MRS-guided HDR brachytherapy boost to the dominant intraprostatic lesion in high risk localised prostate cancer

Abstract

Background: It is known that the vast majority of prostate cancers are multifocal. However radical radiotherapy historically treats the whole gland rather than individual cancer foci.Magnetic resonance spectroscopy (MRS) can be used to non-invasively locate individual cancerous tumours in prostate. Thus an intentionally non-uniform dose distribution treating the dominant intraprostatic lesion to different dose levels than the remaining prostate can be delivered ensuring the maximum achievable tumour control probability.The aim of this study is to evaluate, using radiobiological means, the feasibility of a MRS-guided high dose rate (HDR) brachytherapy boost to the dominant lesion.

Methods: Computed tomography and MR/MRS were performed for treatment planning of a high risk localised prostate cancer. Both were done without endorectal coil, which distorts shape of prostate during the exams.Three treatment plans were compared:- external beam radiation therapy (EBRT) only- combination of EBRT and HDR brachytherapy- combination of EBRT and HDR brachytherapy with a synchronous integrated boost to the dominant lesionThe criteria of plan comparison were: the minimum, maximum and average doses to the targets and organs at risk; dose volume histograms; biologically effective doses for organs at risk and tumour control probability for the target volumes consisting of the dominant lesion as detected by MR/MRS and the remaining prostate volume.

Results: Inclusion of MRS information on the location of dominant lesion allows a safe increase of the dose to the dominant lesion while dose to the remaining target can be even substantially decreased keeping the same, high tumour control probability. At the same time an improved urethra sparing was achieved comparing to the treatment plan using a combination of EBRT and uniform HDR brachytherapy.

Conclusions: MRS-guided HDR brachytherapy boost to dominant lesion has the potential to spare the normal tissue, especially urethra, while keeping the tumour control probability high.

Figure 1

Up: T2-weighted transverse MR image, with the MRSI grid and a color map corresponding to the choline/citrate ratio. Down: MRS spectra for respective voxels.

Figure 2

Underlying MR image to the MRS spectra presented on figure 1A.

Figure 3

Dose distributions for the following plans: conformal external beam plans where dose is relative to the prescription dose to the target (A); the HDR brachytherapy plan where the 100% isodose corresponds to 10Gy (B) and the SIB HDR brachytherapy plan where the 100% isodose corresponds to 7.5Gy (C).

Figure 4

Dose volume histograms (DVHs) for the conformal external beam plans where dose is relative to the prescription dose to the target (A), and for the HDR brachytherapy plans (B) delivering 10Gy to the whole prostate (dashed lines) and the SIB HDR brachytherapy plan (continuous lines). Table on Figure B. shows TCP values for the investigated treatment plans.