Comparison of three strategies in management of independent movement of the prostate and pelvic lymph nodes.

PURPOSE Concurrent irradiation of the prostate and pelvic lymph nodes is technically challenging due to treating one moving target and one immobile target. The purposes of this article are to propose a new management strategy and to compare this strategy to the conventional isocenter shift method and the previously proposed MLC-shifting method. METHODS To cope with two target volumes (one moving and one immobile), the authors propose a new management strategy referred to as multiple adaptive plans (MAPs). This strategy involves the creation of a pool of plans for a number of potential prostate locations. Without requiring any additional hardware or software, the MAP strategy is to choose a plan from the pool that most closely matches the "prostate position of the day." This position can be determined by dual image registrations: One aligned to the implant markers in the prostate and the other aligned to the pelvic bones. This strategy was clinically implemented for a special patient with high risk prostate cancer and pathologically confirmed positive pelvic lymph nodes, requiring concurrent IMRT treatment of the prostate and pelvic lymph nodes. Because this patient had an abdominal kidney, small planning margins around the both targets were desired. Using 17 daily acquired megavoltage cone beam CTs (CBCTs), three sets of validation plans were calculated to retrospectively evaluate the MAP strategy as well as the isoshifting and MLC-shifting strategies. RESULTS According to the validation plans, MAP, isoshifting, and MLC-shifting strategies resulted in D95 of the prostate > 95% of the daily dose on 65%, 100%, and 100% treatment days, respectively. Similarly, D95 of the pelvic lymph nodal was > 95% of the daily dose on 100%, 75%, and 94% of treatment days, respectively. CONCLUSIONS None of the above strategies simultaneously achieved all treatment goals. Among the three strategies, the MLC shifting was most successful. Validation plans based on daily CBCTs are useful to evaluate the effectiveness of the motion management strategies and to provide additional dose guidance if further dose compensation is needed.