title: Impact of pelvic nodal irradiation with intensity-modulated radiotherapy on treatment of prostate cancer.
abstract: OBJECTIVE
  The aim of this study was to evaluate the feasibility of treating the pelvic lymphatic regions during prostate intensity-modulated radiotherapy (IMRT) with respect to our routine acceptance criteria.
  
  
  METHODS
  A series of 10 previously treated prostate patients were randomly selected and the pelvic lymphatic regions delineated on the fused magnetic resonance/computed tomography data sets. A targeting progression was formed from the prostate and proximal seminal vesicles only to the inclusion of all pelvic lymphatic regions and presacral region resulting in 5 planning scenarios of increasing geometric difficulty. IMRT plans were generated for each stage for two accelerator manufacturers. Dose volume histogram data were analyzed with respect to dose to the planning target volumes, rectum, bladder, bowel, and normal tissue. Analysis was performed for the number of segments required, monitor units, "hot spots," and treatment time.
  
  
  RESULTS
  Both rectal endpoints were met for all targets. Bladder endpoints were not met and the bowel endpoint was met in 40% of cases with the inclusion of the extended and presacral lymphatics. A significant difference was found in the number of segments and monitor units with targeting progression and between accelerators, with the smaller beamlets yielding poorer results. Treatment times between the 2 linacs did not exhibit a clinically significant difference when compared.
  
  
  CONCLUSIONS
  Many issues should be considered with pelvic lymphatic irradiation during IMRT delivery for prostate cancer including dose per fraction, normal structure dose/volume limits, planning target volumes generation, localization, treatment time, and increased radiation leakage. We would suggest that, at a minimum, the endpoints used in this work be evaluated before beginning IMRT pelvic nodal irradiation.
authors.affiliation: Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA. r_price@fccc.edu
authors.forename: Robert A
authors.initials: RA
authors.lastname: Price
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Hannoun-Levi
authors.forename: Eric
authors.initials: E
authors.lastname: Horwitz
authors.forename: Mark
authors.initials: M
authors.lastname: Buyyounouski
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Ruth
authors.forename: C-M
authors.initials: CM
authors.lastname: Ma
authors.forename: Alan
authors.initials: A
authors.lastname: Pollack
mesh_terms: D023381:Endpoint Determination; D005240:Feasibility Studies; D006801:Humans; D007422:Intestines / Q000528:radiation effects; D015182:Lymphatic Irradiation; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D010388:Pelvis; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000532:radiotherapy*; D011832:Radiation Injuries / Q000517:prevention & control; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D012007:Rectum / Q000528:radiation effects; D012669:Seminal Vesicles; D014057:Tomography, X-Ray Computed / Q000379:methods; D001743:Urinary Bladder / Q000528:radiation effects