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Prostate cancer treated with image-guided helical TomoTherapy® and image-guided LINAC-IMRT

Correlation between high-dose bladder volume, margin reduction, and genitourinary toxicity

Behandlung des Prostatakarzinoms mit bildgeführter helikaler Tomotherapie und bildgeführter LINAC-IMRT

Korrelation zwischen Harnblasenhochdosisvolumen, Reduktion des Sicherheitsabstands und urogenitaler Toxizität

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Abstract

Background

We compared different image-guidance (IG) strategies for prostate cancer with high-precision IG intensity-modulated radiation therapy (IMRT) using TomoTherapy® (Accuray Inc., Madison, WI, USA) and linear accelerator (LINAC)-IMRT and their impact on planning target volume (PTV) margin reduction. Follow-up data showed reduced bladder toxicity in TomoTherapy patients compared to LINAC-IMRT. The purpose of this study was to quantify whether the treatment delivery technique and decreased margins affect reductions in bladder toxicity.

Patients and methods

Setup corrections from 30 patients treated with helical TomoTherapy and 30 treated with a LINAC were analyzed. These data were used to simulate three IG protocols based on setup error correction and a limited number of imaging sessions. For all patients, gastrointestinal (GI) and genitourinary (GU) toxicity was documented and correlated with the treatment delivery technique.

Results

For fiducial marker (FM)-based RT, a margin reduction of up to 3.1, 3.0, and 4.8 mm in the left–right (LR), superior–inferior (SI), and anterior-posterior (AP) directions, respectively, could be achieved with calculation of a setup correction from the first three fractions and IG every second day. Although the bladder volume was treated with mean doses of 35 Gy in the TomoTherapy group vs. 22 Gy in the LINAC group, we observed less GU toxicity after TomoTherapy.

Conclusion

Intraprostate FMs allow for small safety margins, help decrease imaging frequency after setup correction, and minimize the dose to bladder and rectum, resulting in lower GU toxicity. In addition, IMRT delivered with TomoTherapy helps to avoid hotspots in the bladder neck, a critical anatomic structure associated with post-RT urinary toxicity.

Zusammenfassung

Hintergrund

Wir haben im Rahmen der Prostatakarzinombehandlung verschiedene bildgeführte (IG) Strategien der hochpräzisen intensitätsmodulierten Radiotherapie (IMRT) unter Einsatz der Tomotherapie (TomoTherapy®, Accuray Inc., Madison, Wisconsin, USA) und der Linearbeschleuniger(LINAC)-IMRT sowie deren Einfluss auf die Margingröße verglichen. Wie Nachsorgeuntersuchungen zeigten, war die Harnblasentoxizität bei Patienten mit Tomotherapie im Vergleich zur LINAC-IMRT geringer. In der vorliegenden Studie sollte quantifiziert werden, ob das Bestrahlungsverfahren und reduzierte Sicherheitssäume Einfluss auf die Verringerung der Blasentoxizität haben.

Patienten und Methoden

Es erfolgte eine Analyse der Lagerungskorrekturen von 30 Patienten mit helikaler Tomotherapie und weiteren 30 Patienten, die mit einem LINAC behandelt wurden. Mithilfe dieser Daten wurden drei IG-Protokolle simuliert, basierend auf den Korrekturen von Lagerungsfehlern und auf einer limitierten Zahl bildgeführter Bestrahlungen. Bei allen Patienten wurde die gastrointestinale (GI) und urogenitale (GU) Toxizität dokumentiert und mit dem Bestrahlungsverfahren in Beziehung gesetzt.

Ergebnisse

Bei Anwendung einer Radiotherapie mit Goldmarkern konnte durch Berechnung einer Lagerungskorrektur aus den ersten 3 Fraktionen und einer IG-Untersuchung an jedem zweiten Tag eine Marginreduktion von bis zu 3,1, 3,0 und 4,8 mm in Links-rechts-, superior-inferiorer bzw. anterior-posteriorer Richtung, bei gleichzeitiger Reduzierung der IG-Dosis erreicht werden. Obwohl das Blasenvolumen in der Tomotherapiegruppe mit mittleren Dosen von 35 Gy behandelt wurde, während die LINAC-Gruppe 22 Gy erhielt, war eine geringere urogenitale Toxizität nach Tomotherapie zu verzeichnen.

Schlussfolgerung

Goldmarkerbasierte IGRT der Prostata ermöglicht kleinere Sicherheitssäume. Sie helfen, die Häufigkeit bildgeführter Bestrahlungen mithilfe geeignter IG-Protkolle zu verringern und die Strahlendosis in Blase und Rektum zu minimieren. Dadurch sinkt die urogenitale Toxizität. Darüber hinaus lassen sich mit IMRT unter Einsatz der Tomotherapie „Hotspots“ am Blasenhals vermeiden, einer kritischen anatomischen Struktur, die im Zusammenhang mit der Harnwegstoxizität nach Radiotherapie steht.

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Acknowledgments

SD conceived the study; acquired, analyzed, and interpreted the data; reviewed the literature; and wrote the manuscript. MS was responsible for study design; involved in collection, interpretation, and statistical analysis of data; and assisted with drafting the manuscript. TGW was responsible for coordinating the study and treatment planning; he edited the manuscript and performed a critical revision of scientific content. HS critically reviewed the manuscript. SF helped revising the draft. All authors read and approved the final manuscript.

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Authors and Affiliations

  1. Department of Radiation Oncology, University Hospital Jena, Friedrich-Schiller-University Jena, Bachstrasse 18, 07743, Jena, Germany

    Sonia Drozdz & Thomas G. Wendt

  2. Department of Radiation Oncology, Section of Medical Physics, University Hospital Jena, Friedrich-Schiller-University Jena, Bachstrasse 18, 07743, Jena, Germany

    Michael Schwedas & Henning Salz

  3. Department of Urology, University Hospital Jena, Friedrich-Schiller-University Jena, Lessingstrasse 1, 07743, Jena, Germany

    Susan Foller

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  1. Sonia Drozdz
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Correspondence to Sonia Drozdz.

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S. Drozdz, M. Schwedas, H. Salz, S. Foller and T.G. Wendt state that there are no conflicts of interest.

All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.

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Drozdz, S., Schwedas, M., Salz, H. et al. Prostate cancer treated with image-guided helical TomoTherapy® and image-guided LINAC-IMRT. Strahlenther Onkol 192, 223–231 (2016). https://doi.org/10.1007/s00066-015-0935-y

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  • DOI: https://doi.org/10.1007/s00066-015-0935-y

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