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

Abstract

Background: During 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° 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.

Purpose: The 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.

Methods: The 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 $T_{res}$ . Prostate intrafractional rotational motion $R_{uncorr}$ was recorded but not corrected. The dose differences from the planned dose due to $T_{res}$ + $R_{uncorr}$ , ΔD( $T_{res}$ + $R_{uncorr}$ ) and due to $T_{res}$ alone, ΔD( $T_{res}$ ), were then determined for CTV D98, PTV D95, bladder V6Gy, and rectum V6Gy. The residual dose error due to uncorrected rotation, $R_{uncorr}$ was then quantified: $\Delta D_{Residual}$ = ΔD( $T_{res}$ + $R_{uncorr}$ ) - ΔD( $T_{\mathrm{res}}$ ).

Results: Fractional data analysis shows that the dose differences from the plan (both ΔD( $T_{res}$ + $R_{uncorr}$ ) and ΔD( $T_{res}$ )) for CTV D98 was less than 5% in all treatment fractions. ΔD( $T_{res}$ + $R_{uncorr}$ ) 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, $R_{uncorr}$ induced residual dose error, $\Delta D_{Residual}$ , 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, ∑D( $T_{res}$ + $R_{uncorr}$ ) and ∑D( $T_{res}$ ), was always within 5% of the planned dose for all four structures for every patient.

Conclusions: The 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.

Keywords: motion management; motion-induced dose error; tumor motion.

FIGURE 1

Overview of the study methodology. During treatment, a real‐time tumor motion monitoring system, KIM provided intrafraction prostate tumor translational and rotational motion. Tumor translational motion was managed using a gating strategy and the residual translation is denoted as $T_{res}$. Tumor rotational motion $R_{uncorr}$ remained uncorrected. Dose reconstruction was performed including (a) $T_{res}$ + $R_{uncorr}$ and (b) only $T_{res}$ and the corresponding dose differences were determined: ΔD($T_{res}$ + $R_{uncorr}$) and $\mathrm{\Delta }D(T_{res})$, respectively. The residual dose error due to uncorrected rotation was quantified as: $\mathrm{\Delta }{D}_{Residual}$ = ΔD($T_{res}$ + $R_{uncorr}$) ‐ $\mathrm{\Delta }D(T_{res}$).

FIGURE 2

Number of occurrences of rotation $R_{uncorr}$ in pitch, roll, and yaw axes during 158 treatment fractions analyzed in this work. The full blue line shows the mean rotation angle and the dashed lines show 1 standard deviation for each histogram.

FIGURE 3

Dose differences from the plan (Equations (2)–(5)) due to $T_{res}$ + $R_{uncorr}$ (ΔD($T_{res}$ + $R_{uncorr}$)) and due to $T_{res}$ (ΔD($T_{res}$)) for all 158 treatment fractions analyzed in this work. The dashed lines indicate a 5% dose difference to planned dose.

FIGURE 4

Dose volume histograms for two treatment fractions from two patients where 4.9% (top panel) and 4.5% (bottom panel) underdose occurred in PTV D95 when $T_{res}$ + $R_{uncorr}$ were included in the dose reconstruction. Including $T_{res}$ alone in the dose reconstruction method only shows 0.3% (top panel) and 2.5% (bottom panel) underdose to the PTV, respectively.

FIGURE 5

Histogram of the residual dose error $\mathrm{\Delta }{D}_{Residual}$ (Equation (6)) arising due to uncorrected dynamic rotation. The residual dose error > 0 indicates that D($T_{res}$) underestimates D($T_{res}$ + $R_{uncorr}$) and the residual dose error < 0 indicates that D($T_{res}$) overestimates D($T_{res}$ + $R_{uncorr}$).