ORIGINAL ARTICLE

Evaluation of accuracy and reproducibility of a relocatable

maxillary fixation system for fractionated intracranial
stereotactic radiation therapy
Majella Russo, BAppSc,1 Rebecca Owen, PhD, FIR,2 Anne Bernard, PhD,3 Vaughan Moutrie, BMSc, 1
& Matthew Foote, MBBS (Hons) FRANZCR1,4
1
Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
2
Radiation Oncology Mater Centre, Princess Alexandra Hospital, South Brisbane, Queensland, Australia
3
QFAB Bioinformatics, Institute for Molecular Bioscience, University of Queensland, Brisbane, Queensland, Australia
4
School of Medicine, University of Queensland, Brisbane, Queensland, Australia

Keywords Abstract
Intracranial, radiotherapy, stereotactic
Introduction: Accurate localisation is an essential component for the delivery
Correspondence of intracranial stereotactic treatment. For fractionated stereotactic radiotherapy,
Majella Russo, Department of Radiation we compared the daily localisation accuracy of a standard thermoplastic mask
Oncology, Ground Floor F Princess Alexandra with a new maxillary fixation device (MFD). Methods: Daily pre-treatment kV
Hospital, 199 Ipswich Road, Woolloongabba cone-beam computed tomography (CBCT) scans of 23 patients (12 localised in
4102, Queensland, Australia. Tel: +61 7
the MFD and 11 in the mask) with benign skull-based lesions were reviewed
3176 6568; Fax: +61 7 3176 6127;
E-mail: [email protected]
retrospectively. The set up accuracy was measured in 6° of freedom, to
ascertain both individual and population random and systematic errors. The
Funding Information appropriate clinical target volume to planning target volume margin was
No funding information provided. computed from set up error data. Results: A total of 682 CBCT scans were
evaluated. Systematic (Σ) and random (r) population errors were Σ = 0.8 mm,
Received: 10 February 2015; Revised: 24 0.2 mm and 0.2 mm and r = 0.3 mm, 0.3 mm and 0.2 mm, respectively, for
June 2015; Accepted: 16 August 2015
the standard mask in the left/right (LR), superior/inferior (SI), and anterior/
posterior (AP) translational planes, and Σ = 0.2 mm, 0.1 mm and 0.2 mm and
J Med Radiat Sci 63 (2016) 41–47
r = 0.2 mm, 0.3 mm and 0.2 mm, respectively, for the MFD. There was a
doi: 10.1002/jmrs.142 reduction in rotation errors in the MFD compared to the mask. Margin
calculations suggested an isotropic margin could be safely reduced to 2 mm for
the MFD. Conclusion: The two devices demonstrate similar daily positional
accuracy for fractionated stereotactic treatment of intracranial lesions.
Combined with daily image guidance and couch correction, either of these
devices is a viable frameless option for fractionated stereotactic radiation
therapy.

volume and OAR. Accurate localisation is essential to

Introduction
ensure safe dose delivery to the target while sparing
The management of skull base tumours is complex with surrounding OAR and preserving functional outcome.
lesions frequently abutting or surrounding optic structures These restrictions necessitate reliable patient set up and a
and other cranial nerves. Gross surgical removal is often small imaging action level.
not possible without significant patient morbidity.1,2 Frameless stabilisation devices are becoming
Fractionated stereotactic radiotherapy, hypo- increasingly common in the treatment of stereotactic
fractionated stereotactic radiotherapy and radiosurgery radiation therapy, especially for hypo-fractionated and
are established treatments in the management of skull fully fractionated treatment regimes, due to the invasive
base tumours.1–4 Treatment with radiation is complex nature of the frame-based system. Thermoplastic masks,
due to the proximity of critical organs at risk (OAR), alone or in combination with bite blocks have been used
mandating a steep dose gradient between the treatment successfully for intracranial lesions.5,6 On-board imaging

ª 2015 The Authors. Journal of Medical Radiation Sciences published by Wiley Publishing Asia Pty Ltd on behalf of 41
Australian Institute of Radiography and New Zealand Institute of Medical Radiation Technology.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.
Evaluation of Patient Positioning With Fraxion M. Russo et al.

and couch correction is also employed to assist patient

Pre-simulation
localisation.7
The aim of this study was to evaluate the difference Patients were required to attend a dental appointment to
between a current and a new stabilisation device for ascertain suitability for the new system. A dental mould
patients receiving intracranial fractionated stereotactic was taken and converted into a plaster positive, which
radiotherapy. A new relocatable headframe with a was made into the requisite mouthpiece prior to the
maxillary fixation device (MFD), which differs from the patient presenting to the department.
standard bite-block systems, was assessed for its accuracy
in reproducible daily patient set up, in comparison with
Simulation
the department’s standard immobilisation mask. These
results were then used to determine if current planning Patients attended a planning session for set up simulation
margins were appropriate for the two devices. and a computed tomography (CT) scan. The mouthpiece,
attached to the loosely assembled frontpiece, was inserted
into the patient’s mouth with the vacuum applied to a
Methods
level of 40% (400 mbar at sea level) prior to the patient
being directed onto the head cushion. The frontpiece was
Subject population
placed tension-free onto the headframe before being
Patients were selected for inclusion in this study if they clamped into place. The head cushion was evacuated
were treated using the MFD and had a benign
intracranial tumour diagnosis. A minimum of one viable
maxillary tooth was required for eligibility with the MFD (a)
within our department, to provide an anchor for the
mouthpiece prior to the vacuum suction being applied.
The first 12 patients positioned using the MFD that met
the inclusion criteria were included in this evaluation.
Data were also collected on 11 control patients with
similar benign tumour characteristics treated with the
standard mask in order to compare the accuracy and
reproducibility of the two systems within similar patient
cohorts. Ethics exemption was obtained through the
Institutional Human Research Ethics Committee.
The standard immobilisation device at this institution
for intracranial treatments is a Type-S Head-Only
thermoplastic mask (Civco Medical Solutions, Rotterdam,
The Netherlands), using either the Posifix Supine
Headrests or the Silverman Headrests (Civco Medical (b)
Solutions).

MFD system description

Figure 1 illustrates the primary components of the
Fraxion system (Elekta, Stockholm, Sweden) (referred to
as the MFD). The MFD is a similar device to the eXtend
system for Elekta Perfexion Gamma Knife treatment.8,9
The MFD consists of a table top adapter fastened to a
repositioning carbon fibre headframe, to which
a frontpiece and a mouthpiece are attached. A vacuum
head cushion inserts into the base plate of the headframe.
A patient control unit (PCU) is connected to the
Figure 1. (A) Components of the Elekta Fraxion stabilisation system.
mouthpiece with tubing, providing a vacuum that PCU, headframe and frontpiece with mouthpiece and inflated
correctly positions the mouthpiece and removes saliva vacuum headrest (image courtesy of Princess Alexandra Hospital
from the patient’s mouth. A stereotactic frame and Radiation Oncology Department). (B) Elekta Fraxion system in place
templates are used for daily localisation. for patient set up (image courtesy of Elekta, Elekta catalogue).

42 ª 2015 The Authors. Journal of Medical Radiation Sciences published by Wiley Publishing Asia Pty Ltd on behalf of
Australian Institute of Radiography and New Zealand Institute of Medical Radiation Technology
M. Russo et al. Evaluation of Patient Positioning With Fraxion

before tightening the frontpiece securing screws with a this action level. Any movement using Hexapod required
torque wrench, which was not adjusted for the duration a post-shift verification CBCT scan prior to the
of the patient’s treatment. The PCU provided surveillance commencement of treatment. All CBCT scans were sent
and alarmed if the vacuum fell below 90% of the original to the radiation oncologist for offline review and
level. MFD patients had an hour allocated for their approval. For this study, data were collected without
simulation session, compared to 30 min for the standard influence of couch correction to assess daily stabilisation
device. of the devices alone. Data were also collected at 1 mm/1°
Staff training in the production of mouthpieces and action levels to assess errors if margin reduction was
use of the equipment was originally provided by the applied.
vendor, and then as an in-house training programme.
The dentist involved provided additional support.
Statistical analysis
A CT scan was performed for all patients using the
Aquilion (Toshiba Medical Systems, Europe BV) scanner Systematic set up errors (individual mean set up error,
with 2 mm slices. overall population mean set up error and population
systematic error) and random set up errors (individual
random error and population random error) were
Planning
computed following the formula described by the Royal
The gross tumour volume (GTV) or clinical target College of Radiologists10 (chapter 4). To assess the
volume (CTV) were marked, with a 2–3 mm isotropic significance of the difference of the individual mean set
margin to create the planning tumour volume (PTV) at up error and individual random error between standard
the physician’s discretion. Critical OAR, especially optic and new conditions, independent t-tests were performed.
nerves and optic chiasm, were also given a 2–3 mm Statistical significance was defined as P ≤ 0.05. Statistical
expanded planning risk volume to help shape the rapid analyses were performed using R statistical software
dose falloff and also to provide a small safety margin (http://www.r-project.org/).
whereby high dose did not abut the OAR. Patients were Random and systematic errors for both the individual
planned using intensity modulated radiation therapy and and population (translation and rotation) were calculated
volumetric modulated arc therapy. and recorded using previously published methods.10
Population random (r) and systematic (Σ) errors were
calculated as the mean of the individual random errors
Treatment
and the SD of the individual systematic errors
Treatment was delivered using 6 MV on the Elekta respectively. For calculating set up error and resultant
Axesse linear accelerator, which operates with 4 mm margins,11 both Van Herk’s (2.5Σ + 0.7r) and Stroom’s
multi-leaf collimator leaves. Each day a pre-treatment (2Σ + 0.7r) margin calculations12,13 were selected.
cone-beam computed tomography (CBCT) scan was
taken and a bone match (translation and rotation) was
Results
performed using the Elekta XVI imaging system, within a
clipbox defined by a single radiation oncologist. Observed
Patient demographics
errors were recorded in the left/right (LR), superior/
inferior (SI) and anterior/posterior (AP) translation and Between October 2012 and December 2013, 13 patients
the pitch, roll and yaw rotation directions for each CBCT that met the inclusion criteria were treated using the
scan. Patients were scanned using F0 filter/S10 MFD, and 11 patients with benign skull-based lesions
collimation insert, rotating 100° at a speed of 360° per were treated using the mask on the Elekta Axesse
minute. About 183 frames were captured, and the dose machine. One patient treated with the MFD device was
per CBCT scan was 0.5 mGy. All images were excluded from the study due to poor moulding of the
independently checked by two radiation therapists prior MFD mouthpiece requiring re-simulation. Consequently,
to treatment, and the match results recorded from the a total of 23 patients were included in this evaluation.
initial bone match without adjustment to eliminate inter- Twenty (87%) patients had a skull base meningioma.
user error. Patients were planned using between four and seven
Patients had a 2 mm/2° action level, whereby intensity modulated radiation therapy fields or one to
correction was not applied if errors fell below this level. two volumetric modulated arc therapy arcs. Non-coplanar
Hexapod table correction was made using the IGuide angles were utilised in 18 (78%) of the 23 patients.
tracking system (Elekta), which corrects for all 6° of Patients were treated with a median dose of 54 Gy in 30
freedom, for all treatment fractions that fell outside of fractions (range 50.4–60 Gy in 28–30 fractions).

ª 2015 The Authors. Journal of Medical Radiation Sciences published by Wiley Publishing Asia Pty Ltd on behalf of 43
Australian Institute of Radiography and New Zealand Institute of Medical Radiation Technology
Evaluation of Patient Positioning With Fraxion M. Russo et al.

A total of 682 pre-treatment CBCT scans were Table 2. Errors for individuals in standard mask versus new MFD
analysed, 356 in the test group and 326 in the standard conditions.
group. Mean systematic error (Σ) Mean random error (r)
(mm) (mm)

Errors Standard P- Standard P-

Direction mask MFD value mask MFD value
Table 1 describes the daily set up error and separates the
CBCT images into groups exceeding the action levels Trans (L/ 0.5 0.3 0.43 0.3 0.2 0.52
listed (1 mm/1°, 2 mm/2°). There is a notable difference R)
Trans (S/ 0.5 0.5 0.91 0.3 0.3 0.55
in the number of images falling outside the rotational
I)
thresholds for the standard device compared to the MFD. Trans 0.8 0.6 0.021 0.2 0.2 0.16
The comparison of the mean systematic and random (A/P)
errors between individuals in both devices is displayed in
Table 2. Significantly different results for the MFD were (degrees) (degrees)
found in the AP direction (P = 0.02) and the mean
Rot (pitch) 0.09 0.09 1 0.21 0.16 0.12
random rotation errors in the roll (P = 0) and yaw
Rot (roll) 0.36 0.59 0.35 0.30 0.07 01
(P = 0) values against the mask. Rot (yaw) 0.57 0.49 0.74 0.18 0.09 01
Differences in the individual mean set up errors for
1
rotation are shown in Figure 2. The mask showed a Indicates statistical significance.
MFD, maxillary fixation device; L/R, left/right; S/I, superior/inferior; A/P,
maximum error of 1.02° and the MFD had a maximum
anterior/posterior; trans, translational planes; rot, rotation.
error of 0.21°.

the 1 mm/1° and 2 mm/2° action level thresholds. The

Margin selection
translation errors were comparable for both conditions.
Table 3 shows the summarised data for the population The findings of this study are consistent with similar
random and systematic errors, and the resultant margins published studies. Rosenfelder et al.14 showed errors of
populated from the above-mentioned formulae. A margin 0.3–0.7 mm/° and 0.6–1.5 mm/° for the Gill–Thomas–
of up to 2.2 mm for the mask and less than 1 mm for Cosman frame and three-point thermoplastic shell
the MFD was calculated using Van Herk’s and Stroom’s respectively. An overall error of 1.2 mm was noted in
formulae. Peng et al.’s15 study of a bite plate and thermoplastic
mask. Ruschin et al.9 reported that the Perfexion
repositioning headframe system, which is most similar to
Discussion
the Fraxion system, had a 3D mean positioning
The MFD was evaluated as an alternative device to the displacement of 1.1  0.8 mm.
mask-based immobilisation system for the treatment of Safely reducing planning margins, while adequately
fractionated stereotactic radiotherapy. Differences between treating tumour volumes, can decrease dose to normal
the two devices were most noticeable for rotations, in both brain tissue and critical OAR, leading to better functional

Table 1. Proportion of CBCT images outside imaging action thresholds for the standard mask and new MFD conditions.

Number of images

Translation Rotation

Imaging action threshold Condition Left/right Superior/inferior Anterior/posterior Left/right Superior/inferior Anterior/posterior

≥1 mm/1° Standard 128/326 180/326 171/326 121/326 138/326 105/326

(%) 39.26 55.21 52.45 37.12 42.33 32.21
New 201/356 167/356 143/356 50/356 65/356 67/356
(%) 56.46 46.91 40.17 14.04 18.26 18.82
≥2 mm/2° Standard 67/326 71/326 64/326 22/326 33/326 15/326
(%) 20.55 21.78 19.63 6.75 10.12 4.6
New 61/356 49/356 71/356 5/356 0/356 0/356
(%) 17.13 13.76 19.94 1.4 0 0

MFD, maxillary fixation device; CBCT, cone-beam computed tomography.

44 ª 2015 The Authors. Journal of Medical Radiation Sciences published by Wiley Publishing Asia Pty Ltd on behalf of
Australian Institute of Radiography and New Zealand Institute of Medical Radiation Technology
M. Russo et al. Evaluation of Patient Positioning With Fraxion

3 Ideal mean error

Clinical threshold

Mean error for shift (in degree)

1

–1

–2

–3
rotX.stand

rotX.New

rotY.stand

rotY.New

rotZ.stand

rotZ.New
Figure 2. Individual mean set up errors for rotation in the standard mask and new MFD conditions. rot, rotation; stand, standard; X rotation,
pitch; Y rotation, roll; Z rotation, yaw.

Table 3. Summarised data of errors and Population set up

margin calculations in the standard mask and errors
new MFD devices.
Systematic Random Van Herk’s Stroom’s
Condition Direction (Σ) (r) (2.5Σ + 0.7r) (2Σ + 0.7r)

Standard Trans L/R (mm) 0.8 0.3 2.2 1.8

Trans S/I (mm) 0.2 0.3 0.7 0.6
Trans A/P (mm) 0.2 0.2 0.6 0.5
Rot pitch (degrees) 1.02 0.21
Rot roll (degrees) 0.47 0.30
Rot yaw (degrees) 0.39 0.18
New Trans L/R (mm) 0.2 0.2 0.6 0.5
Trans S/I (mm) 0.1 0.3 0.5 0.4
Trans A/P (mm) 0.2 0.2 0.6 0.5
Rot pitch (degrees) 0.21 0.16
Rot roll (degrees) 0.19 0.07
Rot yaw (degrees) 0.21 0.09

MFD, maxillary fixation device; L/R, left/right; S/I, superior/inferior; A/P, anterior/posterior; trans,
translational planes; rot, rotation.

outcomes for patients with brain tumours.16 Decreasing positioning than the other. However, the margin
the tumour volume may also potentially increase tumour formulae indicate that, based on the daily random and
control or reduce radiation-induced side effects for systematic set up errors alone, our current practice of
patients with a meningioma diagnosis.17 Although the using a 3 mm margin is still feasible for the mask, while
findings suggest the MFD provides better daily a 2 mm margin could be safely considered for the MFD.
reproducibility statistically, there is not enough clinical The results do also suggest that while the two devices are
significance to suggest one device gives superior daily similar clinically, the current institutional practices are of

ª 2015 The Authors. Journal of Medical Radiation Sciences published by Wiley Publishing Asia Pty Ltd on behalf of 45
Australian Institute of Radiography and New Zealand Institute of Medical Radiation Technology
Evaluation of Patient Positioning With Fraxion M. Russo et al.

a high standard. While not assessed in this study, it is

Conflict of Interest
also important to note the significant roles that daily
image guidance and couch correction play in their ability The authors declare no conflict of interest.
to safely reduce margins for these patients.
The potential benefits of margin reduction with the References
MFD need to be considered in the context of changes 1. Sughrue ME, Rutkowski MJ, Aranda D, Barani IJ,
to departmental workflow. Our department was reliant McDermott MW, Parsa AT. Factors affecting outcome
on a dentist to create the plaster positive for the following treatment of patients with cavernous sinus
mouthpiece, and required additional resources and meningiomas. J Neurosurg 2010; 113: 1087–92.
training for staff. The MFD was a more labour intensive 2. Dufour H, Muracciole X, Metellus P, Regis J, Chinot O,
process than the mask, and additional time was required Grisoli F. Long-term tumor control and functional
to fit and clean the mouthpiece daily. Patient outcome in patients with cavernous sinus meningiomas
compliance was essential to the mouthpiece fitting and treated by radiotherapy with or without previous surgery:
working well. Is there an alternative to aggressive tumor removal?
A limitation of this study was that intra-fraction Neurosurgery 2001; 48: 285–96.
motion was not assessed. Further research is warranted to 3. Metellus P, Batra S, Karkar S, et al. Fractionated
determine if the MFD is better able to stabilise patients conformal radiotherapy in the management of cavernous
who are having stereotactic radiation therapy by sinus meningiomas: Long-term functional outcome and
including an intra-fractional component, which may tumor control at a single institution. Int J Radiat Oncol
show a more clinically relevant difference between the Biol Phys 2010; 78: 836–43.
two systems. 4. Elia AE, Shih HA, Loeffler JS. Stereotactic radiation
Another limitation of this study was our inability with treatment for benign meningiomas. Neurosurg Focus 2007;
this current practice to assess isocentric movement when 23: 1–7.
treating non-coplanar fields. It is important to note that 5. Minniti G, Scaringi C, Clarke E, Valeriani M, Osti M,
other potential sources of error, such as imaging Enrici RM. Frameless linac-based stereotactic
resolution and fusion accuracy, mechanical and treatment radiosurgery (SRS) for brain metastases:
isocentre size and positional accuracy, are not included in Analysis of patient repositioning using a mask fixation
the selected margin formulae. However, any potential system and clinical outcomes. Radiat Oncol 2011; 6:
mechanical errors such as differences between the kV and 158–63.
MV isocentres or accurate laser position would be equally 6. Nath SK, Lawson JD, Wang JZ, et al. Optically-
present for both devices. guided frameless linac-based radiosurgery for brain
metastases: Clinical experience. J Neurooncol 2010; 97:
67–72.
Conclusion
7. Tryggestad E, Christian M, Ford E, et al. Inter- and
Equipment capable of precise and accurate intrafraction patient positioning uncertainties for
immobilisation and reproducibility, in combination with intracranial radiotherapy: A study of four frameless,
image guidance and couch correction, is vital to the thermoplastic mask-based immobilization strategies using
delivery of stereotactic radiotherapy. The results of this daily Cone-Beam CT. Int J Radiat Oncol Biol Phys 2011;
study have shown that the MFD provides comparable 80: 281–90.
positioning accuracy and reproducibility to a standard 8. Sayer FT, Sherman JH, Yen CP, Schlesinger DJ, Kersh R,
thermoplastic mask and has the potential to enable Sheehan JP. Initial experience with the extend system:
margin reduction when used in conjunction with daily A relocatable frame system for multiple-session
image guidance and couch correction. Either device is a gamma knife radiosurgery. World Neurosurg 2011; 75:
valid frameless option for intracranial stereotactic 665–72.
radiation therapy. 9. Ruschin M, Nayebi N, Carlsson P, et al. Performance of a
novel repositioning head frame for Gamma Knife
Perfexion and image-guided linac-based intracranial
Acknowledgements stereotactic radiotherapy. Int J Radiat Oncol Biol Phys
The authors thank the staff members and the 2010; 78: 306–13.
management at the Princess Alexandra Hospital, and the 10. The Royal College of Radiologists SoR, Institute of Physics
Private Practice Trust Fund that contributed to time in and Engineering in Medicine. On Target: Ensuring
Geometric Accuracy in Radiotherapy. The Royal College of
the research position. Special thanks to Eric Hew,
Radiologists, London 2008.
Elizabeth Brown, Ryan Lusk and Brock Lamprecht.

46 ª 2015 The Authors. Journal of Medical Radiation Sciences published by Wiley Publishing Asia Pty Ltd on behalf of
Australian Institute of Radiography and New Zealand Institute of Medical Radiation Technology
M. Russo et al. Evaluation of Patient Positioning With Fraxion

11. van Herk M. Errors and margins in radiotherapy. Seminars radiotherapy in a three-point thermoplastic shell. Clin
in Radiat Oncol 2004; 14: 52–64. Oncol 2013; 25: 66–73.
12. Das S, Isiah R, Rajesh B. Accuracy of relocation, 15. Peng LC, Kahler D, Samant S, et al. Quality assessment of
evaluation of geometric uncertainties and clinical frameless fractionated stereotactic radiotherapy using cone
target volume (CTV) to planning target volume (PTV) beam computed tomography. Int J Radiat Oncol Biol Phys
margin in fractionated stereotactic radiotherapy for 2010; 78: 1586–93.
intracranial tumors using relocatable Gill-Thomas- 16. Shields LBE, Coons JM, Dedich C, et al. Improvement of
Cosman (GTC) frame. J Appl Clin Med Phys 2011; 12: therapeutic index for brain tumors with daily image
29–38. guidance. Radiat Oncol 2013; 8: 283–9.
13. Dionisi F, Palazzi MF, Bracco F, et al. Set-up errors and 17. Lee SR, Yang KA, Kim SK, Kim SH. Radiation-induced
planning target volume margins in head and neck cancer intratumoral necrosis and peritumoral edema after gamma
radiotherapy: A clinical study of image guidance with on- knife radiosurgery for intracranial meningiomas. J Korean
line cone-beam computed tomography. Int J Clin Oncol Neurosurg 2012; 52: 98–102.
2013; 18: 418–27.
14. Rosenfelder N, Corsini L, McNair H, et al. Achieving the
relocation accuracy of stereotactic frame-based cranial

ª 2015 The Authors. Journal of Medical Radiation Sciences published by Wiley Publishing Asia Pty Ltd on behalf of 47
Australian Institute of Radiography and New Zealand Institute of Medical Radiation Technology