Image registration and calculation of a biologically effective dose for multisession radiosurgical treatments....

The purpose of this study was to develop techniques for registering image sets associated with staged or multifraction radiosurgical treatments of large targets with the Leksell gamma knife to transform shot coordinates between treatment sessions and produce cumulative dose distributions and to investigate the theoretical biological effects of such protracted treatments by means of such concepts as the linear-quadratic model and biologically effective dose. An image registration technique based on normalized mutual information was adapted to produce one fused-image study from an imaging series acquired during distinct treatment sessions. A spreadsheet computer program was developed to determine coordinate transformations between the associated stereotactic coordinate systems based on digitized coordinates of fiducial markers appearing on the fused images. Coordinates of shots used during one treatment session could then be transformed to the stereotactic space of another session, and cumulative dose distributions could be computed. The procedure was applied to the two-stage treatment of a giant arteriovenous malformation (AVM). Overall uncertainty in each transformed shot position is approximately 0.7 mm. An effective single-fraction dose (D(eff)) was defined and computed for the two-stage AVM treatment. The simple summed dose distribution was compared with the D(eff) distribution. Because dose values differ significantly in overlap regions between the individual distributions, the clinical usefulness of the simple cumulative distribution is dubious. It may be useful for a future update of the GammaPlan treatment planning software to generate effective single-session dose distributions for such cases.