Validation of frame-based positioning accuracy with cone-beam computed tomography in Gamma Knife Icon radiosurgery

Abstract Background Frame based positioning accuracy in Gamma Knife (GK) stereotactic radiosurgery (SRS) is extremely high but removal of a post may be necessary to enable the treatment in selected patients. Objective To verify the positioning accuracy in clinical scenarios with 4 and 3 posts in patients and phantoms using cone-beam CT (CBCT) of Gamma Knife Icon™. Methods We analyzed positioning accuracy for 12 patients with standard 4 post setup using pretreatment CBCT (pre-CBCT) on GK Icon™ and report 4 patients with different clinical scenarios (removal of a post). We performed phantom measurements to verify the frame accuracy via CBCT in different clinical scenarios without the influence of the human patient. Results Mean frame accuracy for 12 patients with 4 posts was 0.35 mm/0.34 degree. Mean motion during treatment was 0.11 mm/0.04 degree. For two of the clinical scenarios where a post was removed, we found acceptable deviations within 0.66 mm/0.61 degree. For 2 patients, a deviation of 2.94 mm/−3.47 degree and 1.85 mm/−0.74 degree was found and replanning was necessary. Phantom measurements showed good agreement when planning MR/CT was performed with 4 or 3 post. Larger deviations of 0.86 mm/0.88 degree were detected when a post was removed after planning MR/CT. Conclusion The frame accuracy with 4 posts before and during GK treatments is as high as expected. For clinical situations, where a post is removed after planning-CT/MR, pre-treatment position verification is strongly suggested using stereotactic CBCT or the P-CT/MR should be repeated to avoid possible mistreatments.