INTRAFRACTIONAL MOTION OF THE PROSTATE DURINGHYPOFRACTIONATED RADIOTHERAPY
*Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA; and
Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
Purpose: To report the characteristics of prostate motion as tracked by the stereoscopic X-ray images of the im-planted ﬁducials during hypofractionated radiotherapy with CyberKnife.Methods and Materials: Twenty-one patients with prostate cancer who were treated with CyberKnife betweenJanuary 2005 and September 2007 were selected for this retrospective study. The CyberKnife uses a stereoscopicX-ray system to obtain the position of the prostate target through the monitoring of implanted gold ﬁducialmarkers. If there is a signiﬁcant deviation, the treatment is paused while the patient is repositioned by movingthecouch.ThedeviationscalculatedfromX-rayimagesacquiredwithinthetimeintervalbetweentwoconsecutivecouch motions constitute a data set.Results:Includedintheanalysiswere427datasetsand4,439timestampsofX-rayimages.Themeandurationforeachdatasetwas697sec.At30sec,amotion>2mmexistsinabout5%ofdatasets.Thepercentageisincreasedto8%, 11%, and 14% at 60 sec, 90 sec, and 120 sec, respectively. A similar trend exists for other values of prostatemotion.Conclusions: With proper monitoring and intervention during treatment, the prostate shifts observed among pa-tients can be kept within the tracking range of the CyberKnife. On average, a sampling rate of
40 sec betweenconsecutive X-rays is acceptable to ensure submillimeter tracking. However, there is signiﬁcant movement varia-tion among patients, and a higher sampling rate may be necessary in some patients.
2008 Elsevier Inc.CyberKnife, Prostate cancer, Fiducial markers, Real-time tracking.
Recent randomized studies for patients with localized pros-tate cancer conﬁrm that improved biochemical failure-freesurvival was achieved by using higher doses of externalbeam radiotherapy (RT)(1–3). Although a higher dose isgood for tumor control, it also carries greater risk of compli-cations to surrounding critical structures, such as the bladder and rectum(4). Because of the inter- and intrafractional mo-tion of the prostate, margin is required when planning a pros-tate radiotherapy. Knowing the extent of prostate movement duringafractionated,andmoreimportantahypofractionated,treatment is necessary to reduce the treatment margin andfacilitate prostate dose escalation(5, 6). A number of tech-niques have been developed for measuring setup variationsand internal organ motion for individual patients from day-to-day and during a treatment fraction(7).Ultrasoundhasbeenausefultoolforprostatetargetlocaliza-tion(8–10). Fung
(8)analyzed the data of 7,825 dailyfractions of 234 prostate patients and indicated average three-dimensional (3D) interfractional displacement of about 7.8 mm. Electronic Portal Imaging Device, on-board kV X-ray imaging, or both of implanted ﬁducials is also widelyusedforinitialsetupandinterfractionalmonitoringofthepros-tatetargetposition(11–17).Arecentdevelopmentinmeasuringsetup variations is the electromagnetic positioning and contin-uous monitoring system from Calypso Medical Technologies(Seattle, WA)(18–20). The difference between skin marksvs. the Calypso System alignment was found to be >5 mm invector length in more than 75% of fractions. Displacements>3 mm and 5 mm for cumulative durations of at least 30 secwere observed during 41% and 15% of sessions, respectively.At our institution, CyberKnife (Accuray, Sunnyvale, CA)hasbeenemployedforPhaseIIhypofractionatedtreatmentof prostate cancer. Through frequent stereoscopic X-ray imag-ing of implanted ﬁducials, the CyberKnife provides an effec-tive way to monitor the position of the prostate target duringa hypofractionated treatment (21). The system records thecenter of mass (CM) of implanted ﬁducials as computed
Reprint requests to: Lei Xing, Ph.D., Stanford University Schoolof Medicine Department of Radiation Oncology, 875 Blake Wilbur Drive, Stanford, CA 94305-5847. Tel: (650) 498-7896; Fax: (650)498-4015; E-mail:firstname.lastname@example.orgConﬂict of interest: none.
This work was supported in part by grants fromthe Department of Defense (Grant No. PC040282) and the NationalCancer Institute (Grant No. 1R01 CA98523 and CA104205).Received Dec 7, 2007, and in revised form April 10, 2008.Accepted for publication April 29, 2008.
Int. J. Radiation Oncology Biol. Phys., Vol. 72, No. 1, pp. 236–246, 2008Copyright
2008 Elsevier Inc.Printed in the USA. All rights reserved0360-3016/08/$–see front matter