Image-guided radiotherapy of the prostate using daily CBCT: the feasibility and likely benefit of implementing a margin reduction

Abstract

Objective: To investigate whether planning target volume (PTV) margins may be safely reduced in radiotherapy of localized prostate cancer incorporating daily online tube potential-cone beam CT (CBCT) image guidance and the anticipated benefit in predicted rectal toxicity.

Methods: The prostate-only clinical target volume (CTV2) and rectum were delineated on 1 pre-treatment CBCT each week in 18 randomly selected patients. By transposing these contours onto the original plan, dose-volume histograms (DVHs) for CTV2 and the rectum were each calculated and combined, for each patient, to produce a single mean DVH representative of the dose delivered over the treatment course. Plans were reoptimized using reduced CTV2 to PTV2 margins and the consequent radiobiological impact modelled by the tumour control probability (TCP) and normal tissue complication probability (NTCP) of the rectum.

Results: All CBCT images were deemed of sufficient quality to identify the CTV and rectum. No loss of TCP was observed when plans using the standard 5-mm CTV2 to PTV2 margin of the centre were reoptimized with a 4- or 3-mm margin. Margin reduction was associated with a significant decrease in rectal NTCP (5-4 mm; p < 0.05 and 5-3 mm; p < 0.01).

Conclusion: Using daily online image guidance with CBCT, a reduction in CTV2 to PTV2 margins to 3 mm is achievable without compromising tumour control. The consequent sparing of surrounding normal tissues is associated with reduced anticipated rectal toxicity.

Advances in knowledge: Margin reduction is feasible and potentially beneficial. Centres with image-guided radiotherapy capability should consider assessing whether margin reduction is possible within their institutes.

Figure 1.

Comparison of image quality between planning CT (left) and CBCT (right).

Figure 2.

(a) Superimposed clinical target volume (CTV₂) contours as delineated on planning scan and weekly cone beam CTs (CBCTs) of a typical patient in axial view. (b) Comparison of the cumulative dose–volume histograms for CTV₂ derived from the planning scan and weekly CBCTs of a typical patient.

Figure 3.

Box plot comparing tumour control probability (TCP) values for all patients using the original planning data and the mean dose–volume histograms (DVHs) of cone beam CT plans reoptimized at decreased margin sizes. CTV, clinical target volume.

Figure 4.

Superimposed rectal contours from the planning CT (black contour) and weekly cone beam CT (white contour) of a typical patient on axial (left) and sagittal (right) views.

Figure 5.

Comparison of the cumulative dose–volume histograms (DVHs) for rectum derived from the planning scan (grey) and weekly cone beam CTs (white) of a typical patient.

Figure 6.

Box plots demonstrating the variation in rectal volume on cone beam CT during treatment for each of patient.

Figure 7.

Change in rectal volume on cone beam CT (CBCT) relative to original planning scan volume.

Figure 8.

Bar chart comparing the normal tissue complication probability (NTCP) values of the original “static” plan to the mean rectal dose–volume histogram of cone beam CTs at standard 5-mm clinical target volume 2 (CTV₂) to planning target volume 2 (PTV₂) margins and for plans re-optimized using decreased margins for each patient.