Accuracy and Precision of an IGRT Solution

Image-guided radiotherapy (IGRT) can potentially improve the accuracy of delivery of radiotherapy treatments by providing high-quality images of patient anatomy in the treatment position that can be incorporated into the treatment setup. The achievable accuracy and precision of delivery of highly complex head-and-neck intensity modulated radiotherapy (IMRT) plans with an IGRT technique using an Elekta Synergy linear accelerator and the Pinnacle Treatment Planning System (TPS) was investigated. Four head-and-neck IMRT plans were delivered to a semi-anthropomorphic head-and-neck phantom and the dose distribution was measured simultaneously by up to 20 microMOSFET (metal oxide semiconductor field-effect transmitter) detectors. A volumetric kilovoltage (kV) x-ray image was then acquired in the treatment position, fused with the phantom scan within the TPS using Syntegra software, and used to recalculate the dose with the precise delivery isocenter at the actual position of each detector within the phantom. Three repeat measurements were made over a period of 2 months to reduce the effect of random errors in measurement or delivery. To ensure that the noise remained below 1.5% (1 SD), minimum doses of 85 cGy were delivered to each detector. The average measured dose was systematically 1.4% lower than predicted and was consistent between repeats. Over the 4 delivered plans, 10/76 measurements showed a systematic error > 3% (3/76 > 5%), for which several potential sources of error were investigated. The error was ultimately attributable to measurements made in beam penumbrae, where submillimeter positional errors result in large discrepancies in dose. The implementation of an image-guided technique improves the accuracy of dose verification, particularly within high-dose gradients. The achievable accuracy of complex IMRT dose delivery incorporating image-guidance is within ± 3% in dose over the range of sample points. For some points in high-dose gradients, submillimeter errors in position can lead to errors > 3%. The precision of the delivery system was demonstrated to be within the experimental noise of the detector system of 1.5% (1 SD).