The dosimetric error due to uncorrected tumor rotation during real-time adaptive prostate stereotactic body radiation therapy

BackgroundDuring prostate stereotactic body radiation therapy (SBRT), prostate tumor translational motion may deteriorate the planned dose distribution. Most of the major advances in motion management to date have focused on correcting this one aspect of the tumor motion, translation. However, large prostate rotation up to 30 degrees has been measured. As the technological innovation evolves toward delivering increasingly precise radiotherapy, it is important to quantify the clinical benefit of translational and rotational motion correction over translational motion correction alone. PurposeThe purpose of this work was to quantify the dosimetric impact of intrafractional dynamic rotation of the prostate measured with a six degrees-of-freedom tumor motion monitoring technology. MethodsThe delivered dose was reconstructed including (a) translational and rotational motion and (b) only translational motion of the tumor for 32 prostate cancer patients recruited on a 5-fraction prostate SBRT clinical trial. Patients on the trial received 7.25 Gy in a treatment fraction. A 5 mm clinical target volume (CTV) to planning target volume (PTV) margin was applied in all directions except the posterior direction where a 3 mm expansion was used. Prostate intrafractional translational motion was managed using a gating strategy, and any translation above the gating threshold was corrected by applying an equivalent couch shift. The residual translational motion is denoted as Tres$T_{res}$. Prostate intrafractional rotational motion Runcorr$R_{uncorr}$ was recorded but not corrected. The dose differences from the planned dose due to Tres$T_{res}$ + Runcorr$R_{uncorr}$, Delta D(Tres$T_{res}$ + Runcorr$R_{uncorr}$) and due to Tres$T_{res}$ alone, Delta D(Tres$T_{res}$), were then determined for CTV D98, PTV D95, bladder V6Gy, and rectum V6Gy. The residual dose error due to uncorrected rotation, Runcorr$R_{uncorr}$ was then quantified: Delta DResidual$\Delta D_{Residual}$ = Delta D(Tres$T_{res}$ + Runcorr$R_{uncorr}$) - Delta D(Tres${T}_{\textit{res}}$). ResultsFractional data analysis shows that the dose differences from the plan (both Delta D(Tres$T_{res}$ + Runcorr$R_{uncorr}$) and Delta D(Tres$T_{res}$)) for CTV D98 was less than 5% in all treatment fractions. Delta D(Tres$T_{res}$ + Runcorr$R_{uncorr}$) was larger than 5% in one fraction for PTV D95, in one fraction for bladder V6Gy, and in five fractions for rectum V6Gy. Uncorrected rotation, Runcorr$R_{uncorr}$ induced residual dose error, Delta DResidual$\Delta D_{Residual}$, resulted in less dose to CTV and PTV in 43% and 59% treatment fractions, respectively, and more dose to bladder and rectum in 51% and 53% treatment fractions, respectively. The cumulative dose over five fractions, n-ary sumation D(Tres$T_{res}$ + Runcorr$R_{uncorr}$) and n-ary sumation D(Tres$T_{res}$), was always within 5% of the planned dose for all four structures for every patient. ConclusionsThe dosimetric impact of tumor rotation on a large prostate cancer patient cohort was quantified in this study. These results suggest that the standard 3-5 mm CTV-PTV margin was sufficient to account for the intrafraction prostate rotation observed for this cohort of patients, provided an appropriate gating threshold was applied to correct for translational motion. Residual dose errors due to uncorrected prostate rotation were small in magnitude, which may be corrected using different treatment adaptation strategies to further improve the dosimetric accuracy.