Chapter 6
IMMOBILIZATION AND
LOCALIZATION
JAMES BALTER, PHD
The steep dose gradients and small margins associated with
modern conformal radiation therapy (RT) and intensity-
modulated radiation therapy (IMRT) demand introspec-
tion into the concepts of patient positioning. This chapter
attempts to aid in the quest to understand what is to be
accomplished by the tools and procedures used to position
a patient for treatment and what paradigms for positioning,
including variations on methods of image guidance, may be
needed. The reader is challenged to consider each anatom-
ic target uniquely and to consider how a specific patient may
be unique compared with others with the same disease site.
Immobilization Systems
Quite often, a vendor will describe the “reproducibility” of
an immobilization system. Herein lies the first opportuni-
ty for consideration. It is necessary to both make a target
immobile (ie, not moving during irradiation) and position
the target correctly. It is a very complex task to achieve both
goals simultaneously via a mechanical system. The most
successful applications of this joint paradigm are found in
the use of stereotactic head frames, which are invasive and
rely on minimal organ motion within the skull.
Coordinate Systems Related to Patient
Positioning
It is useful to consider at least three coordinate systems for
patient positioning. The first set of axes defines the treatment
room and is defined by the axes of gantry and collimator rota-
tion. This system is known most precisely and is usually main-
tained (through positioning lasers) to an accuracy of 2 mm
or better with routine physics quality assurance.
A second coordinate system is somewhat arbitrary but
has been the standard tool for treatment setup verification
for decades. The patient coordinate system defines the gross
position of the anatomic section of the patient to be treat-
ed. This system is routinely assessed by marks placed on
the patient’s skin and/or immobilization device. Alignment
91
of external markers to room lasers remains the standard
practice for patient positioning in the majority of centers
performing conformal RT and IMRT.
The patient coordinate system may also be referred to
by the position and orientation of the regional skeletal
anatomy of the patient visible on radiographic film or on
electronic portal and diagnostic images. Verification of
bony landmark position is routinely performed at the ini-
tiation of treatment and subsequently throughout the treat-
ment course on an infrequent basis (typically weekly).
Although it is possible that some targets (eg, brain tumors
and upper neck lesions) may maintain a fixed location with
respect to regional skeletal anatomy, targets in the tho-
rax, abdomen, and pelvis may vary significantly in posi-
tion relative to the skeleton.
The third coordinate system is the target coordinate sys-
tem. It is reasonable to define the target in this situation as
the clinical target volume. This coordinate system is the
most difficult to establish routinely over the course of treat-
ment; however, target location is the dominant concern of
immobilization and localization. Examples of technolo-
gy for target localization include ultrasonography, radi-
ography of implanted fiducial markers, and in-room
computed tomography (CT) scanners.
By these definitions, it becomes clear that the primary goal
of treatment verification is to register the target and treatment
room coordinate systems. Although the patient coordinate
system is more conveniently established, its relationship to
the target coordinate system may be highly variable. Persistent
use of skin marks or skeletal anatomy to position a patient
requires establishment of this variation and incorporation of
the residual uncertainty into the treatment planning process
to ensure sufficient dose to the target.
Systems for Patient Positioning
The variety of systems developed for patient positioning
is quite extensive, and a detailed list is beyond the scope of
this chapter. For some details, the reader is referred to an
92 / Intensity-Modulated Radiation Therapy
excellent summary by Bentel.1 To provide a framework for
evaluation, an overview of the core technologies that have
been used recently is summarized:
1. Styrofoam cast with foaming agent for customized shap-
ing. Custom foam casts, or alpha cradles, are routinely
used in RT treatments. The general process for creating
an alpha cradle involves placing the patient on a Sty-
rofoam mold encased in a plastic bag. A foaming agent
is poured into the bag, which forms to the patient’s
regional anatomy as it solidifies. Custom foam immo-
bilization has been applied to the concept of distal joint
positioning through the use of very large casts and has
been shown to positively impact reproducibility of posi-
tioning the thorax, abdomen, and pelvis.2,3
2. Evacuated bean bags. A similar concept of customized
shaping to individual patients involves the use of large
bean bags. These bags are sealed with a single access port
containing a valve. As the patient is positioned in the
bag for simulation, the air is evacuated, and the bag is
formed to the patient’s regional anatomy.4,5
3. Thermoplastic material. Thermoplastic sheets are either
solid or perforated sheets of plastic. At relatively low
temperatures, these plastics soften and can be formed
around the patient. They quickly solidify at room tem-
perature. Thermoplastic masks have been routinely used
for immobilization of the head and neck6 but have also
been used as a component in immobilization systems
for the pelvis.7
4. Dental molds and bite blocks. The hard palate is a unique
fixation point for positioning the skull and, by exten-
sion, aiding in configuring the orientation of the upper
neck. It is rigid with respect to the skull, does not move
about as the skin over the skull does, and provides a rel-
atively large surface area for matching with an immo-
bilization system. Various devices have been designed
to take advantage of this unique landmark, ranging from
simple blocks to custom molds and even systems
employing suction to affix the immobilization system
to the upper palate.8,9 A relocatable stereotactic frame
relies heavily on the dental immobilization concept for
positioning accuracy,10,11 as does a slightly less invasive
system employed initially at the University of Florida.12
5. Pins and screws. The highest accuracy routinely report-
ed primarily through the use of a mechanical position-
ing system has been through the use of stereotactic
frames affixed to the skull.
6. Emerging systems. Beyond these well-known systems, a
few other systems have emerged. Many positioning sys-
tems used for thoracic, abdominal, and pelvic position-
ing are simpler in concept, providing flat or generically
contoured surfaces with adjustable arm, head, and pelvic
rests. Although these systems may, at the outset, appear
to be less accurate than the previously mentioned sys-
tems because they minimally adapt to the individual
patient, a further investigation of the role of these sys-
tems in positioning is worthwhile.
Indexed Systems
Some of the more significant developments in precision
therapy over the past decade are related to the integration
of computer-controlled systems in linear accelerators. These
advancements have permitted a minor paradigm shift that
is nonetheless highly significant in reducing the chance of
gross errors in positioning and may improve the accuracy
of routine patient setup.
The position of the treatment couch at setup can be
recorded and used as an interlock with tolerance limits.
This development permits the establishment of a reference
couch position as an aid in setup. To take advantage of this
development, some modern couch tops have labeled indents
or other registration indices to which immobilization
devices can be reproducibly affixed. The combination of
placing the immobilization device in the same place on the
couch and validating the couch position electronically serves
as a significant adjunct to skin marks and lasers for posi-
tioning. It is possible that, for certain body sites, position-
ing the patient relative to the immobilization device and
indexing the device to the digital couch readout may be
as or more reproducible than attempting to set up the
patient to the isocenter using skin marks and lasers. This
concept needs to be approached with caution but is
nonetheless promising. Exploration of the nature of posi-
tion distributions in the subsequent section of this chap-
ter elucidates this concept further.
Nature of Patient Positioning
Regardless of positioning equipment used, there is some
variation in target position over multiple sessions of patient
setup. The position of the target over the course of treat-
ment can be described as a distribution with an average
value and a spread about this average.
The process of simulation, typically performed using
CT, involves one instance of patient positioning. It is unlike-
ly that patients will be observed in their average position
during simulation. Thus, there is an offset between the posi-
tion of the target used for treatment planning and the aver-
age position realized through consistent use of the
immobilization equipment and standard setup procedure.
This difference has been labeled as “systematic” setup error
in the literature. It is incorrect to assume that systematic
error is attributed to differences in couch sag, laser cali-
bration, or other components between simulation and treat-
ment equipment. Owing to the random nature of setup
variation, systematic error will persist, and a major goal of
the localization process involves minimization of random
variation and resolution of systematic offsets.
It is also important to understand a number of addi-
tional features about the patient position distribution. The

random variation in position for the same immobilization
technique may vary significantly between patients in the
same population. Furthermore, these may vary based on
the skill and experience of the therapist performing the
setup. These variations can be ameliorated somewhat
through extensive training and development of standard
procedures for use of positioning systems. It is a critical,
although typically neglected, part of the process of using a
new immobilization system for an institution to establish
its own population statistics of setup variation. In addi-
tion, these measurements should be used for rational deci-
sions in localization strategy, as well as margins and
treatment planning directives. The steep dose gradients
seen in IMRT plans make such a process crucial to safe and
effective treatment.
Localization Strategies
Table 6-1 shows examples of population setup variations
for different body sites. These data were acquired via fre-
quent portal imaging during a planned observation peri-
od. Although images were acquired daily, only a subset of
weekly images was used for setup verification. Orthogonal
portal images were acquired daily, and setup variations were
measured retrospectively. The mean random variation is
clearly a poor predictor of the range of random setup errors
for the population.
Given these average and patient-specific variations, it is
important to determine which strategy will most efficiently
achieve the precision necessary for IMRT. A few strategies
have been studied extensively. The methods described below
present a trade-off of effort (and treatment time) expend-
ed versus accuracy achieved.
Weekly Verification
This strategy (or small variations thereof) is probably the
predominant means of setup verification in use today.
Evolved over the past decades from the advent of portal
films,13 this method involves acquiring portal images to
verify patient position at the initiation of treatment and
then infrequently through the course of treatment.
Corrections are generally based on a threshold for action,
and adjustment is made either on the treatment fraction
TABLE 6-1. Average and Maximum Random Variations in a
Population of Patients
σavg (Maximum) Observed Random Variations, mm
Site Lateral Anterior-Posterior Cranial-Caudal
Pelvis 2.6 (6.2) 2.4 (6.3) 2.7 (7.0)
Chest 3.0 (7.9) 2.6 (7.0) 3.4 (11.8)
Abdomen 2.5 (9.1) 3.1 (9.1) 3.1 (12.4)
Head/neck 2.1 (8.4) 2.2 (8.6) 2.7 (5.8)
Immobilization and Localization / 93
during which images are acquired or on the subsequent
treatment fraction.
This strategy is certainly acceptable for reduction of
gross (eg, over 1 cm) systematic errors. It has no applica-
tion in the reduction of random variation (as is described
further). The potential for this strategy to reduce the mag-
nitude of smaller systematic errors, for which it is gener-
ally believed to be acceptable, is discussed further here.
Figure 6-1 shows the actual data of daily position vari-
ation of a patient for whom daily imaging was performed.
The patient had daily position adjustments. The images
acquired following setup (to skin marks) but prior to adjust-
ment of position were compared with the reference digi-
tally reconstructed radiograph to establish position error.
The data shown represent position variation in the cranial-
caudal axis. A simulation is shown of the impact of week-
ly setup adjustment with “perfect” correction. Perfect
correction is simulated by taking the error seen on the days
of imaging (every fifth fraction) and applying that correc-
tion on all subsequent fractions until the next imaging ses-
sion. It is clearly conceivable that no significant improvement
is made to patient position by weekly adjustment. In fact,
given the selection of the “day,” the potential remains to
increase setup error over doing nothing at all (in this exam-
ple, both the average and the random variation increased
slightly with ideal weekly adjustment).
Pretreatment (On-line) Setup
Adjustment
One of the most labor- and time-intensive methods to
improve setup accuracy involves daily pretreatment local-
ization of the patient. In fact, this procedure is performed
on almost all patients via the use of external marks and
lasers, thus registering the patient coordinate system to some
extent with the room coordinate system. As mentioned
above, however, the veracity of surface localization is like-
ly insufficient to achieve the accuracy necessary for most
5
0
Error (mm)
0 5 10 15 20 25
-5
Setup via skin marks
-10
Setup with weekly film-based
adjustment
-15
Fraction number
FIGURE 6-1. Measured cranial-caudal position offsets (solid line)
and a simulation of setup error via exact implementation of weekly por-
tal films and pretreatment correction (dashed line).
94 / Intensity-Modulated Radiation Therapy
IMRT treatments.
The advent of electronic portal imaging saw a plethora
of studies involving daily targeting of skeletal anatomy, as
well as implanted fiducial markers. These studies showed
a significant reduction in systematic and random varia-
tions, although with the associated cost of increased treat-
ment time. Further advances of in-room imaging, including
the use of an ultrasound system indexed to isocenter posi-
tion, as well as in-room CT scanning and registration to
reference CT data, have provided increased potential to
realize the target position more directly than by conven-
tional radiographic means. These developments are still
quite dynamic, and at the time of writing, it is too early to
state the expected accuracy of using in-room CT.
Within the daily verification paradigm, there are two
subsets of strategies. Under one strategy, all measurements
of target offset are used to correct patient position. Although
seemingly the most accurate strategy, this process comes
at the highest cost in time and needs some further thought
prior to acceptance.
Consider the steps in the process of daily setup verifi-
cation. A measurement is made of position (via imaging
and some visual or computer-aided alignment technique).
This measurement is then translated into instructions to
adjust the treatment, typically by adjustment of the treat-
ment table position. Both the measurement process and
the couch adjustment are not perfect, and their combined
error leads to a limit in the final accuracy that can be
achieved (even assuming that the patient is completely
immobile during the time of imaging, adjustment, and
treatment). This means that even if every measured setup
error is corrected, there is the potential to have a residual
error that is, in fact, introduced by the correction process.
To better understand the magnitude of these residual
errors, it is important to do a self-assessment. Any RT
department that wishes to set margins based on the expect-
ed improvement from daily setup correction should first
determine the accuracy of setup measurement and then
attempt to understand the accuracy of adjustment. Setup
measurement accuracy can be determined by having the
observers (typically therapists) who will perform mea-
surements go through a period of training and then per-
form multiple alignments of the same portal image to itself
and multiple alignments of a series of portal images to a
reference image. The spread of these distributions can give
an estimate of measurement accuracy. Adjustment accu-
racy is more difficult to assess but may be possible to deter-
mine if measurements are acquired both before and after
measurement-based adjustment (eg, on the first day of
treatment). If a distribution of errors measured before and
after adjustment can be acquired, then the change in posi-
tioning error can be compared with the expected mea-
surement error to see whether table adjustment is a
significant confounding factor. Both measurement and
adjustment variation can vary with technology and body
site (possibly as well as user skill) and should be assessed
for new systems.
Given this limit, it is reasonable to consider a slightly
different strategy for adjustment in which measurements
are acquired daily but adjustment is performed only if
the measured position error exceeds a defined threshold.
Using this strategy, the threshold can be selected by body
site as a trade-off of the effort expended versus the accu-
racy achieved. An illustration of this trade-off is shown in
Figure 6-2. It can be seen that as the residual error approach-
es the limit of accuracy for measurement and correction,
dramatic increases in effort yield minimal gain in accura-
cy until, finally, no significant gain is realized, even with
adjustment on every treatment fraction.
Thus, with daily adjustment, it is important to be real-
istic about expectations of effort and accuracy. One impor-
tant thing to think about is whether the random variation
in patient position is so large that it exceeds these accura-
cy limits and is also unacceptably large with respect to treat-
ment planning directives. This area is still under exploration.
For conformal therapy of the prostate, Remeijer and col-
leagues described a margin formula that denotes planning
target volume (PTV) margin size as
PTV margin ≈ 2.5Σ + 0.7σ
where Σ represents the population standard deviation for
systematic error and σ is the random variation standard
deviation.14,15 It is important to note that the latest ver-
sion of van Herk’s formula includes a constant 3 mm reduc-
tion. This value was based on the equivalent uniform dose
formalism, including an estimate of the influence of dose
homogeneity on tumor control, and is not reproduced
1
0.9
0.8
Frequency of repositioning
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 5 10 15 20
Threshold for adjustment (mm)
FIGURE 6-2. Trade-off of residual error versus effort with daily threshold-
based setup adjustment.

here because it requires assumptions that are beyond the
scope of this chapter. The key point of this finding is that
systematic error plays a far more important role in dose
coverage and margins than random variations and that
attempts to reduce the magnitude of systematic varia-
tion achieve most of the benefit possible in positioning for
the majority of patients.
Off-line Setup Correction Strategies
Although a reduction in systematic offset can be achieved
through daily on-line setup measurement and adjustment,
more efficient means of reducing systematic error have
been realized. Given that the systematic error is the aver-
age difference between the reference and treated patient
position, the combination of patient setup error measure-
ments from multiple days will yield a better estimate of the
average error than any single daily setup measurement.
Such measurements do not need to take place completely
while the patient is waiting on the treatment table and thus
can decrease treatment time. The strategies that involve
decisions about treatment made while the patient is not on
the table are considered off-line methods.
There are a number of different off-line strategies of vary-
ing complexity, but the overall issue involves the question
of how many measurements are needed to establish the sys-
tematic error.16–18 Although the results of studies vary, it
has generally been accepted that three to five measurements
are sufficient for estimating the systematic component of
setup variation with sufficient accuracy. There is some ques-
tion as to whether the first treatment fraction should be
considered one of these measurements because many fac-
tors, including patient discomfort, the length of the initial
treatment session, and resolution of potentially complex
gross errors (eg, improper communication of offsets to the
isocenter from the simulated position of the patient), prior
to initial treatment may come into play.
It is still somewhat difficult to implement off-line strate-
gies in most clinics. Although the use of pretreatment local-
ization involves training and use of software that is now
becoming available on most commercial imaging systems,
and the impact on clinic flow is easily seen, the most efficient
use of off-line strategies is still open to discussion. Two lead-
ing strategies involve either (1) a designated therapist spend-
ing a fraction of his or her day analyzing all portal images
acquired in preparation for off-line measurement (with expe-
rience, a single therapist can align all of the images for a 60
patient/day clinic in less than 2 hours per day for a four-
measurement off-line protocol) or (2) having the therapist
at the treatment unit analyze the images for a particular patient
during or after the delivery of each fraction in the off-line
protocol or analyzing all images immediately before the frac-
tion on which action is to be taken. Either of these strategies
can be implemented efficiently with sufficient planning. It
is very useful to develop a database to record alignment results
Immobilization and Localization / 95
and provide an average or predicted correction. Such tools
are generally not available in imaging systems or record-and-
verify software but are not too difficult to produce (a simple
paper worksheet can suffice).
Intratreatment Movement
The subject of intratreatment movement is also critical to
IMRT. Various means have been developed to account for
movement owing to breathing. The most widespread of
these technologies follows the concept of immobilization.
Both active breath-hold19–24 and gating25–27 systems are
designed to restrict the range of positions of internal anato-
my to a fraction of that seen during normal breathing. Note
that these systems do not eliminate the need for margins
for movement. Given that the reproducibility of active
breathing control is limited and the use of phase or ampli-
tude windows for gating permits some intratreatment move-
ment and some variation in position at the gated state,
caution needs to be taken to understand the benefit of these
systems prior to margin reduction. It is strongly recom-
mended that these systems be evaluated locally via fluo-
roscopy or similar means prior to clinical use.28–30
Summary
Our understanding of position variation has evolved sig-
nificantly over the past few years. Parallel developments in
localization technology, computer control, immobilization
technology, and theory of positioning have led to more ratio-
nal and efficient means of achieving reasonable margins
than previously thought possible. Adoption of these tech-
nology and concepts, however, requires significant intro-
spection into the RT process and may require extensive
training and infrastructure development. Nonetheless, it
is likely that both technology and paradigms are necessary
for efficient margin reduction on the order necessary to per-
ceive a benefit from IMRT in most regions of the body.
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