Experimental study of beam distortion due to fiducial markers during salvage HIFU in the prostate

BACKGROUND: Prostate cancer is frequently treated using external beam radiation therapy (EBRT). Prior to therapy, the prostate is commonly implanted with a small number of permanent fiducial markers used to monitor the position of the prostate during therapy. In the case of local cancer recurrence, high-intensity focused ultrasound (HIFU) provides a non-invasive salvage treatment option. However, the impact of the fiducial markers on HIFU treatment has not been thoroughly studied to date. The objective of this study was to experimentally investigate the effect of a single EBRT fiducial marker on the efficacy of HIFU treatment delivery using a tissue-mimicking material (TMM). METHODS: A TMM with the acoustic properties of the prostate was developed based on a polyacrylamide hydrogel containing bovine serum albumin. Each phantom was implanted with a cylindrical fiducial marker and then sonicated using a 3.3 MHz focused bowl HIFU transducer. Two sets of experiments were performed. In the first, a single lesion was created at different positions along either the anteroposterior or left-right axes relative to the marker. In the second, a larger ablation volume was created by raster scanning. The size and position of the ablated volume were assessed using a millimetre grid overlaid on the phantom. RESULTS: The impact of the marker on the position and size of the HIFU lesion was significant when the transducer focus was positioned within 7 mm anteriorly, 18 mm posteriorly or within 3 mm laterally of the marker. Beyond this, the generated lesion was not affected. When the focus was anterior to the marker, the lesion increased in size due to reflections. When the focus was posterior, the lesion decreased in size or was not present due to shadowing. CONCLUSIONS: The presence of an EBRT fiducial marker may result in an undertreated region beyond the marker due to reduced energy arriving at the focus, and an overtreated region in front of the marker due to reflections. Depending on the position of the targeted regions and the distribution of the markers, both effects may be undesirable and reduce treatment efficacy. Further work is necessary to investigate whether these results indicate the necessity to reconsider patient selection and treatment planning for prostate salvage HIFU after failed EBRT.