title: Application of the No Action Level (NAL) protocol to correct for prostate motion based on electronic portal imaging of implanted markers.
abstract: OBJECTIVE
  To evaluate the efficacy of the No Action Level (NAL) off-line correction protocol in the reduction of systematic prostate displacements as determined from electronic portal images (EPI) using implanted markers.
  
  
  METHODS
  Four platinum markers, two near the apex and two near the base of the prostate, were implanted for localization purposes in patients who received fractionated high dose rate brachytherapy. During the following course of 25 fractions of external beam radiotherapy, the position of each marker relative to the corresponding position in digitally reconstructed radiographs (DRRs) was measured in EPI in 15 patients for on average 17 fractions per patient. These marker positions yield the composite displacements due to both setup error and internal prostate motion, relative to the planning computed tomography scan. As the NAL protocol is highly effective in reducing systematic errors (recurring each fraction) due to setup inaccuracy alone, we investigated its efficacy in reducing systematic composite displacements. The analysis was performed for the center of mass (COM) of the four markers, as well as for the cranial and caudal markers separately. Furthermore, the impact of prostate rotation on the achieved positioning accuracy was determined.
  
  
  RESULTS
  In case of no setup corrections, the standard deviations of the systematic composite displacements of the COM were 3-4 mm in the craniocaudal and anterior-posterior directions, and 2 mm in the left-right direction. The corresponding SDs of the random displacements (interfraction fluctuations) were 2-3 mm in each direction. When applying a NAL protocol based on three initial treatment fractions, the SDs of the systematic COM displacements were reduced to 1-2 mm. Displacements at the cranial end of the prostate were slightly larger than at the caudal end, and quantitative analysis showed this originates from left-right axis rotations about the prostate apex. Further analysis revealed that significant time trends are present in these prostate rotations. No significant trends were observed for the prostate translations.
  
  
  CONCLUSIONS
  The NAL protocol based on marker positions in EPI halved the composite systematic displacements using only three imaged fractions per patient, and thus allowed for a significant reduction of planning margins. Although large rotations of the prostate, and time trends therein, were observed, the net impact on the measured displacements and on the accuracy obtained with NAL was small.
authors.affiliation: Division of Medical Physics, Department of Radiation Oncology, Erasmus MC-Daniel den Hoed Cancer Center, 3008 AE Rotterdam, The Netherlands. j.deboer@erasmusmc.nl
authors.forename: Hans C J
authors.initials: HC
authors.lastname: de Boer
authors.forename: Marjolein J H
authors.initials: MJ
authors.lastname: van Os
authors.forename: Peter P
authors.initials: PP
authors.lastname: Jansen
authors.forename: Ben J M
authors.initials: BJ
authors.lastname: Heijmen
mesh_terms: D000465:Algorithms; D006801:Humans; D008297:Male; D009068:Movement; D010384:Pelvic Bones / Q000000981:diagnostic imaging; D011467:Prostate / Q000000981:diagnostic imaging*; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging* / Q000532:radiotherapy*; D011859:Radiography; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D012399:Rotation