# Reconstructed dose and geometric coverage for tight margins using intrafraction re-planning on an integrated magnetic resonance imaging and linear accelerator system for prostate cancer patients

## TL;DR

This study shows that tight margins can be safely used for most prostate cancer patients during MR-guided radiotherapy, reducing the need for larger margins.

## Contribution

The study introduces a sub-fractionation workflow using MR-Linac to safely apply tight margins in prostate cancer radiotherapy.

## Key findings

- 89% of patients completed treatment with initial tight margins of 2–3 mm.
- 57% of patients who switched to larger margins still achieved sufficient dose coverage.
- Tight margins were safely used for 95% of prostate cancer patients on an MR-linac.

## Abstract

A sub-fractionation workflow enables a substantial reduction in planning target volume (PTV) margin in prostate cancer (PCa) patients by reducing systematic motion during magnetic resonance (MR)-guided radiotherapy. This study assessed geometric and reconstructed dose outcomes in patients treated with a tight-margin sub-fractionation workflow on a combined linear accelerator with a 1.5 T MRI scanner (MR-Linac).

We evaluated the sub-fractionation workflow with tight margins (2–3 mm) on 128 PCa patients who completed treatment with 5 × 7.25 Gy (36.25 Gy total dose). A traffic light protocol was applied based on residual motions to detect patients with unexpectedly large motions. When ’red’ traffic light criteria were met, plans with larger margins (5 mm isotropic) were adopted for subsequent fractions. Intra- and inter-fraction dose accumulation was performed via an in-house developed deformable image registration algorithm.

A total of 89 % (114/128) of patients completed treatment with the initial tight margins. The mean 3D intrafraction shifts were 1.0 mm (SD: 0.6 mm) in the group with the tight margins and 1.9 mm (SD: 1.5 mm) in the patient group who switched to large margins. The median accumulated D99% was 34.9 Gy (interquartile range: 34.0–35.3 Gy) for patients with prostate shifts who switched to larger margins. In 57 % (8/14) of these patients, the accumulated D99% was above the threshold of 34.4 Gy.

Tight margins of 2–3 mm can be safely applied for at least 95 % (122/128) of the PCa patients undergoing a sub-fractionation workflow on a 1.5 T MR-linac.