Dosimetric and Radiobiological Evaluation of Delivered Dose Distribution with Intra-Fractional Motion in Prostate Stereotactic Radiation Therapy Treatments Using VMAT and Helical Tomotherapy

Abstract

The implementation of motion-management techniques during intensity modulated radiation therapy (IMRT) is still under challenging issue. Moreover, the dose-per-fraction regime and beam-delivery methods affect the dose distribution owing to the interplay effect. Hypofractionation may be a uniquely appropriate treatment for prostate cancer because of a lower α/β ratio. Several prospective studies support the safety of moderate hypofractionation; however, extreme fractionation may lead to greater toxicity. It has been reported that respiratory motion during IMRT delivery of stereotactic body radiation therapy (SBRT) can lead to dosimetric errors in the target of up to ±20%. Therefore, intra-fractional prostate motion may occur unpredictably during IMRT and lead to under-treatment of the target. In this study, we evaluated the dosimetric and radiobiological effects of the SBRT dose distributions with patient-specific intra-fractional motion in prostate cancer for volumetric modulated arc therapy (VMAT) and helical tomotherapy (HT) using a commercially available six-dimensional (6D) motion system. Dose distributions with patient-specific prostate intra-fractional motion were evaluated using the 6D-motion simulator system, which was coupled to a biplanar diode array detector phantom. These bidirectional prostate motions were acquired from magnetic resonance (MR)-cine images. Then, these motions were continuously generated for approximately 4 min, and dose measurements were repeated 5 times to measure the uncertainty of prostate motion during irradiation. We tested two typical motion patterns: large (over 2.0 mm) and small (under 1.0 mm). The SBRT plan was created in VMAT and HT with a prescription of 36.25 Gy/5 fractions to D95% of the PTV. We compared dose distributions with static irradiations using the 3 dimensional gamma (3D-γ) analysis. Moreover, the equivalent uniform dose (EUD)-based tumor control probability (TCP) and normal tissue complication probability (NTCP) of the rectum were compared with 76 Gy/38 fractions, which is the standard prostate fractionation plan. In the results of the dosimetric evaluation, the pass rate of the γ-analysis (criterion of 2 mm, 3%) was degraded by 9.5% and 22.7% in VMAT and HT plans in the large motion patterns and 3.0% and 8.7% in the small motion patterns, respectively. However, degradation of the D99 for CTV was only 0.7% and 1.8% in VMAT and HT plans, respectively, even in the large motion patterns. Moreover, these errors were negligible in small motion patterns. For the radiobiological evaluation, no significant differences in TCP and NTCP degradations were found in VMAT and HT SBRT plans compared with the standard fractionation plan. SBRT dose distributions with intra-fractional motion over 2.0 mm in prostate cancer were more degraded in HT than those observed in VMAT; however, these dosimetric errors might not be clinically significant degradation for TCP and/or NTCP.