Planning Margins to CTV for Image-Guided Whole Pelvis Prostate Cancer Intensity-Modulated Radiotherapy

Purpose: We investigated the margin recipes with different alignment techniques in the image-guided intensity-modulated radiotherapy (IMRT) of whole pelvis prostate cancer patients. Materials and Methods: Forty-eight computed tomography (CT) scans of eight prostate cancer patients were investigated. Each patient had an initial planning CT scan and 5 consecutive serial CT scans during the course of treatment, all of which were acquired using 3 mm slice separation and 0.94 mm resolution in the axial plane at 120 kVp, on a PQ 5000 CT scanner. Three different whole pelvis planning margin recipes, ranging from 3 to 13 mm, were investigated. A unique IMRT plan was created with each PTV on the initial CT scan, and was then registered to the 5 serial CT scans, by bony alignment or by prostate gland-based alignment. The dose computed on each serial CT scans was accumulated back to the initial CT scan using deformable image registration for final dosimetric evaluation of the interplay of the margin selection and alignment methods. Results: Elective lymph nodes coverage is shown to be independent of the choice between prostate-based and bony-anatomy-based patient repositioning. The prostate gland-based alignment greatly enhanced the coverage to the prostate and SV, especially with small margins. Meanwhile, the soft-tissue alignment also raised the incidental dose to the rectum and reduces the dose to the bladder. With small to intermediate margins, only soft-tissue alignment gave acceptable mean coverage to SV. Margin of 13 mm or more was needed for PLNs to maintain good target coverage. Conclusions: We commend prostate-based alignment along with margins less than or equal to 5 mm around prostate and SV, and margins greater than or equal to 13 mm around the vascular spaces.