Prostate position relative to pelvic bony anatomy based on intraprostatic gold markers and electronic portal imaging

To describe the relative positions and motions of the prostate, pelvic bony anatomy, and intraprostatic gold fiducial markers during daily electronic portal localization of the prostate.

Twenty prostate cancer patients were treated supine with definitive external radiotherapy according to an on-line target localization protocol using three or four intraprostatic gold fiducial markers and an electronic portal imaging device. Daily pretherapy and through-treatment electronic portal images (EPIs) were obtained for each of four treatment fields. The patients' pelvic bony anatomy, intraprostatic gold markers, and a best visual match to the target (i.e., prostate) were identified on simulation digitally reconstructed radiographs and during daily treatment setup and delivery. These data provided quantitative inter- and intrafractional analysis of prostate motion, its position relative to the bony anatomy, and the individual intraprostatic fiducial markers. Treatment planning margins, with and without on-line localization, were subsequently compared.

A total of 22,266 data points were obtained from daily pretherapy and through-treatment EPIs. The pretherapy three-dimensional (3D) average displacement of the fiducial markers, as a surrogate for the prostate, was 5.6 mm, which improved to 2.8 mm after use of the localization protocol. The bony anatomy 3D average displacement was 4.4 mm both before and after localization to the prostate (p = 0.46). Along the superior-inferior (SI), anterior-posterior (AP), and right-left (RL) axes, the average prostate displacement improved from 2.5, 3.7, and 1.9 mm, respectively, before localization to 1.4, 1.6, and 1.1 mm after (all p < 0.001). The pretherapy to through-treatment position of the bony landmarks worsened from 1.7 to 2.5 mm (p < 0.001) in the SI axis, remained statistically unchanged at 2.8 mm (p = 0.39) in the AP axis, and improved from 2.0 to 1.2 mm in the RL axis (p < 0.001). There was no significant intrafractional displacement of prostate position or bony anatomic landmarks. An intermarker distance was identified for all fiducial markers, and 96 were followed daily. Seventy-nine percent had a standard deviation of <1 mm, and 96% were <1.5 mm. Margins were 5.1, 7.3, and 5.0 mm in the SI, AP, and RL axes, respectively, before localization and 2.7, 2.9, and 2.8 mm after localization.

Significant interfractional motion exists for patients' prostate and pelvic bony anatomy. However, these move independently, so the pelvic bony anatomy should not be used as a surrogate for prostate motion. Fiducial markers are stable within the prostate and allow significant margin reduction when used for on-line localization of the prostate.