A biological modeling based comparison of two strategies for adaptive radiotherapy of urinary bladder cancer.

Background Adaptive radiotherapy is introduced in the management of urinary bladder cancer to account for day-to-day anatomical changes. The purpose of this study was to determine whether an adaptive plan selection strategy using either the first four cone beam computed tomography scans (CBCT-based strategy) for plan creation, or the interpolation of bladder volumes on pretreatment CT scans (CT-based strategy), is better in terms of tumor control probability (TCP) and normal tissue sparing while taking the clinically applied fractionation schedules also into account. Material and methods With the CT-based strategy, a library of five plans was created. Patients received 55 Gy to the bladder tumor and 40 Gy to the non-involved bladder and lymph nodes, in 20 fractions. With the CBCT-based strategy, a library of three plans was created, and patients received 70 Gy to the tumor, 60 Gy to the bladder and 48 Gy to the lymph nodes, in 30-35 fractions. Ten patients were analyzed for each adaptive plan selection strategy. TCP was calculated applying the clinically used fractionation schedules, as well as a rescaling of the dose from 55 to 70 Gy for the CT-based strategy. For rectum and bowel, equivalent doses in 2 Gy fractions (EQD2) were calculated. Results The CBCT-based strategy resulted in a median TCP of 75%, compared to 49% for the CT-based strategy, the latter improving to 72% upon rescaling the dose to 70 Gy. A median rectum V30Gy (EQD2) of 26% [interquartile range (IQR): 8-52%] was found for the CT-based strategy, compared to 58% (IQR: 55-73%) for the CBCT-based strategy. Also the bowel doses were lower with the CT-based strategy. Conclusions Whereas the higher total bladder TCP for the CBCT-based strategy is due to prescription differences, the adaptive strategy based on CT scans results in the lowest rectum and bowel cavity doses.

Influence of source batch S dispersion on dosimetry for prostate cancer treatment with permanent implants.

PURPOSE: In clinical practice, specific air kerma strength (SK) value is used in treatment planning system (TPS) permanent brachytherapy implant calculations with (125)I and (103)Pd sources; in fact, commercial TPS provide only one SK input value for all implanted sources and the certified shipment average is typically used. However, the value for SK is dispersed: this dispersion is not only due to the manufacturing process and variation between different source batches but also due to the classification of sources into different classes according to their SK values. The purpose of this work is to examine the impact of SK dispersion on typical implant parameters that are used to evaluate the dose volume histogram (DVH) for both planning target volume (PTV) and organs at risk (OARs). METHODS: The authors have developed a new algorithm to compute dose distributions with different SK values for each source. Three different prostate volumes (20, 30, and 40 cm(3)) were considered and two typical commercial sources of different radionuclides were used. Using a conventional TPS, clinically accepted calculations were made for (125)I sources; for the palladium, typical implants were simulated. To assess the many different possible SK values for each source belonging to a class, the authors assigned an SK value to each source in a randomized process 1000 times for each source and volume. All the dose distributions generated for each set of simulations were assessed through the DVH distributions comparing with dose distributions obtained using a uniform SK value for all the implanted sources. The authors analyzed several dose coverage (V100 and D90) and overdosage parameters for prostate and PTV and also the limiting and overdosage parameters for OARs, urethra and rectum. RESULTS: The parameters analyzed followed a Gaussian distribution for the entire set of computed dosimetries. PTV and prostate V100 and D90 variations ranged between 0.2% and 1.78% for both sources. Variations for the overdosage parameters V150 and V200 compared to dose coverage parameters were observed and, in general, variations were larger for parameters related to (125)I sources than (103)Pd sources. For OAR dosimetry, variations with respect to the reference D0.1cm(3) were observed for rectum values, ranging from 2% to 3%, compared with urethra values, which ranged from 1% to 2%. CONCLUSIONS: Dose coverage for prostate and PTV was practically unaffected by SK dispersion, as was the maximum dose deposited in the urethra due to the implant technique geometry. However, the authors observed larger variations for the PTV V150, rectum V100, and rectum D0.1cm(3) values. The variations in rectum parameters were caused by the specific location of sources with SK value that differed from the average in the vicinity. Finally, on comparing the two sources, variations were larger for (125)I than for (103)Pd. This is because for (103)Pd, a greater number of sources were used to obtain a valid dose distribution than for (125)I, resulting in a lower variation for each SK value for each source (because the variations become averaged out statistically speaking).