EP-1262: Dosimetric impact of poor compliance with full-bladder protocol for prostate patients on Tomotherapy

G. Webster, M. Tiffany, G. Sangha, C. Bode, P. Massey, J. Cashmore, A. Zarkar
2013 Radiotherapy and Oncology  
Purpose/Objective: Prostate patients at our hospital are treated to 74Gy using a full-bladder drinking protocol, which is intended to improve seminal vesicle stability and reduce dose to bowel and bladder. Tomotherapy Planned Adaptive (TomoPA) permits dose distribution evaluation using daily MVCT imaging and is frequently used to assess the dosimetric impact of subjectively-defined incompliance with the drinking protocol. To optimise the clinical workflow, a simple, consistent method is needed
more » ... o identify situations in which plan adaptation may be required. Materials and Methods: For each of 6 prostate patients receiving Tomotherapy,selected due to poor compliance with drinking protocol, 4 MVCT scans showing large reductions in bladder volume were transferred to TomoPA. Bladder and bowel were contoured on the MVCT and the dose distribution recalculated. Compliance with PIVOTAL Trial protocol constraints was quantified. A single observer investigated various potential metrics (i.e. absolute and relative reductions in (i) bladder volume and (ii)bladder extension superior to prostate apex) to determine the optimal criteria for referral to TomoPA. Results: 5/24 MVCT scans were rejected due to limited scan length rendering identification of relevant bladder and bowel unreliable. In the remaining 19 scans, the lower dose PIVOTAL bowel constraints (i.e. V45<158cc,V50<110cc, V55<28cc) were always met, regardless of bladder volume reduction, while higher dose constraints (i.e. V60<6cc, V65=0cc) were exceeded only twice, in the same patient. 'Mandatory' bladder tolerances (i.e.V65<50%, V70<30%) were exceeded in only 2/19 instances, although failure to meet 'optimal' constraints (V50<50%, V60<25%, V70<5%) was widespread in this cohort. The 1cm PTV margins adequately enclosed the seminal vesicles (>56.2Gy) in all cases. No metric consistently predicted dosimetric impact, although>50% bladder volume reduction from initial planning CT appeared to coincide with sharp increases in dose for both bowel (see figure) and bladder. Bladder volume could be measured for this purpose with an abdominal ultrasound probe prior to the patient entering the treatment room. Potential use of linear change in bladder extension, (ruler measurement on the MVCT image) as a predictive metric that would be easily identifiable prior to treatment and require minimal additional time, warrants further study, although the current cohort did not demonstrate a strong correlation in this regard. Conclusions: Tomotherapy prostate plans appear robust to large bladder volume changes, with dosimetric tolerances exceeded in only a few extreme cases. A bladder volume reduction >50% suggests that dosimetric evaluation may be warranted, although confirmation on a larger cohort is required prior to clinical implementation. Purpose/Objective: The purpose of this study is to evaluate an offline adaptive IGRT protocol. Kilovoltage cone-beam CTs (CBCT) acquired during the first radiotherapy treatment sessions were used to adapt the PTV individually to variable organ filling and variation in positioning. Variation in rectum dose was studied. Materials and Methods: Eighteen patients post-prostatectomy with biochemical or macroscopic relapse in the prostate bed and two patients with localized prostate cancer, who underwent primary 3D conformal radiotherapy, were evaluated. The patients received 66.6 to 76.2Gy (1.8Gy x 5weekly). All patients started radiotherapy with a 4 field box technique to at least 18Gy. Then the treatment was continued with a VMAT technique on either the same or the modified PTV. The kV-CBCTs acquired in the first three fractions were transferred to the planning systems (Masterplan, Nucletron Netherlands and Eclipse, Varian Palo Alto CA) and registered with the planning CT. The rectum was delineated in all CBCTs (from below sigmoid flexure to above anal verge) and transferred to the planning CT. The PTV was adapted taking significant variation in organ filling and positioning into account. For planning CT and CBCTs V35 and V60 (volume of organ in % that achieved 35Gy or 60Gy) for rectum were evaluated. The maximum dose to femoral head and femoral neck were evaluated in the planning CT. The modification of the PTV was estimated. Results: Variability of rectum during radiotherapy treatment influences the final administered rectum dose in comparison to planning CT and may influence the PTV. After the evaluation of the CBCTs, the PTV was modified for 15 of 20 patients. The changes of PTV had a range of 82 to -31cm³. Four PTVs were enlarged and nine reduced. The mean change of volume was 21cm³ with a standard deviation of 20cm³. In the planning CT the mean V35 for rectum over all patients was 52% with a standard deviation of 11%. The mean individual changes of V35 in planning CT and CBCTs for the rectum were 39 to 80% with a standard deviation of 1 to 13%. The maximal dose to femoral heads was 42Gy with a standard deviation of 9Gy. Conclusions: An evaluation of rectum volumes in the CBCTs of the first IGRT treatments results in a more realistic estimation of rectal dose and makes an adaptation of the PTV to individual variability in organ fillings and positioning uncertainties feasible. Commencing prostate treatments with a box technique and changing to a VMAT technique, after the PTV modification, is less time-consuming and still enables constrains for organs at risk to be fulfilled. Purpose/Objective: To evaluate the need to correct full daily variation in patient anatomy and set-up when intensity-modulated radiotherapy (IMRT) is delivered in prostate and head and neck cancer patients with the Protura 6 DOF robotic couch (CIVCO Medical Solution). Materials and Methods: Prostate and H&N cancer patients treated with IMRT were selected for this study. Before starting radiation treatment each patient underwent a CT scan for radiotherapy planning. Prostate cancer patients were simulated in supine position with the dual leg CIVCO support system; conventional thermoplastic masks were used for immobilization of H&N patients. All patients received a daily CBCT before treatment to display the patient position and to detect necessary corrections. Geometrical shifts (3-Traslational and 3-Rotational) were identified by manual and/or automatic 3D match (Varian 6D Online Review System) and were then applied to the Protura 6 DOF robotic couch and recorded. Mean translational and rotational corrections and the/a 3D vector of displacement were calculated. Results: From October to December 2012, 5 prostate and 3 H&N patients were included in this ongoing study. One hundred and sixty CBCT studies were analyzed and compared. The mean (±SD) interfraction displacement of the translational corrections for prostate vs H&N patients were -0.2 ± 0.3 vs 0,1 ± 0,2 cm, 0.0 ± 0.3 vs 0,2 ± 0,2 cm and -0.2 ± 0.5 vs 0,0 ± 0,3 cm in vertical, lateral and longitudinal direction. We observed a maximal translation shift (MTS)
doi:10.1016/s0167-8140(15)33568-4 fatcat:dvuu74qtmfafhpygbfxhp3xkaq