Analysis of setup errors and their correlation with clinical factors in image-guided radiotherapy for prostate cancer using different immobilization devices

doi:10.12122/j.issn.1673-4254.2025.12.19

Abstract

Abstract:

Objective To quantitatively analyze setup errors of 4 immobilization devices in precision radiotherapy for prostate cancer, their accuracy differences, and the factors affecting their setup precisions. Methods We conducted a retrospective analysis of 240 prostate cancer patients undergoing image-guided radiotherapy at Sun Yat-sen University Cancer Center from May, 2016 to May, 2024. According to the immobilization devices used, the patients were divided into 1.2 m vacuum bag group (n=60), 1.8 m vacuum bag group (n=60), Orfit frame group (n=60), and customized prone board group (n=60). All the patients received pre-treatment cone-beam CT (CBCT) scans, and setup errors in the right-left (RL), superior-inferior (SI), and anterior-posterior (AP) directions were obtained through XVI system grayscale registration. Further subgroup analyses were performed based on patient stratifications by lymph node irradiation status (n=120 each), age (<65 years, n=80; ≥65 years, n=160), and BMI (BMI<24 kg/m², n=120; BMI≥24 kg/m², n=120). Results The setup errors differed significantly among the 4 groups in three-dimensional directions (P<0.05). The customized prone board group showed minimal errors in the RL (0.02±0.25 cm) and SI (0.01±0.32 cm) directions, but demonstrated the largest error in the AP direction (-0.28±0.36 cm). The patients with lymph node irradiation had significantly greater AP directional errors (-0.22±0.36 cm) than those without (-0.01±0.43 cm; P<0.001). BMI showed a negative correlation with SI directional errors (R=-0.45, P<0.001), while age was not significantly correlated with the setup errors (P>0.05). Conclusion The customized prone board demonstrates clinically significant advantages for its high setup accuracies in RL and SI directions in spite of its systematic AP directional errors. The setup accuracy in the SI direction is especially important for patients with lymph node irradiation or low BMI. Our findings provide quantitative evidence for immobilization device selection and individualized optimization of precision radiotherapy for prostate cancer.

Key words: prostate cancer, immobilization devices, setup errors, body mass index

Xuan GUO, Yang LIU, Yan XIONG, Biaoshui LIU, Ting SONG, Yunfei LI. Analysis of setup errors and their correlation with clinical factors in image-guided radiotherapy for prostate cancer using different immobilization devices[J]. Journal of Southern Medical University, 2025, 45(12): 2718-2725.

Figures/Tables 6

References 36

[1]	Raychaudhuri R, Lin DW, Montgomery RB. Prostate cancer: areview[J]. JAMA, 2025, 333(16): 1433-46. doi：10.1001/jama.2025.0228
[2]	李星, 曾晓勇. 中国前列腺癌流行病学研究进展[J]. 肿瘤防治研究, 2021, 48(1): 98-102.
[3]	Zhai Z, Zheng Y, Li N, et al. Incidence and disease burden of prostate cancer from 1990 to 2017: Results from the Global Burden of Disease Study 2017[J]. Cancer, 2020, 126(9): 1969-78. doi：10.1002/cncr.32733
[4]	Tan EH, Burn E, Barclay NL, et al. Incidence, prevalence, and survival of prostate cancer in the UK[J]. JAMA Netw Open, 2024, 7(9): e2434622. doi：10.1001/jamanetworkopen.2024.34622
[5]	Moll M, Nechvile E, Kirisits C, et al. Radiotherapy in localized prostate cancer: a multicenter analysis evaluating tumor control and late toxicity after brachytherapy and external beam radiotherapy in 1293 patients[J]. Strahlenther Onkol, 2024, 200(8): 698-705. doi：10.1007/s00066-024-02222-w
[6]	Inui S, Ueda Y, Ohira S, et al. Comparison of interfractional setup reproducibility between two types of patient immobilization devices in image-guided radiation therapy for prostate cancer[J]. J Med Phys, 2018, 43(4): 230-5. doi：10.4103/jmp.jmp_20_18
[7]	曹飞, 赵永亮, 李明, 等. 宫颈癌放疗仰、俯卧位固定下的摆位误差及剂量学差异探讨[J]. 现代肿瘤医学, 2019, 27(21): 3862-5.
[8]	赵丰雨, 杜德成. 锥形束CT用于盆腔肿瘤放射治疗摆位中的效果分析[J]. 影像研究与医学应用, 2021, 5(4): 225-6.
[9]	Chen H, Liu YD, Qin SB, et al. Optical surface management system and BladderScan for patient setup during radiotherapy of postoperative prostate cancer[J]. Biomed Res Int, 2024, 2024: 3573796. doi：10.1155/2024/3573796
[10]	丘敏敏, 钟嘉健, 李敏, 等. 鼻咽癌调强放疗摆位不同配准方式对实际剂量学的影响[J]. 中国医疗设备, 2020(11): 94-7, 101.
[11]	Anand M, Parikh A, Shah SP. Comparison of thermoplastic masks and knee wedge as immobilization devices for image-guided pelvic radiation therapy using Cone Beam Computed Tomography[J]. Indian J Cancer, 2020, 57(2): 182-6. doi：10.4103/ijc.ijc_602_18
[12]	Wang L, Chen Z, Li X, et al.Setup errors in radiotherapy for prostate cancer: A retrospective analysis of Chinese patients with different immobilization techniques[J].Cancer Manag Res. 2020;12:12439-12447.
[13]	Inui S, Ueda Y, Ohira S, et al.Impact of body mass index on setup reproducibility in image-guided radiotherapy for prostate cancer[J]. J Appl Clin Med Phys, 2021, 22(3): 214-21.
[14]	Stroom JC, Heijmen BJ. Geometrical uncertainties, radiotherapy planning margins, and the ICRU-62 report[J]. Radiother Oncol, 2002, 64(1): 75-83. doi：10.1016/s0167-8140(02)00140-8
[15]	Van HM, Remeijer P, Lebesque JV. Errors and margins in radiotherapy[J]. Semin Radiat Oncol, 2004, 14(1): 52-64. doi：10.1053/j.semradonc.2003.10.003
[16]	Serizawa I, Kozuka T, Soyano T, et al. Clinical and dosimetric comparison between non-image guided radiation therapy and fiducial-based image guided radiation therapy with or without reduced margin in intensity modulated radiation therapy for prostate cancer[J]. Adv Radiat Oncol, 2024, 9(10): 101612. doi：10.1016/j.adro.2024.101612
[17]	Mirzaei M, Gill S, Sabet M, et al. Treatment efficiency and quality improvement via double imaging modality (DIM) versus single imaging modality (SIM) image-guided radiotherapy for prostate cancer[J]. Tech Innov Patient Support Radiat Oncol, 2025, 33: 100307. doi：10.1016/j.tipsro.2025.100307
[18]	Duffton A, McNee S, Muirhead R, et al. Clinical commissioning of online seed matching protocol for prostate radiotherapy[J]. Br J Radiol, 2012, 85(1020): e1273-81. doi：10.1259/bjr/72368557
[19]	Greer PB, Dahl K, Ebert MA, et al. Comparison of prostate set-up accuracy and margins with off-line bony anatomy corrections and online implanted fiducial-based corrections[J]. J Med Imaging Radiat Oncol, 2008, 52(5): 511-6. doi：10.1111/j.1440-1673.2008.02005.x
[20]	彭庆国, 尹勇, 余宁莎,等. 三种体位固定技术在盆腔肿瘤放疗中的应用比较[J]. 中华肿瘤防治杂志, 2015, 22(12): 974-7, 983.
[21]	Guckenberger M, Meyer J, Wilbert J, et al. Cone-beam CT based image-guidance for extracranial stereotactic radiotherapy of intrapulmonary tumors[J]. Acta Oncol, 2006, 45(7): 897-906. doi：10.1080/02841860600904839
[22]	Foster R, Meyer J, Iyengar P, et al. Localization accuracy and immobilization effectiveness of a stereotactic body frame for a variety of treatment sites[J]. Int J Radiat Oncol Biol Phys, 2013, 87(5): 911-6. doi：10.1016/j.ijrobp.2013.09.020
[23]	Fonteyne V, Villeirs G, Speleers B, et al. Intensity-modulated radiotherapy as primary therapy for prostate cancer: report on acute toxicity after dose escalation with simultaneous integrated boost to intraprostatic lesion[J]. Int J Radiat Oncol Biol Phys, 2008, 72(3): 799-807. doi：10.1016/j.ijrobp.2008.01.040
[24]	De Crevoisier R, Tucker SL, Dong L, et al. Increased risk of biochemical and local failure in patients with distended rectum on the planning CT for prostate cancer radiotherapy[J]. Int J Radiat Oncol Biol Phys, 2005, 62(4): 965-73. doi：10.1016/j.ijrobp.2004.11.032
[25]	黄伯天, 张丹丹, 彭应林, 等. 图像配准条件对头颈部CBCT引导放疗精度影响[J]. 中华放射肿瘤学杂志, 2016, 25(4): 391-4.
[26]	彭清河, 彭应林, 朱金汉, 等. 图像配准方式对宫颈癌后装自适应放射治疗图像配准精度的影响[J]. 南方医科大学学报, 2018, 38(11): 1344-8.
[27]	Shinde P, Jadhav A, Shankar V, et al. Assessment of dosimetric impact of interfractional 6D setup error in tongue cancer treated with IMRT and VMAT using daily kV-CBCT[J]. Rep Pract Oncol Radiother, 2023, 28(2): 224-40. doi：10.5603/rpor.a2023.0020
[28]	Dekker J, Essers M, Verheij M, et al. Dose coverage and breath-hold analysis of breast cancer patients treated with surface-guided radiotherapy[J]. Radiat Oncol, 2023, 18(1): 72. doi：10.1186/s13014-023-02261-0
[29]	李雅宁, 林承光, 杨鑫. 体质量指数对宫颈癌调强放疗摆位误差影响[J]. 中华放射肿瘤学杂志, 2021, 30(2): 186-90.
[30]	Price RG, Lloyd S, Wang XC, et al. Adipose tissue distribution and body mass index (BMI) correlation with daily image-guided radiotherapy (IGRT) shifts of abdominal radiation therapy patients[J]. Cureus, 2023, 15(6): e40979.
[31]	Mulla Z, Hashem R, AlMohamad A, et al. Effect of body mass factors on setup displacement in gynecologic tumors and subsequent effect on PTV margins[J]. Adv Radiat Oncol, 2022, 8(1): 101108. doi：10.1016/j.adro.2022.101108
[32]	李军. 不同年龄前列腺癌患者的临床病理特征与生存状况分析[J]. 新乡医学院学报, 2020, 37(9): 862-4.
[33]	潘启勇, 丁秋娥, 姜仁伟, 等. 盆腔肿瘤常规放疗摆位误差分析[J]. 中国实用医药, 2010, 5(24): 47-8.
[34]	丁伟杰, 孙菁, 陈一兴. 肝肿瘤螺旋断层放疗中患者年龄对摆位误差的影响[J]. 肿瘤, 2016, 36(7): 810-3.
[35]	Bossuyt E, Nevens D, Weytjens R, et al. Assessing the impact of adaptations to the clinical workflow in radiotherapy using transit in vivo dosimetry[J]. Phys Imaging Radiat Oncol. 2023，25:100420. doi：10.1016/j.phro.2023.100420
[36]	王春霞, 宋真, 李红燕, 等. 不同年龄前列腺癌患者疾病不确定感与生活质量[J]. 中国老年学杂志, 2019, 39(1): 200-3.

Metric	1.2 m vacuum bag	1.8 m vacuum bag	Orfit board	Individualized prone	χ²/F	P
Age (year, Mean±SD)	64.2±7.8	65.1±8.2	63.8±6.9	65.5±7.5	0.78	0.505
BMI (kg/m², Mean±SD)	24.1±2.8	23.8±3.1	24.3±2.9	23.9±3.0	0.38	0.769
Clinical stage [n (%)]					2.15	0.542
T3	36 (60.0)	33 (55.0)	35 (58.3)	35 (58.3)
T4	24 (40.0)	27 (45.0)	25 (41.7)	25 (41.7)
Risk stratification [n (%)]					1.08	0.782
Intermediate risk	22 (36.7)	20 (33.3)	19 (31.7)	23 (38.3)
High risk	38 (63.3)	40 (66.7)	41 (68.3)	37 (61.7)
Lymph node irradiation [n (%)]	32 (53.3)	30 (50.0)	28 (46.7)	30 (50.0)	0.74	0.864

Metric	1.2 m vacuum bag	1.8 m vacuum bag	Orfit board	Individualized prone	χ²/F	P
Age (year, Mean±SD)	64.2±7.8	65.1±8.2	63.8±6.9	65.5±7.5	0.78	0.505
BMI (kg/m², Mean±SD)	24.1±2.8	23.8±3.1	24.3±2.9	23.9±3.0	0.38	0.769
Clinical stage [n (%)]					2.15	0.542
T3	36 (60.0)	33 (55.0)	35 (58.3)	35 (58.3)
T4	24 (40.0)	27 (45.0)	25 (41.7)	25 (41.7)
Risk stratification [n (%)]					1.08	0.782
Intermediate risk	22 (36.7)	20 (33.3)	19 (31.7)	23 (38.3)
High risk	38 (63.3)	40 (66.7)	41 (68.3)	37 (61.7)
Lymph node irradiation [n (%)]	32 (53.3)	30 (50.0)	28 (46.7)	30 (50.0)	0.74	0.864

Direction/devices	1.2 m vacuum bag	1.8 m vacuum bag	Orfit board	Individualized prone panel	P
R-Ldirection	0.05±0.28	0.05±0.23	-0.05±0.28^＊ΔΟ	0.02±0.25	<0.001
S-Idirection	-0.06±0.36^＊▲	0.03±0.30	-0.13±0.45^＊▲	0.01±0.32	<0.001
A-Pdirection	0.03±0.24∆^＊	-0.10±0.42^▲	-0.02±0.21^＊▲	-0.28±0.36^Ο	<0.001
≥0.5 cm (%)	15.0%	11.67%	13.33%	18.33%	-

Direction/devices	1.2 m vacuum bag	1.8 m vacuum bag	Orfit board	Individualized prone panel	P
R-Ldirection	0.05±0.28	0.05±0.23	-0.05±0.28^＊ΔΟ	0.02±0.25	<0.001
S-Idirection	-0.06±0.36^＊▲	0.03±0.30	-0.13±0.45^＊▲	0.01±0.32	<0.001
A-Pdirection	0.03±0.24∆^＊	-0.10±0.42^▲	-0.02±0.21^＊▲	-0.28±0.36^Ο	<0.001
≥0.5 cm (%)	15.0%	11.67%	13.33%	18.33%	-

Direction	R-L	S-I	A-P
Have lymph nodes	-0.04±0.30	0.003±0.35	-0.22±0.36
No lymph nodes	0.002±0.29	-0.075±0.47	-0.01±0.43
t	2.14	3.46	4.27
P	0.033	0.001	<0.001