Anatomical and dosimetric assessment of the prostate apex: A pilot comparison of image-guided transperineal ultrasound to conventional computed tomography simulation.

Abstract

Inaccuracies in prostate apex contour delineation based on simulation computed tomography (CT) imaging can impact treatment outcomes and toxicity profiles for prostate cancer radiotherapy. Transperineal ultrasound (TPUS) is a non-invasive imaging modality that can improve delineation of prostate volumes. We performed a pilot analysis to assess for differences in anatomical position between conventional CT and a TPUS delineated prostate apex and determined whether these translated into a clinically significant difference in apical point dose. A 2D 5MHz TPUS autoscan image guidance system was utilised during definitive intensity-modulated radiotherapy (IMRT) for prostate cancer. Distances were measured from a fixed reference point to prostate apex on both US and CT in the mid-sagittal plane. Differences between groups were assessed using the Wilcoxon sign rank test with a two-tailed significance of α=0.05. Fifty-nine consecutive patients were independently assessed. There was strong evidence of a difference between CT and TPUS delineated apex position (P=0.0075). Median apex position was 3.6mm caudal on TPUS vs. CT imaging (95% CI: 2.5-4.8mm). There was strong evidence of a difference in point dose between CT and TPUS delineated apex (P=0.0029). Median point dose at the TPUS contoured apex was 1.9Gy lower than CT (95% CI: 0.7-3.1Gy) corresponding to 98% of prescribed dose. This study demonstrates a difference in anatomical delineation of prostate apex position between CT imaging compared to TPUS, corresponding to a statistically significant difference in apex point dose. Further analysis will determine whether this translates to a clinically significant difference in outcomes.