Surface-guided radiotherapy improves rotational accuracy in gynecological cancer patients.

Background: The aim of this study was to determine if rotational uncertainties in gynecological cancer patients can be reduced using surface imaging (SI) compared to aligning three markers on the patient's skin with in-room lasers (marker-laser). Materials and methods: Fifty gynecological cancer patients treated with external-beam radiotherapy were retrospectively analyzed; 25 patients were positioned with marker-laser and 25 patients were positioned with SI. The values of rotational (pitch and roll) deviations of the patient positions between the treatment-planning computed tomography (CT) and online cone-beam computed tomography (CBCT) were collected for both subcohorts and all treatment fractions after performing automatic registration between the two image sets. Statistical analysis of the difference between the two set-up methods was performed using the Mann-Whitney U-test. Results: The median pitch deviation were 1.5° [interquartile range (IQR): 0.6°-2.6°] and 1.1° (IQR: 0.5°-1.9°) for the marker-laser and SI methods, respectively (p < 0.01). The median roll deviation was 0.5° (IQR: 0.2°-0.9°), and 0.7° (IQR: 0.3°-1.2°) for the marker-laser and SI methods, respectively (p < 0.01). Given the shape of the target, pitch deviations had a greater impact on the uncertainty at the periphery of the target and were considered more relevant. Conclusion: By introducing SI as a set-up method in gynecological cancer patients, higher positioning accuracy could be achieved compared with the marker-laser set-up method. This was demonstrated based on residual deviations rather than deviations corrected for by image-guided radiotherapy (IGRT).