Working Title

The Feasibility of a Dual Isocenter Treatment Planning Approach on a MR-Linac for the
Treatment of Prostate Cancer with Involved Lymph Nodes.

Problem Statement
The problem is the cranio-caudal field length limitations on MR-Linear accelerators prevent
single isocenter planning methods from being used for patients diagnosed with node positive
prostate cancer.

Purpose Statement
The purpose of this study is to determine if a dual isocenter treatment planning approach on a
MR-Linear accelerator provides comparable plan quality to the single isocenter planning
approach for patients diagnosed with node positive prostate cancer.

Goals
The researchers aim to evaluate OAR dose constraints: Rectal dose of V45Gy ≤ 45%, Bladder
dose of V45Gy ≤ 45%, Small bowel dose of V45Gy ≤ 45%, Femoral heads dose of V40Gy ≤
2%, and Penile bulb dose of V40Gy ≤ 50%.

Literature Review Summary

The field of Radiation Oncology is continuously pursuing more accurate and precise
treatment practices by utilizing innovative technologies to minimize uncertainty or error. The
combination of Magnetic Resonance Imaging with a Linear Accelerator (MR-Linac), such as in
the Elekta Unity MR-Linac, integrates the capabilities of a 1.5 tesla MR into image-guided
Radiation Therapy (MRgRT). MRgRT provides greater soft tissue contrast compared with other
image guidance methods, does not add additional radiation dose due to imaging, and allows for
adaptive treatment planning to correct for inter- and intra-fraction anatomical variations. 1 The
adaptive planning approach offers numerous benefits to patients, including increased sparing of
organs at risk (OAR), better coverage to target volumes, and the use of reduced PTV expansion
margins around gross disease that could allow for treatment to higher therapeutic doses. 2,3 Some
disadvantages of adaptive MRgRT include the enclosed bore design of the equipment and the
longer treatment sessions required when compared with a traditional Linac treatment due to the
increase in time required for imaging, real-time adaptive planning, optimization, and treatment
delivery. The previously mentioned factors may limit eligibility for treatment on the MR-Linac
for patients with claustrophobia or for those who may be in too much discomfort to remain still
for longer periods of time. Another restriction of the Elekta Unity MR-Linac is the treatment
field size limitation which presents a technical challenge; however, if this issue is properly
addressed, there is potential to increase the number of patients who receive care from this
modality.4
The Elekta Unity MR-Linac contains a cranio-caudal (CC) field size limitation of 22cm.
There is also the recommendation of at least a 1cm margin in all directions for adaptive planning
purposes that further decreases the maximum field length to only 20cm. Many treatment areas,
especially with node positive disease, require large field sizes beyond that constraint making
their treatment on an MR-Linac unfeasible. This reduces the likelihood of such patients receiving
this novel therapy.5 The treatment of prostate cancer has been shown to benefit from the MR-
Linac capabilities but may not always be within field size tolerance when nodes are involved. 2
Prostate cancer is one of the most prevalent cancers in men worldwide and the presence of node
positive increases the likelihood of recurrence and distant metastases, which all contribute to
worse survival outcomes.6 An emerging approach to combat this issue is the use of dual isocenter
irradiation utilizing RayStation TPS on the Elekta Unity MR-Linac.
The evidence that MRgRT can provide more optimal image guidance and adaptable daily
treatment planning demonstrates that this technology will continue to see expanded use. 2 The
feasibility of a dual isocenter treatment planning approach utilizing RayStation TPS for the
treatment of node positive prostate cancer on an Elekta Unity MR-Linac has the potential to
grant many patients, not currently eligible, to be treated with such an adaptive plan. The obstacle
that is often faced for these patients, however, is the required treatment field length to treat both
the primary tumor with nodal volumes extending beyond the limits of MR-Linacs, preventing
traditional planning methods from being used for these cases. The purpose of this case study is to
incorporate a dual isocenter treatment planning approach on the MR-Linac with RayStation TPS
and compare the plan quality to the traditional planning approach for patients diagnosed with
node positive Prostate cancer. The researchers of this study aim to demonstrate that the
implementation of a dual isocenter planning technique on an MR-Linac will allow for the
treatment of such patients, while still meeting the same dosimetric standards as a plan created for
treatment on a traditional Linac. To determine if treatment plans are comparable, the researchers
will examine PTV coverage and if dose constraints are met for the rectum, bladder, small bowel,
femoral heads, and penile bulb.

References

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