PTV margin for dose escalated radiation therapy of prostate cancer with daily on-line realignment using internal fiducial markers: Monte Carlo approach and dose population histogram (DPH) analysis.

Using internal fiducial markers and electronic portal imaging (EPID) to realign patients has been shown to significantly reduce positioning uncertainties in prostate radiation treatment. This creates the possibility of decreasing the planning target volume (PTV) margin added on the clinical target volume (CTV), which in turn may allow for dose escalation. We compared the outcome of two plans: 70Gy/35fx, 10 mm PTV margin without patient realignment (Reference Plan) vs. 78Gy/39fx, 5 mm PTV margin with patient realignment (Escalated Plan). Four-field-oblique (gantry angles 35 degrees, 90 degrees, 270 degrees, 176 degrees, 325 degrees) beam arrangement was used. Monte Carlo code was used to simulate the daily organ motion. Dose to each organ was calculated. Tumour control probability (TCP) and the effective dose to critical organ (Deff) were calculated using the biologically normalized dose-volume histograms. By comparing the biological factors, we found that the prescription dose can be escalated to 78Gy/39fx with a 5 mm PTV margin when using internal fiducial markers and EPID. Based on the available dose-response data for intermediate risk prostate patients, this will result in a 20% increase of local control and significantly reduced rectal complications provided that less serial dose-volume behaviour of rectum is proven.