRS Brain Setup Correction Strategies
SRS Brain Setup Correction Strategies
CONCLUSIONS:
SRS was well tolerated, with low rates of LR and RN in both
cohorts. However, given the higher potential risk of RN with a
3-mm margin, a 1-mm GTV expansion is more appropriate.
a) Brain
b) Skull
c) Lesion
Brain SRT: How to manage the interfraction uncertainties?
Which structure for image match?
AIM: To evaluate whether the
position of brain metastases remains
stable between planning and
treatment in cranial stereotactic
IJROBP 2007 radiotherapy (SRT).
Treatment of intracranial pressure with steroids did not influence the position of the lesion relatively
to the bony anatomy
Guckenberger M, et al. IJROBP 2007
Brain SRT: How to manage the interfraction uncertainties?
Which image guidance?
100 patients
Patients were initially positioned with a thermoplastic mask system and then aligned with
• orthogonal planar imaging
• 3D CBCT in 4-DOF
• 3D CBCT in 6-DOF.
For each met, the proportion of the gross tumor volume that remained within the 100% prescription
isodose line was estimated under the influence of combinations of translations and rotations (0.0–3.0
mm and 0.0◦–3.0◦, respectively).
Brain SRT: How to manage the interfraction uncertainties?
Which image guidance strategy?
AlignRT
Main results
• The accuracy of the OSI in 1D motion detection was found to be 0.1 mm with uncertainty of ±0.1 mm using the head
phantom.
• The OSI registration against simulation computed tomography (CT) external contour was found to be dependent on the
CT skin definition with ∼0.4 mm variation
• For frame‐based SRS patients, head‐motion magnitude was detected to be <1.0 mm and <1.0° for 98% of treatment time
• For frameless SRT/SRS patients, similar motion magnitudes were observed (<1.1 mm and 1.0° for 98% of treatment time)
→Head‐motion monitoring using near‐real‐time surface imaging provides adequate accuracy and is necessary for
frameless SRS in case of unexpected head motion that exceeds a set tolerance
Brain SRT: How to manage the intrafraction uncertainties?
AlignRT
AIM: To evaluate the initial clinical experience
with a frameless and maskless technique for
stereotactic radiosurgery using minimal patient
immobilization and real-time patient motion
monitoring during treatment
PRO 2012
AlignRT was used for
• Initial setup using the surface of the patient obtained from the planning CT scan.
• Initial setup was confirmed and finalized with cone-beam CT (CBCT) prior to treatment
• Patients were monitored during treatment with surface imaging, and a beam hold-off was initiated when the patient's
motion exceeded a prespecified tolerance (1-2 mm).
Main results
• Average total setup time: 26 minutes (14 minutes for surface imaging)
• Average treatment time: 40 minutes.
• 35% patients needed repositioning during the treatment.
• The average shifts identified from CBCT after initial setup with surface imaging were 1.85 mm in the anterior-posterior
direction, and less than 1.0 mm in the lateral and superior-inferior directions.
• The longest treatment times happened for patients who fell asleep on the treatment table and were moving involuntarily.
Brain SRT: How to manage the intrafraction uncertainties?
AlignRT
Retrospective study
Transl Cancer Res 2014
Surface Image Guided RS: median delivery of 1 fraction (range, 1-5 fraction) and to a median dose of 22 Gy (range, 12-30 Gy).
Main results
Median follow-up: 6.7 months (range, 0.5-45.1 months
• Actuarial 6- and 12-month local control: 90% and 79%
• Actuarial 6- and 12-month overall survival: 80% and 56%
→Outcomes comparable to those with conventional frame-based and frameless SRS techniques
→Greater patient comfort with an open-faced mask and fast treatment time
Brain SRT: take home messages
Treatment Delivery & Setup Correction Strategies
• Image guidance for brain SRT should aim at a repositioning accuracy of less than 1
mm
• The 3D–3D co-registration of the plan CT and daily CT scans with image match on
the skull is an adequate surrogate of the target position
• 6DOF set up correction is critical (particularly for targets with irregular shape that
are close to OARs, and for multiple targets that are treated with a single isocenter)