Reduction of Postradiation Therapy Urinary Toxicity Via Intrafractional Megavoltage-Kilovoltage Prostate Location Monitoring

We hypothesized that an in-house developed system using megavoltage and kilovoltage image guidance (MKIG) to ensure correct prostate positioning during stereotactic body radiation therapy (SBRT) could potentially avoid unwanted doses to nontarget tissues, leading to reduced toxicities. We built a 3-dimensional MKIG platform that accurately tracks prostate implanted fiducials in real time and clinically translated the system to replace a commercial approach, intrafraction motion review (IMR), which only tracks fiducials in the 2-dimensional kilovoltage views. From 2017 to 2019, 150 patients with prostate cancer were treated with SBRT and monitored using MKIG. The motion trace of the fiducials alerts therapists to interrupt and reposition the prostate when displacement exceeds a 1.5 mm threshold. A comparison cohort of 121 patients was treated with the same dose regimen and treatment technique but managed by IMR. Statistics of intrafractional patient shifts and delivery time were collected to evaluate the workflow efficacy. The incidence of grade ≥2 urinary toxicities was analyzed to assess clinical complications. The median follow-up time was 3.7 years (0.2-8.2 years). MKIG treatments had more treatment shifts (1.09 vs 0.28) and a longer average delivery time per fraction (579 ± 205 seconds vs 357 ± 117 seconds) than IMR treatments. Three-quarters (75%) of shifts resulting from MKIG were ≤3 mm, versus 51% in IMR, indicating that MKIG detected and corrected smaller deviations. The incidence of grade ≥2 urinary toxicity was lower in the MKIG than the IMR cohort: 10.7% versus 19.8% (P = .047). On multivariate analysis of late urinary toxicity, only high (>7) preradiation therapy international prostate symptom score (P < .043) and the use of MKIG were selected (P < .029). Automated and quantitative MKIG introduced minimal workflow impact and was superior to IMR in localizing the prostate during SBRT, which correlated with a clinically significant reduction in late urinary toxicity. Further clinical testing using randomized trials will be required to validate the impact on outcomes.