title: Postoperative radiotherapy in prostate cancer: the case of the missing target.
abstract: OBJECTIVE
  Postoperative radiotherapy (XRT) increases survival in high-risk prostate cancer patients. Approximately 50% of patients on long-term follow-up relapse despite adjuvant XRT and the predominant site of failure remains local. Four consensus guidelines define postoperative clinical target volume (CTV) in prostate cancer. We explore the possibility that inadequate CTV coverage is an important cause of local failure. This study evaluates the utility of preoperative magnetic resonance imaging (MRI) in defining prostate bed CTV.
  
  
  METHODS
  Twenty prostate cancer patients treated with postoperative XRT who also had preoperative staging MRI were included. The four guidelines were applied and the CTVs were expanded to create planning target volumes (PTVs). Preoperative MRIs were fused with postoperative planning CT scans. MRI-based prostate and gross visible tumors were contoured. Three-dimensional (3D) conformal four- and six-field XRT plans were developed and dose-volume histograms analyzed. Subtraction analysis was conducted to assess the adequacy of prostate/gross tumor coverage.
  
  
  RESULTS
  Gross tumor was visible in 18 cases. In all 20 cases, the consensus CTVs did not fully cover the MRI-defined prostate. On average, 35% of the prostate volume and 32% of the gross tumor volume were missed using six-field 3D treatment plans. The entire MRI-defined gross tumor volume was completely covered in only two cases (six-field plans). The expanded PTVs did not cover the entire prostate bed in 50% of cases. Prostate base and mid-zones were the predominant site of inadequate coverage.
  
  
  CONCLUSIONS
  Current postoperative CTV guidelines do not adequately cover the prostate bed and/or gross tumor based on preoperative MRI imaging. Additionally, expanded PTVs do not fully cover the prostate bed in 50% of cases. Inadequate CTV definition is likely a major contributing factor for the high risk of relapse despite adjuvant XRT. Preoperative imaging may lead to more accurate CTV definition, which should result in further improvements in survival for patients with high-risk prostate cancer.
authors.affiliation: Division of Radiation Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Croke
authors.forename: Shawn
authors.initials: S
authors.lastname: Malone
authors.forename: Nicolas
authors.initials: N
authors.lastname: Roustan Delatour
authors.forename: Eric
authors.initials: E
authors.lastname: Belanger
authors.forename: Leonard
authors.initials: L
authors.lastname: Avruch
authors.forename: Christopher
authors.initials: C
authors.lastname: Morash
authors.forename: Cathleen
authors.initials: C
authors.lastname: Kayser
authors.forename: Kathryn
authors.initials: K
authors.lastname: Underhill
authors.forename: Johanna
authors.initials: J
authors.lastname: Spaans
mesh_terms: D000368:Aged; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods; D017410:Practice Guidelines as Topic; D011300:Preoperative Care / Q000379:methods; D011471:Prostatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000532:radiotherapy* / Q000601:surgery; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D061106:Radiotherapy Setup Errors; D061089:Radiotherapy, Image-Guided / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000379:methods; D047368:Tumor Burden