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Relocatable fixation systems in intracranial stereotactic radiotherapy

Accuracy of serial CT scans and patient acceptance in a randomized design

Reproduzierbarkeit von Fixationssystemen in der intrakraniellen stereotaktischen Radiotherapie

Genauigkeit durch serielle CT-Scans und Patientenakzeptanz im randomisierten Design

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Abstract

Purpose

The goal was to provide a quantitative evaluation of the accuracy of three different fixation systems for stereotactic radiotherapy and to evaluate patients’ acceptance for all fixations.

Methods

A total of 16 consecutive patients with brain tumours undergoing fractionated stereotactic radiotherapy (SCRT) were enrolled after informed consent (Clinical trials.gov: NCT00181350). Fixation systems evaluated were the BrainLAB® mask, with and without custom made bite-block (fixations S and A) and a homemade neck support with bite-block (fixation B) based on the BrainLAB® frame. The sequence of measurements was evaluated in a randomized manner with a cross-over design and patients’ acceptance by a questionnaire.

Results

The mean three-dimensional (3D) displacement and standard deviations were 1.16 ± 0.68 mm for fixation S, 1.92 ± 1.28 and 1.70 ± 0.83 mm for fixations A and B, respectively. There was a significant improvement of the overall alignment (3D vector) when using the standard fixation instead of fixation A or B in the craniocaudal direction (p = 0.037). Rotational deviations were significantly less for the standard fixation S in relation to fixations A (p = 0.005) and B (p = 0.03). EPI imaging with off-line correction further improved reproducibility. Five out of 8 patients preferred the neck support with the bite-block.

Conclusion

The mask fixation system in conjunction with a bite-block is the most accurate fixation for SCRT reducing craniocaudal and rotational movements. Patients favoured the more comfortable but less accurate neck support. To optimize the accuracy of SCRT, additional regular portal imaging is warranted.

Zusammenfassung

Ziel

Untersuchung zur Lagerungsgenauigkeit von drei verschiedenen Fixationssystemen für die intrakranielle stereotaktische Radiotherapie und die Patientenakzeptanz der verschiedenen Maskensysteme.

Methoden

16 konsekutive Patienten mit Hirntumoren, bei denen eine stereotaktische Radiotherapie geplant war, wurden nach schriftlicher Zustimmung prospektiv in die Studie eingeschlossen (Clinical trials.gov: NCT00181350). Untersuchte Fixationssysteme waren das Maskensystem von BrainLAB® mit und ohne Oberkieferbissplatte (Fixationen S und A) und eine in unserem Haus angefertigte Nackenstütze mit Bissplatte (Fixation B) auf der Basis des BrainLAB®-Rahmens (Fig. 2). Die Reihenfolge der Messungen wurde mit Hilfe eines Cross-Over-Designs (Fig. 1) randomisiert. Die Patientenakzeptanz wurde mit einem Fragebogen evaluiert.

Ergebnisse

Die mittleren dreidimensionalen (3-D) Verschiebungen und Standardabweichungen waren 1,16 ± 0,68 mm für die Standardfixation S, 1,92 ± 1,28 mm und 1,70 ± 0,83 mm für die Fixationen A und B. Es ergab sich eine signifikante Verbesserung des 3-D-Vektors mit der Standardfixation im Vergleich zu den Fixationen A und B in kraniokaudaler Richtung (p = 0,037; Tab. 1). Rotationsabweichungen traten signifikant weniger bei der Standardfixation S auf im Vergleich zu A (p = 0,005) und B (p = 0,03). Elektronische Portfilm-Bildgebung mit „Off-line“-Korrektur verbesserte die Reproduzierbarkeit zusätzlich (Fig. 5). 5 von 8 Patienten bevorzugten die Fixation mit Nackenstütze und Bissplatte.

Schlussfolgerung

Das Maskensystem mit Oberkieferbissplatte erreicht die genaueste Reproduzierbarkeit durch Verringerung der Abweichungen in longitudinaler Richtung und der Rotationen. Patienten bevorzugten die bequemere, aber weniger genaue Fixation mit Nackenstütze. Zusätzliche wiederholte Portfilm-Bildgebung gewährleistet eine weitere Optimierung der Lagerungsgenauigkeit.

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Acknowledgements

We thank Prof. Martijn Berger of the Department for Methodology and Statistics of the University Maastricht for his support in defining and setting up the study design. We also thank Brigitte Reniers PhD, of the Department of Radiation-Oncology (MAASTRO) for providing us set-up data from EPID measurements of stereotactically treated patients at MAASTRO clinic.

Conflict of interest

The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Radiation-Oncology (MAASTRO), GROW (School for Oncology & Developmental Biology), Maastricht University Medical Centre (MUMC), Dr Tanslaan 12, 6229, Maastricht, The Netherlands

    A. Theelen, J. Martens BSc, G. Bosmans PhD, R. Houben MSc, J.J. Jager MD PhD, I. Rutten MD, P. Lambin MD PhD, A.W. Minken PhD &  B.G. Baumert MD PhD

  2. Department of Medical Physics, Radiotherapeutic Institute RISO, Deventer, The Netherlands

    A.W. Minken PhD

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  1. A. Theelen
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  2. J. Martens BSc
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  5. J.J. Jager MD PhD
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  9. B.G. Baumert MD PhD
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Correspondence to B.G. Baumert MD PhD.

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Theelen, A., Martens, J., Bosmans, G. et al. Relocatable fixation systems in intracranial stereotactic radiotherapy. Strahlenther Onkol 188, 84–90 (2012). https://doi.org/10.1007/s00066-011-0018-7

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