PMC9420944_01
Patient 2. (A) Sagittal 68Ga-PSMA-11 PET/CT showing bright posterior bladder wall uptake. (B) Axial MRI showing posterior bladder wall lesion. (C) MR simulation with planned isodose lines. (D) MRgRT-acquired image with delivered isodose lines. Green = GTV, red = PTV, brown = D110%, bold red = D100%, yellow = D90%, and cyan = D80%.
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The patient was treated with MRgRT, with 35 Gy in five fractions delivered twice per week ( Figure 2 ).
Patient 3. (A) Axial 18F-fluciclovine PET/CT showing bright uptake in the left posterior prostate. (B) MRI prostate showing left seminal vesicle invasion. (C) MRgRT-acquired treatment image at the level of mid-prostate. (D) MRgRT-acquired image at the level of seminal vesicle. Green = PTV 4,000 cGy, red = PTV 3,400 cGy, bold yellow = urethra, brown = D110%, bold red = D100%, yellow = D90%, and cyan = D80%.
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He chose to undergo MRgRT SAbR 5 months after biopsy; he was treated with RT directed at left SV and left mid-base crossing midline to 34 Gy in five fractions with SIB of gross disease to 40 Gy in five fractions ( Figure 3 ).
Patient 4. Left panel: diffusion weighted imaging with arrow indicating area of restricted diffusion and correlating location circled on coronal MRI. Right panel: Dose color wash of first fraction: (A) scheduled plan, (B) adapted (delivered) plan; red = PTV, cyan = rectum.
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Varian), 40 Gy delivered in five fractions of 8 Gy to the seminal vesicles. Adaptation was used in two of the five fractions to prioritize rectal dose, with a decrease in rectal D50% by 5%-7% and Dmax by 4%-5%. V40Gy coverage was more than 91% of the PTV for each of the delivered plans and congruent with the initial planning of 92% V40Gy.  Figure 4  demonstrates a representative sagittal comparison of the scheduled and adapted plan, with the improved dose homogeneity visually apparent in addition to the coverage of the target anteriorly with a decreased posterior extent of the 650 cGy line.
Patient 5. Left panel: Axial and coronal views of 18F-fluciclovine PET/CT with focal perirectal uptake inferior to implanted brachytherapy seeds. Middle panel: simulated ART plan with isodose lines. Right panel: Dose color wash of first fraction: (A) scheduled plan, (B) adapted (delivered) plan. Red lines denote the larger PTV 3,000 cGy and smaller PTV 3,500 cGy structures.
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ART treatment of 30 Gy in five fractions to the PTV with a SIB boost of 35 Gy to the GTV ( Figure 5 ). Adaptation was used in all five fractions to improve coverage of the target.