A simulation study of ionizing radiation acoustic imaging (iRAI) as a real-time dosimetric technique for ultra-high dose rate radiotherapy (UHDR-RT).

PURPOSE: Electron-based ultra-high dose rate radiation therapy (UHDR-RT), also known as Flash-RT, has shown the ability to improve the therapeutic index in comparison to conventional radiotherapy (CONV-RT) through increased sparing of normal tissue. However, the extremely high dose rates in UHDR-RT have raised the need for accurate real-time dosimetry tools. This work aims to demonstrate the potential of the emerging technology of Ionized Radiation Acoustic Imaging (iRAI) through simulation studies and investigate its characteristics as a promising relative in vivo dosimetric tool for UHDR-RT. METHODS: The detection of induced acoustic waves following a single UHDR pulse of a modified 6 MeV 21EX Varian Clinac in a uniform porcine gelatin phantom that is brain-tissue equivalent was simulated for an ideal ultrasound transducer. The full 3D dose distributions in the phantom for a 1 × 1 cm2 field were simulated using EGSnrc (BEAMnrc∖DOSXYZnrc) Monte Carlo (MC) codes. The relative dosimetry simulations were verified with dose experimental measurements using Gafchromic films. The spatial dose distribution was converted into an initial pressure source spatial distribution using the medium-dependent dose-pressure relation. The MATLAB-based toolbox k-Wave was then used to model the propagation of acoustic waves through the phantom and perform time-reversal (TR)-based imaging reconstruction. The effect of the various linear accelerator (linac) operating parameters, including linac pulse duration and pulse repetition rate (frequency), were investigated as well. RESULTS: The MC dose simulation results agreed with the film measurement results, specifically at the central beam region up to 80% dose within approximately 5% relative error for the central profile region and a local relative error of <6% for percentage dose depth. IRAI-based FWHM of the radiation beam was within approximately 3 mm relative to the MC-simulated beam FWHM at the beam entrance. The real-time pressure signal change agreed with the dose changes proving the capability of the iRAI for predicting the beam position. IRAI was tested through 3D simulations of its response to be based on the temporal changes in the linac operating parameters on a dose per pulse basis as expected theoretically from the pressure-dose proportionality. The pressure signal amplitude obtained through 2D simulations was proportional to the dose per pulse. The instantaneous pressure signal amplitude decreases as the linac pulse duration increases, as predicted from the pressure wave generation equations, such that the shorter the linac pulse the higher the signal and the better the temporal (spatial) resolutions of iRAI. The effect of the longer linac pulse duration on the spatial resolution of the 3D constructed iRAI images was corrected for linac pulse deconvolution. This correction has improved the passing rate of the 1%/1 mm gamma test criteria, between the pressure-constructed and dosimetric beam characteristics, to as high as 98%. CONCLUSIONS: A full simulation workflow was developed for testing the effectiveness of iRAI as a promising relative dosimetry tool for UHDR-RT radiation therapy. IRAI has shown the advantage of 3D dose mapping through the dose signal linearity and, hence, has the potential to be a useful dosimeter at depth dose measurement and beam localization and, hence, potentially for in vivo dosimetry in UHDR-RT.

Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Evaluation of Obliteration and Review of Associated Predictors.

BACKGROUND: High arteriovenous malformation (AVM) obliteration rates have been reported with stereotactic radiosurgery (SRS), and multiple factors have been found to be associated with AVM obliteration. These predictors have been inconsistent throughout studies. We aimed to analyze our experience with linear accelerator (LINAC)-based SRS for brain AVMs, evaluate outcomes, assess factors associated with AVM obliteration and review the various reported predictors of AVM obliteration. METHODS: Electronic medical records were retrospectively reviewed to identify consecutive patients with brain AVMs treated with SRS over a 27-year period with at least 2 years of follow-up. Logistic regression analysis was performed to identify factors associated with AVM obliteration. RESULTS: One hundred twenty-eight patients with 142 brain AVMs treated with SRS were included. Mean age was 34.4 years. Fifty-two percent of AVMs were associated with a hemorrhage before SRS, and 14.8% were previously embolized. Mean clinical and angiographic follow-up times were 67.8 months and 58.6 months, respectively. The median Spetzler-Martin grade was 3. Mean maximal AVM diameter was 2.8 cm and mean AVM target volume was 7.4 cm3 with a median radiation dose of 16 Gy. Complete AVM obliteration was achieved in 80.3%. Radiation-related signs and symptoms were encountered in 32.4%, only 4.9% of which consisted of a permanent deficit. Post-SRS AVM-related hemorrhage occurred in 6.3% of cases. In multivariate analysis, factors associated with AVM obliteration included younger patient age (P = .019), male gender (P = .008), smaller AVM diameter (P = .04), smaller AVM target volume (P = .009), smaller isodose surface volume (P = .005), a higher delivered radiation dose (P = .013), and having only one major draining vein (P = .04). CONCLUSIONS: AVM obliteration with LINAC-based radiosurgery was safe and effective and achieved complete AVM obliteration in about 80% of cases. The most prominent predictors of AVM success included AVM size, AVM volume, radiation dose, number of draining veins and patient age.

Monitor unit calculations for external photon and electron beams: Report of the AAPM Therapy Physics Committee Task Group No. 71.

A protocol is presented for the calculation of monitor units (MU) for photon and electron beams, delivered with and without beam modifiers, for constant source-surface distance (SSD) and source-axis distance (SAD) setups. This protocol was written by Task Group 71 of the Therapy Physics Committee of the American Association of Physicists in Medicine (AAPM) and has been formally approved by the AAPM for clinical use. The protocol defines the nomenclature for the dosimetric quantities used in these calculations, along with instructions for their determination and measurement. Calculations are made using the dose per MU under normalization conditions, D'0, that is determined for each user's photon and electron beams. For electron beams, the depth of normalization is taken to be the depth of maximum dose along the central axis for the same field incident on a water phantom at the same SSD, where D'0 = 1 cGy/MU. For photon beams, this task group recommends that a normalization depth of 10 cm be selected, where an energy-dependent D'0 ≤ 1 cGy/MU is required. This recommendation differs from the more common approach of a normalization depth of dm, with D'0 = 1 cGy/MU, although both systems are acceptable within the current protocol. For photon beams, the formalism includes the use of blocked fields, physical or dynamic wedges, and (static) multileaf collimation. No formalism is provided for intensity modulated radiation therapy calculations, although some general considerations and a review of current calculation techniques are included. For electron beams, the formalism provides for calculations at the standard and extended SSDs using either an effective SSD or an air-gap correction factor. Example tables and problems are included to illustrate the basic concepts within the presented formalism.

A measurement technique to determine the calibration accuracy of an electromagnetic tracking system to radiation isocenter.

PURPOSE: To present and characterize a measurement technique to quantify the calibration accuracy of an electromagnetic tracking system to radiation isocenter. METHODS: This technique was developed as a quality assurance method for electromagnetic tracking systems used in a multi-institutional clinical hypofractionated prostate study. In this technique, the electromagnetic tracking system is calibrated to isocenter with the manufacturers recommended technique, using laser-based alignment. A test patient is created with a transponder at isocenter whose position is measured electromagnetically. Four portal images of the transponder are taken with collimator rotations of 45° 135°, 225°, and 315°, at each of four gantry angles (0°, 90°, 180°, 270°) using a 3×6 cm2 radiation field. In each image, the center of the copper-wrapped iron core of the transponder is determined. All measurements are made relative to this transponder position to remove gantry and imager sag effects. For each of the 16 images, the 50% collimation edges are identified and used to find a ray representing the rotational axis of each collimation edge. The 16 collimator rotation rays from four gantry angles pass through and bound the radiation isocenter volume. The center of the bounded region, relative to the transponder, is calculated and then transformed to tracking system coordinates using the transponder position, allowing the tracking system's calibration offset from radiation isocenter to be found. All image analysis and calculations are automated with inhouse software for user-independent accuracy. Three different tracking systems at two different sites were evaluated for this study. RESULTS: The magnitude of the calibration offset was always less than the manufacturer's stated accuracy of 0.2 cm using their standard clinical calibration procedure, and ranged from 0.014 to 0.175 cm. On three systems in clinical use, the magnitude of the offset was found to be 0.053±0.036, 0.121±0.023, and 0.093±0.013 cm. CONCLUSIONS: The method presented here provides an independent technique to verify the calibration of an electromagnetic tracking system to radiation isocenter. The calibration accuracy of the system was better than the 0.2 cm accuracy stated by the manufacturer. However, it should not be assumed to be zero, especially for stereotactic radiation therapy treatments where planning target volume margins are very small.

Analysis of couch position tolerance limits to detect mistakes in patient setup.

This work investigates the use of the tolerance limits on the treatment couch position to detect mistakes in patient positioning and warn users of possible treatment errors. Computer controlled radiotherapy systems use the position of the treatment couch as a surrogate for patient position and a tolerance limit is applied against a planned position. When the couch is out of tolerance a warning is sent to a user to indicate a possible mistake in setup. A tight tolerance may catch all positioning mistakes while as the same time sending too many warnings; while a loose tolerance will not catch all mistakes. We develop a statistical model of the absolute position for the three translational axes of the couch. The couch position for any fraction is considered a random variable x(i). The ideal planned couch position x(p) is unknown before a patient starts treatment and must be estimated from the daily positions x(i). As such x(p) is also a random variable. The tolerance, tol, is applied to the difference between the daily and planned position, d(i) = x(i) - x(p). The di is a linear combination of random variables and therefore the density of di is the convolution of distributions of xi and xp. Tolerance limits are based on the standard deviation of d(i) such that couch positions that are more than 2 standard deviation away are considered out of tolerance. Using this framework we investigate two methods of setting x(p) and tolerance limits. The first, called first day acquire (FDA), is to take couch position on the first day as the planned position. The second is to use the cumulative average (CumA) over previous fractions as the planned position. The standard deviation of d(i) shrinks as more samples are used to determine x(p) and so the tolerance limit shrinks as a function of fraction number when a CumA technique is used. The metrics of sensitivity and specificity were used to characterize the performance of the two methods to correctly identify a couch position as in or out of tolerance. These two methods were tested using simulated and real patient data. Five clinical sites with different indexed immobilization were tested. These were whole brain, head and neck, breast, thorax and prostate. Analysis of the head and neck data shows that it is reasonable to model the daily couch position as a random variable in this treatment site. Using an average couch position for x(p) increased the sensitivity of the couch interlock and reduced the chances of acquiring a couch position that was a statistical outlier. Analysis of variation in couch position for different sites allowed the tolerance limit to be set specifically for a site and immobilization device. The CumA technique was able to increase the sensitivity of detecting out of tolerance positions while shrinking tolerance limits for a treatment course. Making better use of the software interlock on the couch positions could have a positive impact on patient safety and reduce mistakes in treatment delivery.

Effect of daily localization and correction on the setup uncertainty: dependences on the measurement uncertainty, re-positioning uncertainty and action level.

With the advent of commercial image-guided radiotherapy, daily correction of the setup uncertainty is feasible. It is beneficial to understand the dependence of the probability density function (pdf) of the corrected setup variation on the action level, localization uncertainty and re-positioning uncertainty so that an appropriate action level is used. Also, that pdf can be used in treatment planning to incorporate setup variation directly in the planning process to generate treatment plans more robust to setup variations. We have found an analytical expression of the pdf of the corrected setup variation assuming normal distributions for the uncertainties. Using the second moment of that pdf as a metric, we have explored the dependence of the metric on the action level for the following cases: (1) the uncertainties in measurement and re-positioning are less than the initial setup uncertainty, (2) the uncertainties in measurement and re-positioning are on the order of the initial setup uncertainty, (3) the uncertainty in measurement is the least and (4) the uncertainty in re-positioning is the least. An optimal action level exists in case 3. We have also found that an action level of [Formula: see text] works well in practice where micro(p) is the mean of the re-positioning uncertainty, sigma(p) is the standard deviation of the re-positioning uncertainty and sigma(m) is the standard deviation of the localization uncertainty. In typical clinical situations, the distribution of the corrected setup variation can be closely approximated by a normal distribution.

A precision translation stage for reproducing measured target volume motions.

The development of 4D imaging, treatment planning and treatment delivery methods for radiation therapy require the use of a high-precision translation stage for testing and validation. These technologies may require spatial resolutions of 1 mm, and temporal resolutions of 2-30 Hz for CT imaging, electromagnetic tracking, and fluoroscopic imaging. A 1D programmable translation stage capable of reproducing idealized and measured anatomic motions common to the thorax has been design and built to meet these spatial and temporal resolution requirement with phantoms weighing up to 27 kg. The stage consists of a polycarbonate base and table, driven by an AC servo motor with encoder feedback by means of a belt-coupled precision screw. Complex motions are possible through a programmable motion controller that is capable of running multiple independent control and monitoring programs concurrently. Programmable input and output ports allow motion to be synchronized with beam delivery and other imaging and treatment delivery devices to within 2.0 ms. Average deviations from the programmed positions are typically 0.2 mm or less, while the average typical maximum positional errors are typically 0.5 mm for an indefinite number of idealized breathing motion cycles and while reproducing measured target volume motions for several minutes.

TG-69: radiographic film for megavoltage beam dosimetry.

TG-69 is a task group report of the AAPM on the use of radiographic film for dosimetry. Radiographic films have been used for radiation dosimetry since the discovery of x-rays and have become an integral part of dose verification for both routine quality assurance and for complex treatments such as soft wedges (dynamic and virtual), intensity modulated radiation therapy (IMRT), image guided radiation therapy (IGRT), and small field dosimetry like stereotactic radiosurgery. Film is convenient to use, spatially accurate, and provides a permanent record of the integrated two dimensional dose distributions. However, there are several challenges to obtaining high quality dosimetric results with film, namely, the dependence of optical density on photon energy, field size, depth, film batch sensitivity differences, film orientation, processing conditions, and scanner performance. Prior to the clinical implementation of a film dosimetry program, the film, processor, and scanner need to be tested to characterize them with respect to these variables. Also, the physicist must understand the basic characteristics of all components of film dosimetry systems. The primary mission of this task group report is to provide guidelines for film selection, irradiation, processing, scanning, and interpretation to allow the physicist to accurately and precisely measure dose with film. Additionally, we present the basic principles and characteristics of film, processors, and scanners. Procedural recommendations are made for each of the steps required for film dosimetry and guidance is given regarding expected levels of accuracy. Finally, some clinical applications of film dosimetry are discussed.

Ideal spatial radiotherapy dose distributions subject to positional uncertainties.

In radiotherapy a common method used to compensate for patient setup error and organ motion is to enlarge the clinical target volume (CTV) by a 'margin' to produce a 'planning target volume' (PTV). Using weighted power loss functions as a measure of performance for a treatment plan, a simple method can be developed to calculate the ideal spatial dose distribution (one that minimizes expected loss) when there is uncertainty. The spatial dose distribution is assumed to be invariant to the displacement of the internal structures and the whole patient. The results provide qualitative insights into the suitability of using a margin at all, and (if one is to be used) how to select a 'good' margin size. The common practice of raising the power parameters in the treatment loss function, in order to enforce target dose requirements, is shown to be potentially counter-productive. These results offer insights into desirable dose distributions and could be used, in conjunction with well-established inverse radiotherapy planning techniques, to produce dose distributions that are robust against uncertainties.

Retrospective analysis of prostate cancer patients with implanted gold markers using off-line and adaptive therapy protocols.

PURPOSE: To determine the efficacy of applying adaptive and off-line setup correction models to bony anatomy and gold fiducial markers implanted in the prostate, relative to daily alignment to skin tattoos and daily on-line corrections of the implanted gold markers. METHODS AND MATERIALS: Ten prostate cancer patients with implanted gold fiducial markers were treated using a daily on-line setup correction protocol. The patients' positions were aligned to skin tattoos and two orthogonal diagnostic digital radiographs were obtained before treatment each day. These radiographs were compared with digitally reconstructed radiographs to obtain the translational setup errors of the bony anatomy and gold markers. The adaptive, no-action-level and shrinking-action-level off-line protocols were retrospectively applied to the bony anatomy to determine the change in the setup errors of the gold markers. The protocols were also applied to the gold markers directly to determine the residual setup errors. RESULTS: The percentage of remaining fractions that the gold markers fell within the adaptive margins constructed with 1.5sigma' (estimated random variation) after 5, 10, and 15 measurement fractions was 74%, 88%, and 93% for the prone patients and 55%, 77%, and 93% for the supine patients, respectively. Using 2sigma', the percentage after 5, 10, and 15 measurements was 85%, 95%, and 97% for the prone patients and 68%, 87%, and 99% for the supine patients, respectively. The average initial three-dimensional (3D) setup error of the gold markers was 0.92 cm for the prone patients and 0.70 cm for the supine patients. Application of the no-action-level protocol to bony anatomy with N(m) = 3 days resulted in significant benefit to 4 of 10 patients, but 3 were significantly worse. The residual average 3D setup error of the gold markers was 1.14 cm and 0.51 cm for the prone and supine patients, respectively. When applied directly to the gold markers with N(m) = 3 days, 5 patients benefited and 3 were significantly worse. The residual 3D error of the gold markers was 1.14 cm and 0.76 cm for the prone and supine patients, respectively. Application of the shrinking-action-level protocol to bony anatomy with an initial action level of 1.0 cm and N(max) = 5 days decreased the residual systematic offset of the gold markers in 2 of 10 patients. The residual average 3D setup error of the gold markers was 1.2 cm and 1.0 cm for the prone and supine patients, respectively. When applied directly to the gold markers with N(max) = 5 days, the residual systematic offset of the gold markers decreased in 6 of 10 patients (0.84 cm and 0.67 cm for the prone and supine patients, respectively). In general, between 3 and 5 of the 10 patients showed significant decreases in setup errors with the application of these off-line protocols, and the remaining patients showed no significant improvement or showed significantly larger setup errors, as determined by the residual error of the gold markers. CONCLUSION: Changes in a prostate cancer patient's systematic and random setup characteristics during the course of therapy often violate the gaussian assumptions of adaptive and off-line correction models. Thus, off-line setup correction procedures, especially those directed at prostate localization using markers, will result in limited benefit to a minority of patients. The relative benefit of on-line localization is still potentially significant if the intrafraction motion is relatively small.

Evaluating the influence of setup uncertainties on treatment planning for focal liver tumors.

PURPOSE: A mechanism has been developed to evaluate the influence of random setup variations on dose during treatment planning. The information available for studying these factors shifts from population-based models toward patient-specific data as treatment progresses and setup measurements for an individual patient become available. This study evaluates the influence of population as well as patient-specific setup distributions on treatment plans for focal liver tumors. METHODS AND MATERIALS: Eight patients with focal liver tumors were treated on a protocol that involved online setup measurement and adjustment, as well as ventilatory immobilization. Summary statistics from these three-dimensional conformal treatments yielded individual and population distributions of position at initial setup for each fraction. A convolution model for evaluation of the influence of random setup variation on calculated dose distributions has been previously described and investigated for application to focal liver radiotherapy by our department. Individual patient doses based on initial setup positions were calculated by convolving the calculated dose distribution with an anisotropic probability distribution function representing the individual patient's random variations. A separate convolution using population-averaged random variations was performed. Individual beam apertures were then adjusted to provide plans that ensured proper dose to the clinical target volume following convolution with population distributions, as well as individual patient position uncertainty models. RESULTS: Individual patient setup distributions for the course of treatment had random setup variations (sigma) that ranged from 2.5 to 5.7 mm (left-right), 2.1 to 8.3 mm (anterior-posterior), and 4.1 to 10.8 mm (cranial-caudal). The population random components were 4.2 mm (left-right), 4.1 mm (anterior-posterior), and 7.0 mm (cranial-caudal) at initial setup. The initial static planned dose distribution overestimated the volume of liver irradiated to high doses, because inclusion of setup uncertainties generally blurred the resulting doses, shifting the higher-dose region of normal liver dose-volume histograms to lower doses. Furthermore, the population-based dose convolution tended to predict a higher risk of radiation damage to the liver (based on an in-house parameterization of the Lyman normal tissue complication probability model) than the individual patient calculations. For an individual plan, application of different individual random variations yielded change in effective volume differences with a 3% range. Plan adjustment to account for random setup variations generally resulted in a lower change in effective volume than initial planning using a planning target volume followed by calculation of delivered dose based on random offsets. CONCLUSION: This study hints at the factors that most strongly influence planning of liver treatments taking into account geometric variations. Given a setup verification methodology that rapidly reduces systematic offsets, the importance of realistic incorporation of geometric variations as an initial step in treatment planning, as well as possible plan refinement, is demonstrated.

An application of Bayesian statistical methods to adaptive radiotherapy.

In adaptive radiotherapy, measured patient-specific setup variations are used to modify the patient setup and treatment plan, potentially many times during the treatment course. To estimate the setup adjustments and re-plan the treatment, the measured data are usually processed using Kalman filtering or by computing running averages. We propose, as an alternative, the use of Bayesian statistical methods, which combine a population (prior) distribution of systematic and random setup errors with the measurements to determine a patient-specific (posterior) probability distribution. The posterior distribution can either be used directly in the re-planning of the treatment or in the generation of statistics needed for adjustments. Based on the assumption that day-to-day setup variations are independent and identically distributed Normal distributions, we can efficiently compute parameters of the posterior distribution from parameters of the prior distribution and statistics of the measurements. We illustrate a simple procedure to apply the method in practice to adaptive radiotherapy, allowing for multiple adjustments of treatment parameters during the course of treatment.

Daily prostate targeting using implanted radiopaque markers.

PURPOSE: A system has been implemented for daily localization of the prostate through radiographic localization of implanted markers. This report summarizes an initial trial to establish the accuracy of patient setup via this system. METHODS AND MATERIALS: Before radiotherapy, three radiopaque markers are implanted in the prostate periphery. Reference positions are established from CT data. Before treatment, orthogonal radiographs are acquired. Projected marker positions are extracted semiautomatically from the radiographs and aligned to the reference positions. Computer-controlled couch adjustment is performed, followed by acquisition of a second pair of radiographs to verify prostate position. Ten patients (6 prone, 4 supine) participated in a trial of daily positioning. RESULTS: Three hundred seventy-four fractions were treated using this system. Treatment times were on the order of 30 minutes. Initial prostate position errors (sigma) ranged from 3.1 to 5.8 mm left-right, 4.0 to 10.1 mm anterior-posterior, and 2.6 to 9.0 mm inferior-superior in prone patients. Initial position was more reproducible in supine patients, with errors of 2.8 to 5.0 mm left-right, 1.9 to 3.0 mm anterior-posterior, and 2.6 to 5.3 mm inferior-superior. After prostate localization and adjustment, the position errors were reduced to 1.3 to 3.5 mm left-right, 1.7 to 4.2 mm anterior-posterior, and 1.6 to 4.0 mm inferior-superior in prone patients, and 1.2 to 1.8 mm left-right, 0.9 to 1.8 mm anterior-posterior, and 0.8 to 1.5 mm inferior-superior in supine patients. CONCLUSIONS: Daily targeting of the prostate has been shown to be technically feasible. The implemented system provides the ability to significantly reduce treatment margins for most patients with cancer confined to the prostate. The differences in final position accuracy between prone and supine patients suggest variations in intratreatment prostate movement related to mechanisms of patient positioning.

Daily targeting of intrahepatic tumors for radiotherapy.

INTRODUCTION: A system has been developed for daily targeting of intrahepatic tumors using a combination of ventilatory immobilization, in-room diagnostic imaging, and on-line setup adjustment. By reducing geometric position uncertainty, as well as organ movement, this system permits reduction of margins and thus potentially higher treatment doses. This paper reports our initial experience treating 8 patients with focal liver tumors using this system. METHODS AND MATERIALS: The system includes diagnostic X-ray tubes mounted on the wall and ceiling of a treatment room, an active matrix flat panel imager, in-room control for image acquisition and setup adjustment, and a ventilatory immobilization system via active breathing control (ABC). Eight patients participated in the study, two using an early prototype ABC unit, and the remaining six with a commercial ABC system and improved setup measurement tools. Treatment margins were reduced, and dose consequently increased because of increased confidence in target position under this protocol. After daily setup via skin marks, orthogonal radiographs were acquired at suspended ventilation. The images were aligned to the CT model using the diaphragm for inferior-superior (IS) alignment, and the skeleton for left-right (LR) and anterior-posterior (AP) alignment. Adjustments were made for positioning errors greater than a threshold (3 or 5 mm). After treatment, retrospective analysis determined the final setup accuracy, as well as the error in initial setup measurement performed before setup adjustment. RESULTS: Two hundred sixty-two treatment fractions were delivered on eight patients, with 171 treatments requiring repositioning. Typical treatment times were 25-30 min. Patients were able to tolerate ABC throughout the course of treatment. Breath holds up to 35 s long were used for treatment. The use of on-line imaging and setup adjustment reduced setup errors (sigma) from 4.0 mm (LR), 6.7 mm (IS), and 3.8 mm (AP) to 2.1 mm (LR), 3.5 mm (IS), and 2.3 mm (AP). Prescribed doses were increased using this system by an average of 5 Gy. CONCLUSIONS: Daily targeting of intrahepatic targets has been demonstrated to be feasible. The potential for reduction in treatment margin and consequential safe dose escalation has been demonstrated, while maintaining reasonable treatment delivery times.