Evaluating the effect of higher Monte Carlo statistical uncertainties on accumulated doses after daily adaptive fractionated radiotherapy in prostate cancer.

For twenty prostate cancer patients, daily plans were simulated for 5 fractions and three modes of variation: rigid whole body translations, local-rigid prostate translations and local-rigid prostate rotations. For each mode and fraction, adaptive plans were generated from a clinical reference plan using three MC uncertainty values: 1 % (standard), 2 % and 3 % per plan. Dose-volume criteria were evaluated for accumulated doses, checking plan acceptability and comparing higher uncertainty plans to the standard.

A 2-3 % MC statistical uncertainty was clinically feasible. Using a 2 % uncertainty setting reduced calculation times at the cost of limited relative dose-volume differences.

Increasing the statistical uncertainty setting from 1 % to 2-3 % caused an accumulated median target D_98% reduction of 0.1 Gy, with interquartile ranges (IQRs) up to 0.12 Gy. Rectum V_35Gy increased in median up to 0.16 cm³ with IQRs up to 0.33 cm³. The bladder V_28Gy and V_32Gy showed median increases up to 0.24 %-point, with IQRs up to 0.54 %-point. Using 2 % uncertainty reduced calculation times by more than a minute for all modes of variation, with no further time gain when increasing to 3 %.

Monte Carlo (MC) based dose calculations are widely used in radiotherapy with a low statistical uncertainty, being accurate but slow. Increasing the uncertainty accelerates the calculation, but reduces quality. In online adaptive planning, however, dose is recalculated every treatment fraction, potentially decreasing the cumulative calculation error. This study aimed to evaluate the effect of higher MC statistical uncertainty in the context of daily online plan adaptation.