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J Appl Clin Med Phys. 2019 Oct 6. doi: 10.1002/acm2.12745. [Epub ahead of print]

Gamma Knife® icon CBCT offers improved localization workflow for frame-based treatment.

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Radiation Oncology, University of Mississippi Medical Center, Jackson, MS, USA.
Radiology, University of Mississippi Medical Center, Jackson, MS, USA.
Neurosurgery, University of Mississippi Medical Center, Jackson, MS, USA.



The purpose of this study was to compare two methods of stereotactic localization in Gamma Knife treatment planning: cone beam computed tomography (CBCT) or fiducial. While the fiducial method is the traditional method of localization, CBCT is now available for use with the Gamma Knife Icon. This study seeks to determine whether a difference exists between the two methods and then whether one is better than the other regarding accuracy and workflow optimization.


Cone beam computed tomography was used to define stereotactic space around the Elekta Film Pinprick phantom and then treated with film in place. The same phantom was offset known amounts from center and then imaged with CBCT and registered with the reference CBCT image to determine if measured offsets matched those known. Ten frameless and 10 frame-based magnetic resonance imaging (MRI) to CBCT patient fusions were retrospectively evaluated using the TG-132 TRE method. The stereotactic coordinates defined by CBCT and traditional fiducials were compared on the Elekta 8 cm Ball phantom, an anthropomorphic phantom, and actual patient data. Offsets were introduced to the anthropomorphic phantom in the stereotactic frame and CBCT's ability to detect those offsets was determined.


Cone beam computed tomography defines stereotactic space well within the established limits of the mechanical alignment system. The CBCT to CBCT registration can detect offsets accurately to within 0.1 mm and 0.5°. In all cases, some disagreement existed between fiducial localization and that of CBCT which in some cases was small, but also was as high as 0.43 mm in the phantom domain and as much as 1.54 mm in actual patients.


Cone beam computed tomography demonstrates consistent accuracy in defining stereotactic space. Since both localization methods do not agree with each other consistently, the more reliable method must be identified. Cone beam computed tomography can accurately determine offsets occurring within stereotactic space that would be nondiscernible utilizing the fiducial method and seems to be more reliable. Using CBCT localization offers the opportunity to streamline workflow both from a patient and clinic perspective and also shows patient position immediately prior to treatment.


CBCT; Gamma Knife; frame-based; icon; radiosurgery workflow


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