SABR treatments were delivered using a Varian Edge linear accelerator with a 6°-of-freedom couch. EMT beacon localization telemetry was used to measure the intertransponder distance (ITD) difference (defined as the difference of distance between any 2 EMTs measured at planning and before each treatment fraction), and the geometric residual (GR; defined as root mean squared error of intertransponder distance) was calculated. A GR < 0.2 cm was required to proceed with EMT-guided RG-SABR. Daily setup and verification cone beam CT scans were performed daily to verify beacon positions pre- and posttreatment and to assess for the possibility of beacon migration. EMT positional data were captured in real-time during each fraction to ensure data fidelity throughout the entire setup and treatment procedure and to allow personnel to gain familiarity with the operation of the EMT system. For the first 2 patients (phase 1), the beam was not gated on/off using EMT telemetry and patients were treated FB. For phase 2, patients were FB and the beam was gated on/off automatically using the EMT telemetry. For 1 patient, who was simulated and treated with a prone DIBH technique because of tumor location, audio coaching was used to provide feedback to the patient when EMT telemetry confirmed they were in a proper breath hold.
Edge linear accelerator
Manufactured by Agilent Technologies
Sourced in United States
The Edge linear accelerator is a compact and versatile medical device designed for radiation therapy. It generates high-energy X-rays or electron beams for the treatment of various types of cancer. The Edge linear accelerator provides precise and targeted radiation delivery to the tumor site, while minimizing exposure to surrounding healthy tissues.
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7 protocols using edge linear accelerator
1
Electromagnetic Tracking for Stereotactic Body Radiotherapy
2
SBRT for Stereotactic Radiotherapy
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The original patient treatments were all prescribed with the standard regiment of a total dose of 50 Gy in 5 fractions. SBRT plans were generated for each of the 20 patients, strictly following the clinical and dosimetric objectives of RTOG 0915. The plans were generated using Pinnacle3TM treatment planning system (TPS, v9.10, Philips Medical Systems, Cleveland, USA) for an Edge linear accelerator (Varian, Palo Alto, CA) equipped with 120 MLC leaves (Millennium MLC) and 6MV photon beam. All the patients received SBRT on a linear accelerator equipped with CBCT using online IGRT (Varian, Palo Alto, CA) for every fraction.
3
Personalized IMRT for SBRT
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Targets and OARs were delineated on a MIM Maestro Station (MIM Vista Corp, Cleveland, US-OH) based on four-dimensional CT (4DCT) by radiation oncologists. All structures were reviewed and approved by an experienced radiation oncologist before being used for planning design. All the treatment plans were planned on the average 4DCT image using the Pinnacle Treatment Planning System (TPS) (V9.10, Philips Radiation Oncology Systems, Fitchburg, WI, USA) for an Edge™ linear accelerator (Varian Medical Systems, Palo Alto, CA) equipped with a high-definition 120 multileaf collimator (MLC). The included treatment plans ranged from three to eight fractions, and the planning method was similar to our previous research (15 (link)). In short, treatments were planned following the guidelines of RTOG 0813 (16 (link)) or 0915 (17 (link)) depending on its tumor size, the patient’s physical condition, and location, which employed the IMRT technique with 10 or more 6MV fields. Collimator and couch angles were adjusted according to the individual situation. The collapsed cone convolution (CCC) algorithm was used for dose calculation with a calculation resolution of 1.0 mm.
4
Orbital Low-Grade NHL Radiation Therapy
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All patients were immobilized with a custom thermoplastic mask and received computed tomography (CT) scans on a Brilliance BigBore scanner (Philips Healthcare, Andover, MA, USA) with a 1 mm slice thickness. The CT images were transferred to treatment planning system (Eclipse Version 13.6, Varian Medical Systems Inc., Palo Alto, CA) for volumetric modulated arc therapy (VMAT) plan generation. The clinical target volume (CTV) was defined as the specific orbit lesion. The CTV-to-planned target volume (PTV) treatment margins were 2 mm. The prescription dose was delivered to CTV by 4 Gy in 2 fractions for first line treatment, and additional 24 Gy in 12 fractions for cases with local recurrence. Plans were generated for an EDGE linear accelerator (Varian Medical Systems, Palo Alto, CA) using 6 MV photons with high-definition multi-leaf collimator(MLC). 2 partial arcs rotating from 260° to 100° clockwise then back were used. Five patients with bilateral lesions were treated simultaneously.
All patients underwent excisional biopsies prior to RT. Radiothearpy was given when ocular adnexal low-grade NHL was pathologically confirmed. Time duration between operation and RT was usually within one month.
All patients underwent excisional biopsies prior to RT. Radiothearpy was given when ocular adnexal low-grade NHL was pathologically confirmed. Time duration between operation and RT was usually within one month.
5
Linear Accelerator Beam Control Protocol
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The coordinate systems used here are described by the International Electrotechnical Commission publication IEC 61217.20 Control point sequences were designed for the 10 MV flattening filter free beam of an Edge linear accelerator (Varian Medical Systems, Palo Alto, CA) equipped with a 120-leaf NDS120HD MLC, having leaf width of 2.5 mm in the central 8 cm and 5 mm in the outer 14 cm.
6
Automated Treatment Plans for IMRT
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Static IMRT plans were made for all patients using 5 to 7 coplanar beams with 6 MV on Pinnacle 9.10 TPS. The beams' angle was designed according to the patient current clinical situation. Edge linear accelerator (Varian Medical Systems, Palo Alto, CA) was selected. The optimization algorithm used the direct machine parameter optimization (DMPO) and the dose calculation employed the collapsed cone concentration (CCC) algorithm. The dose rate of all plans was 600 MU/min, and the grid resolution of the dose calculation was 3 mm.
In the design of the plan, 95% of the PTV received 100% of the prescribed dose. One percent of the PTV not to exceed 110% of the prescribed dose and 1% of the PTV not less than 95% of the prescribed dose. The OARs' dose constraint was based on our center clinical standard, which details are listed in Table 2 . To reduce the required planning time, improve the plan overall quality, and reduce the differences between the plan designers, the auto-planning module that was built in the pinnacle 9.10 TPS, was used to generate plans. Using the same beam setting and optimization objectives for OARs, two treatment plans were independently generated for each patient according to two PTVs: Plan-0 was optimized using the PTV-0 and Plan-1 with the PTV-1.
In the design of the plan, 95% of the PTV received 100% of the prescribed dose. One percent of the PTV not to exceed 110% of the prescribed dose and 1% of the PTV not less than 95% of the prescribed dose. The OARs' dose constraint was based on our center clinical standard, which details are listed in Table 2 . To reduce the required planning time, improve the plan overall quality, and reduce the differences between the plan designers, the auto-planning module that was built in the pinnacle 9.10 TPS, was used to generate plans. Using the same beam setting and optimization objectives for OARs, two treatment plans were independently generated for each patient according to two PTVs: Plan-0 was optimized using the PTV-0 and Plan-1 with the PTV-1.
7
Retrospective Lung Cancer IMRT Plans
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From May 2018 to June 2020, 612 IMRT treatment plans of lung cancer patients were retrospectively selected. All these clinical plans were designed by three experienced dosimetrists. Each of these original clinical plans consisted of four to seven coplanar 6 MV photon beams. An Edge linear accelerator (Varian, Palo Alto, CA) was selected for dose delivery. All plans were normalized; thus, 95% of the PTV received 100% of the prescription dose. Each treatment plan consisted of a computed tomography (CT) scan, PTV contour(s), OAR contours, prescription dose, beam arrangement, optimization goals, and clinically delivered dose distribution that was calculated in the Pinnacle 9.10 treatment planning system (TPS; Philips Healthcare, Fitchburg, WI, USA). All the contours of PTV and OARs were delineated by junior radiation oncologists and reviewed by experienced radiation oncologists. OARs included left lung, right lung, total lung, spinal cord, and heart in this study.
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