Implementing daily soft tissue image guidance with reduced margins for post-prostatectomy radiotherapy: research-based changes to clinical practice.

Introduction: We have previously demonstrated that daily soft tissue matching with reduced anisotropic margins provides an ideal balance between prostate bed coverage and meeting organ at risk constraints. The aim of this study was to evaluate the implementation of this approach in clinical practice.
Methods: Thirty-eight radiation therapists (RTs) completed offline IGRT training involving six patients. After training was completed, this approach was implemented clinically. The first 24 patients were evaluated with a central review of match displacements and geographic miss (GM). An assessment of treatment times and planning parameters was also performed.
Results: During offline training, the anterior-posterior (AP) match discrepancy had the largest mean variation ranging from -0.46 to 0.06 cm and undetected geographic miss occurred in 17% of alignments. The mean time taken to treat the first 24 patients ranged from 12.2 to 20.6 min. The smaller anisotropic margin resulted in similar target coverage but achieved reduced doses to the bladder (V65Gy from 36% to 27%, V40Gy from 54% to 51%) and rectum (V65Gy from 20% to 19%, V60Gy from 27% to 24%, V40Gy from 42% to 38%). The matches of 806 CBCT images in 24 patients were reviewed. The mean match ranged from -0.12 to 0.17 cm AP, -0.14 to 0.14 cm superior-inferior (SI) and -0.04 to 0.04 cm left-right (LR). An undetected geographic miss was found in the prostate bed in 17 (2.1%) images and lymph nodes in 2 (0.2%) images.
Conclusions: Daily soft tissue IGRT with reduced anisotropic margins for post-prostatectomy radiotherapy has been successfully implemented. RTs performed better with real-time online matching than they did in offline training, perhaps influenced by having several RTs perform online matching. Daily soft tissue IGRT did not prolong treatment time.
(© 2019 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.)