This is a summary of the design and concept of the RefleXion X1, a system for biology-guided radiotherapy (BgRT). This system is a multi-modal tomography (PET, fan-beam kVCT, and MVD) treatment machine that utilizes imaging and therapy planes for optimized beam delivery of IMRT, SBRT, SRS, and BgRT radiotherapy regimens. For BgRT delivery specifically, annihilation photons emanating outward from a PET-avid tumor are used to guide the delivery of beamlets of radiation to the tumor at subsecond latency. With the integration of PET detectors, rapid beam-station delivery, real-time tracking, and high-frequency multi-leaf collimation, the BgRT system has the potential to deliver a highly conformal treatment to malignant lesions while minimizing dose to surrounding healthy tissues. Furthermore, the potential use of a single radiotracer injection to guide radiotherapy to multiple targets opens avenues for debulking in advanced and metastatic disease states.

Objectives: In this study, we characterize the imaging-mode performance of the positron emission tomography (PET) subsystem of the RefleXion X1 machine using the NEMA NU-2 2018 standard. Methods: The X1 machine consists of two symmetrically opposing 900 arcs of PET detectors incorporated into the architecture of a ring-gantry linear accelerator rotating up to 60 RPM. PET emissions from a tumor are detected by the PET detectors and used to guide the delivery of radiation beam. Imaging performance of the PET subsystem on X1 machine was evaluated based on1 sensitivity of the PET detectors,2 spatial resolution,3 count-loss performance,4 Image quality, and daily system performance check. Results: PET subsystem sensitivity was measured as 0.183 and 0.161 cps/kBq at the center and off-center positions, respectively. Spatial resolution: average FWHM values of 4.3, 5.1, and 6.7 mm for the point sources at 1, 10, and 20 cm off center, respectively were recorded. For count loss, max NECR: 2.63 kcps, max true coincidence rate: 5.56 kcps, and scatter fraction: 39.8%. The 10 mm sphere was not visible. Image-quality contrast values were: 29.6%, 64.9%, 66.5%, 81.8%, 81.2%, and background variability: 14.8%, 12.4%, 10.3%, 8.8%, 8.3%, for the 13, 17, 22, 28, 37 mm sphere sizes, respectively. Conclusions: When operating in an imaging mode, the spatial resolution and image contrast of the X1 PET subsystem were comparable to those of typical diagnostic imaging systems for large spheres, while the sensitivity and count rate were lower due to the significantly smaller PET detector area in the X1 system. Clinical efficacy when used in BgRT remains to be validated. Advances in knowledge: This is the first performance evaluation of the PET subsystem on the novel BgRT machine. The dual arcs rotating PET subsystem on RefleXion X1 machine performance is comparable to those of the typical diagnostic PET system based on the spatial resolution and image contrast for larger spheres.

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Background and purpose The purpose of this study of pancreatic cancer patients treated with respiratory‐guided stereotactic body radiotherapy (SBRT) on a standard linac was to investigate (a) the intrafractional relationship change (IRC) between a breathing signal and the tumor position, (b) the impact of IRC on the delivered dose, and (c) potential IRC predictors. Materials and methods We retrospectively investigated 10 pancreatic cancer patients with 2–4 implanted fiducial markers in the tumor treated with SBRT. Fluoroscopic images were acquired before and after treatment delivery simultaneously with the abdominal breathing motion. We quantified the IRC as the change in fiducial location for a given breathing amplitude in the left–right (LR), anterior–posterior (AP), and superior–inferior (SI) directions from before to after treatment delivery. The treatment plans were re‐calculated after changing the isocenter coordinates according to the IRCs. Four treatment‐ or patient‐related factors were investigated as potential predictors for IRC using linear models. Results The average (±1 SD) absolute IRCs in the LR, AP, and SI directions were 1.2 ± 1.2 mm, 0.7 ± 0.7 mm, and 1.1 ± 0.8 mm, respectively. The average 3D IRC was 2.0 ± 1.3 mm (range: 0.4–5.3 mm) for a median treatment delivery time of 8.5 min (range: 5.7–19.9 min; n = 31 fractions). The dose coverage of the internal target volume (ITV) decreased by more than 3% points in three of 31 fractions. In those cases, the 3D IRC had been larger than 4.3 mm. The 3D IRC was found to correlate with changes in the minimum breathing amplitude during treatment delivery. Conclusion On average, 2 mm of treatment delivery accuracy was lost due to IRC. Periodical intrafractional imaging is needed to safely deliver respiratory‐guided SBRT.

Introduction: Small fields photon dosimetry is associated with many problems. Using the right detector for measurement plays a fundamental role. This study investigated the measurement of relative output for small photon fields with different detectors. It was investigated for three-photon beam energies at SSDs of 90, 95, 100 and 110 cm. As a benchmark, the Monte Carlo simulation was done to calculate the relative output of these small photon beams for the dose in water. Materials and Methods: 6, 10 and 15 MV beams were delivered from a Synergy LINAC equipped with an Agility 160 multileaf collimator (MLC). A CC01 ion chamber, EFD-3G diode, PTW60019 microdiamond, EBT2 radiochromic film, and EDR2 radiographic film were used to measure the relative output of the linac. Measurements were taken in water for the CC01 ion chamber, EFD-3G diode, and the PTW60019. Films were measured in water equivalent RW3 phantom slabs. Measurements were made for 1 × 1, 2 × 2, 3 × 3, 4 × 4, 5 × 5 and a reference field of 10 × 10 cm2. Field sizes were defined at 100cm SSD. Relative output factors were also compared with Monte Carlo (MC) simulation of the LINAC and a water phantom model. The influence of voxel size was also investigated for relative output measurement. Results and Discussion: The relative output factor (ROF) increased with energy for all fields large enough to have lateral electronic equilibrium (LEE). This relation broke down as the field sizes decreased due to the onset of lateral electronic disequilibrium (LED). The high-density detector, PTW60019 gave the highest ROF for the different energies, with the less dense CC01 giving the lowest ROFs. Conclusion: These are results compared to MC simulation, higher density detectors give higher ROF values. Relative to water, the ROF measured with the air-chamber remained virtually unchanged. The ROFs, as measured in this study showed little variation due to increased SSDs. The effect of voxel size for the Monte Carlo calculations in water does not lead to significant ROF variation over the small fields studied.