Medical Dosimetry 44 (2019) 1–6

Medical Dosimetry
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Dosimetry Contribution:

Offline adaptive radiation therapy in the treatment of prostate cancer:

a case study
Evgenia Nigay, M.S., R.T.(T)∗, Heath Bonsall, M.S., C.M.D., R.T.(T), Beverly Meyer, M.S., R.T.(R)(T),
Ashley Hunzeker, M.S., C.M.D., Nishele Lenards, M.S., C.M.D., R.T.(R)(T), F.A.A.M.D.
Medical Dosimetry Program at the University of Wisconsin, La Crosse, WI

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this case study is to develop a method to account for the difference in the daily volumes
Received 21 October 2017 in the bladder, rectum, and targets in prostate radiotherapy and to compare the predicted dose to the
Revised 18 December 2017
actual dose to these organs. Five patients, both prospectively and retrospectively, were selected from 2
Accepted 18 December 2017
different cancer centers, with a biopsy-confirmed diagnosis of prostate cancer. The patients’ planning tar-
get volume (PTV) and organs at risk (OAR) were contoured on the computed tomography (CT) dataset
Keywords: using either Eclipse or Monaco treatment planning systems (TPSs). Cone-beam computed tomography
Adaptive radiation therapy (CBCT) scans were collected before each daily treatment and exported to MIM software for analysis. The
prostate cancer automatically generated reports evaluated the organ volume changes, the actual dose received during
MIM software
a single fraction, and the projected dose to each organ at the completion of the treatment course via
comparative cumulative dose-volume histograms (DVHs). Volume changes in the bladder and rectum can
cause notable variations in the prescribed dose vs the actual dose received. MIM software was proven
to have utility prospectively by tabulating daily dose and projecting final doses, potentially aiding physi-
cians in decisions about the boost plans, thus making offline adaptive radiation therapy (ART) clinically
manageable.
© 2018 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.

Introduction planning each patient who is receiving radiation therapy treat-

ment.3 Cone beam computed tomography (CBCT) is considered to
Among men in the United States, prostate cancer is the sec- be the standard check utilized for online ART before daily radia-
ond most common cancer and one of the most common causes tion treatments. As studies have shown, the use of CBCT can de-
of death.1 Radiation therapy, both external and brachytherapy, for crease the acute and chronic side effects to the genitourinary and
prostate cancer is a highly utilized form of treatment in cancer gastrointestinal systems.4
centers throughout the United States. With external radiotherapy, ART can play an important role in decreasing unwanted dose
doses required for tumor response can reach 70 Gy. Due to such to critical structures and normal tissues. Prostate bed and intact
high doses, delivery of a sufficient dose to the prostate or prostate prostate radiation treatments are heavily reliant upon proper and
bed while limiting dose to adjacent radiosensitive structures, such consistent bladder filling as well as rectal emptying. When these 2
as the bladder and rectum, proves to be difficult.2 Organs at risk criteria are not adequately reproduced according to the computed
(OAR) are highly mobile, morphing shapes that can make dose de- tomography (CT) planning scan, the dose delivered to the target
livery highly speculative, creating questionable dose to the OAR. can be considerably altered.2 Basing the plan on 1 CT scan, daily
Even as sophisticated as the plans have become for radiation ther- changes in patient positioning by even a few millimeters can result
apy, they cannot account for daily changes in patient anatomy.3 in deviation from the intended dose.4 The International Commis-
Adaptive radiation therapy (ART) has been around for decades.3 sion on Radiological Units and Measurements recommends regular
However, technical complications can make ART difficult to come reports be completed on the received dose to the planning OAR
to fruition, namely, the timely efforts in re-contouring and re- volume, which is now available through the use of daily CBCT.5
Daily changes in positions of OAR and their respective volumes
can alter dose considerably, warranting investigation. Retrospec-
∗
Reprint requests to Evgenia Nigay, M.S., R.T.(T), Medical Dosimetry Program at tively analyzing the dose to the target can reveal a high fluctuation
the University of Wisconsin, La Crosse, WI. in minimum dose to the prostate.6 To track the daily doses to the
E-mail address: [Link]@[Link] (E. Nigay).

[Link]
0958-3947/© 2018 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.
2 E. Nigay, H. Bonsall and B. Meyer et al. / Medical Dosimetry 44 (2019) 1–6

Table 1
Prescription details for the initial plan for patient nos. 1-5

Site Patient no. 1 Patient no. 2 Patient no. 3 Patient no. 4 Patient no. 5

Prostate Prostate fossa Prostate Prostate Prostate

Prescription dose 54 Gy/30 fx 50.4 Gy/28 fx 45 Gy/25 fx 50 Gy/20 fx 45 Gy/25 fx
Planning technique VMAT, 2 full arcs IMRT, 9 beams IMRT, 9 beams IMRT, 9 beams IMRT, 9 beams

target and OAR, MIM software (Cleveland, OH) has been utilized.7 CBCTs based on the priorities provided by the respective attending
MIM software is a suite of tools that allows for efficient contour- physician. Generally, patients were aligned to implanted fiducials if
ing, rigid and deformable registration, and plan evaluation. It has they were present. If nodal volumes or prostate fossa were being
been utilized in an accurate and automated ART workflow in con- treated, the local bony anatomy was used. The CBCT scans along
junction with methods that use deformable CBCT contours. In this with any shifts made were sent to the MIM software for analysis.
case study, the adaptive radiotherapy assistant automated the pro-
cess of fusing the daily CBCT to the planning CT, deforming the Treatment planning
dose and the contours, and generating reports of the findings. The
goal of this research study was to develop a method to account for Specified by the physician, the treatment goals included uni-
the actual difference in the volumes from day to day and to com- form coverage of the PTV while keeping the dose to the blad-
pare the predicted dose to the actual dose delivered to the blad- der and rectum as low as possible. The prescription dose varied
der, rectum, and targets. The workflows were designed to edit the depending on whether the target was the intact prostate or the
transferred contours and evaluate them as part of the process. prostate fossa. The treatment plans were created using either the
volumetric arc therapy or static intensity-modulated radiation ther-
Case Description apy. Patient no. 1 was treated to the intact prostate using a 2-
full arc volumetric arc therapy. Patients 2 through 5 were treated
Patient selection using static intensity-modulated radiation therapy with a 9-beam
arrangement. The prescription for each patient is summarized in
Patients for this study were selected in a retrospective as well Table 1. For the purpose of this study, only the initial plans with-
as prospective manner. Each patient was diagnosed with prostate out the boost were used.
adenocarcinoma confirmed via biopsy. Selected patients were to Desired dose to critical structures was not to exceed the guide-
have the external radiotherapy treatments to the intact prostate lines set forth by the Quantitative Analyses of Normal Tissue Ef-
with or without nodal involvement or to the prostate bed. fects in the Clinic (QUANTEC) and the Radiation Therapy Oncol-
For the simulation, patients were placed in the supine position ogy Group (RTOG). Constraints by the RTOG were utilized for
with a pillow under the head and arms high on their chest, hold- both prostate and prostate fossa plans; additionally, QUANTEC con-
ing a ring. The legs were immobilized in a Vac-Lok (CIVCO Radio- straints were used for the prostate fossa plans. As per QUANTEC
therapy, Coralville, IA). Each patient received a set of permanent constraints, volume of rectum receiving 50 Gy (V50 ) cannot exceed
marks in the pelvic region, anteriorly and on either side, to provide 50% of the total organ volume (V50 ≤ 50%), volume receiving 60 Gy
a reference point for treatment planning. Radiopaque markers were cannot exceed 35% (V60 ≤ 35%), and volume receiving 65 Gy cannot
placed on these marks to visualize them during the scan. Patients exceed 25% (V65 ≤ 25%). For the bladder, volume receiving 65 Gy
were scanned head first, using 2-mm slices on either Siemens SO- cannot exceed 50% of the organ volume (V65 ≤ 50%) and volume re-
MATOM Emotion 16 or Siemens SOMATOM Definition AS (Simens, ceiving 70 Gy cannot exceed 35% (V70 ≤ 35%). Following the RTOG
Erlangen, Germany) CT scanner. constraints, volume of the rectum receiving 40 Gy cannot exceed
As per the clinic’s protocol, the patients were instructed to 55% (V40 ≤ 55%) and volume of the bladder receiving 40 Gy can-
empty their rectum and fill their bladder before the simulation not exceed 70% (V40 ≤ 70%). The summary of the dose-volume con-
and each day before treatment. If the rectum was too full, patients straints can be found in Table 2.
were asked to have a bowel movement before repeating the scan. For each patient, the daily CBCT was completed and exported
Patients were also instructed to have a low-residue diet for the du- into MIM software, where the assistant looked for the daily CBCTs
ration of the treatment to help prevent or reduce diarrhea. as they were exported. Once it recognized a new CBCT, MIM au-
tomatically ran through a workflow that performed a deformable
registration with dose and contour transfer. Another workflow was
Target delineation
then used by the reviewing medical dosimetrist to go through each
of the deformed contours and make edits where necessary. The
Once the simulation scan was complete, the target delineation
software then adjusted and generated the report of the findings.
and treatment planning were performed using either the Elekta
These reports provided information on the organ volume changes,
Monaco 5.11.01 TPS (Elekta, Stockholm, Sweden) or Varian Eclipse
planning dose to each organ compared to the actual dose received
13.7 TPS (Varian, Palo Alto, CA). The clinical target volume (CTV)
during a single fraction, and the projected dose to each organ at
was contoured by the physician on the CT dataset. The planning
the completion of the treatment course.
target volume (PTV) was created by expanding the CTV by 3 mm
posteriorly and 5 mm in all other directions for the intact prostate
or 8 mm in all directions for the prostate fossa. Once the CT dataset Table 2
was received by the medical dosimetrist, OAR were contoured. The Constraints from QUANTEC and RTOG for OAR
OAR of interest for this study included the rectum and bladder vol- QUANTEC RTOG
umes.
Bladder V65 ≤ 50% V40 ≤ 70%
Before each treatment, the patients were imaged using CBCT. V70 ≤ 35%
The scans were matched to the initial planning CT scan to ensure Rectum V50 ≤ 50% V40 ≤ 55%
the precise target location as well as consistency in bladder filling V60 ≤ 35%
V65 ≤ 25%
and rectal emptying during each treatment. Each site aligned the
 E. Nigay, H. Bonsall and B. Meyer et al. / Medical Dosimetry 44 (2019) 1–6 3

Fig. 1. Patient no. 1—cumulative DVH showing planned dose vs total delivered dose; 30 fractions (fx). (Color version of figure is available online.)

Fig. 2. Patient no. 2—cumulative DVH showing planned dose vs total delivered dose; 28 fx. (Color version of figure is available online.)

Plan analysis and evaluation Patient no. 4 was analyzed while on treatment using a hypo-
fractionated prescription and showed no deviation in CTV coverage
Patient no. 1 was analyzed retrospectively for all 30 treatment on the comparative cumulative DVH (Fig. 4). The PTV coverage was
fractions. The comparative cumulative dose-volume histograms reduced from 96.66% of the volume covered by the prescription
(DVHs) showed no significant variations in the actual delivered dose to 91.25%. The bladder received the dose that was similar to
dose when compared to the planning dose (Fig. 1). The PTV cover- the planned dose. The dose to the rectal volume was higher than
age was slightly less than anticipated, with 95.85% of the volume planned, with 15% of the volume receiving 43.36 Gy vs 37.47%.
being covered by 95% of the prescription dose vs 98.07% of the Patient no. 5 was analyzed while on treatment. The CTV and
volume covered by 95% of the prescription dose during the ini- the PTV coverage were comparable between the planned dose and
tial planning. Overall, the actual dose to the bladder was slightly actual received dose (Fig. 5). The cumulative dose to the bladder
lower than the planned dose, and the actual dose to the rectum volume also did not deviate from the initially planned dose. Rec-
was slightly higher than the planned dose but without significant tal volume, however, received a higher-than-anticipated dose. The
variation. Doses to the CTV were also comparable. dose to 15% of the rectal volume was 43.29 Gy, an increase from
Patient no. 2 was analyzed while on treatment. The compar- 40.55 Gy.
ative cumulative DVH showed actual dose delivered to the CTV The reports were generated for each daily fraction for all the
to be comparable to the planning dose (Fig. 2). The PTV received patients. The DVH created showed the variations between plan-
lower dose than planned, with 95% of the dose received by 95.53% ning doses and actual single fraction doses. Daily variations of dose
of the volume vs the planned 98.29% of the volume. The dose re- received by the OAR were recorded. Overall, the dose received by
ceived by the rectum was consistent during daily treatments but the OAR on a daily basis fluctuated only slightly, with more notable
was overall higher than the initially planned dose. The dose to changes recorded in the dose received by the rectal volume. In all 5
the bladder was comparable and slightly lower than the planned patients, the greatest variation in dose for the 15% of the rectal vol-
dose. ume was 15.72% higher than the planned dose. The dose received
The comparative cumulative DVH for patient no. 3, who was an- by 15% of the bladder volume was 3% lower than the planned dose.
alyzed while on treatment, showed a comparable coverage of the Daily variations in OAR volumes were also recorded with signifi-
CTV and the PTV (Fig. 3). The actual dose to 15% of the rectum was cant fluctuations from fraction to fraction. Fig. 6 shows the varia-
36.75 Gy, an increase from the planned dose of 32.91 Gy. The rectal tions in bladder volume between the initial planning CT and each
volume overall also received a higher dose than planned. The dose daily fraction for all 5 patients. Fig. 7 shows the daily variations in
received by the bladder was very comparable. rectal volume for all patients.
4 E. Nigay, H. Bonsall and B. Meyer et al. / Medical Dosimetry 44 (2019) 1–6

Fig. 3. Patient no. 3—cumulative DVH showing planned dose vs total delivered dose; 25 fx. (Color version of figure is available online.)

Fig. 4. Patient no. 4—cumulative DVH showing planned dose vs total delivered dose; 20 fx. (Color version of figure is available online.)

Fig. 5. Patient no. 5—cumulative DVH showing planned dose vs total delivered dose; 25 fx. (Color version of figure is available online.)

Conclusion retrospectively was proven to be too time-consuming. This renders

the software most useful for the patients who are currently on
For each patient, there were notable variations when compar- treatment.
ing planning dose with the actual dose delivered to the target and The data collected were for research purposes and for evalua-
OAR, especially the rectum daily dose. The daily changes in turn tion of the efficiency of the offline ART process, and were therefore
add up to a cumulative dose that differs from the initial planning not reviewed by physicians. For further research, physicians can be
dose. These findings prove that there is utility in using the MIM involved to determine whether the results are clinically significant,
software to track the changes. When completed while the patients as dose tracking during the initial portion of the plan will provide
are on treatment, the entire process from uploading the daily CBCT useful information when designing the boost plan. Because the ac-
scan into the software to editing the contours and generating the tual delivered dose will be available from the initial plan, it will
reports takes between 5 and 10 minutes. Analyzing all the CBCTs provide the planner with a better idea of how much of the dose is
 E. Nigay, H. Bonsall and B. Meyer et al. / Medical Dosimetry 44 (2019) 1–6 5

Fig. 6. Daily variations in bladder volume for patient nos. 1-5 (fx. 0 = initial planning volume). (Color version of figure is available online.)

Fig. 7. Daily variations in rectal volume for patient nos. 1-5 (fx. 0 = initial planning volume). (Color version of figure is available online.)

still allowable to the OAR. The target coverage can also be adjusted could be to re-optimize the plan before the daily treatment if the
for the boost plan if it was not adequate during the initial plan. In variations are significant enough.
addition, knowing the actual doses received might aid physicians Because the software monitors daily doses, it takes each frac-
in deciding whether further dose escalation is feasible or if the tion into account and not only compares the daily variations, but
OAR would be overdosed. The next step in utilizing the software also creates a projected final dose. This function of MIM software
makes analyzing the dose delivered on a daily basis very useful.
6 E. Nigay, H. Bonsall and B. Meyer et al. / Medical Dosimetry 44 (2019) 1–6

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