An opposed matched field IMRT technique for prostate cancer patients with bilateral prosthetic hips

Intensity-modulated radiation therapy (IMRT) has gained wide-spread use for treating patients with prostate cancer, yet developing a plan for patients with bi-lateral metal hip prostheses implants may be challenging. The high atomic number of the metallic hips not only gives rise to streak artifacts that obscure anatomy but also attenuates laterally directed fields by a significant amount that cannot be reliably ascertained from the CT dataset. A common approach to planning directs five IMRT fields such that incidence through the metal hips is avoided. While this technique generally gives adequate PTV coverage, it may escalate the rectal dose if beams, which would otherwise be incident from a lateral direction, are angled toward a posterior direction in order to avoid the prosthesis. In this work, we propose and investigate a new technique which alleviates this problem by introducing asymmetric opposed fields that are edge-matched along a plane that is tangent to the metal prostheses. With this approach, a posterior oblique field is oriented closer to the lateral direction but does not irradiate the ipsilateral prosthesis. The portion of the target eclipsed by the prosthesis is irradiated by the opposed matched anterior oblique field which, again, avoids the corresponding ipsilateral prosthesis. While the proposed technique may improve rectal sparing and PTV coverage, the dose along the match plane is sensitive to intrafraction motion. In the worse case of intrafraction motion perpendicular to the plane occurring in the time interval between the deliveries of successive fields of the opposed matched pair, the induced error is typically about 5 cGy per mm of target motion for a 200 cGy fraction. To reduce the induced error, several approaches to broadening the penumbra at the match plane were investigated and compared to conventional IMRT plans for three patients. Phantom measurements were performed to evaluate the effectiveness of these approaches. Match-plane shifts of 4 mm in a single step, in two 2 mm steps, and in four 1 mm steps, were effective in reducing the worse case induced error to 2.8 cGy per mm. Imposing match-plane shifts precludes the use of intensity modulation for the opposed matched field pairs. Therefore, we favor an approach whereby the opposed matched fields overlap by 4 mm. Since both fields contribute fluence to the overlap region, the worse case induced error was observed to be typically within 2.9 cGy per mm. In conclusion, the use of this technique should be considered for patients with bilateral metal hip implants who do not meet dose-volume criteria by conventional IMRT techniques.