Simulation of intrafraction motion and overall geometrical accuracy of a frameless intracranial radiosurgery process.

We conducted a comprehensive evaluation of the clinical accuracy of an image-guided frameless intracranial radiosurgery system. All links in the process chain were tested. Using healthy volunteers, we evaluated a novel method to prospectively quantify the range of target motion for optimal determination of the planning target volume (PTV) margin. The overall system isocentric accuracy was tested using a rigid anthropomorphic phantom containing a hidden target. Intrafraction motion was simulated in 5 healthy volunteers. Reinforced head-and-shoulders thermoplastic masks were used for immobilization. The subjects were placed in a treatment position for 15 minutes (the maximum expected time between repeated isocenter localizations) and the six-degrees-of-freedom target displacements were recorded with high frequency by tracking infrared markers. The markers were placed on a customized piece of thermoplastic secured to the head independently of the immobilization mask. Additional data were collected with the subjects holding their breath, talking, and deliberately moving. As compared with fiducial matching, the automatic registration algorithm did not introduce clinically significant errors (<0.3 mm difference). The hidden target test confirmed overall system isocentric accuracy of < or =1 mm (total three-dimensional displacement). The subjects exhibited various patterns and ranges of head motion during the mock treatment. The total displacement vector encompassing 95% of the positional points varied from 0.4 mm to 2.9 mm. Pre-planning motion simulation with optical tracking was tested on volunteers and appears promising for determination of patient-specific PTV margins. Further patient study is necessary and is planned. In the meantime, system accuracy is sufficient for confident clinical use with 3 mm PTV margins.