Developing and validating a simple urethra surrogate model to facilitate dosimetric analysis to predict genitourinary toxicity

Ragu Ratnakumaran; Jonathan Mohajer; Samuel J Withey; Douglas H Brand; Ernest Lee; Andrew Loblaw; Shaun Tolan; Nicholas van As; Alison C Tree; PACE Trial Investigators

doi:10.1016/j.ctro.2024.100769

Developing and validating a simple urethra surrogate model to facilitate dosimetric analysis to predict genitourinary toxicity

Clin Transl Radiat Oncol. 2024 Mar 26:46:100769. doi: 10.1016/j.ctro.2024.100769. eCollection 2024 May.

Authors

Ragu Ratnakumaran^{1

2}, Jonathan Mohajer¹, Samuel J Withey¹, Douglas H Brand³, Ernest Lee¹, Andrew Loblaw⁴, Shaun Tolan⁵, Nicholas van As^{1

2}, Alison C Tree^{1

2}; PACE Trial Investigators

Affiliations

¹ The Royal Marsden NHS Foundation Trust, London, UK.
² Radiotherapy and Imaging Division, Institute of Cancer Research, London, UK.
³ Department of Medical Physics and Bioengineering, University College London, UK.
⁴ Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
⁵ The Clatterbridge Cancer Centre, Liverpool, UK.

Abstract

Purpose: The urethra is a critical structure in prostate radiotherapy planning; however, it is impossible to visualise on CT. We developed a surrogate urethra model (SUM) for CT-only planning workflow and tested its geometric and dosimetric performance against the MRI-delineated urethra (MDU).

Methods: The SUM was compared against 34 different MDUs (within the treatment PTV) in patients treated with 36.25Gy (PTV)/40Gy (CTV) in 5 fractions as part of the PACE-B trial. To assess the surrogate's geometric performance, the Dice similarity coefficient (DSC), Hausdorff distance (HD), mean distance to agreement (MDTA) and the percentage of MDU outside the surrogate (UOS) were calculated. To evaluate the dosimetric performance, a paired t-test was used to calculate the mean of differences between the MDU and SUM for the D99, D98, D50, D2 and D1. The D(n) is the dose (Gy) to n% of the urethra.

Results: The median results showed low agreement on DSC (0.32; IQR 0.21-0.41), but low distance to agreement, as would be expected for a small structure (HD 8.4mm (IQR 7.1-10.1mm), MDTA 2.4mm (IQR, 2.2mm-3.2mm)). The UOS was 30% (IQR, 18-54%), indicating nearly a third of the urethra lay outside of the surrogate. However, when comparing urethral dose between the MDU and SUM, the mean of differences for D99, D98 and D95 were 0.12Gy (p=0.57), 0.09Gy (p=0.61), and 0.11Gy (p=0.46) respectively. The mean of differences between the D50, D2 and D1 were 0.08Gy (p=0.04), 0.09Gy (p=0.02) and 0.1Gy (p=0.01) respectively, indicating good dosimetric agreement between MDU and SUM.

Conclusion: While there were geometric differences between the MDU and SUM, there was no clinically significant difference between urethral dose-volume parameters. This surrogate model could be validated in a larger cohort and then used to estimate the urethral dose on CT planning scans in those without an MRI planning scan or urinary catheter.

Keywords: Prostate radiotherapy; Stereotactic body radiotherapy; Surrogate; Urethra.