Dosimetric accuracy of a staged radiosurgery treatment

Evaluation of Clinical Application and Dosimetric Comparison of Treatment Plans of Gamma Knife and CyberKnife in Treating Arteriovenous Malformations

PURPOSE

To analyze and compare the characteristics of dose distributions for Leksell Gamma Knife Perfexion (LGK-PFX) and CyberKnife (CK) in treating arteriovenous malformations (AVMs).

SUBJECTS AND METHODS

Twenty-four patients with AVMs who received CK radiosurgery at a prescribed dose (PD) of 16-25 Gy in a single fraction were selected. A LGK-PFX treatment plan with the same PD was designed for each patient. Dosimetric values for both systems were compared with respect to the conformity index (CI); selectivity index (SI); gradient index (GI) of 75, 50, and 25% of the PD; heterogeneity index; volume of the brain tissue covered by doses of 10 and 12 Gy; maximum dose delivered to the brainstem; and beam-on time.

RESULTS

The CIs of LGK-PFX and CK were 0.744 ± 0.075 and 0.759 ± 0.071 (p = 0.385), respectively. The SIs of LGK-PFX and CK were 0.764 ± 0.081 and 0.780 ± 0.076 (p = 0.424), respectively. The GI75%, GI50%, and GI25% values of LGK-PFX and CK were 1.028 ± 0.123 and 2.439 ± 0.338 (p < 0.001), 3.169 ± 0.265 and 4.972 ± 0.852 (p < 0.001), and 8.650 ± 0.914 and 14.261 ± 2.476 (p < 0.001), respectively. Volumes of the brain tissue covered by 10 Gy and 12 Gy for LGK-PFX and CK (p < 0.001) exhibited a significant difference.

CONCLUSIONS

LGK-PFX and CK exhibited similar dose conformity. LGK-PFX showed superior normal tissue sparing.

Reproducibility and geometric accuracy of the Fixster system during hypofractionated stereotactic radiotherapy

Background

Hypofractionated radiotherapy has been used for the treatment of AVMs and brain metastases. Hypofractionation necessitates the use of a relocatable stereotactic frame that has to be applied on several occasions. The stereotactic frame needs to have a high degree of reproducibility, and patient positioning is crucial to achieve a high accuracy of the treatment.

Methods

In this study we have, by radiological means, evaluated the reproducibility of the isocenter in consecutive treatment sessions using the Fixster frame. Deviations in the X, Y and Z-axis were measured in 10 patients treated with hypofractionated radiotherapy.

Results

The mean deviation in the X-axis was 0.4 mm (range -2.1 – 2.1, median 0.7 mm) and in the Y-axis -0.3 mm (range -1.4 – 0.7, median -0.2 mm). The mean deviation in the Z-axis was -0.6 (range -1.4 – 1.4, median 0.0 mm).

Conclusion

There is a high degree of reproducibility of the isocenter during successive treatment sessions with HCSRT using the Fixster frame for stereotactic targeting. The high reducibility enables a safe treatment using hypofractionated stereotactic radiotherapy.

Geometric interpretation of the gamma dose distribution comparison technique: interpolation-free calculation

The gamma dose comparison tool has been used by numerous investigators to quantitatively compare multidimensional dose distributions. The gamma tool requires the specification of dose and distance-to-agreement (DTA) criteria for acceptable variations between the dose distributions. The tool then provides a comparison that simultaneously evaluates the dose difference and distance to agreement of the two dose distributions. One of the weaknesses of the tool is that the comparison requires one of the dose distributions to have a relatively high spatial resolution, with points spaced significantly closer than the DTA criterion. The determination of gamma involves an exhaustive search process, so the computation time is significant if an accurate gamma is desired. The reason for the need for high spatial resolution lies with the fact that the gamma tool measures the closest point in one of the dose distributions (the evaluated distribution) with individual points of the other distribution (the reference distribution) when the two distributions are normalized by the dose difference and DTA criteria for the dose and spatial coordinates, respectively. The closest point in the evaluated distribution to a selected reference distribution point is the value of gamma at that reference point. If individual evaluated dose distribution points are compared, the closest point may not accurately reflect the closest value of the evaluated distribution as if it were interpolated on an infinite resolution grid. Therefore, a reinterpretation of the gamma distribution as the closest geometric distance between the two distributions is proposed. This is conducted by subdividing the evaluated distribution into simplexes; line segments, triangles, and tetrahedra for one, two, and three-dimensional (3D) dose distributions. The closest distance between any point and these simplexes can be straightforwardly computed using matrix multiplication and inversion without the need of interpolating the original evaluated distribution. While an exhaustive search is still required, not having to interpolate the evaluated distribution avoids the drastic growth of calculation time incurred by interpolation and makes the gamma tool more practical and more accurate. In our experiment, the geometric method accurately computes gamma distributions between 3D dose distributions on a 200 x 200 x 50 grid within two minutes.

Anatomic Landmarks Versus Fiducials for Volume-Staged Gamma Knife Radiosurgery for Large Arteriovenous Malformations

PURPOSE

The purpose of this investigation was to compare the accuracy of using internal anatomic landmarks instead of surgically implanted fiducials in the image registration process for volume-staged gamma knife (GK) radiosurgery for large arteriovenous malformations.

METHODS AND MATERIALS

We studied 9 patients who had undergone 10 staged GK sessions for large arteriovenous malformations. Each patient had fiducials surgically implanted in the outer table of the skull at the first GK treatment. These markers were imaged on orthogonal radiographs, which were scanned into the GK planning system. For the same patients, 8-10 pairs of internal landmarks were retrospectively identified on the three-dimensional time-of-flight magnetic resonance imaging studies that had been obtained for treatment. The coordinate transformation between the stereotactic frame space for subsequent treatment sessions was then determined by point matching, using four surgically embedded fiducials and then using four pairs of internal anatomic landmarks. In both cases, the transformation was ascertained by minimizing the chi-square difference between the actual and the transformed coordinates. Both transformations were then evaluated using the remaining four to six pairs of internal landmarks as the test points.

RESULTS

Averaged over all treatment sessions, the root mean square discrepancy between the coordinates of the transformed and actual test points was 1.2 +/- 0.2 mm using internal landmarks and 1.7 +/- 0.4 mm using the surgically implanted fiducials.

CONCLUSION

The results of this study have shown that using internal landmarks to determine the coordinate transformation between subsequent magnetic resonance imaging scans for volume-staged GK arteriovenous malformation treatment sessions is as accurate as using surgically implanted fiducials and avoids an invasive procedure.

Assessment of imaging studies used with radiosurgery: a volumetric algorithm and an estimation of its error

✓ The Gamma Knife has played an increasingly important role in the neurosurgical treatment of patients. Intracranial lesions are not removed by radiosurgery. Rather, the goal of treatment is to induce tumor control. During planning, the creation of dose–volume histograms requires an accurate volumetric analysis of intracranial lesions selected for radiosurgery. In addition, an accurate follow-up imaging analysis of tumor volume is essential for assessing the results of radiosurgery. Nevertheless, sources of volumetric error and their expected magnitudes must be properly understood so that the operator may correctly interpret apparent changes in tumor volume. In this paper, the authors examine the often-neglected contributions of imaging geometry (principally image slice thickness and separation) to overall volumetric error.

One of the fundamental sources of volumetric error is that resulting from the geometry of the acquisition protocol. The authors consider the image sampling geometry of tomographic modalities and its contribution to volumetric error through a simulation framework in which a synthetic digital tumor is taken as the primary model. Because the exact volume of the digital phantom can be computed, the volume estimates derived from tomographic “slicing” can be directly compared precisely and independently from other error sources. In addition to providing empirical bounds on volumetric error, this approach provides a tool for guiding the specification of imaging protocols when a specific volumetric accuracy, or volume change sensitivity, for particular structures is sought a priori.

Using computational geometry techniques, the volumetric error associated with image acquisition geometry was shown to be dependent on the number of slices through the region of interest (ROI) and the lesion volume. With a minimum of five slices through the ROI, the volume of a compact lesion could be calculated accurately with less than 10% error, which was the predetermined goal for the purposes of computing accurate dose–volume histograms and determining follow-up changes in tumor volume.

Accurate dose–volume histograms can be generated and follow-up volumetric assessments performed, assuming accurate lesion delineation, when the object is visualized on at least five axial slices. Volumetric analysis based on fewer than five slices yields unacceptably larger errors (that is, > 10%). These volumetric findings are particularly relevant for radiosurgical treatment planning and follow-up analysis. Through the application of this volumetric methodology and a greater understanding of the error associated with it, neurosurgeons can better perform radiosurgery and assess its outcome.