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Background  An accurate, reproducible, and comfortable immobilization device is essential for stereotactic radiotherapy (SBRT) in patients with lung cancer. This study compared thermoplastic masks (TMP) and vacuum cushion (VCS) system to assess the differences in interfraction and intrafraction setup accuracy and the impact of body mass index (BMI) with respect to the immobilization choice.    Methods  This retrospective study was conducted on patients treated with lung SBRT between 2012 and 2015 at the Zhejiang cancer hospital. The treatment setup accuracy was analyzed in 121 patients. A total of 687 cone beam computed tomography (CBCT) scans before treatment and 126 scans after treatment were recorded to determine the uncertainties, and plan target volume margins. Data were further stratified and analyzed by immobilization methods and patients’ BMI. The t-test (Welch) was used to assess the differences between the two immobilization systems when stratified by the patients’ BMI.    Results  For patients with BMI ≥ 24, the mean displacements for the TMP and VCS systems were 1.4 ± 1.2 vs. 2.4 ± 2.0 mm at medial-lateral (ML) direction ( p  < 0.001); 2.0 ± 1.9 vs. 2.0 ± 1.9 mm at cranial-caudal (CC) direction ( p  = 0.917); and 2.4 ± 1.4 vs. 2.6 ± 2.1 mm at anterior-posterior (AP) direction, ( p  = 0.546). The rate of acceptable errors increased dramatically when immobilized by TMP. In the case of patients with BMI < 24, the mean displacements for the TMP and VCS systems were 1.8 ± 1.4 vs. 2.1 ± 1.8 mm at ML direction ( p  = 0.098); 2.9 ± 2.3 vs. 2.2 ± 2.2 mm at CC direction ( p  = 0.001); and 1.8 ± 1.8 vs. 2.3 ± 2.0 mm at CC direction, ( p  = 0.006). The proportion of acceptable errors increased after immobilization by VCS. No difference was detected in the intrafraction setup error by different immobilization methods.    Conclusions  The immobilization choice of SBRT for lung tumors depends on the BMI of the patients. For patients with BMI ≥ 24, TMP offers a better reproducibility with significantly less interfractional setup displacement than VCS, resulting in fewer CBCT scans. However, VCS may be preferred over TMP for the patients with BMI < 24. Therefore, an optimal immobilization system needs to be considered in different BMI groups for lung SBRT.

Choice of immobilization of stereotactic body radiotherapy in lung tumor patient by BMI