Dosimetric effects of anatomical changes during fractionated photon radiation therapy in pancreatic cancer patients

Pancreatic tumors show large interfractional position variation. In addition, changes in gastrointestinal gas volumes and body contour take place over the course of radiation therapy. We aimed to quantify the effect of these anatomical changes on target dose coverage, for the clinically used fiducial marker-based patient position verification and, for comparison, also for simulated bony anatomy-based position verification. Nine consecutive patients were included in this retrospective study. To enable fraction dose calculations on cone-beam CT (CBCT), the planning CT was deformably registered to each CBCT (13-15 per patient); gas volumes visible on CBCT were copied to the deformed CT. Fraction doses were calculated for the clinically used 10 MV VMAT treatment plan (with for the planning target volume (PTV): D-98% = 95%), according to fiducial marker-based and bony anatomy-based image registrations. Dose distributions were rigidly summed to yield the accumulated dose. To evaluate target dose coverage, we defined an iCTV(+ 5 mm) volume, i.e., the internal clinical target volume (iCTV) expanded with a 5 mm margin to account for remaining uncertainties including delineation uncertainties. We analyzed D-98%, D-mean, and D-2% for iCTV(+ 5 mm) and PTV (i.e., iCTV plus 10 mm margin). We found that for fiducial marker-based registration, differences between fraction doses and planned dose were minimal. For bony anatomy-based registration, fraction doses differed considerably, resulting in large differences between planned and accumulated dose for some patients, up to a decrease in D98% of the iCTV+ 5 mm from 95.9% to 85.8%. Our study shows that fractionated photon irradiation of pancreatic tumors is robust against variations in body contour and gastrointestinal gas, with dose coverage only mildly affected. However, as a result of interfractional tumor position variations, target dose coverage can severely decline when using bony anatomy for patient position verification. Therefore, the use of intratumoral fiducial marker-based daily position verification is essential in pancreatic cancer patients