As the novel ExacTrac Dynamic system (Brainlab AG, Germany) has been installed at our clinic in October 2019 prior to clinical release, an evaluation of the workflow for the incorporation of real-time surface guidance using optically visible light with thermal imaging to the current in-room real-time X-ray tracking system was carried out. The differences between surface guidance and X-ray internal anatomy verification can now be evaluated directly using the same system. We determined a difference in positioning of 0.3±0.1 mm in the lateral direction, -0.7±0.1 mm longitudinal, and 0.6±0.1 mm vertical in mean (± standard deviation) for a couch angle of 0°, and -0.1±0.3 mm (lateral), -0.2±0.3 mm (longitudinal), and -0.1±0.2 mm (vertical) for both couch rotations. Positioning via surface guidance and X-ray imaging both are in good agreement to each other and no deviations larger than 1mm between both modalities were found. For a future perspective, additional quality measurements and verifications must be carried out, to generate a valid and safe workflow for the usage of this novel patient positioning device. As the SGRT/IGRT system will be used for radiosurgery treatment, the potential sources of errors and uncertainties have to be determined and compensated for. 

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