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Background  To improve the delivery of radiotherapy in gynecologic malignancies and to minimize the irradiation of unaffected tissues by using daily kilovoltage cone beam computed tomography (kV-CBCT) to reduce setup errors.    Methods  Thirteen patients with gynecologic cancers were treated with postoperative volumetric-modulated arc therapy (VMAT). All patients had a planning CT scan and daily CBCT during treatment. Automatic bone anatomy matching was used to determine initial inter-fraction positioning error. Positional correction on a six-degrees-of-freedom (6DoF) couch was followed by a second scan to calculate the residual inter-fraction error, and a post-treatment scan assessed intra-fraction motion. The margins of the planning target volume (M PTV ) were calculated from these setup variations and the effect of margin size on normal tissue sparing was evaluated.    Results  In total, 573 CBCT scans were acquired. Mean absolute pre-/post-correction errors were obtained in all six planes. With 6DoF couch correction, the M PTV  accounting for intra-fraction errors was reduced by 3.8–5.6 mm. This permitted a reduction in the maximum dose to the small intestine, bladder and femoral head ( P  = 0.001, 0.035 and 0.032, respectively), the average dose to the rectum, small intestine, bladder and pelvic marrow ( P  = 0.003, 0.000, 0.001 and 0.000, respectively) and markedly reduced irradiated normal tissue volumes.    Conclusions  A 6DoF couch in combination with daily kV-CBCT can considerably improve positioning accuracy during VMAT treatment in gynecologic malignancies, reducing the M PTV . The reduced margin size permits improved normal tissue sparing and a smaller total irradiated volume.

radiation oncology

Positioning accuracy during VMAT of gynecologic malignancies and the resulting dosimetric impact by a 6-degree-of-freedom couch in combination with daily kilovoltage cone beam computed tomography