S90 I. J.

Radiation Oncology ● Biology ● Physics Volume 63, Number 2, Supplement, 2005

150 Anatomic Landmarks vs Fiducials for Staged Gamma Knife Radiosurgery for Large Arteriovenous
Malformations

P. Petti,1 J. Coleman,1 M. McDermott,2 D. Larson1

1
Dept. of Radiation Oncology, University of California San Francisco, San Francisco, CA, 2Dept. of Neurological Surgery,
University of California San Francisco, San Francisco, CA

Purpose/Objective: Gamma Knife (GK) radiosurgery for large AVMs is often conducted in stages. The target is divided into
sub-volumes which are irradiated to full dose in treatment sessions separated by 3– 6 months. Isocenter coordinates and dose
distributions calculated for the first treatment session are mapped to subsequent sessions by determining the transformation
between the first and subsequent image sets. Either surgically-placed fiducial markers or internal anatomical landmarks can be
used to determine the transformation. The surgical-marker method is considered to be the standard technique, potentially
accurate to within 0.5 mm. However, this technique is invasive and requires the analysis of an additional pair of orthogonal
radiographs. The purpose of this investigation is to compare the accuracy of using internal anatomical points as opposed to
surgically-placed fiducials in the image registration process.
Materials/Methods: Ten patients with large AVMs previously treated at our institution using staged GK radiosurgery with
surgically-placed fiducials were selected for comparison. Four markers (3-mm titanium screws) were embedded in the outer
table of the skull of each patient. These markers were imaged on orthogonal radiographs obtained with the patient immobilized
in the Leksell head frame and imported into the GK planning system. For the same patients, 4 internal landmarks were defined
on MRI studies (3D TOF with gadolinium contrast, 1 mm to 3 mm slice spacing). Internal landmarks included superficial veins
in the frontal, temporal or occipital lobes, the pituitary stalk, and midline veins or arteries. The transformation between the two
coordinate systems was ascertained using the Solver tool in Excel to minimize the chi-squared discrepancy between entered and
transformed coordinates. To evaluate the accuracy of the transformation determined by both methods, the difference between
the transformed and actual (measured) coordinates of several internal test points, i.e., PTM公((XT⫺XM)2⫹(YT⫺YM)2⫹(ZT⫺ZM)2),
was calculated. The same test points were used to evaluate both methods, and these test points were different from those used
to determine the transformation.
Results: See table 1 for results. The value of PTM averaged over the test points ranged from 0.9 mm to 2.0 mm when the
transformation was determined using internal points and from 1.2 mm to 2.5 mm when surgically-placed fiducials were used.
The standard deviation in these mean values was between 0.2 mm and 1.5 mm. The fact that the standard deviation is, in some
cases, comparable to the average value of PTM indicates that the accuracy of the transformation approaches the accuracy with
which corresponding points can be identified on the MRI scans. Averaged over all patients, the value of PTM is 1.4 mm using
internal landmarks and 1.9 mm using surgically-placed fiducials.
Conclusions: Using internal landmarks to determine the coordinate transformation between subsequent MRI scans for
staged GK AVM treatments yields comparable results to the standard external-fiducial technique and avoids an invasive
procedure.

151 Geometric Evaluation of Image Guided Adaptive Radiotherapy (ART) for Prostate Cancer

E. Meldolesi,1,2 D. Lockman,2 D. Yan,2 A. Martinez2

1
Radiation Oncology, Florence University, Florence, Italy, 2Radiation Oncology, William Beaumont Hospital, Royal Oak,
MI

Purpose/Objective: Image guided ART for prostate cancer has been implemented in William Beaumont Hospital Radiation
Oncology for prostate cancer treatment since early 1999, with 760 patients treated. In this treatment process, multiple CT and
portal images are acquired for each patient during the first week of treatment delivery, and used as feedback to form a new