Practical Radiation Oncology (2015) 5, e689-e695

www.practicalradonc.org

Original Report

Implementation and validation of a new fixation

system for stereotactic radiation therapy: An
analysis of patient immobilization
Stephanie Lang PhD , Claudia Linsenmeier MD, MSc, Michelle L. Brown MBBS, MPH,
Frederique Cavelaars RT(T), Alessandra Tini RT(T), Christopher Winter RT(T),
Jerome Krayenbuehl PhD
Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
Received 13 October 2014; revised 18 February 2015; accepted 23 March 2015

Abstract
Purpose: Stereotactic radiation therapy is an established treatment technique for intracranial
malignancies. We evaluated a new intracranial immobilization system with an emphasis on
determining the intrafraction motion and the correlation of this motion with treatment time.
Methods and materials: Patients were immobilized using the trUpoint ARCH fixation system
(CIVCO Medical Solutions). We collected data from 85 lesions in 73 patients treated between
November 2011 and December 2013. Sixty-nine of 73 patients (95%) used the complete mask
system; for the remaining 4 patients, the system had to be adapted. Patients were treated using
volumetric modulated arc therapy stereotactic radiation therapy on a TrueBeam linear accelerator
(Varian Medical Systems, Palo Alto, CA). Fraction doses of 2-8 Gy were applied in 4-30 fractions.
Daily cone beam computed tomography imaging was performed before the treatment and was
matched to the reference computed tomography using a 6-degrees-of-freedom automatching
procedure. Additionally, posttreatment cone beam computed tomography scans were performed to
assess intrafraction motion for 67 patients (375 fractions).
Results: The average 3-dimensional setup error was 2.1 2.9 mm. The mean pitch and roll was
0.1 0.7 and 0.2 0.7. A total of 98.0% of the pitch values and 98.9% of the roll values were
b 1.5. Mean intrafractional motion was 0.51 mm ( 0.27) and mean treatment time was 10.1
minutes ( 1.4). The maximum intrafractional motion was 2.0 mm in the longitudinal direction;
95% of the total shifts were b 1.4 mm. The linear regression showed a weak but significant
influence (R 2 = 0.26, P = .01) of the treatment time on the total intrafractional shift.
Conclusions: The new intracranial immobilization system appears to be robust in terms of setup
accuracy, intrafraction motion, and repositioning of the mask system.
2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Introduction
Corresponding author. Department of Radiation Oncology, University Hospital Zurich, Rmistr. 100, 8091, Zurich, Switzerland.
E-mail address: Stephanie.lang@usz.ch (S. Lang).

Hypofractionated and conventionally fractionated stereotactic radiation therapy (SRT) are established radiation therapy
treatment techniques for benign and malignant intracranial

http://dx.doi.org/10.1016/j.prro.2015.03.007
1879-8500/ 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

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Practical Radiation Oncology: November-December 2015

Figure 1 Stereotactic mask system: The patient is fixated using a thermoplastic mask, a bite block, a nose fixation, and a cushion. The
mask, bite block, and cushion are custom-made for each patient.

malignancies that deliver a high dose to the tumor in multiple

fractions. 1-4 In daily clinical practice, SRT of brain metastases
and other intracranial malignancies is widely used. Several
clinical studies have demonstrated the benefit of SRT on local
control in brain metastases, either with or without prior
resection or whole brain radiation therapy. 5-11
To minimize side effects and maximize the dose to the
tumor, small margins between the clinical target volume and
the actual treated volume are chosen, requiring highly
accurate treatment delivery. 12,13 However, several uncertainties need to be considered for such treatments: computed
tomography (CT) to magnetic resonance imaging registration
uncertainties 14; contouring, patient setup and treatment
delivery uncertainties; and intrafractional patient motion. 15-17
Historically, stereotactic radiosurgery was performed with a
frame-based invasive procedure with the aim of minimizing
position uncertainties. SRT used a rigid, relocatable frame or
mask system which was time consuming and more
complicated than more modern fixation systems. 18 With
new possibilities in image guidance and immediate online
corrections, the procedure is more comfortable for patients
and less time consuming, albeit with similar accuracy. 19,20
Methods to enhance the accuracy and ease of use of
these commonly used stereotactic treatments are warranted. In this study, we evaluated a new mask system for SRT
with an emphasis on determining the intrafraction motion
and correlation of this motion with treatment time.
Additionally, interfraction stability and treatment margins
were calculated and compared with other commercially
available fixation systems.

Methods and materials

Stereotactic mask system
Patients were immobilized using the CIVCO trUpoint
ARCH fixation system (CIVCO Medical Solutions). This

fixation system is comprised of an individual head

cushion, open face thermoplastic mask, bite block and
nose fixation, and the arch upon which they are mounted.
All patient specific components are custom fit at the time
of the planning CT for each patient (Fig 1). For most of the
patients, a baseplate overlay was used for positioning in
combination with the CIVCO trUpoint ARCH. Patients
treated with noncoplanar arcs were immobilized using a
table extension because of problems with the gantry
clearance at the head of the table. The nose fixation and
bite blocks were made of plastic and the transmission
through these parts was measured using a film in 1.4-cm
depth of solid water and compared with the calculated
transmission in the Eclipse planning system (Varian
Medical Systems, Palo Alto, CA).

Patient characteristics
Data were collected from 85 lesions in 73 patients
treated between November 2011 and December 2013 with
the CIVCO fixation system for stereotactic irradiation.
Fifty-eight patients were treated for a single lesion, 12
patients had 2 lesions, and 1 patient had 3 metastases. The
mean age of the patients was 61.5 years (range, 31-84). We
treated 41% males and 59% females, of whom 23% had
received previous irradiation. The primary tumors were of
numerous histologies, with brain metastases being the
most commonly treated entity. The main primary tumors
were lung (39%), melanoma (25%), and breast (20%). A
smaller number of patients was treated for glioblastoma
recurrence, meningioma, or metastases from gastrointestinal tumors, thyroid cancer, and other rare histologies.
Sixty-nine of 73 patients (95%) used the full mask system.
Three patients were treated without nose fixation because
of tumors located between the eyes and to avoid scatter
dose from the nose fixation to the eyes. One patient was
treated without a mask and nose fixation because of
claustrophobia, 4 patients were edentulous, and 4 patients
wore teeth prostheses during treatment.

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691

Figure 2 Pitch-and-roll values of the initial patient setup. Pitch-and-roll values larger than 1.5 were not accepted and the patient
required repositioning.

Treatment technique
Patients were treated using stereotactic volumetric
modulated arc therapy on a TrueBeam linear accelerator
(Varian Medical Systems). Fraction doses of 2-8 Gy were
applied in 4-30 fractions; 11 patients were treated using
6-MV flattening filter free beams and 62 using 6-MV
flattened beams. Daily cone beam CT (CBCT) imaging
was performed before treatment for all 73 patients and was
matched to the reference CT using a 6-degrees-of-freedom
(DoF) automatching procedure. Automatching was checked
and, if needed, manually corrected by the responsible
clinician. Pitch and roll could not be corrected because of
the absence of a 6-DoF treatment table. In case of pitch or roll
values larger than 1.5, patient setup was repeated. Fourdimensional couch corrections were applied. Additionally,
posttreatment CBCTs were performed to assess intrafraction
motion for 67 patients (375 fractions).

machine uncertainties were not included in the margin

calculation. Margins were calculated for treatment times
shorter and longer than 12 minutes, an arbitrary time selected
to represent an average treatment appointment slot.
A subgroup analysis was performed for 9 patients for
whom an adapted mask system was used or for whom the
mask system was not perfectly suited because they were
edentulous or were wearing teeth prostheses, as described
in the Patient characteristics section.
For 10 patients, posttreatment CBCTs were additionally matched on the bite block and the nose fixation and
bite block/nose fixation matches were compared with bony
anatomy matches to assess reproducible positioning of the
fixation devices with respect to the bony anatomy.

Results
Setup accuracy

Data analysis and statistics

For 10 patients, initial CBCT matching to the reference
planning CT was independently performed by 5 radiographers to assess setup accuracy. An independent surface
tracking system to verify the setup accuracy was not used.
Intrafractional motion was calculated comparing pre- and
posttreatment CBCT for all 67 patients (375 fractions).
The 3-dimensional absolute shift was calculated by adding
lateral, longitudinal, and vertical shifts in quadrature. The
treatment time between the start of the first CBCT and the
end of the second CBCT was measured. The dependence
of the intrafractional motion on the treatment time was
evaluated using a linear regression. The van Herk formula
M = 2.5 + 0.7 was used for planning target volume
margin calculation, where represents the systematic and
the random uncertainty. 21 Systematic and random errors
were calculated for intrafractional motion as well as patient
setup inaccuracy. Total was then calculated: =
( 2patient setup + 2intrafraction motion) 1/2 as well as total :
= ( 2patient setup + 2intrafraction motion) 1/2. Contouring and

The mean total setup shift between the setup based on

the mask and the CBCT was 2.1 2.9 mm. The mean pitch
and roll was 0.1 0.7 and 0.2 0.7 (Fig 2). Patient setup
was corrected online in 4 DoF (lateral, longitudinal,
vertical, and rotation) based on the CBCT. Pitch and roll
could not be corrected because of lacking a 6-DoF couch.
A total of 98.0% of the pitch values and 98.9% of the roll
values were b 1.5. For values N 1.5, a new clinical setup
of the patient was performed and the CBCT repeated.
Systematic and random setup errors were 0.1 and 0.2 mm,
respectively. Fig 3 shows the learning curve in setting up
the patient with the mask system. The first 20 patients had
to be resetup quite frequently because of large pitch or roll
values. The frequency of repeat setups subsequently
decreased over time.

Intrafractional motion
The intrafractional motion of all patients is shown in Fig 4.
There was no systematic drift in any of the directions. The

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Figure 3 Learning curve for performing the setup with the new mask system. At the beginning we experienced large pitch-and-roll
values before treatment compared with the planning computed tomography.

Figure 4

Dependence of the total shifts of the patients during the treatment fractions on the treatment time.

maximum intrafractional motion was 2 mm longitudinally,

and 95% of the total shifts were b 1.4 mm. Mean total shift
during treatment was 0.51 mm (0.27); mean treatment time
was 10.1 minutes (1.4). The linear regression showed a
weak but significant influence (R 2 = 0.26, P = .01) of the

Figure 5

treatment time on the total intrafractional shift (Fig 4).

Systematic intrafractional uncertainties were b 0.2 mm;
random intrafractional uncertainties b 0.32 mm. Clinical
target volume to planning target volume margins (including
setup uncertainty and intrafractional uncertainty) for treatment

Absorption of the bite block and nose fixation and modeling in the Eclipse treatment planning system.

Practical Radiation Oncology: November-December 2015

times b 12 minutes were 0.7 mm; they were 0.85 mm for

treatment times N 12 minutes. The subgroup of the patients
with the adapted mask system showed a mean intrafractional
motion of 0.43 (0.24) mm, and treatment took 9.5 (1.6)
minutes, which was not significantly different (P = .589)
compared with the whole group.

Dosimetric accuracy and repositioning of the

mask system
Transmission measurements through the bite block
and nose fixation of the frame system showed absorption of
25 4% for the nose fixation and 28 5% for the bite block.
The absorption was correctly modeled in the Eclipse treatment
planning system, as demonstrated in Fig 5. A gamma
agreement analysis with 3%/1 mm showed a gamma score of
100%; with 2%/1 mm, the gamma score was 97%. However,
there was a repositioning inaccuracy of the mask system of up
to 3 mm with respect to the bony anatomy (Fig 6).

Discussion
This study evaluated the accuracy of a new intracranial
immobilization system for stereotactic treatments in 73
patients. Increasingly, departments have changed their
practice from using invasive mask systems to those that
require noninvasive fixation. This benefits the patient by not
requiring a minor procedure for fixing a rigid head ring, as
was the case for many previous stereotactic radiosurgery
procedures, and has potential benefits for streamlining
departmental workflows. Using the trUpoint ARCH fixation
system, our patients undergo individual customization of the
mask, bite block, and nose fixation at the time of the planning
CT. They no longer require a referral to a specialist dentist for
forming the bite block because it can be constructed by
radiation therapy personnel.
The mask system consists of a head cushion, bite block, nose
fixation, and open face thermoplastic mask. The open face
thermoplastic mask is convenient for the patients and may be
particularly useful for those patients with claustrophobia.

Figure 6

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693

However, there were concerns about the intrafractional patient

stability because of this partly open mask. We confirmed
excellent intrafractional stability in our patient cohort through
systematic intrafractional uncertainties b 0.2 mm and random
intrafractional uncertainties b 0.32 mm. Verbakel et al 19 studied
the intrafractional motion of 43 patients treated with SRT during
79 fractions. The intrafraction motion was 0.35 0.21 mm
(maximum, 1.15 mm) in their study using the Brainlab
stereotactic mask system (Feldkirchen, Germany), which
consists of 3 parts: a support mask for the back of the head; 3
separate firm structures for the nose, chin, and forehead; and the
frontal fixation. In comparison, we found a mean intrafractional
shift of 0.51 mm (0.27), which is slightly larger compared with
Verbakel et als result. This may be explained by the
performance status of our patient cohort because many patients
were highly palliative and had problems lying on the treatment
couch, whereas the patient cohort of Verbakel et al. was a mixed
group of patients with brain metastases, vestibular schwannomas, and meningiomas. Similarly, Santvoort et al 22 evaluated the
intrafractional motion during stereotactic radiation surgery or
SRT using the Brainlab mask system with 2 different bite block
systems and found mean values of 0.44 mm and 0.59 mm, which
are comparable to our results. Tryggestad et al 23 evaluated 4
different CIVCO mask systems and found a mean intrafractional
motion between 0.7 and 1.1 mm. Compared with our system,
they used a mask that fully covered the face but they did not
use a bite block and nose fixation. The comparison to our
achieved intrafractional motion of 0.51 mm suggests that the
bite block adds additional stability to the system compared
with just using the thermoplastic mask alone.
Hoogemann et al 24 treated 32 patients with intracranial
lesions immobilized with a 2-mm-thick thermoplastic
mask and a headrest (Sinmed BV, Reeuwijk, The
Netherlands) with the CyberKnife system (Accuray).
Intrafractional motion was assessed using stereoscopic
images every 2 minutes. They found that the systematic
and random errors increased with increasing treatment
time. Our study showed a mean increase in the total shift of
0.03 mm/min in agreement with Hoogemann et al., who
demonstrated an increase of the systematic shift of 0.05
mm/min. 24 Similarly Guckenberger et al 25 showed a
significantly increased mean intrafractional error of 1.2

Position of the mask system with respect to the bony anatomy. Lat, lateral; lng, longitudinal; vrt, vertical.

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0.7 mm for treatments times longer than 23 minutes,

compared with 0.7 0.5 mm for treatment times 23
minutes (P b .01). For immobilization they used a
thermoplastic mask (Unger Medizintechnik, MhlheimKrlich, Germany) with either a double or a single layer.
The increased instability of the patients with increased
treatment time is probably from relaxation of the patient
and increased discomfort with time; however, this was not
further investigated in this study.
The intrafractional motion of the subgroup of 9 patients
using an adapted mask system or for whom the mask system
was not perfectly suited because they were edentulous or
were wearing teeth prostheses was comparable to the whole
group of patients. There was a slight reduction in treatment
time. This might be due to optimized treatment procedures
for these patients because the radiation therapists were aware
of needing a short treatment time for these often highly
palliative patients or those suffering from claustrophobia.
At the beginning of using the mask system, we
identified issues with large pitch-and-roll values after the
first setup of the patient. Because of the lack of a 6-DoF
couch, we had to perform a second setup for these patients.
However, we found that after treating 20 patients, the
positioning improved and we had to do a second setup
much less frequently (Fig 3), suggesting a learning curve.
One explanation is that the therapists have to firmly push
the head of the patient into the cushion when making the
mask for the patient. This requires experience of the
therapists and appears to have improved with time.
The dose absorption of the nose fixation and the bite
block were rather large for a direct field (25% and 28%,
respectively) but were correctly modeled in the planning
system. However, the positioning of these pieces with
respect to the bony anatomy differed by up to 3 mm;
therefore, irradiating through these parts may lead to
under- or overdosage of up to 28% in small areas. Our
clinical planning protocols stipulate avoidance of these
parts using an avoidance sector. If this is not possible
because of violating organ-at-risk tolerances, the positioning of these parts need to be checked daily and have to be
within 1 mm compared with the bony anatomy. Alternatively, treating without the nose fixation is an option.
One limitation of our study is the lack of information on
the intrafractional motion between the 2 CBCTs. It might
be that the patient shifted during treatment and, after a
certain time, shifted back into the initial position. This shift
would remain undetected in our study. Murphy et al 26
used orthogonal kilovoltage imaging to show a systematic
drift for some patients, whereas for others, the motion
during treatment delivery is random. The random errors
lead to a smearing of the dose distribution; however, the
drift leads to severe dosimetric errors. Our method detects
these more severe errors and might miss the random errors
during delivery.
Our margin calculation according to Van Herk et al 21
was limited by the fact that no contouring uncertainty and

Practical Radiation Oncology: November-December 2015

no linear accelerator inaccuracy were considered in the

calculation. However, our calculated systematic and
random setup and intrafractional uncertainties can be
used in combination with department-specific contouring
and delivery system inaccuracy to calculate departmentspecific margins.
Our study did not include a prospective assessment of
patient comfort using the trUpoint ARCH fixation system.
Given that the mask has an open face, it is possible that this
mask system is more comfortable and may benefit those
patients with claustrophobia. This would be an important
aspect to investigate and is a limitation of this study.

Conclusion
Our noninvasive intracranial immobilization system for
stereotactic treatments with a customized mask, cushion,
bite block, and nose fixation appeared to be robust in terms
of setup accuracy, intrafraction motion, and repositioning
of the mask system. Daily CBCT and online matching was
performed to attain this accuracy and to achieve optimized
patient safety.

Acknowledgments
We thank the medical radiation therapists in our
department for collecting data for this study.

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