Ultra-hypofractionated prostate cancer radiotherapy: Dosimetric impact of real-time intrafraction prostate motion and daily anatomical changes

Purpose: To retrospectively assess the differences between planned and delivered dose during ultrahypofractionated (UHF) prostate cancer treatments, by evaluating the dosimetric impact of daily anatomical variations alone, and in combination with prostate intrafraction motion. Methods: Prostate intrafraction motion was recorded with a transperineal ultrasound probe in 15 patients treated by UHF radiotherapy (36.25 Gy/5 fractions). The dosimetric objective was to cover 99 % of the clinical target volume with the 100 % prescription isodose line. After treatment, planning CT (pCT) images were deformably registered onto daily Cone Beam CT to generate pseudo-CT for dose accumulation (accumulated CT, aCT). The interplay effect was accounted by synchronizing prostatic shifts and beam geometry. Finally, the shifted dose maps were accumulated (moved-accumulated CT, maCT). Results: No significant change in daily CTV volumes was observed. Conversely, CTV V-100% was 98.2 +/- 0.8 % and 94.7 +/- 2.6 % on aCT and maCT, respectively, compared with 99.5 +/- 0.2 % on pCT (p < 0.0001). Bladder volume was smaller than planned in 76 % of fractions and D5cc was 33.8 +/- 3.2 Gy and 34.4 +/- 3.4 Gy on aCT (p = 0.02) and maCT (p = 0.01) compared with the pCT (36.0 +/- 1.1 Gy). The rectum was smaller than planned in 50.3 % of fractions, but the dosimetric differences were not statistically significant, except for D1cc, found smaller on the maCT (33.2 +/- 3.2 Gy, p = 0.02) compared with the pCT (35.3 +/- 0.7 Gy). Conclusions: Anatomical variations and prostate movements had more important dosimetric impact than anatomical variations alone, although, in some cases, the two phenomena compensated. Therefore, an efficient IGRT protocol is required for treatment implementation to reduce setup errors and control intrafraction motion.