HDR prostate monotherapy: dosimetric effects of implant deformation due to posture change between TRUS- and CT-imaging.

HDR monotherapy for prostate cancer consists of four fractions. The first fraction is delivered with online TRUS-based treatment planning. For the last three fractions the treatment plan is based on a CT-scan acquired in between fractions 1 and 2. The patient position (high lithotomy, rectal US probe) during TRUS-guided catheter implantation and first fraction differs from the patient position in the CT-scan and the remaining three fractions (lowered legs, no TRUS probe). This study describes the effect of posture changes on dose distributions when a plan designed for the TRUS anatomy is applied to the CT-scan anatomy. The aim is to quantify dosimetrical errors that would result from skipping the use of a planning CT-scan, and rely for all fractions on the TRUS plan. Such a procedure would substantially reduce the involved workload, and would increase patient comfort. For three prostate cancer patients, images were acquired during TRUS-guided catheter implantation. Furthermore, a CT-scan (no US probe in rectum, different position of legs) was acquired and matched with the TRUS set. On both TRUS and CT, prostate, urethra and rectum were delineated and all catheters were traced. For each patient, an optimized treatment plan was designed using TRUS images and contours. Catheters with obtained dwell positions of the TRUS plan were transferred individually to the catheter positions in the CT. Changes in dose distribution due to relocation of catheters were evaluated using DVHs. For all patients the dose distributions changed significantly due to rearrangement of the catheters, having most impact on the urethra (maximum observed change: 32% volume receiving > or = 120% of the prescribed dose) and a reduction of PTV coverage (6-28%). Implant deformation when changing from TRUS patient set-up to CT set-up affected negatively the quality of optimized treatment plans. Inclusion of more patients in this study was planned, but because of the observed strong negative effects it is already concluded that the TRUS plan cannot be used for the last three fractions with a deviating patient set-up.