Ultrahypofractionated radiotherapy for localised prostate cancer: The impact of daily MRI-guided adaptive radiotherapy on delivered dose

Abstract

Introduction

Magnetic resonance image-guided adaptive radiotherapy (MRIgART) reduces uncertainties by correcting for day-to-day target and organ-at-risk deformation and motion. This is the first study to examine the dosimetric impact of MRIgART for ultrahypofractionated prostate cancer treatment, compared to standard-of-care image-guided non-adapted radiotherapy.

Methods

Twenty patients with localised prostate cancer, who received ultrahypofractionated MRIgART on the Unity MR linac (Elekta, Sweden) were retrospectively analysed. Online daily MRI was acquired for replanning (MRI_session) and a second for position verification before treatment (MRI_verification). To compare delivered dose with and without adaptation, three plans were generated offline per fraction; a session plan (reference plan adapted to MRI_session anatomy), a verification plan (session plan recalculated on MRI_verfication anatomy), and a non-adapted plan (reference plan recalculated on MRI_verfication anatomy). Target and organ-at-risk doses were calculated, and dose difference evaluated.

Secondary analysis, using deformable dose accumulation, estimated verification and non-adapted dose to primary target (CTVpsv) substructures; prostate, gross tumour volume (GTV) and proximal 1 cm of seminal vesicles (1cmSV). Impact of prostate, rectum and bladder volume changes on dose were evaluated.

Results

Median dose to 95 % of the CTVpsv was significantly higher with adaptation; 40.3, 40.0 and 38.2 Gy for session, verification, and non-adapted plans. Adaptation achieved a lower median urethra V42Gy dose but bladder V37Gy dose was lower when not adapting. Rectum V36Gy dose was similar for adapted and non-adapted plans.

CTVpsv substructure dose difference was greatest for 1cmSV; 40.0 versus 37.5 Gy for verification/non-adapted plans. Adaptation achieved significantly higher prostate only, but not GTV doses. Prostate and rectal volume changes had a negative impact on non-adapted dose only.

Conclusion

MRIgART, offers significant dosimetric benefit for ultrahypofractionated prostate cancer compared to non-adapted strategies. Greatest benefit is expected for those with SV or high-risk of SV involvement, persistent rectal gas, prostate swelling and for the application of novel dose strategies including GTV dose escalation and non-involved prostate dose de-escalation.