Using deep learning generated CBCT contours for online dose assessment of prostate SABR treatments

Prostate Stereotactic Ablative Body Radiotherapy (SABR) is an ultra-hypofractionated treatment where small setup errors can lead to higher doses to organs at risk (OARs). Although bowel and bladder preparation protocols reduce inter-fraction variability, inconsistent patient adherence still results in OAR variability. At many centers without online adaptive machines, radiation therapists use decision trees (DTs) to visually assess patient setup, yet their application varies. To evaluate our center's DTs, we employed deep learning-generated cone-beam computed tomography (CBCT) contours to estimate daily doses to the rectum and bladder, comparing these with planned dose-volume metrics to guide future personalized DT development. Two hundred pretreatment CBCT scans from 40 prostate SABR patients (each receiving 40 Gy in five fractions) were auto-contoured retrospectively, and daily rectum and bladder doses were estimated by overlaying the planned dose on the CBCT using online rigid registration data. Dose-volume metrics were classified as "no", "minor", or "major" violations based on meeting preferred or mandatory goals. Twenty-seven percent of fractions exhibited at least one major bladder violation (with an additional 34% minor), while 14% of fractions had a major rectum violation (10% minor). Across treatments, five patients had recurring bladder V37 Gy major violations and two had rectum V36 Gy major violations. Bowel and bladder preparation significantly influenced OAR position and volume, leading to unmet mandatory goals. Our retrospective analysis underscores the significant impact of patient preparation on dosimetric outcomes. Our findings highlight that DTs based solely on visual assessment miss dose metric violations due to human error; only 23 of 59 under-filled bladder fractions were flagged. In addition to the insensitivity of visual assessments, variability in DT application further compromises patient setup evaluation. These analyses confirm that reliance on visual inspection alone can overlook deviations, emphasizing the need for automated tools to ensure adherence to dosimetric constraints in prostate SABR.