Dosimetric Impact of Intrafraction Prostate Motion and Interfraction Anatomical Changes in Dose-Escalated Linac-Based SBRT

SIMPLE SUMMARY: With an ever-growing acceptance by the radiation oncology community, stereotactic body radiation therapy (SBRT) has become an increasingly common option for localized prostate cancer in recent years. However, such high doses per fraction require the specific management of the inter- and intrafraction movements of the target. In this work, synchronized motion-inclusive dose distributions using intrafraction motion data provided by a novel electromagnetic transmitter-based device were reconstructed and recomputed on deformed CTs reflecting the CBCT daily anatomy to represent the actual delivered dose. To our knowledge, there have been no previously published studies where the dosimetric impact on the target and organs at risk (OARs) of both intrafraction prostate motion and interfraction anatomical changes was investigated together in dose-escalated linac-based SBRT. Moreover, treatments that would have been delivered without any organ motion management (non-gated) were simulated to also evaluate the dosimetric benefit of employing continuous monitoring, beam gating, and motion correction strategies. ABSTRACT: The dosimetric impact of intrafraction prostate motion and interfraction anatomical changes and the effect of beam gating and motion correction were investigated in dose-escalated linac-based SBRT. Fifty-six gated fractions were delivered using a novel electromagnetic tracking device with a 2 mm threshold. Real-time prostate motion data were incorporated into the patient’s original plan with an isocenter shift method. Delivered dose distributions were obtained by recalculating these motion-encoded plans on deformed CTs reflecting the patient’s CBCT daily anatomy. Non-gated treatments were simulated using the prostate motion data assuming that no treatment interruptions have occurred. The mean relative dose differences between delivered and planned treatments were −3.0% [−18.5–2.8] for CTV D99% and −2.6% [−17.8–1.0] for PTV D95%. The median cumulative CTV coverage with 93% of the prescribed dose was satisfactory. Urethra sparing was slightly degraded, with the maximum dose increased by only 1.0% on average, and a mean reduction in the rectum and bladder doses was seen in almost all dose metrics. Intrafraction prostate motion marginally contributed in gated treatments, while in non-gated treatments, further deteriorations in the minimum target coverage and bladder dose metrics would have occurred on average. The implemented motion management strategy and the strict patient preparation regimen, along with other treatment optimization strategies, ensured no significant degradations of dose metrics in delivered treatments.