A randomized trial of supine vs. prone positioning in patients undergoing escalated dose conformal radiotherapy for prostate cancer

Background and purpose: The optimal treatment position for patients receiving radical radiation therapy for prostate cancer has been a source of controversy. To resolve this issue, we conducted a randomized trial to evaluate the effects of supine and prone positioning on organ motion, positioning errors, and dose to critical organs during escalated dose conformal irradiation for localized prostate cancer and patient and therapist satisfaction with setup technique. Patients and methods: Twenty eight patients were randomized to commence treatment immobilized in the supine or prone position and were subsequently changed to the alternate positioning for the latter half of their treatment. Patients underwent CT simulation and conformal radiotherapy planning and treatment in both positions. The clinical target volume encompassed the prostate gland. Alternate day lateral port films were compared to corresponding simulator radiographs to measure the isocentre positioning errors (IPE). Prostate motion (PM) and total positioning error (TPE) were measured from the same films by the displacements of three implanted fiducial markers. Dose volume histograms (DVHs) for the two treatment positions were compared at the 95, 80 and 50% dose (D%) levels. The patients and radiation therapists completed weekly questionnaires regarding patient comfort and ease of setup. Results: Seven patients, who started in the supine position, subsequently refused prone position and received their whole treatment supine. Small bowel in the treatment volume, not present in the supine position, prevented one patient from being treated prone. PM in anterior posterior direction was statistically significantly less in the supine position (P < 0.05). There was no significant difference in superior inferior PM for the two treatment positions. No statistically significant difference between supine and prone positioning was observed in isocentre positioning error (IPE) or total positioning error (TPE) due to a policy of daily pre-treatment correction. However, more pretreatment corrections were required for patients in the prone position. The DVH analysis demonstrated larger volumes of the bladder wall, rectal wall and small bowel within the D95, D80 and D50% when comparing the planning target volumes (PTVs) actually treated for prone positioning. When the prone PTV was expanded to account for the greater PM encountered in that position, a statistically significant difference (P < 0.007) was observed in favour of the supine position at all dose levels. In the prone position, four patients had small bowel within the 60 Gray (Gy) isodose and in the supine position, no patients had small bowel in the 60 or 38 Gy volumes. Supine position was significantly more comfortable for the patients and setup was significantly easier for the radiation therapists. The median patient comfort score was 0.79 (Standard deviation (SD) 0.03) supine and 0.45 (SD 0.05) prone (P < 0.001). The therapist convenience of setup was 0.80 (SD 0.016) supine and 0.54 (SD 0.025) prone (P < 0.005). No statistically significant difference was seen for the other parameters studied. Conclusions: We demonstrated significantly less PM in the supine treatment position. There was no difference for either treatment position in IPE or TPE, however, more pre-treatment corrections were required in the prone position. Prone position required a larger PTV with resulting increased dose to critical organs. There were statistically significant improvements at all dose levels for small bowel, rectal wall and bladder wall doses in the supine position once corrections were made for differences in organ motion. Linear analogue scores of patient comfort and radiation therapist convenience demonstrated statistically significant improvement in favour of the supine position. Supine positioning has been adopted as the standard for conformal prostatic irradiation at our centre. (C) 2003 Elsevier Ireland Ltd. All rights reserved.