A phantom study of the immobilization and the indications for using virtual isocenter in stereoscopic X‐ray image guidance system referring to position localizer in frameless radiosurgery

A frameless radiosurgery system is using a set of thermoplastic mask for fixation and stereoscopic X-ray imaging for alignment. The accuracy depends on mask fixation and imaging. Under certain circumstances, the guidance images may contain insufficient bony structures, resulting in lesser accuracy. A virtual isocenter function is designed for such scenarios. In this study, we investigated the immobilization and the indications for using virtual isocenter. Twenty-four arbitrary imaginary treatment targets (ITTs) in phantom were evaluated. The external Localizer with positioner films was used as reference. The alignments by using actual and virtual isocenter in image guidance were compared. The deviation of the alignment after mask removing and then resetting was also checked. The results illustrated that the mean deviation between the alignment by image guidance using actual isocenter (Iso(img)) and the localizer(Iso(loc)) was 2.26 mm ± 1.16 mm (standard deviation, SD), 1.66 mm ± 0.83 mm for using virtual isocenter. The deviation of the alignment by the image guidance using actual isocenter to the localizer before and after mask resetting was 7.02 mm ± 5.8 mm. The deviations before and after mask resetting were insignificant for the target center from skull edge larger than 80 mm on craniocaudal direction. The deviations between the alignment using actual and virtual isocenter in image guidance were not significant if the minimum distance from target center to skull edge was larger or equal to 30 mm. Due to an unacceptable deviation after mask resetting, the image guidance is necessary to improve the accuracy of frameless immobilization. A treatment isocenter less than 30 mm from the skull bone should be an indication for using virtual isocenter to align in image guidance. The virtual isocenter should be set as caudally as possible, and the sella of skull should be the ideal point.