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Designed as a practical guide to linac radiosurgery, the book addresses the pertinent aspects of stereotactic treatment delivery. In recent years, there has been a.
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Linac radiosurgery : a practical guide

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Linac Radiosurgery

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Furthermore, the referring neurosurgeon, coresponsible for delineating the treatment target during planning, was present during treatment delivery to lend expertise to the analysis of the IGRT. The effect of gantry sag was 0. The IGRT isocenter was within 0. Couch walkout had a maximum discordance of 0. These values were based on a statistical analysis of individual isocenter congruency tests performed for this machine and imaging combination. Therefore, imaging was performed for each treatment couch angle prior to treatment arc delivery.

This map reflected a treatment strategy that would ensure the following: a clearance could be achieved without collision for all treatment angles and with the ancillary treatment cone mounted, b a sufficient number of arc angles could be achieved from a suitable number of unique angles that would make this high dose stereotactically achievable with quality gradient indices, and c normal tissues such as the brain and entry dose through the spinal cord could be achieved without comprising the desired treatment dose.

This projection map is shown in Fig. It was concluded that a typical occipital neuralgia treatment plan could be delivered using approximately arc degrees while avoiding collisions, unnecessary brain dose, and entry dose through the spinal cord. After establishing the parameters for simulation, fusion, and treatment planning, the same phantom was used to define the conditions for treatment delivery with BrainLab's ExacTrac image guidance system.

Infrared markers were used to provide the initial setup and x rays were acquired to match to bony anatomy. A simulated treatment was performed with additional intrafractional imaging performed at each treatment couch position. The average translational magnitude of correction to realign the phantom's vertical, longitudinal, and lateral position was 1. The average rotational magnitude of correction applied to correct the phantom's pitch, yaw, and roll was 0. The dose grid resolution in the treatment planning system was set to 0. At its closest point, the spinal cord was measured to be The spinal cord received: D 1.

The brain received: D A gradient index was evaluated for this plan based on a metric established for a cohort of functional disease patients treated using this linear accelerator and conical collimated SRS beam. The gradient index from our metric cohort was 3.

Postplan analysis was performed by developing a composite plan with each arc's isocenter modified from the shared planning isocenter by that arc's residual spatial corrections as identified by IGRT and below the threshold required for positional correction determined immediately prior to the arc's delivery. Postplan dosimetry determined that the spinal cord received the following: D 1. Furthermore, the brain received: D Linear accelerator equipment parameters are presented using the International Electrotechnical Commission IEC accelerator convention.


Twelve of these required repositioning and subsequent reimaging for verification. Spatial deviations, once corrected, are significantly improved using error analysis with an accepted threshold of 0. Rotational deviations, on the other hand do not show a significant improvement postcorrection with an accepted threshold of 1. For this treatment, more stringent tolerances were applied for spatial versus rotational corrections because a spatial target miss would not be acceptable, whereas rotational deviations would not change target dose due to the large number of arc angles employed and the isotropic nature of the dose distribution.

No subsequent radiation was delivered. The patient is currently being followed by neurosurgery. No repeat imaging has been done to date. SRS for functional diseases including neuralgias has been well established with demonstrable precision using both frame and frameless approaches. While conditions such as trigeminal and glossopharyngeal neuralgia have been successfully treated using SRS, occipital neuralgia treated with any type of SRS modality and immobilization technique has not, to date, been reported in literature.

Demonstration of this successfully delivered SRS dose using a frameless SRS approach provides an important alternative for patients suffering from occipital neuralgia and who have exhausted traditional pain management strategies.

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The use of stereotactic cones on gantry mounted linear accelerator presents an increased risk of collision that is well understood for cranial applications but requires more detailed review for extracranial applications. Furthermore, the use of a stereotactic frame may preclude treatment for occipital neuralgia. The frame would present challenges to treatment planning as beams would pass through the frame. Recent advances in Gamma Knife technology allow for SRS treatments to be delivered extracranially for the cervical spine and head and neck applications.

CyberKnife offers the capability of being able to treat at this treatment level. However, no application of these treatment modalities have yet to be reported in the literature. Limitations imposed by avoiding unnecessary beam entry dose through the brain, beam overlap, and beam entry through the spinal cord were identified and overcome.

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The phantom and, subsequently, the patient underwent a supine setup. However, for the image guidance system used, ExacTrac prone positioning is not supported. Other linear accelerators may have different factors requiring other methods of correction. Rather, this treatment site is a new application for a mature functional disease SRS program.

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The results of these studies were within satisfactory limits as per IROC analysis. From the treatment projection map, we determined collision avoidance verification tests are recommended for each patient. This facilitates keeping arcs ipsilateral to the treatment side and guided from the medial, anterior, and posterior aspects to mitigate collision risk and unnecessary brain dose. The implementation of IGRT for this target had to accommodate previously placed cervical spine fusion titanium instrumentation. This hardware is rigid but beyond the treatment site. The additional use of posterior immobilization via a moldable cushion helped provide additional immobilization such that it was determined that the levels of the hardware could be used for image guidance relative to the level of the isocenter.

The validity of this was evaluated and confirmed during image guidance. Stereotactic Computed Tomography. Stereotactic Magnetic Resonance Imaging.

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Radiosurgery Treatment Planning. Dose Selection. Radiation Delivery. Patient Follow-Up. University of Florida Results. Stereotactic Radiotherapy. Average Review.

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