# Patient setup variation on Elekta Unity and its impact on adaptive planning

## TL;DR

This study examines patient setup variations on the Elekta Unity MR-linac and evaluates how adaptive planning can handle these variations in brain, pancreas, prostate, and rectum treatments.

## Contribution

The study provides empirical evidence on setup variations and their impact on adaptive planning workflows for the Elekta Unity system.

## Key findings

- Significant patient setup variations were observed, especially in pancreas and pelvis treatments.
- Adaptive planning workflows effectively maintained target coverage and organ sparing despite setup variations.
- The ATS workflow required significantly more time than the ATP workflow.

## Abstract

The unique design of the MR‐linac may restrict the use of effective immobilization devices, resulting in significant patient setup variations (PSVs). The purpose of this study is to analyze the PSVs on the Elekta Unity system and investigate their impact on adaptive planning.

The PSVs for 10 brain, 10 pancreas, five prostate, and five rectum patients previously treated on Elekta Unity were analyzed. The five prostate and five pancreas plans were selected to investigate the impact of PSVs on adaptive planning. The reference scans were shifted by 1, 2, and 3 cm in the left–right (LR) and superior–inferior (SI) directions to simulate PSVs. Both the adaptive‐to‐position (ATP) and adaptive‐to‐shape (ATS) workflows were executed. The adaptive planning time, number of monitor units (MUs), and dosimetric metrics quantifying target coverage and organ‐at‐risks (OARs) sparing were compared.

For brain treatments, the average/maximum PSVs were −0.2 ± 0.3 cm/0.8 cm (LR), 0.3 ± 0.7 cm/1.8 cm (SI), and 0.8 ± 0.7 cm/1.8 cm in the anterior–posterior (AP) direction. For pancreas treatments, the PSVs are −0.1 ± 1.0 cm/3.8 cm (LR), −0.1 ± 0.8 cm/3.5 cm (SI), and 0.3 ± 0.3 cm/1.3 cm (AP). Pelvis treatments had similar PSVs as pancreas treatments. The ATS workflow took two to three times longer than the ATP workflow. The only trend observed was that the plan MUs increased slightly (< 10%) with PSVs in the ATP workflow for prostate patients. Both workflows effectively reproduced target coverage and OAR sparing, regardless of the magnitude of the PSVs.

Significant PSVs were observed on Elekta Unity due to suboptimal patient immobilization. Using prostate and pancreas treatments as examples, we demonstrated that adaptive planning can effectively accommodate such PSVs. Nevertheless, efforts should be made to minimize PSVs—particularly rotations—to mitigate intra‐fraction motion and reduce treatment time.