Comparison between Conventional IMRT Planning and a Novel Real-Time Adaptive Planning Strategy in Hypofractionated Regimes for Prostate Cancer: A Proof-of-Concept Planning Study.

In prostate cancer external beam radiation therapy (EBRT), intra-fraction prostate drifts may compromise the treatment efficacy by underdosing the target and/or overdosing the organs at risk. In this study, a recently developed real-time adaptive planning strategy for intensity-modulated radiation therapy (IMRT) for prostate cancer was evaluated in hypofractionated regimes against traditional treatment planning based on a treatment volume margin expansion. The proposed workflow makes use of a "library of plans" corresponding to possible intra-fraction prostate positions. During delivery, at each beam end, the plan prepared for the position of the prostate closest to the current one is selected and the corresponding beam delivered. This adaptive planning strategy was compared with the traditional approach on a clinical prostate cancer case where different prostate shift magnitudes were considered. Five, six and fifteen fraction hypofractionated schemes were considered for each of these scenarios. When shifts larger than the treatment margin were present, using the traditional approach the seminal vesicles were underdosed by 3-4% of the prescribed dose. The adaptive approach instead allowed for correct target dose coverage and lowered the dose on the rectum for each dosimetric endpoint on average by 3-4% in all the fractionation schemes. Standard intensity-modulated radiation therapy planning did not always guarantee a correct dose distribution on the seminal vesicles and the rectum. The adaptive planning strategy proposed resulted insensitive to the intra-fraction prostate drifts, produced a dose distribution in agreement with the dosimetric requirements in every case analysed and significantly lowered the dose on the rectum.