Introduction/ Aim

Traditionally treatment through hip prosthesis is not advised due to the inability to accurately
calculate the dose. In fact high atomic number of metallic prosthesis create artifacts in the
kilovoltage CT image (KVCT sim), due to large attenuation coefficient in the diagnostic X-ray
range. This artifacts may hinder anatomic structure delineation, so physicians have to draw bigger
margins in order to be sure to include the target, and at the same time, provide erroneous density
information used for dose calculation .
Differently, by using higher energy Tomotherapy , the MVCT does not suffer strong artifacts from
the prosthesis and provide sufficient (even if not excellent) [1-2] soft-tissue contrast to help
delineate the prostate, bladder and rectum making treatment technically possible.
In addition, intraprostatic markers implantation as surrogate of prostate position can further help in
patient set up and organ motion correction.
In the current study we would like to show the feasibility to treat a patient with prostate cancer and
bilateral hip replacement, who would otherwise not be treatable with a standard approach.
Materials and Methods
A 75 years old low risk prostate cancer patient with bilateral hip replacement was addressed for
radiotherapy to our Department after refusal of treatment from another Institution.
A first KVCT sim was acquired to highlight the expected artifacts (fig 1a) and was used as
reference for planning MVCT acquisition.
Three gold markers were placed in the prostate (left base, apex and right mid-gland) under
ultrasound guidance by the referring Urologist .
MVCT scans of the pelvic region(fig 1b) was acquired (volumetric acquisition, pitch 1, 2mm
reconstruction) as for standard kVCT sim, with the patient in the treatment position, 10 days after
implantation, when markers stability was achieved. The patient was asked to keep a full bladder and
an empty rectum, in order to reduce inter-fraction organ filling variability.
The physician contoured the prostate without seminal vesicles as Clinical Target Volume (CTV)
and the rectum, bladder, femoral heads as the organs at risk; a 5 mm margin was added to define
PTV (Fig 2). The plan was optimized according to our constraints for organs at risk and regarding
PTV coverage PTV 70: 7000 cGy , 2.5 Gy fraction; Rectum: V50<=50, V60<=35, V65<=25, V70
<=20, Bladder: V65<=50%
The patient underwent HT treatment in 28 fractions for a cumulative dose of 70Gy.
Daily marker match was performed between daily MVCT and planning MVCT in order to correct
the prostate position.
Results
No artifacts were found both in planning MVCT and in daily MVCT with sufficient soft-tissue
contrast to help delineate the target and the OARs. The visibility of the markers was good enough
to help on line prostate position correction.
Good tolerance during treatment and in the 4 months after the end of the radiotherapy was
recorded.
Discussion and Conclusion
For our prostate patients with bilateral prostheses, treatment with conventional conformal
techniques provides unacceptable plans; uncertainties in CTV delineation and dose calculation
errors in KVCT-based treatment plans can be substantially reduced by using the MVCT and
intraprostatic markers implantation can help in on-line prostate position correction. Our experience

confirmed the role of MVCT together with intra-prostatic implanted markers in offering a safe
external beam treatment to the patients who otherwise would not have been able to be treated.
References
1)

2)

Moti Raj Paudel et al; Clinical Evaluation of Normalized Metal Artifact Reduction in kVCT Using MVCT Prior Images
(MVCT-NMAR) for Radiation Therapy Treatment Planning. Int J Radiation Oncol Biol Phys, 89, 3, 682, 2014
Paul J. Keall,Radiotherapy Dose Calculations In The Presence Of Hip Prostheses. Medical Dosimetry, 28, 2,
107112, 2003