Stereotactic Radiosurgery (SRS) and Stereotactic Radiation Therapy (SRT)

applications for the management of intracranial lesions are rapidly adopted by the
Radiation Therapy (RT) community resulting in safer treatments and a better quality
of life for patients than ever before.

The clinical efficacy and superiority of SRS/SRT against conventionally fractionated

radiotherapy, such as Whole Brain RT, for the treatment of brain malignant primary
and metastatic lesions, benign tumors, and functional disorders, have been proven by
the scientific community over the last two decades. The main advantage of SRS is the
accurate delivery of high radiation doses with sub-millimeter precision, in a single or a
hypofractionated treatment scheme. Compared with conventional RT, the delineated
target volume in SRS is smaller, the conformity of the dose distribution is higher, and
the dose gradient from the periphery of the target to the surrounding healthy tissue is
steeper. To fulfill these characteristics, contemporary SRS treatment plans are
designed and delivered through the combination of sophisticated software with high
precision hardware components for the main treatment system. Careful, integration
between different sub-systems and the main system is required to further increase
treatment accuracy and efficacy. However, the integration of these systems in
delivering customized treatment for each patient increases the complexity of the
whole procedure and consequently the possibility of unintended radiation exposure to
healthy tissue. The consequences of errors when delivering high-dose fraction/s of
radiation – just millimeters beyond their intended site – can have a far-reaching
physiological impact compromising tumor control probability and normal tissue
complication probability treatment objectives.

The key differences between conventional RT and SRS, as well as the high level of
complexity in SRS increase the requirements for accuracy and precision in each
treatment, highlighting the need for a Patient-Specific Quality Assurance (PSQA)
protocol in the clinic. According to international guidelines and recommendations, a
PSQA procedure in SRS should include the verification of patient setup and
immobilization, an independent check of the treatment plan including all the
individual treatment delivery parameters, absolute and relative dose measurements,
and a dry-run of the treatment delivery. The aforementioned checks of a patient’s SRS
treatment can be performed within the framework of End-to-End testing of each
treatment plan. Through this procedure which acts as a treatment simulation, the
clinical team can assess the overall treatment process accuracy from start to finish,
including the patient’s immobilization, imaging, treatment planning, setup, image
guidance, and treatment delivery. Therefore all links in the treatment chain are
holistically tested and verified. Each link of this End-to-End testing should be
implemented by the clinical team member who clinically performs it, so the procedure
simulates the treatment realistically.

The PSQA program of each clinic should determine the appropriate methodology and
equipment for each SRS modality in order to conduct the treatment verification
accurately for each patient. The equipment that is commonly used for PSQA includes
a large variety of dosimetry detectors, phantoms and/or devices that simultaneously
act as both phantoms and detectors. The most common detectors that are suitable for
dosimetry measurements in SRS are small-volume ionization chambers, dosimetry
diodes, microdiamond detectors, plastic scintillators, radiochromic films, polymer
gels, electronic portal imaging devices calibrated for dose response, and 2D or 3D
detector arrays. The vast majority of these detectors are placed within a phantom that
represents the patient’s head to perform dose measurements. Phantoms for SRS
applications are either of a generic standard shape such as spheres and cylinders or are
anthropomorphic.

Within the framework of the described equipment available for PSQA in SRS, the pre-
treatment imaging of the phantom for planning purposes is performed once and the
structure sets of each patient are relocated to match the detector’s plane or point
resulting in selective structures’ dosimetry instead of the actual plan evaluation. Then,
the patient’s treatment plan is recalculated on the phantom geometry and the measured
dose is reconstructed within the patient’s anatomy resulting in artificially determined
in vivo dose distribution acting more as a plan-specific rather than a true patient-
specific approach. As mentioned above, the dose gradients in SRS are too steep and
the target sizes too small for the detector’s resolution, especially in 2D or 3D detector
arrays. In the case of electronic portal imaging devices, the treatment plan is verified
without the presence of any phantom and the measured portal images are combined
with a back-projection algorithm to predict the dose in the patient’s Computed
Tomography (CT) dataset.

The current status of PSQA in SRS doesn’t take into account the effect of the actual
patient’s anatomy and lacks patient-specific 3D dosimetry. A promising solution that
addresses these challenges is the combination of patient-specific phantoms with
polymer gel 3D dosimetry. The rapid advances in 3D-printing technology permit swift
creation of an actual patient facsimile with bone- and tissue-mimicking materials
using the CT data of the real patient. Moreover, the usage of a polymer gel as a brain
equivalent material, in terms of interaction with radiation, and as a 3D dosimeter,
provide an evaluation of every patient’s targets without any compromise. This
methodology can be adopted in an End-to-End PSQA framework for each patient
where the patient’s immobilization equipment and setup/monitoring methodologies
are utilized.

Due to the complexity of planning and delivery of IMRT, patient-specific QA is recommended for
every new patient before the start of IMRT delivery. This could potentially detect any gross errors
such as the wrong beam energy, wrong patient plan, or any data transfer errors from the TPS to
the delivery system. Accurate multileaf collimator (MLC) leaf positioning plays an essential role in
the effective implementation of intensity modulated radiation therapy (IMRT). patient-specific
IMRT quality assurance (QA) procedures to minor MLC leaf positioning errors. The agreement
between calculation and measurement is evaluated using both absolute distance-to-agreement
(DTA) analysis and γ index with 2%/2 mm or 3%/3 mm criteria.