Per-Irradiation Monitoring by kV-2D Acquisitions in Stereotactic Treatment of Spinal and Non-Spinal Bony Metastases...

An on-board imager on a linear accelerator allows the acquisition of kV-2D images during irradiation. Overlaying specific structures on these images enables the visual verification of movement at regular frequencies. Our aim was to validate this tracking method for the stereotactic treatment of bone metastases.

Shifts in three translational directions were simulated using an anthropomorphic phantom. For these simulated shifts, planar images were acquired at different angles of incidence, with overlaid volumes of interest. A blinded test was then administered to the 18 participants to evaluate their decisions regarding whether to stop treatment. The results considered the experience of the operators. Quantitative analyses were performed on the intra-fractional images of 29 patients.

Participants analyzed each image with an average (standard deviation) decision time of 3.0 s (2.3). For offsets of 0.0, 1.0, 1.5, and 2.0 mm, the results were 78%, 93%, 90%, and 100% for the expert group and 78%, 70%, 79%, and 88% for the less-experienced group. Clinical feedback confirmed this guidance technique and extended it to non-spinal bony metastases. Sudden movements exceeding the 2.0 mm threshold occurred in 3.3% of the analyzed fractions, with a detection rate of 97.8% for vertebral locations. For non-vertebral bone locations, movements exceeding a threshold of 3.0 mm occurred in 3.5% of cases and were detected in 96.5%.

The clinical use of planar OBI and superimposed structures for visual-image guidance in bone stereotactic treatment was validated using an anthropomorphic phantom and clinical feedback.