Process managment and Quality Assurance of Intracranial Stereotactic Treatment

Summary September 2006, the Netherlands Commission of Dosimetry (NCS) installed a subcommittee on quality assurance and quality control for intracranial stereotactic treatment. The idea behind this was setting up a report in which institutions with considerable knowledge on the subject share their experience with starters and users. There were several reasons for the introduction of this report: 1) the development of dedicated stereotactic treatment devices, such as Gamma Knife, Cyberknife and Linac, the latter using add-ons like cones and MLC; 2) the rapid development of relocatable frames instead of invasive frames, allowing the introduction of fractionated stereotactic treatment; 3) the implementation of frameless stereotactic radiosurgery and radiotherapy in combination with imaged guided positioning technology like kV-imaging and cone beam CT; 4) the difficulties inherent in small field dosimetry; a proper understanding of do’s and don’ts is essential; 5) the introduction of stereotactic treatment in hospitals as a standard technique “like any other”. The creation of the report was a long and complex process. Different technologies for intracranial stereotactic treatment as described above were already available or in fast development. In a rapidly evolving field as radiotherapy, considering only technology would outdate the report, even during the process of writing it. Therefore, we focused on the critical question: what is the basic requirement for providing a safe and high-quality stereotactic treatment. Technology itself is not the only main quality assurance and quality control parameter. Department organization, skills of users, treatment process structure, etc. have to be considered as well. Finally, nomenclature used in intracranial stereotactic treatment was and still is not always obvious, so definitions and descriptions should be established/specified. These considerations crystallized into a report with starting point the process management to setup a new technology into a routine treatment facility as well as to retain it. The report is set up in a modular way: the in- and excluded subjects of this report (chapter 1), a short history to introduce intracranial stereotactic treatment (chapter 2), the generic structure of the stereotactic treatment process (chapter 3) and generic advice based on that treatment process (chapter 4). Detailed advice is presented in additional chapters. With the setup of this report in this way each reader can easily find specific points of interest. In the digital version hyperlinks have been set to support that easy use. Of course: the novice in the field should start at the beginning! Throughout the whole report the subcommittee has added “reflecting” points, indicated by the symbol (symbol is only visible in the original pape): Statement. The content of those points might help the reader to reflect on important aspects of intracranial stereotactic treatment, both when starting or continuing an existing program in their department. As authors we would summarise our main message in the following two statements: Statement 1. Do not start or continue stereotactic radiosurgery (SRS) or radiotherapy (SRT) unless you have the capability, organisation and patient mix required for stereotactic treatment. Statement 2. Stereotactic treatment has to fulfil quantitative quality and safety prerequisites, based on multidisciplinary risk analyses and setup conform current international standards for stereotactic treatment