Radiotherapy treatment strategy for prostate cancer with lymph node involvement

Sammanfattning: Radiotherapy is a common and useful method for treating prostate cancer, often using gold fiducial markers in the prostate as guidance. However, when there is a high risk of lymph node involvement, the independent motion of volumes causes complications in patient positioning since there is a choice between position against the gold fiducial markers or the bone anatomy. This leads to expansion of margins for either the prostate or the pelvic lymph nodes. In this thesis two different treatment strategies were performed and compared against given treatment plans. The purpose was to evaluate the standard treatment and to be able to recommend a new clinical approach for treatment of high-risk prostate cancer. Nine high-risk prostate cancer patients with their given treatment plans were used as a baseline. The patients underwent a planning CT and five CBCTs during the treatment. Two new treatment plan setups were done, a robust treatment and a sequential treatment with three and nine different plans respectively. The baseline and the robust treatment used gold fiducial markers as reference, with a prescribed dose of 2.20 Gy over 35 fractions with a VMAT. The sequential treatment used both gold fiducial markers and bone anatomy as reference, done by 35 fractions with a prescribed dose of 0.6 Gy with a single arc and 1.6 Gy with a dual arc respectively. A total of thirteen different treatment plan setups for each patient were simulated 100 times each, resulting in 11700 simulated treatments in total. The resulting simulated treatments were evaluated by the percentage passing nine different clinical goals, as well as dose and percentage volume averages for these goals. The results from the simulated robust treatments showed a decrease in percentage passing and D98 for the prostate and an increase in percentage passing and D98 for the lymph nodes and vesicles compared to the baseline. An increase in percentage passing and D98 was seen in the sequential treatment strategy for both targets compared to the baseline. The rectum had a larger percentage passing the clinical goals and a lower V69, V74 and V59 for both the robust and sequential treatment strategies. The D2 for the external were lower in the robust treatment strategy but higher in the sequential treatment strategy, while the D2 to the femoral heads were lower for both compared to the baseline treatment strategy. In conclusion, an improved dose coverage was seen in the sequential strategy with good sparing of risk organs. The robust treatment strategy showed promising results for sparing risk organs, but with a less robust dose coverage of the prostate.