title: A strategy for the use of image-guided radiotherapy (IGRT) on linear accelerators and its impact on treatment margins for prostate cancer patients.
abstract: OBJECTIVE
  In external beam radiotherapy of prostate cancer, the consideration of various systematic error types leads to wide treatment margins compromising normal tissue tolerance. We investigated if systematic set-up errors can be reduced by a set of initial image-guided radiotherapy (IGRT) sessions.
  
  
  METHODS
  27 patients received daily IGRT resulting in a set of 882 cone-beam computed tomographies (CBCTs). After matching to bony structures, we analyzed the dimensions of remaining systematic errors from zero up to six initial IGRT sessions and aimed at a restriction of daily IGRT for 10% of all patients. For threshold definition, we determined the standard deviations (SD) of the shift corrections and selected patients out of this range for daily image guidance. To calculate total treatment margins, we demanded for a cumulative clinical target volume (CTV) coverage of at least 95% of the specified dose in 90% of all patients.
  
  
  RESULTS
  The gain of accuracy was largest during the first three IGRTs. In order to match precision and workload criteria, thresholds for the SD of the corrections of 3.5 mm, 2.0 mm and 4.5 mm in the left-right (L-R), cranial-caudal (C-C), and anterior-posterior (A-P) direction, respectively, were identified. Including all other error types, the total margins added to the CTV amounted to 8.6 mm in L-R, 10.4 mm in C-C, and 14.4 mm in A-P direction.
  
  
  CONCLUSIONS
  Only initially performed IGRT might be helpful for eliminating gross systematic errors especially after virtual simulation. However, even with daily IGRT performance, a substantial PTV margin reduction is only achievable by matching internal markers instead of bony anatomical structures.
authors.affiliation: University Clinic for Radiotherapy and Radio-Oncology, Landeskrankenhaus Salzburg, Paracelsus Medical University Salzburg, Salzburg, Austria. olaf.nairz@med.uni-heidelberg.de
authors.forename: Olaf
authors.initials: O
authors.lastname: Nairz
authors.forename: Florian
authors.initials: F
authors.lastname: Merz
authors.forename: Heinz
authors.initials: H
authors.lastname: Deutschmann
authors.forename: Peter
authors.initials: P
authors.lastname: Kopp
authors.forename: Helmut
authors.initials: H
authors.lastname: Schöller
authors.forename: Franz
authors.initials: F
authors.lastname: Zehentmayr
authors.forename: Karl
authors.initials: K
authors.lastname: Wurstbauer
authors.forename: Gerhard
authors.initials: G
authors.lastname: Kametriser
authors.forename: Felix
authors.initials: F
authors.lastname: Sedlmayer
mesh_terms: D000465:Algorithms; D006801:Humans; D008297:Male; D015233:Models, Statistical; D010315:Particle Accelerators; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging* / Q000532:radiotherapy*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D020266:Radiotherapy, Conformal / Q000592:standards*; D012189:Retrospective Studies; D012984:Software; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000379:methods*