Setup Uncertainties of Anatomical Sub-Regions in Head-and-Neck Cancer Patients After Offline CBCT Guidance

Purpose: To quantify local geometrical uncertainties in anatomical sub-regions during radiotherapy for head-and-neck cancer patients. Methods and Materials: Local setup accuracy was analyzed for 38 patients, who had received intensity-modulated radiotherapy and were regularly scanned during treatment with cone beam computed tomography (CBCT) for offline patient setup correction. In addition to the clinically used large region of interest (ROI), we defined eight ROIs in the planning CT that contained rigid bony structures: the mandible, larynx, jugular notch, occiput bone, vertebrae C1-C3, C3-C5, and C5-C7, and the vertebrae caudal of C7. By local rigid registration to successive CBCT scans, the local setup accuracy of each ROI was determined and compared with the overall setup error assessed with the large ROI. Deformations were distinguished from rigid body movements by expressing movement relative to a reference ROI (vertebrae C1-C3). Results: The offline patient setup correction protocol using the large ROI resulted in residual systematic errors (1 SD) within 1.2 mm and random errors within 1.5 mm for each direction. Local setup errors were larger, ranging from 1.1 to 3.4 mm (systematic) and 1.3 to 2.5 mm (random). Systematic deformations ranged from 0.4 mm near the reference C1-C3 to 3.8 mm for the larynx. Random deformations ranged from 0.5 to 3.6 mm. Conclusion: Head-and-neck cancer patients show considerable local setup variations, exceeding residual global patient setup uncertainty in an offline correction protocol. Current planning target volume margins may be inadequate to account for these uncertainties. We propose registration of multiple ROIs to drive correction protocols and adaptive radiotherapy to reduce the impact of local setup variations.