Positioning errors and prostate motion during conformal prostate radiotherapy using on-line isocentre set-up verification and implanted prostate markers.

PURPOSE: To evaluate treatment errors from set-up and inter-fraction prostatic motion with port films and implanted prostate fiducial markers during conformal radiotherapy for localized prostate cancer. METHODS: Errors from isocentre positioning and inter-fraction prostate motion were investigated in 13 men treated with escalated dose conformal radiotherapy for localized prostate cancer. To limit the effect of inter-fraction prostate motion, patients were planned and treated with an empty rectum and a comfortably full bladder, and were instructed regarding dietary management, fluid intake and laxative use. Field placement was determined and corrected with daily on-line portal imaging. A lateral portal film was taken three times weekly over the course of therapy. From these films, random and systematic placement errors were measured by matching corresponding bony landmarks to the simulator film. Superior-inferior and anterior-posterior prostate motion was measured from the displacement of three gold pins implanted into the prostate before planning. A planning target volume (PTV) was derived to account for the measured prostate motion and field placement errors. RESULTS: From 272 port films the random and systematic isocentre positioning error was 2.2 mm (range 0.2-7.3 mm) and 1.4 mm (range 0.2-3.3 mm), respectively. Prostate motion was largest at the base compared to the apex. Base: anterior, standard deviation (SD) 2.9 mm; superior, SD 2.1 mm. Apex: anterior, SD 2.1 mm; superior, SD 2.1 mm. The margin of PTV required to give a 99% probability of the gland remaining within the 95% isodose line during the course of therapy is superior 5.8 mm, and inferior 5.6 mm. In the anterior and posterior direction, this margin is 7.2 mm at the base, 6.5 mm at the mid-gland and 6.0 mm at the apex. CONCLUSIONS: Systematic set-up errors were small using real-time isocentre placement corrections. Patient instruction to help control variation in bladder and rectal distension during therapy may explain the observed small SD for prostate motion in this group of patients. Inter-fraction prostate motion remained the largest source of treatment error, and observed motion was greatest at the gland base. In the absence of real-time pre-treatment imaging of prostate position, sequential portal films of implanted prostatic markers should improve quality assurance by confirming organ position within the treatment field over the course of therapy.