CBCT evaluation of inter- and intra-fraction motions during prostate stereotactic body radiotherapy: a technical note

Abstract

Background: In most clinical trials, gold fiducial markers are implanted in the prostate to tune the table position before each radiation beam. Yet, it is unclear if a cone-beam computed tomography (CBCT) should be performed before each beam to monitor a possible variation of the organs at risk (OARs) fullness, especially in case of recto-prostatic spacer implantation. The present study aimed at assessing the inter- and intra-fraction movements of prostate, bladder and rectum in patients implanted with a hyaluronic acid spacer and undergoing prostate stereotactic body radiotherapy (SBRT).

Methods: Data about consecutive patients undergoing prostate SBRT were prospectively collected between 2015 and 2019. Inter-and intra-fraction prostate displacements and volume variation of organs at risk (OARs) were assessed with CBCTs.

Results: Eight patients were included. They underwent prostate SBRT (37.5Gy, 5 fractions of 7.5Gy) guided by prostate gold fiducial markers. Inter-fraction variation of the bladder volume was insignificant. Intra-fraction mean increase of the bladder volume was modest (29 cc) but significant (p < 0.001). Both inter- and intra-fraction variations of the rectum volume were insignificant but for one patient. He had no rectal toxicity. The magnitude of table displacement necessary to match the prostate gold fiducial marker frequently exceeded the CTV/PTV margins (0.4 cm) before the first (35%) and the second arc (15%). Inter- and intra-fraction bladder and rectum volume variations did not correlate with prostate displacement.

Conclusion: Major prostate position variations were reported. In-room kV fiducial imaging before each arc seems mandatory. Intra-fraction imaging of the OARs appears unnecessary. We suggest that only one CBCT is needed before the first arc.

Trial registration: NCT02361515, February 11th, 2015.

Keywords: Bladder; Cone beam CT, motion; Organs at risk; Prostate cancer; Radiotherapy; Rectum; Stereotactic body radiotherapy.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Evolution of the mean bladder volume before and during SBRT fraction, compared to the bladder on planning CT-scan. The bladder volume assessed on the planning CT-scan divided the bladder volume assessed on the CBCT performed before the first (blue line) and the second arc (orange line) (1 = volumes were equal)

Fig. 2

Individual data about the evolution of the bladder volume assessed during SBRT fraction, compared to the bladder assessed before SBRT fraction. The bladder volume assessed on the CBCT performed before the first arc divided the bladder volume assessed on the CBCT performed before the second arc (1 = volumes were equal). Abbreviation: P: Patient

Fig. 3

Evolution of the mean rectum volume assessed before and during SBRT fraction, compared to the rectum on planning CT-scan. The rectum volume assessed on the planning CT-scan divided the rectum volume assessed on the CBCT performed before the first (blue line) and the second arc (orange line) (1 = volumes were equal)

Fig. 4

Individual data about the evolution of the rectal volume assessed during SBRT fraction, compared to the rectum assessed before SBRT fraction. The rectal volume assessed on the CBCT performed before the first arc divided the rectal volume assessed on the CBCT performed before the second arc (1 = volumes were equal). Abbreviation: P: Patient

Fig. 5

Example of the effect of hydrogel rectal spacer (blue), preventing the rectal wall to move anteriorly. The prostate is in pink, the bladder in yellow