Evaluation of tracking accuracy of the CyberKnife system using a webcam and printed calibrated grid.

Tracking accuracy for the CyberKnife's Synchrony system is commonly evaluated using a film-based verification method. We have evaluated a verification system that uses a webcam and a printed calibrated grid to verify tracking accuracy over three different motion patterns. A box with an attached printed calibrated grid and four fiducial markers was attached to the motion phantom. A target marker was positioned at the grid's center. The box was set up using the other three markers. Target tracking accuracy was evaluated under three conditions: 1) stationary; 2) sinusoidal motion with different amplitudes of 5, 10, 15, and 20 mm for the same cycle of 4 s and different cycles of 2, 4, 6, and 8 s with the same amplitude of 15 mm; and 3) irregular breathing patterns in six human volunteers breathing normally. Infrared markers were placed on the volunteers' abdomens, and their trajectories were used to simulate the target motion. All tests were performed with one-dimensional motion in craniocaudal direction. The webcam captured the grid's motion and a laser beam was used to simulate the CyberKnife's beam. Tracking error was defined as the difference between the grid's center and the laser beam. With a stationary target, mean tracking error was measured at 0.4 mm. For sinusoidal motion, tracking error was less than 2 mm for any amplitude and breathing cycle. For the volunteers' breathing patterns, the mean tracking error range was 0.78-1.67 mm. Therefore, accurate lesion targeting requires individual quality assurance for each patient.

Optimization of Fluence Map for CyberKnife Raster Scanning Intensity Modulated Radiotherapy.

BACKGROUND/AIM: Stereotactic body radiotherapy for prostate cancer using CyberKnife with circular cone requires a long treatment time. Raster scanning intensity modulated radiotherapy (RS-IMRT) has a potential of improving treatment efficacy, introducing shorter treatment time, better target dose uniformity, and lower organ at risk (OAR) dose. The purpose of the study was to develop a fluence optimization system for RS-IMRT. PATIENTS AND METHODS: RS-IMRT plans were created for five prostate cancer patients treated with the Novalis system and parameters were compared to the Novalis treatment plans. From 80 nodes available for the CyberKnife, twelve nodes were arbitrarily selected. On the beam's eye view of each beam, a 100×100 matrix of optimization points was created at the target center plane. The beam fluence map was optimized using the attraction-repulsion model (ARM). The beam fluence maps were converted to the scanning sequence using the ARM and a final dose calculation was performed. RESULTS: For planning target volume (PTV), RS-IMRT plans showed higher dose covering 2% of the volume (D2%) and lower D98% compared to the Novalis plans. However, the homogeneity was within our Institutional clinical protocol. The RS-IMRT plans showed significantly lower OAR dose parameters including bladder volume receiving 100% of prescribed dose (V100%) and dose delivered to 5 cm3 of rectum (D5 cc). CONCLUSION: We developed a fluence optimization system for RS-IMRT that performs the entire RS-IMRT treatment planning process, including scanning sequence optimization and final dose calculation. The RS-IMRT was capable of generating clinically acceptable plans.

Evaluation of Lung and Liver Tumor Dose Coverage Treated With the CyberKnife Synchrony System With Consideration of Measured Tracking Errors.

BACKGROUND/AIM: Lung and liver tumor dose coverage was evaluated for the CyberKnife synchrony respiratory tracking system (SRTS) with consideration of the motion tracking accuracy measured for motion patterns of individual patients. PATIENTS AND METHODS: Seven treatment plans of six cases treated with the SRTS were evaluated. The motion phantom was moved with the motion data derived from the treatment log files. A laser emitted from the linac head to the moving phantom block was recorded with a webcam, and the tracking accuracy was evaluated. The dose volume histogram (DVH) of planning target volume (PTV) and gross tumor volume (GTV) were calculated by a pencil beam algorithm with shifting the beams with Gaussian random numbers mimicking the measured tracking errors. RESULTS: The tracking errors measured with the motion phantom in the lateral direction were within ±2 mm for 90% of beam-on time. The tracking errors in the longitudinal direction were within ±3.0 mm and ±1.1 mm for 90% and 50% of beam-on time, respectively. Although one case showed a decrease in the dose covering 95% of PTV (D95%) by 1.8%, the change in the dose covering 99% of GTV (D99%) was within 1%. CONCLUSION: This study evaluated the motion tracking errors of the SRTS by a motion phantom moved with the patients' respiration signal, and the impact of the tracking errors on the target coverage was calculated. Even for respiratory patterns with large maximum tracking errors, sufficient GTV coverage is achievable if the beam is accurately delivered for high percentage of beam-on time.

Dosimetric performance of two linear accelerator-based radiosurgery systems to treat single and multiplebrain metastases.

OBJECTIVE: To evaluate and compare the dosimetric plan quality for noncoplanar volumetric arc therapy of single and multiple brain metastases using the linear accelerator-based radiosurgery system HyperArc and a robotic radiosurgery system. METHODS: 31 tumors from 24 patients were treated by stereotactic radiosurgery using the CyberKnife system. CT images, structure sets, and dose files were transferred to the Eclipse treatment planning system for the HyperArc system. Dosimetric parameters for both plans were compared. The beam-on time was calculated from the total monitor unit and dose rate. RESULTS: For normal brain tissue, the received volume doses were significantly lower for HyperArc than for CyberKnife_G4 and strongly correlated with the planning target volume (PTV) for cases of single brain metastasis. In addition, the difference in volume dose between CyberKnife_G4 and HyperArc was proportional to the PTV. For multiple brain metastases, no significant difference was observed between the two stereotactic radiosurgery systems, except for high-dose region in the normal tissue. In low dose for brain minus PTV, when the maximum distance among each target was above 8.0 cm, HyperArc delivered higher dose than CyberKnife_G4. The mean ± SDs for the beam-on time were 15.8 ± 5.3 and 5.6 ± 0.8 min for CyberKnife_G4 and HyperArc, respectively (p < .01). CONCLUSION: HyperArc is best suited for larger targets in single brain metastasis and for smaller inter tumor tumor distances in multiple brain metastases. ADVANCES IN KNOWLEDGE: The performance of HyperArc in comparison with CyberKnife_G4 was depended on defined margin and tumor distances.

Impacts of respiratory phase shifts on motion-tracking accuracy of the CyberKnife Synchrony™ Respiratory Tracking System.

PURPOSE: The SynchronyTM Respiratory Tracking System (SRTS) component of the CyberKnife® Robotic Radiosurgery System (Accuray, Inc., Sunnyvale CA) enables real-time tracking of moving targets by modeling the correlation between the targets and external surrogate light-emitting diode (LED) markers placed on the patient's chest. Previous studies reported some cases with respiratory phase shifts between lung tumor and chest wall motions. In this study, the impacts of respiratory phase shifts on the motion-tracking accuracy of the SRTS were investigated. METHODS: A plastic scintillator was used to detect the position of the x-ray beams. The scintillation light was recorded using a camera in a dark room. A moving phantom moved a U-shaped frame on the scintillator with a 4th power of sinusoidal functions. Three metallic markers for motion tracking and four fluorescent tapes were attached to the frame. The fluorescent tapes were used to identify phantom position and respiratory phase for each video frame. The beam positions collected, when considered relative to the phantom motion, represent the degree of tracking error. Beam position was calculated by adding error value to phantom position. Motions with respiratory phase shifts between the target and an extra stage mimicking chest wall motion were also tested for LED markers. Log files of the SRTS were analyzed to evaluate correlation errors. RESULTS: When target and LED marker motions were synchronized with a respiratory cycle of 4 s, the maximum tracking errors for 90% and 95% of beam-on time were 1.0 mm and 1.2 mm, respectively. The frequency of tracking errors increased when LED marker motion phase preceded target motion. Tracking errors that corresponded to 90% beam-on time were within 2.4 mm for 5-15% of phase shifts. In contrast, the tracking errors were very large when the LED marker delayed to the target motions; the maximum errors of 90% beam-on time were 3.0, 3.8, and 7.5 mm for 5%, 10%, and 15% of phase shifts, respectively. The patterns of the tracking errors derived from the scintillation light were very similar to those of the correlation data of the SRTS derived from the log files, indicating that the tracking errors caused mainly due to the errors in modeling the correlation data. With long respiratory cycle of 6 s, the tracking errors were significantly decreased; the maximum tracking errors for 95% beam-on time were 1.6 mm and 2.2 mm for early and delayed LED motion. CONCLUSION: We have investigated the motion-tracking accuracy of the CyberKnife SRTS for cases with the respiratory phase shift between the target and the LED marker. The maximum tracking errors for 90% probability were within 2.4 mm when the target delays to the LED markers. When LED marker delays, however, very large tracking errors were observed. With a long respiratory cycle, the tracking errors were greatly improved to less than 2.2 mm. Coaching slow breathing will be useful for accurate motion tracking radiotherapy.

Evaluation of the accuracy of the CyberKnife Synchrony™ Respiratory Tracking System using a plastic scintillator.

PURPOSE: The Synchrony™ Respiratory Tracking System of the CyberKnife® Robotic Radiosurgery System (Accuray, Inc., Sunnyvale, CA, USA) enables real-time tracking of moving targets such as lung and liver tumors during radiotherapy. Although film measurements have been used for quality assurance of the tracking system, they cannot evaluate the temporal tracking accuracy. We have developed a verification system using a plastic scintillator that can evaluate the temporal accuracy of the CyberKnife Synchrony. METHODS: A phantom consisting of a U-shaped plastic frame with three fiducial markers was used. The phantom was moved on a plastic scintillator plate. To identify the phantom position on the recording video in darkness, four pieces of fluorescent tape representing the corners of a 10 cm × 10 cm square around an 8 cm × 8 cm window were attached to the phantom. For a stable respiration model, the phantom was moved with the fourth power of a sinusoidal wave with breathing cycles of 4, 3, and 2 s and an amplitude of 1 cm. To simulate irregular breathing, the respiratory cycle was varied with Gaussian random numbers. A virtual target was generated at the center of the fluorescent markers using the MultiPlan™ treatment planning system. Photon beams were irradiated using a fiducial tracking technique. In a dark room, the fluorescent light of the markers and the scintillation light of the beam position were recorded using a camera. For each video frame, a homography matrix was calculated from the four fluorescent marker positions, and the beam position derived from the scintillation light was corrected. To correct the displacement of the beam position due to oblique irradiation angles and other systematic measurement errors, offset values were derived from measurements with the phantom held stationary. RESULTS: The average SDs of beam position measured without phantom motion were 0.16 and 0.20 mm for lateral and longitudinal directions, respectively. For the stable respiration model, the tracking errors (mean ± SD) were 0.40 ± 0.64 mm, -0.07 ± 0.79 mm, and 0.45 ± 1.14 mm for breathing cycles of 4, 3, and 2 s, respectively. The tracking errors showed significant linear correlation with the phantom velocity. The correlation coefficients were 0.897, 0.913, and 0.957 for breathing cycles of 4, 3, and 2 s, respectively. The unstable respiration model also showed linear correlation between tracking errors and phantom velocity. The probability of tracking error incidents increased with decreasing length of the respiratory cycles. Although the tracking error incidents increased with larger variations in respiratory cycle, the effect on the cumulative probability was insignificant. For a respiratory cycle of 4 s, the maximum tracking error was 1.10 and 1.43 mm at the probability of 10% and 5%, respectively. Large tracking errors were observed when there was phase shift between the tumor and the LED marker. CONCLUSION: This technique allows evaluation of the motion tracking accuracy of the Synchrony™ system over time by measurement of the photon beam. The velocity of the target and phase shift have significant effects on accuracy.