ANALYSIS OF THREE-DIMENSIONAL SET-UP UNCERTAINTIES IN HEAD AND NECK 3D CRT

Bojan trbac* med. physicist, Aleksandar Kostovski RTT, Zoran Kuzmanovi med. physicist, Milomir Milakovi med. physicist International Medical Centers, Banja Luka, B&H
*Corresponding

author: bojan.strbac@euromedic.ba

Introduction
The goal of radiotherapy is to treat tumor cells within CTV. In order to take geometrical uncertainty into consideration we introduce PTV which contains CTV+ margin. Set up margin should be optimized to prevent inadvertent irradiation of surrounding normal tissue. A treatment uncertainty can be an uncertainty in organ shape and motion, beam geometry and patient set-up. Set up deviations have been divided into systematic and random contributions. The systematic contributions are due to differences in the patient set up at simulation and actual treatment delivery, and the random contributions are due interfractional variations in the patient set up during the overall course. The patients set up displacement, , is sum of the systematic and random contributions and refer to the difference between reference image (DRR) and portal image.

Results
The population systematic errors in the AP portal images in the caudal cranial longitudinal direction 0.95 mm, and 1.87 mm in the left right lateral direction. The population systematic errors in the caudal cranial longitudinal direction 1.62 mm, and 1.27 mm in the dorsal ventral vertical direction in the lateral filed (900). The population random error in the corresponding directions was 1.70, 1.96, 1.90 and 1.47 mm. The mean 3D vector length of displacement was 2.14 mm. Table 1: Summary of results [mm]. Field Direction caudal cranial longitudinal -1.50 2.33 0.38 1.70 0.95 AP left right lateral LATERAL dorsal ventral vertical -3 2.4 0.12 1.47 1.27 Caudal cranial longitudinal -2.17 3.50 0.23 1.90 1.62

Objectives
Each clinic should measure its own systematic and random errors as a part of QA program of treatment delivery by verification of treatment field positions to document the efficiency of immobilization method and reproducibility of treatment. The objective of the study is evaluation of geometric uncertainties in a population with tumors of head and neck region as necessary step to develop strategy to reduce set-up and transfer errors during the course of treatment in the newely opened radiotherapy centre in Banja Luka, Bosnia and Herzegovina.

Min deviation Max deviation moverall set-up set-up

-4.67 3.50 -0.10 1.96 1.87

P number of patient, N total number of images, np number of images per individual patient:

Table 2: CTV-PTV margin [mm] Systematic error AP longitudinal AP lateral Lat vertical 0.95 1.87 1.27 Random error 1.70 1.96 1.47 ICRU 62 Stroom van Herk

3D vectors of displacement

1.95 2.70 1.94

3.09 5.11 3.57

3.56 6.04 4.20

Methods
The assessment of errors was done comparing two orthogonal portal images (PI) with Digitally Reconstructed Radiographs (DRRs) by matching bone anatomy landmarks with anatomy matching software: Varian Offline Review. DRRs were obtained from the CT simulator and were considered the reference images while acquired portal images were obtained using EPID system attached to Varian linear accelerators. To establish an accurate estimate for all systematic and random errors, we analyzed P=25 patients undergoing 3D conformal radiotherapy, head and neck region, with at least one weekly image and overall 250 PI. 5-pt Orfit masks were used for patient immobilization. Mean displacements, population systematic and random errors and 3D vector of displacement were calculated. For each direction and each patient, measurement of displacement between portal and referent image represents the total error in patient positioning. This displacement is a combination of both random and systematic components. We can separate two components by acquiring multiple images. Systematic error for individual patient is represented by the mean deviation along given axis, mp . The distribution of systematic error is determined by standard deviation of the values of the mean displacements of all individual patients, moverall. For each individual patient, the random displacement was assessed by subtraction of the systematic displacement from the daily displacement. For the whole population, the distribution of random errors was expressed by the standard deviation from all individual random errors. To calculate 3D vector length, the measured 1D deviation in the three directions are quadratically combined. The mean 3D set-up deviation was calculated as the average of the 3D vector lengths of the deviations over all measured fractions.

Conclusion
We evaluate set-up uncertainties in patients receiving conventional radiotherapy for head and neck cancers. Thirty patients were included in study. The total number of portal images studied for anterior and lateral direction was 266. Translations displacement were measured in 134 anterior and 132 lateral portal images and were assessed in left right lateral direction and caudal cranial longitudinal direction in AP field and dorsal ventral vertical direction and caudal cranial longitudinal direction in the lateral field. The sampling distribution of the mean errors is assumed to follow normal distribution. Since absolute values of in all cases, there is no significant overall moverall 2setup P systematic deviation at the 95% confidence limit. A PTV margin of 5 mm seems to be adequate for majority of patients.

References
[1] Geometric uncertainties in Radiotherapy. Prepared by Working Party of The British Institute of Radiology 2003; Appendix 2c:36-43. [2] Patent Positioning Correction Strategies in Radiotherapy: A Portal Imaging Study. Sofie Mansson ; Master of Science Thesis. [3] Giraud P, De Rycke Y, Rosenwald JC, Cosset JM. Conformal radiotherapy planning for lung cancer: analysis of set-up uncertainties. Cancer Invest. 2007 Feb;25(1):38-46. [4] Budrukkar A, Dutta D, Sharma D, Yadav P, Dantas S, Jalali R. Comparison of geometric uncertainties using electronic portal imaging device in focal three-dimensional conformal radiation therapy using different head supports. J Cancer Res Ther. 2008 Apr-Jun;4(2):70-6. [5] S J Thomas, MA, MSc, PhD. Margins between clinical target volume and planning target volume for electron beam therapy. British Journal of Radiology (2006) 79, 244-247. [6] K Krishna Murthy, Zakiya Al-Rahbi, SS Sivakumar, CA Davis, R Ravichandran, Kamal El Ghamrawy. Verification of setup errors in external beam radiation therapy using electronic portal imaging. J Med Phys 2008 Volume : 33 | Issue : 2 | Page : 49-53